Procedures Flashcards by B M

Describe the indications for cholecystectomy

Symptomatic gallstones (biliary colic)
Acute cholecystitis or cholangitis
Gallstone pancreatitis (delayed)

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Describe the procedure for cholecystectomy briefly with reference to key anatomy

Usually laparoscopic

Identify Calot’s triangle (cystic duct, hepatic duct, free liver edge)- important to ensure correct ligation of cystic artery
Dissect and ligate cystic duct + cystic artery
Removal GB

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Describe the complications of cholecystectomy

Surgical: bile leak, damage to surrounding structures (eg hepatic artery), bleeding, conversion to open
Anaesthetic: N+V, sore throat, muscle aches, allergy/anaphylaxis, death
Short term post-op: pain, wound infection, DVT
Long term post-op: adhesions, recurrence of gallstones, steatorrhoea

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Describe the indications for gastrectomy

Gastric malignancy
Bariatric surgery
Peptic ulcer

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Describe the complications of gastrectomy

Surgical: damage to surrounding structures
Anaesthetic
Immediate post-op: bleeding, wound infection, pain, anastomotic leak
Long-term post-op: dumping syndrome, diarrhoea, vitamin deficiency, small stomach syndrome, adhesions

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Describe the post-op care for gastrectomy

Immediate:

NBM, IV fluids/TPN for 1-2 weeks
NGT + suction

Long-term:

Vitamin supplementation (B12, iron)
Small frequent meals, low dairy

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What are the types of gastrectomy?

Partial
Total
Sleeve (remove left side)
Oesophagogastrectomy

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Describe the indications for Nissen fundoplication

In following conditions when severe/not responding to medical Mx: 
-Severe GORD
-Barrett's oesophagus
-Hiatus hernia
To reduce acid moving up the oesophagus

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Describe the procedure of fundoplication

Laparoscopic

Narrow the oesophageal hiatus
Wrap the fundus of the stomach around the lower oesophagus

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Describe the complications of fundoplication

Surgical: damage to surrounding structures
Anaesthetic: see elsewhere
Short term post-op: pain, bleeding, infection, DVT
Long-term post-op: dysphagia, failure to control symptoms, adhesions

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Describe the post-op care of fundoplication

May go home same/next day

- Soft food diet for first 1-2 weeks

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Describe the indications for oesophagectomy

-Oesophageal malignancy

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Describe the types of oesophagectomy

Ivor Lewis: abdo incision + right thoracotomy. Middle third tumours
Minimally invasive: w laparoscopy + thoracoscopy
Transhiatal: only neck and abdo incision
McKeown: upper third tumour. Three incision.

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Describe the procedure of oesophagectomy briefly

Resect the tumour area
Mobilise stomach into chest
Anastomose the distal oesophagus to stomach

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Describe the post-op care for oesophagectomy

Diet: clear liquid -> liquid -> soft food -> normal diet

Jejunostomy tube until eating normally eg. 4-6 weeks

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Describe the complications of oesophagectomy

Surgical: bleeding, recurrent laryngeal nerve damage
Anaesthetic
Short term post-op: pain, wound infection, DVT, anastomotic leak
Long term post-op: dumping syndrome, weight loss, GORD, dysphagia, recurrence, adhesions

Describe the indications for splenectomy

Splenomegaly
Ruptured spleen
Haematological malignancy
Abscess

Describe the complications of splenectomy

Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: pain, wound infection/dehiscence, DVT
Long term post-op: adhesions, infections (encapsulated bacteria)

Describe the indications for Whipple’s procedure

Pancreatic lesions: cancer, cysts

Cholangiocarcinoma

Describe the process of a Whipple’s procedure (briefly)

Open surgery (Chevron, midline)

Dissect + move pancreas
Remove the antrum to duodenum + head of pancreas + GB
Anastomose stomach and jejunum
Attach pancreas to free end of jejunum

Describe the complications of a Whipple’s procedure

Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: wound infection, bile leak, DVT, pancreatitis
Long term post-op: DM, recurrence, delayed gastric emptying

Describe the complications of rectal prolapse repair

Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: wound infection, DVT, pain, bowel obstruction
Long term post-op: recurrence, fistula, sexual dysfunction, mesh complications

Describe the process of rectal prolapse repair

Can be open/lap abdominal approach (rectopexy) or perineal
Abdo: use sutures/mesh sling to attach rectum to sacrum
Delorme: shorten rectum by removing mucosa
Altemeier: resect rectum segment + anastomose to sigmoid colon

Describe the pros and cons of open vs laparoscopic abdominal surgery

Open:

Pros: better exposure, allows full resection/removal of large structures
Cons: longer recovery time, higher rate of complications (wound infection, pain, bleeding)

Laparoscopic:

Pros: smaller scars, decreased risk of complications, shorter recovery
Cons: may not be practical (eg. inserting large stents), reduced visibility, not used in emergencies

Describe the indications for laparotomy

Perforation Intraperitoneal bleeding Penetrating trauma Malignancy (resection)

Describe the procedure for laparoscopy

- Make 3-4 0.5mm incisions for entry, usually 1 umbilical - Tilt table, inflate abdo w carbon dioxide gas - Insert trocars + instruments

Describe the post-op side effects of laparoscopic surgery + post-op care

- Bloating - Nausea - Pain in chest/shoulders/neck May go home same day depending on complications Return to work after 1 week ish

Describe the indications for liver transplant

Acute liver failure eg paracetamol OD, hepatitis Cirrhosis Malignancy

Describe the complications of liver transplant

Intra-operative: bleeding, bile leak, damage to surrounding structures Anaesthetic Short term post-op: delayed graft function, pain, wound infection, anastomotic leak, DVT Long term post-op: recurrence, graft rejection, comp of immunosuppression

Describe the relevant liver anatomy + types of resection

Liver divided into 2 lobes + 8 segments Each has own portal triad (hepatic A and V, portal V) Anatomic resection: resection of lobes/segments Non-anatomic resection: resection of lesion w/o regard to lobes/segments

Describe the indications for haemorrhoidectomy

Grade 3-4 Failure of medical management Incarcerated haemorrhoids

What are the types of haemorroidectomy

Closed: excision + closure Open: no closure of wound Stapling + rubber band ligation

Describe the complications of haemorrhoidectomy

Intra-operative: damage to surrounding structures, bleeding Anaesthetic Short term post-op: pain, bleeding, wound infection, urinary retention Long term post-op: recurrence, incontinence, stricture

Describe the types of bariatric surgery

Most common: - Roux-en-Y gastric bypass: resect stomach + connect gastric pouch to jejunum, leave stomach + duodenum in situ - Sleeve gastrectomy: remove left side of stomach-> smaller tube-like stomach, holds less food Others: -Gastric banding

Describe the indications for bariatric surgery

- Obesity (class III- BMI >40) | - Obesity (class II- BMI 35-39.9) + complications eg. OA, T2DM

Describe the benefits of bariatric surgery

- Considerable weight loss (usually in first 1-2 years) - Reduction in mortality due to obesity - Reduction in T2DM + other complications

Describe the pre-op considerations for bariatric surgery

- Suitability + anaesthetic review - OGD - Liver reduction diet for 3 weeks prior to surgery (strict calorie reduction to shrink liver)

Describe the post-op care for bariatric surgery

- Admission usually for 1 night - Diet: liquid 2 wk -> pureed 2 wk -> soft food - Thrombotic prophylaxis - Stop/change diabetes medication - Follow up with bariatric dietician - Supplementation (B12 for life)

Describe the complications of bariatric surgery

- Intra-operative: bleeding, damage to surrounding structures, - Anaesthetic: may be significant eg. difficulty intubating, cardiac complications, death - Short term post-op: DVT, pain, wound infection, pneumonia, anastomotic leak - Long term post-op: weight regain, change in bowel habits, dumping syndrome, strictures, adhesions, nutritional deficiency