Anatomy and Dictations Flashcards
How do you mobilize the liver?
Grasp the falciform ligament and divide it. Place downward traction on its posterior edge and liver. Further transect the falciform ligament to the coronary ligament, and incise this further to the right triangular ligament. Incise the lateral attachments and bluntly lift the liver off of Gerota’s fascia of the right kidney and diaphragm.
How do you strip the right hemidiaphragm?
Incise the peritoneum along the anterior edge of the diaphragm along the costal margin with cautery. Grasp the free edge with Allis clamps, and develop the plane between the diaphragm and its peritoneum. Continue until the anterior coronary ligament and right triangular ligament reflect onto the surface of the liver.
- The inferior phrenic A/V may be encountered and clipped
- This exposes the bare area of the liver. The IVC is here, just to the right of the falciform
- The right phrenic nerve is here as well
How do you perform a diaphragmatic resection?
Small lesions may be resected using an EndoGIA stapler without entering the pleural cavity. The lesion is grasped with a long Allis clamp, tented downward, and the EndoGIA used to staple and divide the tented diaphragm and invasive lesion.
Larger lesions may require entry into the pleural space, and are excised sharply with Metzenbaums to avoid thermal injury to lungs. The lesion is resected en bloc with peritoneal, muscular and pleural layers.
How do you close a defect in the diaphragm?
Small defects may be closed with figure-of-eight permanent sutures.
Larger defects require permanent mesh with interruptid permanent sutures.
How do you evacuate air from the thorax after a diaphragm resection?
A purse string suture is placed widely around the hole and #14 French red Robinson catheter is placed through the hole into the pleural cavity. Anesthesia gives the patient a maximal inspiration, suction is applied to the catheter, and the catheter is pulled as the suture is tied down.
Alternatively, a chest tube may be placed for prolonged pleural drainage.
Branches of the Celiac Trunk?
- Left gastric
- Splenic
- Common hepatic
Blood supply to the omentum?
- Left gastroepiploic (branch of splenic artery)
2. Right gastroepiploic (branch of gastroduodenal artery)
Branches of the SMA?
The SMA supplies the small bowel and right hemicolon. Thus, branches are:
- Inferior pancreaticoduodenal
- Middle colic
- Right colic
- Ileocolic
- Ileal branches
- Jejunal branches
Windows of Deaver?
There are no anastomoses between vasa recta before reaching the bowel wall. The avascular spaces between adjacent vasa recta are called the Window of Deaver.
Avascular Space of Treves?
The large, avascular space between the ileocolic artery and the terminal SMA within the small bowel mesentery.
What makes up the portal vein?
The SMV and the splenic vein
Branches of the IMA?
The IMA supplies the left hemicolon. Thus, the branches are:
- Left colic
- Sigmoid
- Superior rectal
Critical point of Sudeck
Area between the lowest sigmoid artery and superior rectal artery at the rectosigmoid junction.
Most common site of ischemic bowel injury from hypotension?
The ileocecal junction
Can you ligate the IMA at its origin?
Yes, so long as the marginal artery of Drummond is intact, and thus the SMA will take over. Furthermore, the anastomoses between the superior and middle rectal arteries are adequate to supply the sigmoid and descending colon.
What systems supply to rectum and anus?
- IMA system via superior rectal
- Middle sacral
- Internal iliac system, via middle rectal, pudendal which gives rise to inferior rectal
Femoral triangle
- Inguinal ligament
- Adductor longus
- Sartorius
Floor:
Lateral iliopsoas and medial pectineus muscles
Splenectomy
- Retract the spleen medially and inferiorly. 2. Divide the splenocolic and splenophrenic ligament.
- Enter the lesser sac.
- Divide the gastrosplenic ligament, which contains the short gastric arteries.
- Grasp the hilum of the spleen. Identify the artery and vein, ligate both, artery first, with silk suture. Use GIA stapler to transect distal the the ligation.
Ureteral injury below the cardinal ligament?
Ureteroneocystotomy
Total pelvic exenteration
1) Explore the abdomen and pelvis, ruling out metastatic disease.
2) Incise lateral pelvic peritoneum and develop the paravesical and para-rectal spaces. Perform PPLND.
3) Evaluate resectability and biopsy and suspicious lesions. If negative…
4) Transect the IP ligaments.
5) Ligate the anterior division of the hypogastric.
6) Dissect the parametrial tissue at the pelvic sidewall down to the levator sling with Ligasure.
6) Divide sigmoid mesentery with Ligasure and sigmoid with GIA stapler.
7) The areolar space between the sacrum and rectosigmoid is dissected down to the levator sling.
8) The bladder is dissected free of the pubic ramus.
9) The ureters are transected at an appropriate distance from the tumor.
10) The urethra, vagina and rectum (TA-55) are transected as low as needed to
obtain adequate tumor-free margins.
If tumor is close or below the levator sling, perineal phase:
1) Lateral attachments of the vagina are transected until the paravaginal space is encountered from below.
2) Tissue posterior to the anus is incised and carried toward the coccyx, with clamping and transection of tissue until the presacral space is encountered.
3) Subpubic incision made and peddles secured until space of Retzius is encountered.
Per GOG manual, “Colostomy, urinary diversion using an intestinal conduit and isolation of the pelvic cavity is carried out according to personal technique of the surgeon. Primary low reanastomosis is acceptable in selected cases.”
Management of a pancreatic injury after splenectomy?
Obtain CT to confirm Place IR-guided drain Bowel rest TPN Antibiotics
Inguinofemoral LND
Inguinal = superficial
- Identify my landmarks, borders of the femoral triangle
- Make incision 2cm below and parallel to the inguinal ligament.
- Dissect through Camper’s fascia.
- Remove node-bearing fatty areolar tissue which lies deep to Camper-s fascia, superficial to Colles fascia, the cribriform fascia and the fascia lata.
- In the process, the superficial epigastric, superficial circumflex, and superficial external pudendal vessels may be ligated. The saphenous is preserved, but may be taken.
Femoral = deep
- Incise the cribiform fascia medial to the femoral vein an removal nodal tissue medial to this.
- The deep external pudendal artery comes off here, and may be ligated.
Complications of IFLND?
- Wound infection/breakdown 30%
- Lymphocyst 10-30%
- Lymphedema
- Nerve injuries
Rectosigmoid resection and EEA anastomosis
The sigmoid was mobilized. The EndoGIA
stapler was used to transect the sigmoid colon proximal to the mass. The mesentery was then serially dissected with the Ligasure. The pararectal tissues were then
dissected to the levator plate. The rectum was transected with a curved Curved Contour stapler.
The proximal end of the sigmoid colon was opened by resecting the staple line and sized with the EEA sizers. A purse-string stitch of 2-0 PDS was then placed along the edge. The appropriately sized anvil was then placed
within the proximal lumen, and the pursestring suture was tied down.
The EEA stapler was carefully placed through the rectum and to
the end of the distal end of bowel. The proximal and distal ends were
thereby connected by placing the anvil in proximity to the EEA stapler.
The EEA stapler was fired and slowly withdrawn.
*intact donuts, bubble test
Scalene node resection
1) Identify boundary landmarks: inferiorly, the subclavian vein / clavicle;
medially posterior border of sternocleidomastoid muscle and the internal jugular vein
superiorly the inferior border of omohyoid.
2) 5-6 cm incision parallel above the clavicle
3) Any enlarged or suspicious nodes are to be excised or biopsied if unresectable.
4) Scalene fat pad overlying the scalenus anticus muscle between the borders in the location described above in item 1), is to be removed if no nodes are palpable.
5) Structures which should be identified and trauma avoided are: jugular and subclavian veins, the phrenic nerve, and the thoracic duct.
6) The transverse cervical vessels may course through the fat pad and can be ligated and divided.
7) Drainage recommended, but optional.
*taken from GOG surgical manual and Morrow
Psoas hitch
- Take down ipsilateral bladder pillar
- Incise anterior bladder wall
- Suture bladder to psoas with 2-0 prolene. *spare genfem nerve
- Make musical incision form new ureteral orifice in the dome, tunnel 3cm, pull ureter through and suture with 4-0 vicryl
- Place double J stent
Foley in for 10 days
Stent for 6 weeks
Boari flap
Similar to psoas hitch, but with a flap of bladder that is elongated and fashioned to the psoas
- Divide both bladder pillars.
- Flap width 4cm, length is the length of the ureteral defect, plus 4cm if you plan to tunnel (non-refluxing)
- Suture to psoas with prolene (nonabsorbable)
- Bring ureter through post shows flap and secure
- Roll tube anteriorly and close with absorbable suture
Ileal conduit
20cm of ileum
Principles of surgical hemorrhage: pelvic bleeding such that CV unstable?
Compress the aorta below the renal vessels. This can be done for 1-2 hours without compromising the extremities.
SLN for uterine cancer
- 1.25mg/mL ICG
- Inject deep and superficial at 3 and 9 o’clock
- Near-infrared imager to identify green nodes
- If no mapping, then use Mayo criteria to determine whether or not to stage
Gracilis myocutaneous flap
Type II blood supply: one dominant and several minor Pericles.
Dominant: Pedicle from medial femoral circumflex artery, which emerges between adductor longus and brevis
Type II vs Type II radical hysterectomy
Type II:
- Uterine artery ligated where it crosses the ureter.
- Parametria half the distance to the sidewall.
- Uterosacrals half the length.
- 1-2cm (1/3) of vagina.
“The purpose of the type II is to remove paracervical tissue while preserving blood supply to the ureters and bladder.”
Type III:
- Uterine artery ligated at its origin.
- Parametria at the sidewall.
- Uterosacrals close to the sacrum.
- 2-3cm (1/2) of vagina.
Principles of surgical hemorrhage: basics
Morrow:
- Apply pressure (finger, sponge stick, packing)
- While pressure is present, optimize exposure, instruments, lighting, suction, blood products.
- Packing is an option. Parachute pack.
- Hypogastric artery ligation, distal to the posterior division
TA stapler
“Thoraco-abdominal” stapler
30, 60, 90mm lengths
Double row of titanium staples
2.5, 3.5 or 4.8mm staples
GIA stapler
Used to divide bowel 60 and 80mm lengths Two double rows of titanium staples Divides between the double rows White: 2.5mm, compresses to 1mm Blue: 3.5mm, compresses to 1.5mm Green: 4.1mm, compresses to 2mm
EEA stapler
“End-to-end anastomosis” stapler
Principles of bowel resection?
- Preserve as much healthy bowel as possible
- Rule out obstruction or fistula proximal to the resection
- Water-tight
- Tension-free
- Hemostatic
How do you perform a radical trachelectomy?
Develop the paravesical and pararectal spaces. Perform pelvic LND.
The round ligaments are divided. The uterine vessels are divided at their origin from the hypogastric vessels. Care is taken to preserve intact the infundibulopelvic and tubo-ovarian ligaments as they will constitute the main source of vascular supply to the uterus. The parametria and paracolpos, along with the uterine vessels, are mobilized with the trachelectomy specimen. A complete ureteral dissection through the parametrial tunnel is required as in a type III radical hysterectomy procedure. The posterior cul-de-sac is incised, and the uterosacral ligaments are divided.
The required length of vaginectomy is then resected circumferentially via an anterior colpotomy, and the specimen is completely separated from the vagina distally. This may be facilitated by the use of a vaginal cylinder to help delineate the vagina. Proximally, the specimen is excised approximately 5 mm below the internal os and is sent for frozen section analysis. If margins are secure, a permanent cerclage is placed abdominally circumferentially at the level of the isthmus. The lower uterine segment is reanastomosed to the vaginal apex with six to eight interrupted absorbable sutures.
Boundaries of the paramedical space?
Anterior - pubic symphysis
Posterior - cardinal ligament
Medial - obliterated umbilical artery
Lateral - external iliac vein
Boundaries of the pararectal space
Anterior - cardinal ligament
Posterior - sacrum
Medial - ureter, rectum
Lateral - internal iliac artery
Boundaries of pelvic LND?
Bifurcation of the aorta Deep circumflex iliac vein Psoas muscle Umbilical artery Obturator nerve
Miami Pouch
- Transect ileum 10cm from the IC junction.
- Transect T-Colin distal to the middle colic artery.
- Anastomose ileum to T-colon to re-establish continuity of the GI tract.
- Grasp midpoint of colon and bring T-colon to cecum. Suture back wall with 3-0 silk and detubularize. Staple back wall.
- Bring ureters through the back wall, spatula for and sew to the mucosa.
- Fold pouch over and staple other walls.
- 14F catheter into the ileum, purse string around the IC junction to bolster the valve.
- Staple to excise excess ileum.
Rectal anastomoses:
Very low
Low
High
Less than 7cm from the anal verge
7-11cm is low
Greater than 11 is high
*cervix is at 8-10cm. Most ovarian LAR will be just below the peritoneal reflection, which is 8cm or so from the anal verge
Muscles of external anal sphincter?
Levator ani
Staples sizes open and closed?
GIA:
- 8 to 1.5mm
- 5 to 2.0mm
Circular: 28mm staples give an 18.2mm anastomosis
Risk factors for anastomotic leak?
Leak rate 5-15% Low albumin < 2.5 Age > 80 Obesity DM Tension Anastomosis below 6cm (very low) Radiation
Rhomboid flap
Rotational
Best for perineal defects to preserve vaginal and anal openings
V-Y Flaps
Local advancement flap of skin and SQ tissue for lateral defects
Gluteal fold / IE Lotus flap
Transpositions flap
Both axial and random blood supply
Any defect
Length can be 4 times width
Sartorius Transposition
Elevate the sartorious from the fatty tissue over the pectineus.
Transect the sartorious from the ASIS.
Cover the femoral vessels and sew the sartorious to the inguinal ligament.
Attach lateral aspect of muscle to the iliopsoas and pectineus.
Attach medial aspect to pubic tubercle.
Vessels in superficial inguinal triangle?
- Superficial epigastric
- Superficial circumflex iliac
- Superficial external pudendal
RAM flaps
Type III: two dominant Pericles
Blood supply is superior or inferior epigastrics
Tensor fascia lata flap
Type I blood supply from lateral circumflex femoral artery
