Abdomen

Question 1

Peritoneal dialysis catheter placement

Answer 1

Insufflate, place catheter so the top of the coil lays at top of pubic tubercle w deep cuff in the rectus muscle, tunnel the catheter through subQ, peform omentopexy if needed, and instill 1L of saline and ensure it flows out freely with gravity

Question 2

Hepatic Resection

Answer 2

Place central line with CVP monitoring with goal CVP < 5 during dissection
Right subcostal incision
Exploratory laparotomy to evaluate for metastases
Introp ultrasound to identify lesion and look for other masses and mark capsule with lines of resection
Secure portal triad with Rummel tourniquet without tying down
Dissect and ligate the portal vessels and hepatic vein feeding the mass
perform parenchymal dissection using combo of ultrasonic ligation, aquamantis, argon beam, and ligating largest vessels and ducts with clips
Completion ultrasound to document preserved inflow and outflow to remnant liver
Leave drain

Question 3

Whipple

Answer 3

Diagnostic lap for mets. Perform midline laparotomy. Takedown hepatic flexure, Kocherize duodenum to IVC
Divide stomach or proximal duodenum depending on pylorus preservation
Cholecystectomy.
Ligate GDA, create tunnel posterior to pancreatic neck preserving SMA/SMV. Divide the neck with stapler.
Divide proximal jejunum and create choledochojejunostomy and pancreaticojejunostomy over stents. Then perform gastrojejunostomy.
Leave drains by the anastomoses and close

Question 4

RnY hepaticoJejunostomy

Answer 4

Subcostal incision, Expose/dissect the portal triad, taking care to dissect anterior to CBD.
Identify the the confluence of the left and right hepatic ducts for the anastomosis.
Identify ligament of treitz and divide Roux limb 15 centimeters distal.
Ligate the CBD distal to the perforation after removing the stent. Debride all devitalized tissue and perform an end-to-side hepaticojejunostomy over a stent in two layers, followed by a jejunojejunostomy.
Place drains then close.

Question 5

VARD

Answer 5

Use the IR drain to guide port placement into retroperitoneum/infected collection. Look with the laparoscope you can then use ring forceps to debride the pancreas.

Question 6

CBD Exploration

Answer 6

Make longitudinal choledochotomy near the junction of the cystic and common bile ducts and anterior surface
Clear stones w irrigation w 1 mg IV glucagon, then fogarty, then choledochoscope
Close choledochotomy over a T-tube drain then perform cholangiogram via T-tube.
Leave surgical drains around the common bile duct.

Question 7

Inguinal hernia repairs

Answer 7

Line between the ASIS and pubic symphysis
Transverse incision 2 finger breaths above pubic symph
Dissect to external oblique aponeurosis.
Dissect around cord contents and hernia sac, then ligate hernia sac with a stick tie

Lichtnstein:
Fix the mesh to the public symphysis, shelving edge of the inguinal ligament and conjoint tendon. Suture lateral tails of the mesh around the cord, external oblique, scarpas fascia and skin. And at the end I would make sure the testicle is placed back in the scrotum.

Bassini:
sew the shelving edge of the inguinal ligament directly to the conjoint tendon.

McVay:
suturing the conjoined tendon to Cooper’s ligament from the pubic tubercle up to femoral vein. Transition stitch is placed incorporating the conjoined tendon, Cooper’s ligament, the femoral sheath at the medial aspect of the femoral vein, and the inguinal ligament.
Then repair remaining floor by approximating the conjoined tendon to the inguinal ligament extending laterally to the area of the internal ring. Relaxing incision along rectus sheath or external oblique aponeuroisis if needed

Question 8

Complex abdominal hernia repair

Answer 8

Midline lap + LOA

Incise posterior rectus sheath 0.5 centimeter from its medial border and free entire posterior rectus sheath from muscle from ribs to pubis and laterally to linea semilunaris
Then approximate the two edges

TA release:
1/2 cm medial to linea semilunaris incise the posterior rectus sheath to find the transversus abdominis muscles and divide those with electrocautery and develop retromuscular plane
suture posterior rectus sheath closed and place a large piece of polypropylene mesh on top
close the anterior rectus sheath on top
leave drains on top of the fascia, and close the skin.