Oral Boards Flashcards
(120 cards)
1
Q
RSI
A
- Preoxygenate
- Give roc (1 mg/kg) and ketamine (1 mg/kg)
- Use Mac blade, visualize the vocal cords, pass ETT past the vocal cords, check for color change on capnography, listen for BL breath sounds, secure ETT
- CXR to confirm placement
2
Q
Cricothyrotomy (surgical airway)
A
*Bag mask ventilate prior
1. Extend neck
2. Palpate for cricothyroid membrane (inferior to thyroid cartilage, superior to cricoid cartilage)
3. Make 3cm vertical skin incision through skin
4. 1cm transverse incision over membrane
5. Place a bougie into trachea
6. Pass a lubricated 6mm cuffed ETT over the bougie, remove the bougie
7. Check capnography
8. Secure tube
3
Q
Liver transplant
A
*A-line, central line (for CVP measurement)
1. R-sided hockey stick incision
2. Divide 4 ligamentous attachments of liver
3. Dissect hepatoduodenal ligament (divide hepatic artery branches, high ligation of common hepatic duct, isolate portal vein)
4. IVC
a. Caval replacement technique (classic):
Isolate and divide retrohepatic vena cava
Anastomose supra and infrahepatic vena cava
b. Piggyback technique:
Divide short hepatic veins with resection of liver off vena cava
Anastomose suprahepatic vena cava to recipient hepatic vein cuff, ligate infrahepatic vena cava
5. Portal vein anastomosis
6. Hepatic artery anastomosis
7. Bile duct anastomosis
8. Close
4
Q
Kidney transplant
A
- Place 3-way foley to instill bladder
- Hockey stick incision R groin
- Divide inferior epigastric vessels
- Divide through abdominal wall, remain retroperitoneal by sweeping peritoneum medially
- Identify and dissect out external iliac vessels, ligating lymphatics
- End-to-side anastomosis to donor renal artery and vein with fine monofilament suture, reperfuse kidney
- Fill bladder, donor ureter to bladder anastomosis with absorbable suture over a ureteral stent
- Close detrusor muscle loosey with absorbable suture
- Check anastomosis and hemostasis
- Close incision in several anatomic layers
5
Q
Awake tracheostomy (pre-laryngectomy)
A
- Administer local anesthesia
- 3cm vertical incision in midline below cricoid cartilage
- Dissect down to avascular plane of midline raphe b/w sternohyoid and sternothyroid muscles, divide any overlying thyroid isthmus tissue to reach trachea
- Identify inferior border of cricoid cartilage and retract superiorly
- Place trach between second and third tracheal rings
6
Q
Biochemical adrenal workup
A
- BMP (K)
- Aldosterone
- Renin
- Early AM cortisol (or can go straight to 1mg low dose dexamethasone suppression test)
- ACTH
- DHEA-S
- Plasma fractionated metanephrines
7
Q
Laparoscopic left adrenalectomy
A
- Right lateral decubitus
- Ports along subcostal margin
- Take down splenic flexure of colon and lateral attachments to spleen, mobilizing both medially to reveal the adrenal gland
- Identify and ligate the adrenal vein (comes off L renal vein, stay close to adrenal gland to avoid injury to renal vein)
- Mobilize the adrenal gland, taking vessels with cautery
- Place specimen in endocatch bag, close
8
Q
Laparoscopic right adrenalectomy
A
- Left lateral decubitus
- Ports along subcostal margin
- Mobilize R lobe of liver by taking down right triangular ligament, retracting R lobe of liver medially-anteriorly to reveal adrenal gland
- Dissect plane between adrenal gland and IVC
- Identify and ligate R adrenal vein
- Mobilize the adrenal gland, taking vessels with cautery
- Place specimen in endocatch bag, close
9
Q
RNY hepaticojejunostomy
A
- Right subcostal incision
- Careful portal dissection to identify anatomy
- Careful dissection of bile duct, staying on anterior side to preserve remaining vasculature posteriorly (if needed, identify and expose the long extrahepatic portion of the left hepatic duct to find a healthy spot for anastomosis)
- Run jejunum from LOT and find a spot that easily reaches to the RUQ, divide bowel with a GIA stapler, make hole in transverse colon mesentery to the right of the middle colic vessels, bring roux limb up
- Make broad (2cm) enterotomy on roux limb and create end-to-side hepaticojejunostomy with absorbable fine monofilament suture in interrupted fashion
- Stapled JJ
- Leave drain
10
Q
Elective open AAA repair
A
- Monitor w/ a-line, central line, foley
- Midline incision
- Reflect small bowel to right, lift T-colon, insert retractor
- Dissect duodenum from IVC and aorta, exposing proximal clamp site (just below renal arteries)
- Dissect aorta distally to iliac arteries, exposing distal clamp sites
- Choose appropriate graft size, heparinize (80u/kg), lasix, and mannitol
- Clamp iliac arteries and then aorta
- Open aneurysm sac opposite IMA, remove thrombus, oversew back-bleeding lumbar arteries
- Sew in graft starting proximally, then distally, with 3-0 monofilament suture
- Unclamp, give protamine, ensure hemostasis
- Close aneurysm sac and retroperitoneum over graft (prevent aorto-enteric fistula)
- Close, check distal pulses
11
Q
Open ruptured AAA repair
A
- Midline incision
- Immediately gain supraceliac aortic control by dividing gastrohepatic ligament and R crus and bluntly dividing around R crus to place clamp around aorta
- Reflect small bowel to right, lift T-colon, insert retractor
- Dissect duodenum from IVC and aorta, exposing proximal clamp site (just below renal arteries)
- Dissect aorta distally to iliac arteries, exposing distal clamp sites
- Choose appropriate graft, heparinize
- Clamp iliac arteries
- Open aneurysm sac opposite IMA, remove thrombus, oversew back-bleeding lumbar arteries
- Sew in graft starting proximally, then distally, with 3-0 monofilament suture
- Unclamp (one iliac at a time to avoid profound hypotension w/ LE reperfusion), ensure hemostasis
- Close aneurysm sac and retroperitoneum over graft (prevent aorto-enteric fistula)
- Close, check distal pulses (consider leaving open bc high risk of ACS)
12
Q
ABI
A
<0.9 = PAD
<0.5 = rest pain/critical limb ischemia
13
Q
Common femoral artery exposure
A
- Feel for pulse
- Vertical incision ⅓ above inguinal ligament and ⅔ below it
- Open femoral sheath
- Dissect out femoral artery and its branches, control w/ vessel loops
13
Q
Below-knee popliteal artery exposure
A
Frog leg position
1. Incision 1 cm medial to the posterior border of the tibia (be careful of GSV!)
2. Retract gastroc posteriorly, dissect soleus from the tibia
3. Identify popliteal artery medial to the popliteal vein and tibial nerve
14
Q
Heparin dose for vascular cases
A
80u/kg
15
Q
Open LE bypass
A
- Prep low abdomen and BL extremities
- Dissect out inflow and outflow target vessels FIRST before harvesting vein (gotta make sure you have adequate targets)
- Harvest ipsilateral GSV (or can do contralateral, or arm vein, or PTFE)
- Use tunneling device to create tunnel
- HEPARINIZE (80u/kg)
- Perform distal anastomosis, then proximal, being sure not to kink graft
- Intraop duplex to assess patency of graft
- LE pulse exam
16
Q
PAD workup (vascular workup and preop workup)
A
Vascular workup:
1. ABI
2. Segmental pressures (ABI along whole leg) - can further evaluate with CTA w/ runoff
3. Toe pressures (in DM)
Preop workup:
1. Cardiac eval
2. Vein mapping
17
Q
GSV harvest
A
- Expose saphenous vein [MEDIAL] of adequate harvest through skip incisions
- Ligate side branches
- Ligate and divide vein distally and at sapheno-femoral junction proximally
18
Q
Post-op mgmt after LE bypass
A
- ASA 81 (or plavix) for everyone
- Surveillance duplex US at 1, 6, and 12 months, then annually
19
Q
Open femoral endarterectomy
A
- Systemic heparin (bolus 80 u/kg, followed by drip 18u/kg/h w/ PTT goal 60-80)
- Prep abdomen, BLEs from groin to toes circumferentially
- Vertical incision over/below the inguinal ligament over the pulse
- Dissect down to femoral sheath, ligating lymphatic branches
- Identify common femoral, SFA, and profunda arteries and encircle with vessel loops
- Further systemic heparin to PTT 60-80
- Tighten vessel loops, open femoral artery transversely at bifurcation
- Pass 5Fr fogarty catheter proximally until it returns twice with no thrombus; repeat distally
- Flush with heparinized saline, close arteriotomy with 5-0 prolene suture interrupted
- Close incision in layers
- Check for distal pulses/signals
- Consider ppx 4-compartment fasciotomies if ischemia >6h
20
Q
Indications for CEA
A
Asymptomatic with >70% stenosis
Symptomatic with >50% stenosis
21
Q
CEA
A
- A-line for BP monitoring
- Position supine, arms tucked, neck gently extended and turned to contralateral side
- Incision along anterior border of SCM, divide platysma, retract SCM laterally
- Identify and open carotid sheath, identity and protect vagus and hypoglossal nerves, divide facial vein (it’s usually positioned just over the carotid bifurcation)
- Identify and encircle CCA, ECA, ICA w/ vessel loops
- Systemic heparin (80u/kg)
- Clamp ICA, then CCA, then ECA
- Assess stump pressure of ICA, if inadequate place shunt
- Longitudinal arteriotomy from CCA to ICA ending distal to clot, perform endarterectomy, place tacking sutures if needed, flush w/ heparinized saline
- Sew in patch with 5-0 prolene suture
- Backbleed ICA and ECA, forward bleed CCA; check hemostasis of patch; remove clamps from ECA, then CCA, then ICA
- Place subplatysmal drain
- Close neck in layers
- Completion US and check neuro status prior to leaving OR
22
Q
When to perform CEA after CVA
A
In pts who have recovered neurologically: CEA 1-2 weeks after CVA
In pts who have not yet recovered: wait at least 3 weeks (the risk of operating too soon is conversion of an ischemic stroke to a hemorrhagic stroke)
Evolving stroke sx: CEA ASAP to prevent major stroke
23
Q
Open pancreatic debridement
A
- Upper midline incision
- Divide gastrocolic ligament to access lesser sac and expose pancreas
- Drain any purulent material and debride any necrotic tissue, preserving as much healthy pancreatic tissue as possible
- Leave drains
- Consider placing feeding tube
- Ensure hemostasis and close
24
Pyloromyotomy
1. Supine, general anesthesia, NGT
2. Transverse RUQ incision over palpable pylorus
3. Retract omentum down, deliver antrum and pylorus through incision
4. Palpate entire length of pylorus, make incision along pylorus serosa onto gastric antrum
5. Bluntly separate deep muscle fibers, looking for bulge of mucosa
6. Leak test through NGT
25
Peds cases by age
1. Newborn (<2 weeks) --> malrotation w/ midgut volvulus
2. 1-2 months --> pyloric stenosis
3. 1-2 yrs --> intussusception
4. 2 yrs --> Meckel's
26
Ladd's procedure
1. Upper transverse incision
2. Herniate the small bowel, detorse small bowel counterclockwise, inspect small bowel (resect anything frankly necrotic, anything dusky leave to re-eval at the end)
3. Divide Ladd’s bands (b/w R colon and R abd side wall)
4. Appendectomy
5. Broaden small bowel mesentery
6. Place small bowel to the right, colon to the left
27
Open reduction of intussusception
1. Transverse incision in RUQ
2. Exteriorize intussusception
3. Put gentle pressure on intussuscepiens (colon)
4. After reduction, examine bowel for injury/viability and lead point
5. If unable to reduce, do ileocolic resection
28
Resuscitation bolus for peds
Blood bolus for peds
Adequate UOP for resuscitation
20 cc/kg of NS
10 cc/kg blood
1.5-2 cc/kg/hr
29
Open Meckel's diverticulectomy
1. Transverse RLQ incision
2. Inspect and assess the diverticulum
3. Ligate any mesenteric vessels feeding the diverticulum
4. Perform diverticulectomy (if Meckel’s is uncomplicated, has a narrow neck, no concern for ectopic tissue at the base) or segmental resection with primary anastomosis (if Meckel’s has a broad base, concern for ectopic tissue at the base, extensive surrounding ulceration)
5. Incidental appendectomy
30
Trauma laparotomy
1. Prep from chin to knees
2. Midline incision from xiphoid to pubis
3. Pack all 4 quadrants, systematically remove packs starting from area that does not appear to be bleeding
4. Initial control of bleeding areas by manual pressure or clamp (communicate w/ anesthesia when clamping large arteries)
31
Kocher maneuver (steps & what it exposes)
Steps: incise peritoneum lateral to duodenal C-loop and mobilize the duodenum and pancreatic head medially
Exposes: first, second, and a portion of the third portion of the duodenum; pancreatic head; bile duct
32
Cattell-Braasch maneuver (steps & what it exposes)
Steps: incise white line of Toldt lateral to the right colon; rotate right colon, cecum, duodenum, and panc head medially; IDENTIFY & PROTECT RIGHT URETER
Exposes: entire right RP (IVC, R kidney & renal artery/vein), superior mesenteric blood vessels
33
Options for duodenal injury repair
-Simple repair, w/ or w/o debridement
1. Double-layer closure with inner absorbable and outer non-absorbable suture transversely
2. Buttress w/ omentum if possible
3. Leave drains!
-Pyloric exclusion
1. Repair of duodenal injury (or leave duodenostomy tube if can't repair it)
2. Pyloric exclusion (w/ noncutting [TA] stapler)
3. Gastrojejunostomy
4. Leave drains!
-Duodenostomy tube
-Roux-en-Y duodenojejunostomy (Roux limb to duodenal injury)
-Whipple (last resort!!!)
34
BIRADS
1. Negative - routine screening
2. Benign - routine screening
3. Low suspicion for malignancy - close f/u w/ repeat imaging 3-6 months
4. Suspicious for malignancy - CNBx
5. Highly suggestive of malignancy - CNBx
35
Lumpectomy with SLNBx
1. Preoperatively send pt to rads for wire localization of tumor, and nuclear medicine for injection of radioactive colloid into the breast for radioactive localization during SLNBx
2. Inject blue dye (isosulfan blue or methylene blue [but contraindicated in pregnancy]) into peri- and sub-areolar regions, massage for 5 minutes
3. Make incision, follow wire down, use wire and palpation to core out lesion
4. Place specimen on faxitron to ensure clip is in specimen, orient specimen in at least 2 locations prior to sending to path
5. Aggressive hemostasis, close
6. SLNBx: incision at edge of hair-bearing area of axilla, divide clavipectoral fascia, identify and remove any blue nodes, use gamma probe to detect node w/ maximum radioactive activity and remove that as well as all nodes with 10% or more of the sentinel node count
36
Laparoscopic splenectomy
Laparoscopic splenectomy
1. Right lateral decubitus, place ports inferior to L costal margin
2. Evaluate abdomen for accessory splenic tissue (MC splenic hilum, greater omentum, splenocolic regions)
3. Mobilize splenic flexure of colon
4. Divide short gastrics (gastrosplenic ligament), retracting stomach to patient’s right which exposes the splenic hilum
5. Mobilize the inferior pole of the spleen by taking down splenophrenic, splenorenal ligaments, identifying and protecting the tail of the pancreas
6. Divide splenic hilar vessels with vascular stapler
7. Take down superior attachments
8. Place in 15mm endocatch bag, deliver opening to port, morcelate with ringed forceps
9. Double check for hemostasis, close
37
Initial trauma evaluation
ABCDEs (check for patent airway, breath sounds, pulses, GCS/pupil, exposure), large bore IV access, and start blood transfusion in 1:1:1 ratio
38
VATS wedge resection
1. Intubate w/ double lumen ETT for single lung ventilation
2. Lateral decubitus position
3. Bronchoscopy to confirm correct location of ETT, eval for other lesions
4. Identify lesion, resect w/ endoscopic stapler
5. Remove lesion w/ endocatch bag and send for frozen path if will change mgmt. (i.e. if will require lobectomy or LN dissection if positive for CA)
6. Close, leave chest tube
39
Open extended right hemicolectomy
1. Lithotomy, arms out, foley
2. Midline incision, exploratory laparotomy (examine peritoneal surfaces, liver)
3. Divide white line of Toldt, mobilize right colon from lateral to medial
4. Enter lesser sac at hepatic flexure, remove greater omentum from stomach, mobilize splenic flexure
5. Divide mesentery: high ligation of ileocolic, middle colic, and ascending branch of left colic artery pedicles
6. Divide colon at healthy proximal and distal margins, perform ileocolic anastomosis
7. Leave drain, close
40
Open L hemicolectomy
1. Lithotomy, arms out, foley
2. Midline incision
3. High ligation of IMV at level of LOT
4. High ligation of L colic artery at its origin from the IMA
5. Complete medial to lateral mobilization of the splenic flexure
6. Identify and protect L ureter
7. Transect white line of Toldt
8. Transect splenocolic and gastrocolic ligaments
9. Transect colon at healthy proximal and distal margins
10. Stapled colo-colonic anastomosis, leave drain
41
Open liver resection
1. Monitoring w/ a-line and central line, keep CVP < 5, foley, supine position
2. Upper midline incision, evaluate abdomen and liver, palpate the mass
3. Mobilize the liver as necessary (depending on where the tumor is), get control of porta hepatis
4. Intraop liver US to demarcate lesion
5. Resect parenchyma with ultrasonic dissector, clipping/tying large vessels
6. Assure hemostasis, +/- drain, close
42
VATS blebectomy and pleurodesis
1. Intubate w/ double lumen ETT for single lung ventilation
2. Lateral decubitus position
3. Bronchoscopy to eval for correct ETT placement, as well as neoplasm, infx, or aberrant anatomy
4. Resect apical bullae with reinforced, linear GIA stapler
5. Perform pleurodesis (mech = w/ scratch pad, or chemical = w/ talc)
7. Close, leave chest tube
43
Chest tube sizes
24 Fr
16 Fr for PTX pigtail catheter
28 Fr for thick pus
44
Open LAR
1. Position lithotomy, foley, DRE & irrigation
2. Low midline incision
3. Evaluate for mets
4. Lateral to medial mobilization of the L and sigmoid colon, starting by dividing the white line of Toldt
5. Identify and protect L ureter
6. High ligation of IMA
7. Take down splenic flexure to mobilize L colon, ligate IMV at inferior border of the pancreas
8. Divide mesocolon at site of proximal transection
9. Perform total mesorectal excision by entering plane b/w visceral and parietal layers of endopelvic fascia
a. High tumors: dissect 5cm distal to tumor
b. For medium to low tumors: dissect to pelvic floor (where mesorectum ends)
10. Transect distal rectum
11. Transect colon at proximal site ensuring good margins
12. Create end-to-end anastomosis with EEA stapler, check for 2 donuts
13. Air leak test
14. DLI if needed
45
McVay repair
1. Open inguinal floor
2. Suture conjoint tendon to Cooper's ligament, with transition stitch just medial to the femoral vein that incorporates conjoint tendon, Cooper's ligament, and inguinal ligament (closes down femoral space)
3. Relaxing incision on rectus sheath
46
Parkland formula
Give 4 cc/kg/%TBSA in first 24 hours (give 1/2 the volume in the first 8 hours)
47
Myopectineal orifice
Conjoint tendon, iliopubic tract, inferior epigastric artery, and pubic symphysis
48
Gallstone ileus operation
1. Make enterotomy proximal to gallstone, away from any diseased bowel
2. Milk the stone proximally out of the enterotomy
3. Run the rest of bowel/colon to make sure no other stones
4. Close the enterotomy transversely
5. Do not take GB out at that surgery
Wait 2-3 months for everything to calm down, and should get MRCP prior to fully understand biliary anatomy
49
BKA
1. Exsanguinate all the blood from the lower extremity up towards the thigh and place a sterile tourniquet
2. Mark out the borders of my incision making sure to leave more of a posterior flap
3. Remove all muscle and soft tissue off the bone using electrocautery
4. Use an oscillating saw to transect the tibia first, then the fibula about 2 cm proximal to where I transected the tibia
5. Tie off all vessels and nerves (greater saphenous vein/nerve, anterior tibial artery/nerve, posterior tibial artery/nerve, peroneal artery/nerve, lesser saphenous vein)
6. Take down tourniquet and assess for bleeding
7. Irrigate wound and close the fascia first, then the skin using vertical mattress sutures
50
Thyroidectomy
1. Use nerve monitor
2. Position w/ neck extended
3. Collar incision 2 fingerbreadths above the sternal notch
4. Create subplatysmal flaps
5. Separate strap muscles, divide over the midline raphe to expose the thyroid gland
6. Dissect superior pole vessels close to thyroid (to avoid superior laryngeal nerve)
7. Mobilize thyroid lobe anteriorly and medially to identify RLN in tracheoesophageal groove
8. Identify & inspect parathyroid glands (& preserve their blood supply), reimplant if any concern
51
Distal SFA exposure (Hunter's canal)
1. Medial longitudinal incision along distal ⅓ of the thigh along the anterior border of the sartorius muscle
2. Find femoral sheath between sartorius and adductor magnus muscles (femoral artery is medial to the vein here)
52
Arterial shunt placement
Heparinize, fogarty balloon catheter proximal and distal to remove all clot and get good forward and back bleeding, use largest argyle shunt that will fit inside the vessel, tie a silk suture in middle of the shunt, place shunt into proximal and distal ends of the vessel and tie the shunt to both ends of the vessel, then tie both ends to the middle suture to prevent shunt migration
53
Truncal vagotomy with pyloroplasty
Divide vagus nerves at the hiatus, send for path to confirm you have nerve
Incise longitudinally across the pylorus onto the antrum of stomach, close transversely (Heinecke-Mikulicz), leave drain
54
Truncal vagotomy with antrectomy
Divide vagus nerves at the hiatus, send for path to confirm you have nerve
Divide stomach at proximal antrum (halfway from GEJ to pylorus), identify and ligate R gastric pedicle, divide duodenum just distal to pylorus, oversew duodenal stump, bring up loop of proximal jejunum in antecolic fashion, 2-layer GJ anastomosis, leave drain (B2)
55
Zenker’s diverticulectomy, cricopharyngeal myotomy
1. Supine, neck extended, turned towards right
2. Incision over anterior border of SCM
3. Dissect down ventral to carotid sheath and identify diverticulum between the esophagus and cervical spine
4. Perform stapled resection of the diverticulum
5. Perform myotomy of the cricopharyngeal muscle
6. Leave drain, close
56
LIFT (ligation of intersphincteric fistula tract)
Curvilinear incision over the fistula tract at the intersphincteric groove, ligate the fistula in between the internal and external sphincters, curretage the tract, suture ligate the external os
57
Endoanal advancement flap
Open and curettage fistula tract, suture close the internal os, advance the mucosa, submucosa, and muscle from proximal to distal to cover the internal os
58
Endovascular LE stent
1. Access common femoral artery in contralateral groin
2. Get a wire to the bifurcation and shoot an aortogram
3. Pass wire up and over to the affected side and perform arteriogram of the affected side
4. Place a stent over the diseased segment, perform completion angiogram
5. Pulse check (or doppler signal)
6. Keep on ASA/statin postoperatively
59
Salpingo-oophorectomy
1. Expose the infundibulopelvic ligament by dissecting the peritoneum around it
2. Identify the ureter, the iliac arteries, and veins
3. Ligate the ovarian vessels
4. Dissect the ovary and fallopian tubes from its peritoneal attachments
5. Once the ovary and fallopian tube are isolated from all the surrounding structures, ligate the fallopian tube at its base as it enters the uterus and send for pathology
60
Anterior and posterior component separations and TAR
Anterior - create lipocutaneous flaps 2cm distal to semilunaris line, incise external oblique fascia and separate the external and internal oblique muscles in the avascular plane
Posterior - incise the posterior rectus sheath 1cm lateral to linea alba to enter posterior rectus space, dissect entire posterior rectus space in avascular plane
TAR - incise posterior rectus sheath 0.5cm medial to linea semilunaris to get to the transversus abdominus muscle; divide this muscle and release posteriorly
61
Whipple
1. Diagnostic laparoscopy to eval for mets, upper midline incision, palpate for mets
2. Enter lesser sac by removing greater omentum from transverse colon, identify infra-pancreatic SMV and ensure plane b/w SMV and pancreas
3. Extended Kocher maneuver to level of L renal vein
4. Portal dissection, palpate for aberrant hepatic arterial anatomy
5. Divide GDA
6. Cholecystectomy, identify cystic duct insertion into bile duct, transect CBD at level of CHD
7. Transect stomach 3-4cm proximal to pylorus (non-pylorus-sparing)
8. Transect jejunum 10cm distal to LOT, mobilize LOT, pass jejunum beneath transverse colon mesentery to RUQ
9. Transect pancreas, send for frozen to assess margins
10. Reconstruction
PJ - 2 layer
HJ - 1 layer
GJ - 1 layer
10. Leave drains at HJ and PJ, close
62
Colonoscopy
1. Left lateral decubitus
2. Moderate sedation
3. DRE
4. Insert c-scope into anus, advance through the colon to the TI, intubate TI
5. Withdraw slowly over 8 minutes, examining mucosa circumferentially and behind all folds
6. Retroflex in the distal rectum
63
ABI
Take BP on both arms and affected lower extremity, divide the highest arm SBP by the SBP in the lower extremity
64
Esophageal perforation repair (principles)
-2 layer anastomosis w/ inner absorbable
-Buttress w/ intercostal muscle, pleura, or pericardium
-Leak test
-Leave NGT
-Widely drain
-Consider feeding tube vs dobhoff
65
Indications for parathyroidectomy
1. Sx
2. Age < 50
3. Pathologic fractures
4. Kidney stones
5. Decreased CrCl (<60)
6. T-score < -2.5 on DEXA scan
7. Ca 1 above upper limit of normal
66
Total abdominal colectomy
1. Lithotomy, foley
2. Mobilize ascending colon and hepatic flexure, ligate ileocolic vascular pedicle, divide across ileum
3. Mobilize sigmoid and descending colon, take down splenic flexure, ligate inferior mesenteric and middle colic vascular pedicles
4. Mobilize and ligate upper mesorectum, divide across upper rectum
5. Bring out end ileostomy
6. Possibly oversew +/- leave drain at rectal stump (for UC)
67
Mastectomy
1. Elliptical incision to include nipple-areolar complex & any skin involving/close to tumor
2. Make superior and inferior flaps that extend superiorly to the clavicle, medially to sternum, inferiorly to IMF, and laterally to lat dorsi
3. Dissect breast off of chest wall, taking pectoralis fascia w/ breast specimen
4. Orientation sutures on specimen
Hemostasis, drain, close
68
Axillary lymph node dissection
1. Incision at inferior edge of hair-bearing area
2. Divide clavipectoral fascia
3. Identify axillary vein superiorly
Borders of ALND:
Superior - axillary vein
Medial - chest wall
Lateral - lat dorsi
Posterior - subscapularis
4. Identify and protect thoracodorsal bundle (laterally) and long thoracic bundle (medially, on chest wall)
5. En bloc removal of all level I and II nodes (lateral to pec minor)
6. Hemostasis, drain, close
69
Puestow (lateral panceaticojejunostomy)
1. Midline incision
2. Divide short gastrics to access pancreatic body
3. Kocherize the duo to identify the pancreatic head
4. Identify and mark the pancreatic duct with a 25-gauge needle or intraop US
5. Dissect through the pancreatic parenchyma towards the duct using electrocautery, from the tail to the head
6. Run 15cm distal to LOT and bring up roux limb, perform side-to-side pancreaticojejunostomy over a stent, followed by JJ
7. Leave drains, close
70
Beger procedure
1. Midline incision
2. Divide short gastritis to access pancreatic body
3. Kocherize the duo to identify the pancreatic head
4. Core out pancreatic head, leaving a rim of pancreatic tissue to preserve the vasculature
5. Run 15cm distal to LOT and bring up roux limb, performing end-to-side PJ to the pancreatic tail over a stent and side-to-side PJ to the pancreatic head, followed by JJ
6. Leave drains, close
70
Fray procedure
1. Midline incision
2. Divide short gastritis to access pancreatic body
3. Kocherize the duo to identify the pancreatic head
4. Identify and mark the pancreatic duct with a 25-gauge needle or intraop US
5. Core out pancreatic head
6. Run 15cm distal to LOT and bring up roux limb, and perform lateral side-to-side pancreaticojejunostomy over a stent, followed by JJ
7. Leave drains, close
71
IOC
1. Place clip across cystic duct
2. Make small incision on anterior portion of cystic duct
3. Place a cholangiogram catheter into the cystic ductotomy and secure it with a clip
4. Inject diluted dye through the cholangiogram and obtain fluoroscopic images with C-arm, being sure to identify filling of the duodenum and the R and L hepatic ducts
72
Hemorrhoidectomy
1. Positioning
If hemorrhoid anterior → prone jack-knife
If hemorrhoid posterior → supine lithotomy
2. Perform DRE
3. Insert anoscope to identify hemorrhoid
4. Clamp it with a peon
5. Resect hemorrhoid above the mucosa with electrocautery
6. Close incision with running absorbable suture
73
Total gastrectomy
1. Survey abdomen for distant mets
2. Mobilize GE junction and esophagus, taking a margin of crura
3. Separate the omentum from the transverse colon
4. Divide the short gastric vessels, and skeletonize the celiac, splenic, and common hepatic arteries for a modified D2 lymphadenectomy
5. Ligate L, R, and gastroepiploic arteries at their bases
6. Divide esophagus at GEJ, duo just distal to the pylorus, and jejunum for the RNY EJ
7. Perform EJ and JJ, leave drain, place J tube
74
Tunneled dialysis catheter
1. Pt under sedation (does not need to be GETA)
2. Use needle to access R IJ
3. Insert wire and then place catheter sheath
4. Make counter incision on anterior chest, tunnel dialysis catheter under the subQ tissue, and insert it into the sheath
5. Peel away the sheath while advancing the dialysis catheter
6. Shoot completion XR and ensure you get appropriate venous blood back from the catheter
75
AVF
1. GETA
2. Use US to map out trajectory of the vein and artery
3. Incision to expose both the vein and artery
4. Systemic heparin
5. Clamp vein and artery
6. Ligate the distal vein, spatulate the end, perform and arteriotomy, and construct and end-to-side anastomosis using 6-0 non-absorbable suture
7. Listen for a bruit and feel for a thrill, feel for distal pulses
76
Peritoneal dialysis
1. Diagnostic laparoscopy, evaluate for hernias
2. ~5cm incision over rectus off midline, divide anterior fascia, retract muscle, enter abdominal cavity, place catheter so that tip coils in pelvis, deep cuff is just below anterior fascia
3. Tunnel catheter so superficial cuff is in subQ
4. Introduce 1L NS through the catheter into the abdomen to ensure it flows appropriately, then place the bag on the ground to make sure it drains adequately
5. Ometal pexy
77
Rectus sheath hematoma evacuation / ligate inferior epigastric artery
Prep abd/both thighs, Incision over the hematoma, open rectus sheath, evacuate hematoma, identify/ligate bleeding vessel, leave drain in rectus space and subQ
If you need to formally ligate inferior epigastric artery- incision over inguinal ligament, follow inguinal ligament down to femoral artery, find takeoff of IEA right below inguinal ligament, clamp to make sure bleeding stops, then ligate
78
Lap chole with IOC in pregnant patient
1. Consult OBGYN for fetal monitoring
2. Positioning:
-Shield under pt’s abdomen for C-arm
-Slightly L side down to offload IVC
2. Open Hassan entry, shift ports superiorly based on fundal height
3. Proceed w/ standard approach of cholecystectomy by dissecting structures of cystic triangle and obtain critical view
4. Clip GB side of cystic duct, create ductotomy, place cholangiocatheter into bile duct
5. Perform IOC by injecting 50/50 mixture of contrast and injectable saline
79
Bassini
Sew shelving edge of inguinal ligament directly to conjoint tendon
80
Anaphylactic reaction tx
1. Stop all infusions/medications
2. Put in ICU, do all the ICU stuff (foley, central line, etc)
3. Resuscitate with fluids
4. 100 mcg of 1:10,000 epi (1/10 of epi in the crash cart)
5. 200 mcg epi
6. 50 mg IV Benadryl
7. 5 mg/kg hydrocortisone
8. Epi gtt
81
APR
1. Survey abdomen for mets
2. Mobilize L colon and sigmoid down to the peritoneal reflection, staple distal sigmoid
3. High ligations of IMA and superior rectal artery
4. TME to the level of the pelvic floor
5. From perineal side, dissect towards the rectum to meet the intra-abdominal dissection
6. Close perineal defect using a myocutaneous flap (ask PRS if necessary)
7. Leave drain in pelvis
8. Bring up end colostomy, close abdomen, mature ostomy
82
Open CBD exploration
1. Cholecystectomy with a dome-down approach, follow cystic duct to CBD
2. Make anterior LONGITUDINAL choledochotomy near junction of cystic and common bile ducts
3. Attempt to clear stones by:
-Flushing
-Glucagon
-Fogarty balloon proximally and distally
-Choledochoscope to visualize entire CBD and remove any stones with wire basket if needed
4. Close choledochotomy over a T-tube
5. Shoot cholangio through T-tube to make sure everything is patent before leaving OR
6. Leave surgical drains around CBD
83
T tube mgmt
1. Send pt home w/ it, return to clinic in 2 weeks
2. Cholangio to make sure no proximal/distal obstruction
3. Cap trial for 2 weeks, if pt tolerates OK to take it out
4. Counsel pt there is a small risk of leak/fistula from the tube site
84
LE 4-compartment fasciotomies
1. Medial longitudinal incision 2 fingerbreadths posterior to the tibia down through the fascia, peel soleus off the tibia to release deep and superficial posterior compartments
2. Lateral longitudinal incision 2 fingerbreadths anterior to the fibula down through the fascia, make H-shaped incision in the intramuscular septum to release the anterior and lateral compartments
85
Control of liver injury in OR
Packing (sandwich packing above and below the liver, compressing capsule)
Pringle
Suture ligation
Clipping
Hemostatic agents
Coagulation/argon
Packing w/ omentum
Tractotomy with linear stapler (to at least help identify what is bleeding so you can address it)
Balloon tamponade
Hepatorrhaphy (blunt needle, chromic suture to sew capsule together)
Hepatectomy/wedge resection
Atriocaval shunt
Total hepatic isolation
86
Dantrolene dose
2.5 mg/kg q5 minutes until symptoms resolve
87
Hypercalcemia treatment
1. NS
2. Loop diuretics (lasix)
3. Bisphosphonate
4. Calcimimetic
5. HD
88
Thyroid storm
MEDICAL EMERGENCY - admit to ICU
1. B-blocker
2. Methimazole
3. Lugol’s solution (KI - blocks body’s production of thyroid hormone)
4. Steroids
5. Tylenol
6. Volume resuscitation
7. Cooling blankets
89
Narcan dose
Starting dose: 0.01mg/kg (0.7mg in 70kg adult) - so generally safe to start with 0.5mg
90
Flumazenil dose
0.2 mg
91
How to place Blakemore tube
1. Insert the tube into the stomach, confirm placement by injecting air and listening with a stethoscope for a rush of air
2. Inject contrast diluted with saline into the gastric port balloon and then retract the tube back until feeling resistance; then get a KUB to ensure the gastric portion is pressed up against the GEJ
3. Inject contrast diluted with saline into the esophageal port to tamponade the esophagus and again shoot KUB to confirm placement
4. Keep the tube on traction
92
Altemeier
1. Use Babcocks to evert the prolapse through the anus into the operative field
2. Full thickness incision 1cm proximal to the dentate line, carry through mesorectum, take mesentery with electrocautery
3. Create coloanal anastomosis with 2-0 vicryl interrupted sutures
93
Pilonidal cystectomy
Infected --> just do I&D, followed by surgical resection of the cyst
1. Prone jacknife
2. Spread buttocks w/ tape
3. Elliptical incision that includes entirety of chronic draining pits
4. Ellipse affected tissue, taking as deep as needed to get grossly normal tissue
5. If sinuses track laterally, debride w/ curettage
6. Once excised, gauge tissue approximation:
- Primary closure over a drain (ideal, but higher risk of recurrence)
- Marsupilization
- Healing by secondary intention, w/ or w/o WV
94
LRINEC score
>6 = concerning
WBC
Hgb
Na
Cr
Glucose
CRP
95
Renal failure algorithm
1. Flush foley
2. Check medications, stop all nephrotoxic (ACE-i, ARB, metformin, NSAIDs, lovenox)
3. FeNa (or FeUrea in pt on diuretics: <33 = prerenal)
4. Renal US to eval for hydronephrosis
5. Consider HD:
a. Check electrolytes (high K+ → EKG, Ca gluconate, insulin/D50)
b. ABG to eval for acidosis
c. CXR to eval for volume overload
d. Consult renal
96
Chemical pleurodesis med/dose
500mg doxy + 50mg NS
97
Trans-abdominal rectopexy
1. Lower midline incision
2. Dissect posterior rectum all the way to pelvic floor
3. Pull redundant rectum out of pelvis, pexy the peritoneal edge of the rectum to the pelvic floor using permanent suture
4. If pt w/ significant constipation, perform sigmoidectomy with primary anastomosis
98
Laparoscopic cystgastrostomy
1. Enter abdomen laparoscopically
2. Anterior gastrotomy
3. Pass finder needle through posterior gastric wall into pseudocyst to localize pseudocyst
4. Make hole in posterior stomach into pseudocyst, enlarge with a fire of the endo stapler
5. Close anterior gastrotomy in 2 layers
6. Leave drain, NGT, and dobhoff tube for feeds
99
Modified radical mastectomy (MRM)
1. Elliptical incision including NAC
2. Superior and inferior skin flaps, encompassing all breast tissue within the borders of the breast: clavicle (superior), lat dorsi (lateral), IMF (inferior), sternum (medial)
3. Take pec fascia
4. Perform ALND
ALND borders: axillary vein (superior), subscapularis (posterior), lat dorsi (lateral), serratus anterior (medial)
Protect thoracodorsal and long thoracic bundles
5. Close over drains
100
Inguinal LN dissection
1. Frog-leg patient
2. Curvilinear incision from just under ASIS to the midline of the inguinal ligament
3. Find the most superficial node to the iliac artery (Clouquet’s node), send this for frozen
If positive → proceed w/ deep inguinal LN dissection (all nodes posterior to Cloquet’s node)
If negative → you’re done
101
Congo red apple green bifringence
Medullary thyroid carcinoma
102
Homemade wound vac
1. Obtain sterile XR cover, cut some slits, place it over the bowel subfascially
2. Place sterile gauze over the cover
3. Place a few JP drains over the gauze
4. Cover with sterile towels, cover with ioban, place JPs to suction
103
Central neck LN dissection
Remove all lymph tissue from hyoid bone superiorly, carotid arteries laterally, brachiocephalic vessels inferiorly
104
Criteria for EVAR
1. Aorta landing zone 20mm diameter, 10-15mm length
2. Aorta not significnatly angled (<60 degrees) or calcified
3. Iliac 10-20mm diameter, 20mm length
105
EVAR
Get intravascular access in one of the femoral vessels, shoot an aortogram, and then place a sheath with a wire. Once I get up to the aneurysmal sac, I would deploy the stent infrarenal. I would then cannulate the contralateral side and deploy another graft in the iliac artery, and then shoot a completion angiogram, check for distal pulses and close with a percutaneous device.
106
SMA bypass
1. Midline incision, survey all bowel
2. Expose supraceliac aorta by dissecting gastrohepatic ligament and R crus (make sure no aberrant or replaced L hepatic artery in gastrohepatic ligament)
3. Expose the celiac and SMA at base of the mesentery (if unable to expose the vessels there, do L to R medial visceral rotation)
4. Heparinize
5. Use side-biting aortic clamp to sew proximal anastomosis
***If aorta is too calcified, do retrograde bypass from iliac vessels
6. Unclamp aorta, clamp graft, clamp distal targets and perform distal anastomoses with PTFE graft
107
Iliofemoral venous thrombectomy
What to do if residual disease?
Postop mgmt?
1. Prep/drape leg circumferentially and lower abdomen
2. Expose/control the common femoral vein, deep femoral vein, superficial femoral vein, GSV
3. Transverse venotomy over the CFV, use 4-5Fr Fogarty distally and proximally to remove clot/thrombus
4. Close primarily
5. Completion venogram, pulse check, consider fasciotomies
If residual disease → repeat Fogarty, angioplasty, flush with TPA
Postop: admit to ICU, q1h neurochecks, keep hep gtt, trend CK/Cr, monitor UOP
108
Endovenous GSV ablation
Postop mgmt and #1 complication
1. Use US to find GSV just below the knee, access vein with needle, wire, and sheath
2. Place ablation catheter through the sheath and go up to saphenofemoral junction
3. Inject tumescence around GSV throughout it’s course
4. Begin ablation 2cm distal to saphenofemoral function and carry down along the course of the GSV
5. Remove catheter/sheath, hold pressure for hemostasis
6. Venous duplex at the end to eval for DVT at saphenofemoral junction
Post op - get venous duplex at 48h to eval again for DVT (known complication → treat with AC)
109
Hysterectomy
1. Pfannensteil incision
2. Identify and ligate the round ligament, ovarian ligament, and infundibulopelvic ligament
3. Mobilize the bladder
4. Ligate the uterine artery and vein
5. Ligate the posterior then anterior halves of the cardinal ligament
6. Clamp the boundary between the portio vaginalis and the vagina
7. Incise the vagina and remove the uterus
8. Close the vaginal cuff
9. Hemostasis
10. Close the retroperitoneum
11. Close the abdominal wall
110
ARDS algorithm
Goals for ARDS tx
1. Low TV ventilation (TV 6mL/kg of IBW), plateau pressures < 30
2. Ensure adequate sedation (RASS -5)
3. Prone positioning (18h on, 6h off)
4. Paralyze (cisatracurium gtt)
5. APRV (P high 20, T high 4, P low 0, T low 0.4)
6. VV ECMO (pt must have reversible condition, be OK for AC, AND TALK TO FAMILY!)
Goals:
-Minimize fluids
-Goal PaO2 55-80
-Goal PO2 88-95%
-Plateau pressure < 30
-pH 7.3-7.45
111
Bronchoscopy and BAL
Performed under moderate sedation or general anesthesia
Pass flexible bronchoscope through the trachea (rings are anterior; flat portion is posterior) and bronchi. R bronchi is anterior.
BAL: "Wedge" the scope into a subsegmental bronchus, instill ~50cc normal saline and then suction it out, do this twice
112
Distal pancreatectomy
1. Upper midline incision
2. Take down splenic flexure to reveal spleen and distal pancreas
3. Identify and preserve the splenic vessels
4. Divide the pancreas with a stapler
5. Remove specimen, leave drains
If performing splenectomy: divide splenic vessels with vascular stapler, take spleen w/ specimen
113
Modified Hanley procedure
1. Incision between anal verge and coccyx (across anococcygeal ligament, pic below) to get to postanal space
2. Drain abscess
3. Seton is placed around sphincter complex
4. Two lateral counter incisions over BL ischial fossa
114
Lateral internal sphincterotomy
1. Confirmation of the fissure and hypertonic/spastic sphincter
2. Insertion of the retractor and identification of the internal sphincter or intersphincteric groove
3. Incision of the perianal skin overlying the intersphincteric groove
4. Isolation of the internal sphincter and division under direct vision
5. Fissure debridement
6. Closure of the sphincterotomy site with absorbable sutures
115
TEG
Long R time: PCC
Long K time: cryo
Shallow alpha angle: cryo
Low MA: platelets
High Ly30: TXA
116
How to manage air embolus
1. Position trendelenberg, R side up
2. Aspirate 60cc blood from central line
117
How to obtain bladder pressure
1. Lay patient supine
2. Zero bladder pressure transducer at level of iliac crest along mid-axillary line
3. Instill 25cc into the bladder using 3-way stopcock
4. Wait for transducer to equilibriate
5. Measure bladder pressure at end expiration
118
DRIL
1. Ligate the artery just distal to the fistula
2. Use GSV graft to bypass the artery distal to the fistula
So the fistula is still functioning - but you are bypassing the "steal" area (aka fistula) to the distal artery
