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
