Alimentary Tract

Question 1

ECF Takedown

Answer 1

Enter abdomen through intact fascia
Elliptical incision to resect the fistula en bloc with surrounding inflamed tissue
Complete adhesiolysis and drainage of abscesses.
Resect the fistulized segment of bowel with reanastomosis with omentum placed over it if available.
primary abdominal wall closure vs bridging mesh

Question 2

Heller Myotomy

Answer 2

Dissect out the esophagus and proximal stomach taking care not to injure the vagus nerves
Perform myotomy until the mucosa pops out, extending 2 cm onto stomach and 5 cm proximally onto esophagus
EGD and perform leak test
Dor fundoplication

If microperf, do Dor then NPO for 5 days w UGI on POD5

If macroperf, close mucosa w absorbable, close myotomy, buttress repair, perform posterior myotomy

Question 3

APR

Answer 3

Explore for metastasis.
Mobilize the left colon and sigmoid down to the peritoneal reflection
Perform proximal transection High ligations of the IMA and superior rectal artery
Start total mesorectal excision until I get to the pelvic floor
Dissect from perineal slide continuing cephalad to meet the intra-abdominal portion of the dissection. Once the specimen is freed from the surrounding structures, remove it and close the defect.
If the field had previously been radiated, close the defect using a myocutaneous flap, and then close the soft tissue and skin in several layers.
Leave a drain in the pelvis, bring up the ostomy, close the fascia and then mature the ostomy.

Question 4

Delorme

Answer 4

mucosal sleeve reduction:
Dissect mucosa and submucosa off the muscularis propria 1 cm proximal to dentate.
Resect redundant mucosa
Plicate the muscularis
Anastomose the mucosal layers

Question 5

Zenker’s

Answer 5

Incision on anterior border of SCM
would dissect down ventral to the carotid sheath and identify the diverticulum between the esophagus and cervical spine. I would perform a stapled resection of the diverticulum. I would then perform a myotomy of the cricopharyngeal muscle, leave a drain, and then close the skin.
If <2 cm resect and close vs leave alone, if large stapled resection

Question 6

Altemeier

Answer 6

Lithotomy, proctoscopy to check prep
Lone star retractor
Divide circumferentially 1 cm proximal to dentate
dissect and excised redundant pouch of douglas/hernia sac anteriorly
divide posterior/lateral mesorectum with energy device
Deliver redundant bowel
Posterior levatorplasty if needed
Reanastomose bowel

Question 7

Ivor Lewis

Answer 7

Dissect through the hepatogastric ligament making sure not to injure an aberrant left hepatic artery,
dissect the phrenoesophageal ligament and mobilize the esophagus and stomach
ligate the left gastric/gastroepiploic arteries, short gastrics
Preserve right gastric and gastroepiploic arteries
staple 5 cm below the gastroesophageal junction send margin for frozen
pyloroplasty
L lateral decub, right sided thoracotomy. incision in the 5th intercostal space
mobilize the esophagus making sure to ligate the azygous vein to allow for enough mobility.
place the patient supine, make a left sided neck incision, resect esophagus and send the esophageal margin for a frozen biopsy.
deliver the gastric conduit through the chest and into the neck to make a side-to-side stapled anastomosis.
insert a nasogastric tube to perform a leak test, if negative leave the NG tube distal to my anastomosis.
leave a penrose drain in the neck and chest tube

Question 8

Hiatal hernia/fundoplication

Answer 8

3 cm abdominal esophagus.
60 Fr bougie

Question 9

Total gastrectomy for cancer

Answer 9

Explore
Mobilize GE junction and esophagus, take margin of crura
Separate omentum from transverse colon and divide lesser esac
Divide short gastric
Skeletonize celiac, splenic, and common hepatic arteries to take lymph nodes
Ligate left and right gastric and gastroepiploic arteries at their base
Divide esopahgus/stomach/jejunum, send margins
Reconstruct with EJ/JJ