Cancer Operations

Question 1

R Adrenalectomy

Answer 1

Modified left lateral decubitus
if lap - obtain laparoscopic access and triangulate 4 ports to RUQ
a. Mobilize liver medially, taking down right triangular ligament and hepatic flexure as necessary
b. Follow IVC until identification of R adrenal vein
c. Dissect circumferentially with energy device
d. Clip adrenal vein then divide
e. Complete circumferential dissection and remove
f. obtain hemostasis and close

Question 2

distal pancreatectomy

Answer 2

1. Diagnostic laparoscopy.
2. Open lesser sac via gastrocolic ligament, divide short gastrics, mobilize splenic flexure.
3. Mobilize exposed pancreas from retroperitoneum, usually medial to lateral starting on inferior border. Watch for splenic vein posteriorly, splenic artery and celiac axis cephalad/superiorly.
4. Splenic vessels are now exposed; divide if splenectomy is planned. Divide pancreas with stapler.
5. Remove distal pancreas +/- spleen in retrieval bag. Ensure hemostasis and close.

Question 3

L Adrenalectomy

Answer 3

right lateral decubitus
if lap - obtain laparoscopic access and triangulate 4 ports to LUQ
a. mobilize splenic flexure medially
b. divide splenorenal ligament
c. mobilize spleen/tail of pancreas medially
d. identify L adrenal vein by following L renal vein then ligate
e. circumferentially dissect the rest of the gland free from the kidney/spleen/RP
f. ensure hemostasis and close

Question 4

Simple Mastectomy

Answer 4

1. Elliptical incision encompassing prior biopsy sites and nipple areolar complex extending from just medial to the sternum to the midaxillary line
2. create skin flaps and resect all breast tissue - clavicles superiorly, inframammary fold inferiorly, sternum medially, and latissimus dorsi laterally
3. amputate breast tissue and ensure hemostasis
4. place drain then close

Question 5

SLNB

Answer 5

1. Preoperative injection of radiolabelled sulfur colloid and intraoperative injection of blue dye
2. Gamma probe to confirm uptake in axilla
3. Arm extended/chest wall, and axilla prepped
4. Incision 2 finger breadths below hairline area
5. Open clavipectoral fascia
6. Identify all “hot” and “blue” nodes and remove
7. Send any additional suspicious nodes
8. Wound closed in layers
   if can’t find a sentinel lymph node, then proceed to axillary dissection of levels 1 and 2 nodes

Question 6

ALND

Answer 6

Discuss no paralytic with anesthesia
1. Arm extended, chest wall, axilla, and arm prepped
3. Curvilinear incision 2 finger breaths below hairline of axillary crease
4. Open clavipectoral fascia
5. Identify latissimus and follow superiorly to the axillary vein
6. Identify pec minor and remove all level 1 and 2 lymph nodes (lateral and deep) within the axilla taking care to avoid injury to the thoracodorsal bundle(usually posterior to lateral thoracic vein, a tributary of axillary vein) or the long thoracic nerve
7. ensure hemostasis and then leave a closed suction drain
8. close

Question 7

Modified radical Mastectomy

Answer 7

1. Elliptical incision encompassing prior biopsy sites and nipple areolar complex extending from just medial to the sternum to the midaxillary line
2. create skin flaps and resect all breast tissue - clavicles superiorly, inframammary fold inferiorly, sternum medially, and latissimus dorsi laterally
3. amputate breast tissue and ensure hemostasis
4. continue dissection laterally through clavipectoral fascia
5. complete ALND by taking all level 1/2 LNs and preserving thoracodorsal bundle and long thoracic nerve
6. leave closed suction drains in axilla and under skin flaps
7. close in layers

Question 8

Superficial groin dissection

Answer 8

1. Leg flexed and externally rotated
2. S-shaped incision over inguinal ligament and curving over femoral vessels
3. Skin flaps
4. Boundaries are inguinal ligament superiorly, sartorius muscle laterally, adductor longus medially,
   and apex of the femoral triangle distally
5. Remove all lymphatic tissue, divide saphenous vein
6. Take Cloquet’s (most superior femoral node at inferior border of inguinal ligament) node, if positive needs retroperitoneal LN dissection
7. To prevent the femoral vessels from being exposed in the event of a wound disruption, the sartorius
   muscle is often detached from its origin on the ASIS and sutured to the inguinal ligament
8. Deep dissection is achieved by dividing inguinal ligament and rolling peritoneum to expose iliacs
9. Placed drain and close in layers with detached sartorius over the femoral vessels

Question 9

Subareolar Ductectomy

Answer 9

1. Identification of duct causing discharge by intubation of the duct with lacrimal duct probe and
   injection with isosulfan blue dye
2. Periareolar incision and areola lifted up with skin hooks
3. Blue ducts excised or quadrant excised with ligation of proximal and distal ducts
4. Subareolar wedge excision for quadrant responsible or total areolar ductal excision if no quadrant
5. Incision closed
6. Work up breast mass if any

Question 10

Esophagectomy

Answer 10

Abdomen
1. start supine
2. lap access
3. incise gastrocolic omentum
4. divide short gastrics and L gastroepiploic
Truncal vagotomy/pyloroplasty
5. divide gastroheptic liagment, L gastric a. and vein
6. staple lesser curve parallel to greater curve with 5cm wide conduit
7. place j-tube
8. D2 lymphadenectomy (perigastric, celiac, splenic hilar, RP nodes
9. tie conduit to distal esophagus

Chest
1. LL decub
2. R thoracotomy - L 5th inte
3. divide IPL
4. resect esophagust at level of azygous vein
5. anastomosis

Question 11

Subtotal Gastrectomy wD2

Answer 11

1. Staging laparoscopy with gastric washings for cytology (M1 disease if cytology +)
2. Convert to open via upper midline
3. Omentum lifted and dissected off transverse colon
4. Right and left gastroepiploic and majority of short gastric vessels divided
5. Duodenum divided 2cm distal to pylorus with GIA; oversew staple line with interrupted Lemberts
6. Left & right gastric arteries divided; feel for replaced left hepatic artery in gastrohepatic ligament
7. Stomach divided 5cm proximal to tumor with GIA stapler
8. D2 lymphadenectomy taking all perigastric, celiac, splenic hilar, and periportal lymph tissue
9. 2 layer - hand-sewn B2 with 2-layer side-side anastomosis with NGT advanced down efferent limb

Question 12

Distal Gastrectomy

Answer 12

1. Staging laparoscopy with gastric washings for cytology (M1 disease if cytology +)
2. Convert to open via upper midline
3. Kocherize to mobilize duodenum
4. Mobilize distal stomach by dividing gastrocolic ligament and enter lesser sac
5. Right gastroepiploic artery divided near GDA and left gastroepiploic is spared
6. Incise gastrohepatic ligament and divide right gastric artery and branches of the left gastric artery
7. Duodenum divided 2cm distal to pylorus with GIA; oversew staple line with interrupted Lemberts
8. Stomach divided 5cm proximal to tumor with GIA stapler
9. Reconstruction with an antecolic Billroth II Loop GJ in a side-to-side hand-sewn 2 layers with NGT
   advanced down efferent limb
10. Close

Question 13

Transanal Excision

Answer 13

1. Indications
   a. For carcinoma in situ or clinical T1N0
   b. <7cm from anal verge
   c. Size <3cm (4cm) and <1/3 rectal circumference
   d. Mobile (fixed is T3 disease)
2. Patient positioned with tumor lying posterior
3. Circumferential anal block placed
4. Lone star retractor
5. 1cm margins scored around tumor
6. Excise rectal wall full thickness down to perirectal fat
7. Orient specimen
8. Close defect with 3-0 PDS
9. Leave presacral drain if cannot close

Question 14

R colectomy

Answer 14

1. Lower midline incision
2. Place retractor and pack bowel to left
3. Identify cecum and take down lateral peritoneal reflection working laterally to medially and
   identifying the right ureter
4. Proceed and take down the hepatic flexure from retroperitoneal attachments and identify the
   duodenum
5. Divide the ileum and divide the colon to the right of the middle colic artery
6. High ligation of the ileocolic pedicle
7. Divide the mesentery of the right colon
8. Assess ends for good perfusion
9. Hand-sewn end-to-side ileocolic 2 layer anastomosis or a side-to-side stapled functional end-to-end
   anastomosis with a GIA and TA stapler
10. Irrigate and close

Question 15

Sigmoidectomy

Answer 15

1. Modified lithotomy position
2. Lower midline incision
3. Place retractor and pack bowel to right
4. Identify sigmoid and take down lateral peritoneal reflection working laterally to medially
5. Identify the left ureter
6. Proceed and take down the splenic flexure from retroperitoneal attachments
7. Divide the sigmoid mesocolon preserving the IMA, IMV, left colic and sigmoidal in distal sigmoid
   resection taking only superior rectal, or preserving superior rectal and taking left colic and sigmoidal
   for proximal tumor
8. Divide sigmoid colon with a TA-stapler above the pelvic brim
9. Divide the proximal colon with a GIA stapler
10. Double staple technique with an EEA stapler with the anvil placed into a pursestring in the proximal
    colon and stapler from below, normally 28 or 31 sizing
11. Air leak test and check donuts
12. Irrigate and close

Question 16

LAR

Answer 16

1. Modified lithotomy position
2. Lower midline incision
3. Place retractor and pack bowel to right
4. Identify sigmoid and take down lateral peritoneal reflection working laterally to medially and
   identifying and protecting the left ureter
5. Proceed and take down the splenic flexure from retroperitoneal attachments
6. Divide the IMV as it emerges from the LOT
7. Divide the IMA preserving the left colic artery
8. Divide descending colon with GIA above sigmoid flexure
9. Score peritoneum down to pelvic brim
10. The sigmoid mesentery is lifted off the retroperitoneum
11. Use as handle to begin pelvic dissection; begin by scoring circumferentially, working posteriorly
    first using a St. Mark’s retractor; the avascular plane between the visceral and parietal layers of the
    endopelvic fascia is developed and characterized by loose areolar tissue and continues sharply
    through Waldeyer’s fascia (rectosacral fascia that extends from S4 to the rectum)
12. Lateral dissection on mesorectum to avoid injury to hypogastric nerves and laterally retract and
    protect both ureters
13. The anterior dissection is often developed last; in men the dissection is continued through
    Denonvilliers fascia; in women retracting stitch through uterus to tack anteriorly can be used if
    needed
14. Divide rectum with TIA stapler at pelvic floor aiming for a minimum 1cm distal margin
15. Remove colon staple line, insert anvil, purse string with prolene, and insert a 28mm EEA stapler
    using end-to-end technique
16. Air leak test and check donuts
17. Consider a diverting

Question 17

APR

Answer 17

1. As for LAR prior to rectal division
2. Go from below with Lone Star retractor placed
3. An elliptical incision is made around the anus including the entire sphincter mechanism
4. Dissection continues with cautery posteriorly until the coccyx is encountered
5. The anococcygeal ligament is then divided and the previous dissected presacral space is entered just
   anterior to the coccyx
6. The levator muscles are hooked with the surgeon’s finger and divided bilaterally with cautery
7. The dissection continues anterolaterally
8. In males, the anterior portion of the dissection is challenging to avoid injury to the membranous
   urethra and prostate; in females, retraction of the vagina facilitates separation of anterior rectum and
   posterior vaginal wall
9. Eversion of the specimen through the perineal opening may help facilitate the remaining anterior
   dissection plane
10. The excision is completed circumferentially and the specimen is removed through the perineal
    wound
11. The levator ani muscles may be reapproximated in the midline if possible
12. The perineal incision requires

Question 18

R hepatectomy

Answer 18

1. Reverse L incision in RUQ
2. Take down falciform ligament
3. Place retractors
4. Cholecystecotmy
5. Isolate the hepatic inflow at the porta hepatis and place a rummel tournoqit for pringle control as needed
6. Mobilize R liver by taking down triangular and hepatocaval ligaments including RP attachments over adrenal gland and Kocher to expose infrahepatic cava
7. Dissect and expose R hepatic vein and place vessel loop around it for control
8. Dissect out and divide right hepatic artery
   and right portal vein after confirming anatomy with intra-operative ultrasound
9. Line of demarcation is marked out following vessel division
10. Divide liver with combination of ligasure, silk ties, and clips using a Kelly clamp crush technique
11. Take the bile duct in the liver with an endoGIA vascular stapler
12. Divide right hepatic vein with endoGIA vascular stapler (can take early with mobilized right liver)
13. Hemostasis and remove Pringle
14. Leave close suctioned drain and close

Question 19

L hepatectomy

Answer 19

1. Upper midline incision
2. Take down falciform ligament
3. Mobilize L lobe of liver by taking down triangular ligament and RP attachments
4. Dissect L hepatic vein
5. Dissect and vicryl suture around the left hepatic vein
6. Enter lesser sac and Rummel around the porta for occlusion later
7. Dissect out and take left hepatic artery
8. Take left portal vein
9. Pringle as needed; line of demarcation is marked out following vessel division
10. Divide liver with combination of ligasure, silk ties, and clips using a Kelly clamp crush technique
11. Take the bile duct within liver with an endoGIA vascular stapler
12. Divide left hepatic vein with endoGIA vascular stapler
13. Hemostasis and remove Pringle

Question 20

Parathyroidectomy

Answer 20

Supine, arms tucked, neck extended
IV access for monitoring of parathyroid hormone
RLN monitoring ETT
Baseline parathyroid hormone level
collar incision
Raise subplatysmal flaps
Open midline raphe, retract strap muscles
Retract thyroid gland medially
Develop plane between gland and prevertebral fascia
Ligate middle thyroid vein
Look for ***parathyroid gland
Then excise gland and collect samples