Abdomen Core Flashcards
Peritoneal Dialysis Catheter Insertion - Lap
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
When ok to do PD after catheter insertion
2 weeks
Diaphragmatic hernia repair
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
Inguinal hernia - open
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
Inguinal hernia - robotic
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
Distal pancreatectomy
*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
Pancreatic pseudocyst drainage
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
Rectus sheath hematoma - OR
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
To ligate inferior epigastric 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
Expectations s/p rectus sheath hematoma
Can last for 3-6 months, setting expectations with pt is important!
Strangulated ventral hernia - OR (bowel is viable)
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
Strangulated ventral hernia - OR (bowel NOT viable)
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
Recurrent hernia repair with prior mesh placement
Explant any un-incorporated mesh
Strangulated ventral hernia, fascia not closing
Fascial release, can bridge with biologic or biosynthetic with understanding that something more will need done in the future
Diaphragmatic hernia - Workup/Diagnostics
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
Diaphragmatic hernia - OR
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
Capnothorax during diaphragmatic hernia repair
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
Unable to obtain 3 cm intraabdominal esophagus during diaphragmatic hernia repair
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
Post op CXR for diaphragmatic hernia shows apical PTX
Not uncommon, generally do not require intervention
Ensure appropriate oxygenation
High flow O2 to assist with resorption of capnothorax
Tachycardia s/p diaphragmatic hernia repair
R/o leak, DVT, MI, PE, bleeding
EKG, CXR, labs incl CBC, ABG, BMP, trops
Air fluid level in mediastinum s/p diaphragmatic hernia repair
Esophageal perforation with leak
Water soluble contrast CT
Leak s/p diaphragmatic hernia repair
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
Bowel obstruction 2/2 strangulated hernia - prior to sedation?
Place NG tube - don’t want to deal with aspiration pneumonitis in addition to other problems!
Strangulated inguinal hernia - OR prep
Ensure NGT functional
RSI
Groin incision, possible lap vs ex lap
Pre op abx
