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ORAL BOARDS > Abdomen Core > Flashcards

Abdomen Core Flashcards

1
Q

Peritoneal Dialysis Catheter Insertion - Lap

A

Access to peritoneal cavity- open Hassan
One port for camera in mid abdomen, at least one more lateral port for grasping instruments
Lyse any adhesions present
Insert catheter through abdominal wall - deep cuff placed in between ant and post rectus sheaths
End of catheter tunneled SQ to exit site in lateral wall - superficial cuff 2+ cm from exit site
Can suture tip to pelvic sidewall, can do omentopexy
Catheter trial - 250-1000 mL in adults

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2
Q

When ok to do PD after catheter insertion

A

2 weeks

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3
Q

Diaphragmatic hernia repair

A

Robotic, pt positioned supine in steep reverse T
Access - Hassan, working ports along R and L costal margin and a R lateral port for liver retractor. 1-2 LUQ 5 mm ports laterally
Dissection along inner border of crura (incise gastrohepatic ligament to improve access to R crus)
Develop plane bluntly
ID and preserve anterior and posterior vagal nn
Penrose drain placed around esophagus/vagus nn
Any excess sac removed from gastric attachments after complete reduction, incl 3 cm of intra-abdom esophagus
Divide short gastrics
Crural defect closed posterior to esophagus using multiple nonabsorb pledgeted sutures, incorporating peritoneum
Partial or full fundoplication over 60F bougie
EGD @ end

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4
Q

Inguinal hernia - open

A

Oblique incision 2 FB above inguinal ligament
Using electrocautery, dissect to superficial epis and ligate
Carry through Camper’s and Scarapa’s
Open EO aponeurosis with a scissor in direction of fibers
Mobilize external oblique flaps bluntly
Can ID iliohypogastric n between IO and EO (superior, medial to spermatic cord)
Encircle spermatic cord with Penrose, dissect sac away from cord structures and return to abdomen if direct (OR open and reduce contents then suture ligate if indirect)
Polypropylene mesh secured to pubic tubercle, conjoint tendon and shelving edge using running 2-0 ethibond
Reapprox EO and close skin

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5
Q

Inguinal hernia - robotic

A

Port at umbilicus + either side lateral to rectus sheath
Incise peritoneum from ipsilateral medial umbilical fold –> ASIS
Preperitoneal space bluntly dissected from ant iliac spine laterally to medial umbilical fold medially and below Coopers inferiorly
Hernia sac dissected from cord structures, returned to peritoneal cavity
Mesh introduced and positioned to cover entire myopectineal orifice
Peritoneal defect closed using tacks or sutures

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6
Q

Distal pancreatectomy

A

*preop vaccine in prep for possible splenectomy
Midline incision
Explore for mets
Place bookwalter and mobilzie splenic flexure to reflect downwards
Divide gastrocolic ligament to enter lesser sac and retract transverse colon inferiorly
Divide short gastrics using ligasure (unless preserving spleen), divide posterior gastric attachments to pancreas and retract stomach superiorly
Use intraop US if you cant see the lesion
Careful dissection of vessels away from posterior pancreas until splenic hilum reached
Endo GIA stapler to transect pancreas, oversew with running locking 3-0 prolene
Leave drain

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7
Q

Pancreatic pseudocyst drainage

A

IO ultarsound to define necrotic collection
Anterior gastrotomy (at least 5 cm) to expose post gastric wall
Aspiration of fluid for microbiology cultures
Electrocautery for entry into cavity
Biopsy wall to exclude epithelial lined cyst
Explore pseudocyst cavity, debride necrosis
Anastomosis (at least 5 cm) completed with locking PDS

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8
Q

Rectus sheath hematoma - OR

A

Longitudinal incision over the hematoma and extend 5 cm prox and distally
Open rectus sheath, evacuate hematoma
ID any bleeding vessels and oversew
Leave drains in rectus sheath + SQ

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9
Q

To ligate inferior epigastric a

A

Oblique incision in groin under inguinal ligament, follow down to femoral artery. Branches off prox femoral artery (comes off medially). First test clamp then ligate with silks

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10
Q

Expectations s/p rectus sheath hematoma

A

Can last for 3-6 months, setting expectations with pt is important!

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11
Q

Strangulated ventral hernia - OR (bowel is viable)

A

Don’t forget to resuscitate, NGT for decompression, pre op abx, etc
Midline incision AWAY from hernia
Adhesiolysis, working way towards fascial defect/hernia sac
Reduce hernia by placing gentle traction on distal, non dilated portion
Extend fascial defect PRN
Connect incision with hernia defect
Fully mobilize bowel, inspect for viability
Completely excise sac
Macroporous, polypropylene mesh in retrorectus or underlay fashion

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12
Q

Strangulated ventral hernia - OR (bowel NOT viable)

A

Resect any necrotic segments, primary anastomosis ensuring 2 viable ends of bowel
Attempt primary closure, if available can do underlay biologic or biosynthetic
Can temporize with bridging biologic or vicryl mesh
Close skin over closed suction drains

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13
Q

Recurrent hernia repair with prior mesh placement

A

Explant any un-incorporated mesh

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14
Q

Strangulated ventral hernia, fascia not closing

A

Fascial release, can bridge with biologic or biosynthetic with understanding that something more will need done in the future

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15
Q

Diaphragmatic hernia - Workup/Diagnostics

A

Don’t forget to r/o cardiac etiology with any sx of chest discomfort**
UGI fluoroscopy to characterize hernia (anatomy), look for dysmotility or stricture, diverticulum
Upper endoscopy - mucosal pathology suggestive of Barretts/malignancy or esophagitis, biopsy any abnormalities, random antral bx for H pylori
Baseline labs incl coags if anemia present (Cameron’s ulcers) and ensure recent cscope
Manometry - not as reliable d/t altered anatomy
pH probe - more applicable to GERD w/o hernia

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16
Q

Diaphragmatic hernia - OR

A

Minimally invasive, transabdominal robotic
Obtain access: optiview technique with veress needle insuff with camera port 15 cm below xiphoid
Ports triangulated to hiatus
Liver retractor
Gentle retraction, reduce hernia contents and open gastrohepatic ligament, beginning dissection of hernia sac along inner border of crura
Completely excise hernia sac and perform high circumferential mediastinal dissection in order to provide 3 cm intraabdom esophagus, taking care to ID and preserve anterior and posterior vagus nn
Divide short gastrics to fundus in order to construct fundoplication
Anterior fundoplication with non-absorbable sutures (make sure 2-3 cm long, 1 cm apart)
Close crural defect over bougie using pledgeted non absorbable suture
Construct partial 270 degree posterior wrap

17
Q

Capnothorax during diaphragmatic hernia repair

A

Lower insufflation pressure
Equalize pressure between pleura and peritoneal cavity by placing red rubber
Evacuate at the end of the case by bringing red rubber out through the skin and have anesthesia give several deep breaths

18
Q

Unable to obtain 3 cm intraabdominal esophagus during diaphragmatic hernia repair

A

Maximally mobilize with high mediastinal dissection to level of pulmonary vv
If esophagus looks foreshortened, can perform gastropexy using suture or G tube
Can consider collis gastroplasty

19
Q

Post op CXR for diaphragmatic hernia shows apical PTX

A

Not uncommon, generally do not require intervention
Ensure appropriate oxygenation
High flow O2 to assist with resorption of capnothorax

20
Q

Tachycardia s/p diaphragmatic hernia repair

A

R/o leak, DVT, MI, PE, bleeding

EKG, CXR, labs incl CBC, ABG, BMP, trops

21
Q

Air fluid level in mediastinum s/p diaphragmatic hernia repair

A

Esophageal perforation with leak

Water soluble contrast CT

22
Q

Leak s/p diaphragmatic hernia repair

A

Return to OR for lap or open exploration with EGD
IF can identify leak, attempt primary repair if able
Adv endoscopist for covered stent if needed
Leave drain(s)
Consider distal feeding access

23
Q

Bowel obstruction 2/2 strangulated hernia - prior to sedation?

A

Place NG tube - don’t want to deal with aspiration pneumonitis in addition to other problems!

24
Q

Strangulated inguinal hernia - OR prep

A

Ensure NGT functional
RSI
Groin incision, possible lap vs ex lap
Pre op abx

25
Q

Strangulated inguinal hernia - OR

A

1 FB above inguinal ligament
Dissect EO and incise in direction of fibers to open inguinal canal, ID and protect ilioinguinal nerve
After ID hernia sac and spermatic cord, encircle with penrose drain and dissect sac away from cord structures, open sac and assess viability of contents
If bowel viable, can reduce contents, ligate sac at internal ring and perform mesh repair (lightweight macroporous polypropylene mesh, secured to conjoint tendon superiorly and shelving edge inferiorly)

26
Q

Sliding hernia - what not to do in OR?

A

Don’t say you’d open the sac

27
Q

Necrotic bowel during strangulated inguinal hernia repair

A

Low midline lap
Bassini tissue repair
Approx conjoint tendon to inguinal ligament with prolene suture

28
Q

Femoral hernia (strangulated)

A

Approximate lateral edge of rectus (conjoint tendon) to Coopers ligament (medially)
Transition stitch of conjoint tendon to inguinal ligament

29
Q

H&P in umbilical hernia with cirrhosis

A

Optimally manage cirrhosis
Childs pugh/Melds scores, is he followed by hepatology or being considered for transplant
recall portal HTN –> umbilical vein dilation
Ascites and cirrhosis maximally optimized

30
Q

Medical optimization of cirrhosis

A

Refer to hepatology for medical mgmt of ascites iwth Na restriction, diuretics, paracentesis
If ascites not controlled medically, can consider TIPS

31
Q

If MELD>15 + hernia

A

Ensure no signs of obstruction or strangulation
Transplant list
Repair hernia at time of transplant

32
Q

Incarcerated hernia + cirrhosis - pre op

A

Place NGT for decompression

Send labs for CBC, CMP, coags**, type + cross

33
Q

Incarcerated hernia + cirrhosis - OR

A

After reducing hernia
Close in layers
Close peritoneum with vicryl
Interrupted permanent prolene sutures to close fascia
Subq tissues/skin with running absorbable

34
Q

Post op hernia repair + cirrhosis

A

Ensure ascites controlled - serial para, judiciously manage intravascular volume and support kidney function (every liter removed = 6-8g albumin)
Antibiotics - fluoroquinolone x 14 days as SBP ppx

35
Q

Unable to determine if inguinal or femoral hernia - incision placement

A

Standard inguinal hernia with plans to divide transversalis fascia to expose femoral space
Dissection can be above or below inguinal ligament

36
Q

If hernia sac cannot be reduced (femoral), next steps?

A

Divide lacunar ligament
If still cannot be reduced, transect inguinal ligament
The sac can be reduced through the femoral defect to transition it into an inguinal defect

37
Q

Borders of femoral canal

A

Superior: inguinal ligament
Inferior: Coopers
Lateral: femoral vein
Medial: junction of iliopubic tract + lacunar ligament

38
Q

Component separation

A

Midline lap
Remove all prosthetic material, address any bowel issues
Elevate lipocutaneous flaps 2 cm lateral to linea semilunaris (lateral edge of rectus)
Incise EO fascia and separate EO and IO to 3-4 cm above costal margin and to inguinal ligament inferiorly
Release posterior rectus sheath by incising 1 cm lateral to linea alba
Develop retromiuscular plane to linea semilunaris, preserving neurovascular bundles
Place mesh underlay below muscle and above posterior sheath, place drains over mesh to improve incorporation
Reapproximate midline fascia with interrupted figure of 8 sutures (0 PDS)
Close SQ/flaps over drains

ORAL BOARDS (11 decks)

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