Core Operations Flashcards
Intra-abdominal Abscess - Drainage
Hassan technique break into abscess cavity Culture abscess Place a closed suction drain in cavity, exteriorize
Peritoneal Dialysis Catheter Insertion
Hassan technique Place catheter in pelvis exteriorize catheter with some tunnelling test by putting fluid in and getting it back out
Peritoneal Lesion - Biopsy
Hassan technique Use biopsy forceps Send specimen for fresh/frozen/permanent get hemostatis with cautery
Abdominal Wall Reconstruction - Components Separation
Midline laparotomy Reduction of hernia sac/abdominal wall contents skin flaps Incise external oblique fascia place retrorectus mesh Bring midline together
Inguinal Hernia - Repair
incise external oblique to the external inguinal ring dissect out the hernia sac and reduce preserve vas, vessels and, genitofemoral nerve 4a: tension free mesh reconstruction: soft tissue over the pubic tubercle (name?), conjoint tendon, shelving edge of inguinal ligament, leave keyhole to reconstruct the internal inguinal ring 4b: if contaminated, Remember Relaxing incision, transition stitch, close femoral canal with interrupted sutures from transversalis and transversus to Cooper’s ligament and the lacunar ligament on the inferior edge of Pouparts ligament, transitioning to interuupted sutures from conjoint tendon to the shelving edge of the inguinal ligament close external oblique fascia to reconstruct external inguinal ring
Femoral hernia repair
incise external oblique to the external inguinal ring retract the inferior leaf of the external oblique superiorly reduce the femoral hernia, pull neck up while applying counter pressure through the hernial mass 4a: place mesh plug in femoral space and suture in 3 spots (not medially into femoral vein) 4b: if contaminated, Relxing incision, transition stitch, close femoral canal with interrupted sutures from transversalis and transversus to Cooper’s ligament and the lacunar ligament on the inferior edge of Pouparts ligament, transitioning to interuupted sutures from conjoint tendon to the shelving edge of the inguinal ligament close the external oblique
Miscellaneous Hernias - Repair
Obturator: laproscopic, reduce, Spigelian: lumbar:
‘Ventral Hernia - Repair*
Hassan LUQ reduce hernia underlay coated mesh with 4 transfascial sutures and tacks
Cholecystectomy with or without Cholangiography
Infraumbilical Hassan expose the critical view of safety
1. Clear the hepatocystic triangle (cystic duct, the common hepatic duct, and inferior edge of the liver) of fatty and fibrous tissue.
2. Dissect the lower 3rd of the gallbladder from the gallbladder fossa.
3. Two and only 2 structures entering the gallbladder.
perform cholangiogram if indicated clip and divide duct and the artery take gallbladder off the cystic plate
Cholecystostomy
RUQ incision pursestring suture in GB enter GB and place foley catheter, inflate balloon tie purstring externalize drain
Choledochoenteric Anastomosis
Fashion roux limb: start at LOT count 10cm, divide bowel with stapler Bring roux limb up to the bile duct: sew back wall with 4-0 PDS before cutting into bowel, do duct to bowl mucosa anastomosis, interrupted PDS Count another 50cm below choledochoenteric anastomosis and do stapled end to side anstomosis of small bowel
Choledochoscopy
Incise cystic duct place wire, use baloon dilator to dilate duct hook cholecoscope up to saline, advance into duct Visualize stones, extract with wire basket, drive scope into duo if necessary withdraw scope, shoot competion cholangiogram
Common Bile Duct Exploration - Open
Longitudinal incision in CBD pass choledochoscope,
(4F Fogarty catheter for initial sweeps, 8 F angioplasty balloon to dilate the orifice. 12F introducer catheter used for repeat passage of choledochoscope.
make sure hooked up to saline visualize stones, extract with wire basket, pass fogarty Place t-tube and shoot cholangiogram Secure t-tube with 3-0 PDS
Hepatic Abscess - Drainage
Kocher incision ultasound the abscess Incise and expose abscess cavity, disrupt loculations Leave a drain in the abscess cavity
Hepatic Biopsy
Hassan technique Use harmonic to cut out a desired piece Obtain hemostasis
Pancreatectomy - Distal
45degree right lateral decubitus Supraumbilical hasson Lift up stomach and enter lesser sac through generous incision in omentum up to the short gastrics Tunnel under pancreas along SMV/portal vein Divide with thick stapler Dissect remainder of the pancreas off the splenic artery and vein
Pancreatic Debridement
midline laparotomy Enter lesser sac through omentum or transverse colon Manually debride necrotic pancreat tissue Place large sump drains Place g-tube and feeding J-tube
Pancreatic Pseudocyst - Drainage
Midline laparotomy Incise anterior stomach Aspirate contents with needle incise 3-4cm posterior stomach and some cyst wall, elipse this out, send cyst wall to path for frozen to be sure not cystic neoplasm with epithelial lining Running 3-0 pds suture for hemostasis to create the cyst-gastrostomy Close anteror gastrostomy in 2 layers
Splenectomy
Vaccinate for encapsultated organisms: pneumococcus, meningococcus, h-flu 45 degree right lateral decubutus Hassan supraumbilical Look for accessory spleen tissue in hilum, omentum Mobilize splenic flexure Enter lesser sac by dividing omentum, divide short gastric take hilum with vascular stapler, taking care not to involve the tail of the pancreas
Splenectomy/Splenorrhaphy - Partial
pledgeted 2-0 vicryl mattress sutures to repair isolated linear laceration in spleen apply neunet low threshold for splenectomy
‘Antireflux Procedures*
Suptraumbilical hassan enter lesser sac through pars flaccida dissect along right crus, completely reducing/excising any hernia sac incise short gastrics and dissect along left crus Identify and protect the vagus nerves create 2cm floppy nissen wrap, suture with 2-0 ticron over 52 Fr Bougie
Cricopharyngeal Myotomy with Zenker’s Diverticulum - Excision
Incision along anterior border of left SCM retract carotid sheath elements laterally perform myotomy over a 52fr bougie in the cricopharngeus, use right angle to elevate muscularis off of the mucosa staple off the diverticulum with a TA stapler over a 52fr bougie perform a leak test
Esophageal Perforation - Repair/Resection
Use a swallow study to find the level of the perforation: cervical, upper 2/3 of chest, lower 1/3 chest, or abdomen Choose approach: cervical: anterior border of the SCM, upper 2/3 of chest: right posterolateral thoracotomy, lower 2/3 of chest: left thoracotomy 3a: Medialize the lung by taking down inferior pulmonary ligament 3b: upper midline laparotomy 4a: Open pleura over healthy distal esophagus, perform myotomy, debride edge of perforation 4b: mobilize esophagus from the mediastinum to the crura 5: Stent esophagus with NGT 6: Close defect in 2 layers: PDS 7a: buttress with pleura, pericardium, or intercostal muscle 7b: buttress repair with a Dor or Thal fundoplication 8: place drains
Paraesophageal Hernia - Laparoscopic Repair
Supraumbilical hassan enter lesser sac through pars flaccida dissect along right crus, completely reducing/excising any hernia sac incise short gastrics and dissect along left crus, reducing excising any hernia sac Identify and protect the vagus nerves Suture the cura over 52Fr Bougie create 2cm floppy nissen wrap, suture with 2-0 ticron over 52 Fr Bougie
Paraesophageal Hernia - Open Repair
Upper midline incision enter lesser sac through pars flaccida dissect along right crus, completely reducing/excising any hernia sac incise short gastrics and dissect along left crus, reducing excising any hernia sac Identify and protect the vagus nerves Suture the cura over 52Fr Bougie create 2cm floppy nissen wrap, suture with 2-0 ticron over 52 Fr Bougie
Duodenal Perforation - Repair
Kocherize duodenum if necessary debride perforation and perform graham patch with silk sutures Leave a closed suction drain
Gastrectomy - Partial/Total
completely mobilize omentum off of the transverse colon Kocher manuever Ligate right gastric artery Transect duodenum Take short gastrics Reflect stomach cephalad to expose the celiac plexus and left gastric artery, ligate left gastric artery Take all the celiac, aortic, splenic nodes with the dissection Transect esophagus
Gastrostomy
2 box shaped purse strings with 2-0 silk, leave needle on incise stomach place 12fr foley, inflate balloon exteriorize the folew throught the left upper quadrant Tie pursestrings, suture to the abdominal wall
Vagotomy and Drainage
Incise pars flaccida and expose distal esophagus, putting penrose drain around it identify anterior (coming from left) and posterior (coming from right) vagus nerves, elevate with nerve hooks resect 1 cm of nerve between metal hemoclips, sent to pathology for frozen section confirmation Kocherize duodenum 4cm logitudinal incision across pylorus, close transversely with interrupted 3-0 vicryl and silk lembert sutures
Adhesiolysis
Identify LOT Run SM to the cecum, dividing adhesions sharply Look for enterotomies and deserosalizations and repair them transversely
‘Feeding Jejunostomy*
Identify portion of midjejunum that goes up to anterior abdominal wall comfortably (30-40cm from LOT) fashion 2 concentric box sutures on antimesenteric jejunum, 3-0 silk, leave needles on incise jejunum and place a 12fr red rubber catheter downstream exteriorize the red rubber catheter tie the pursestrings and suture to the anterior abdominal wall
Ileostomy
pass a penrose through mesentery of desired sement of ileum (10-15cm proximal to cecum) Mark proximal and distal with suture incise nickle out of RUQ muscle split and incise fascia to allow 2 fingers Bring penrose and loop through apeture, exchange for rod Incise on antimesenteric border close to the skin on the distal side 3 3-0 chromic sutures to the distal skin use back of pickup to invert the stoma 3 3-0 chromic sutures to the proximal skin
Ileostomy Closure
incise 1-2mm of skin around ostomy dissect down to the bowel wall, freeing the bowel from the abdominal wall Use a 80mm blue linear stapler on antimesenteric border and a TA-60 blue stapling device to close the opening in the common channel
Small Intestinal Resection
identify desired area of resection and come through mesentery right under the bowel transect the bowel with a 60mm blue stapler maintaining a bias to avoid corner ischemia excise mesentery as necessary: get nodes if cancer operation Excise antimesenteric corners of the staples introduce a 60mm blue GIA stapler and fire along antimesenteric border, ensure hemostasis Offset staple lines and close common channel opening with a TA 60 stapler close mesenteric defect.
Superior Mesenteric Artery Embolectomy/Thrombectomy
Ignore dead bowel, thrombectomy first Lift transverse colon, find the middle colic and follow it to the SMA Heparinize Obtain proximal and distal control Make transverse incision in soft SMA Pass #4 fogerty catheter Shoot completion angiogram, if there is still an occlusion then bypass from infrarenal aorta to arteriotomy site close arteriotomy with interruped 4-0 prolene
Appendectomy
Infraumbilical Hassan, 5mm supraumbilical, 5mm LLQ Free appendix from surrounding structures Make mesoappendiceal window take appendix with gold tri-stapler flush with the cecum take mesoappendix with gold tristapler
Colectomy - Partial
Incise white line of tolt and mobilize colon from retroperitoneal attachments Identify ureter and reflect laterally Ligate vessels (usually need to take 2 named for formal resection) at the base of the mesentery, take lots of lymph nodes
Colectomy - Subtotal (with Ileorectal Anastomosis/Ileostomy)
Lithotomy position Transect TI with stapler Incise White line of Tolt on right, mobilize hepatic flexure Enter lesser sac, take down splenic flexure Incise white line of tolt on the left, connect lateral mobilization Find both ureters and retract them laterally Ligate the vessels and take the mesentery Dissect clearly distal to the rectosigmoid junction, excising surrounding mesorectum Transect rectum with Contour or TA stapler Sew anvil into the terminal ileum End to end EEA stapler anastomosis Completion proctoscopy with air leak test
Colostomy
Excise 2cm circular piece of skin in LLQ Muscle split and make cruciate incision in anterior rectus sheath to accomidate 2 fingers Exteriorize colon and excise the staple line Full thickness bites to dermis with 3-0 vicryl, no brooke Size and apply ostomy appliance
Colostomy Closure
Lower midline incision Identify and dissect out the distal sigmoid stump Take down the ostomy by incising 1mm of skin around stoma and separate from abdominal wall Mobilize splenic flexure if necessary Freshen edges by restapling EEA stapler anastomosis: sew anvil in proximally, put staper through anus
Anal Cancer - Excision
mark out 1cm margins around the tumor (if tumor bigger than 2cm need to do APR) remove skin down and subcutaneous fat reconstruct with a V-Y advancement flap
Anal Fistulotomy/Seton Placement
Enema Prone jackknife Bilateral pudental nerve blocks and 4-quadrant perianal block use fistula probe and or peroxide injection to identify fistula tract 4a: cut down on the fistula probe, currett out the epithelialized tract 4b: if through too much sphincter complex (>30%) place a seton by tying vessel loop to probe and pulling it through then tying it to itelf with silk suture
Anal Sphincterotomy - Internal
Enema Prone jacknife Identify intersphinceteric groove by palpation on right side of anal canal incise mucosa overlying the intersphincteric groove develop intersphinteric plane with hemostat divide internal sphincter distal to proximal, stop at level of the dentate line close mucosal defect with 3-0 vicryl
Anorectal Abscess - Drainage
Prone jacknife Local infiltration 1-2 cm cruciate incision overlying area of maximal induration hemostat to lyse loculations irrigate and pack
Banding for Internal Hemorrhoids
Enema Prone jacknife Locate 3 hemorrhoidal bundles: right anterior, right posterior, left lateral Ensure acting proximal to dentate line load the band on device, target vascular bundle just proximal the hemorrhoid and fire
Hemorrhoidectomy
Enema prone jackknife elevate submucosal space with local incise perianal skin and undermine hemorrhoid complex, leaving sphincter down Place Buie clamp across hemorrhoid complex, sharply remove hemorrhoid 3-o vicryl suture at vascular bundle, run up the clamp, remove clamp reapproximate mucosa with the 3-0 vicryl reapproximate anoderm with another 3-0 vicryl, leaving edge open for easy drainage
Perianal Condylomas - Excision
Prone jacknife Acetic acid cut them out with scissors fulurate with bovie
Bronchoalveolar Lavage
100% O2 insert bronchoscope inject 10cc saline aspirate into leukin trap: send for, aerobic, anaerobic, fungus, cytology
Bronchoscopy
100% O2 insert bronchoscope Identify carina identify the right upper middle and lower segments identify the left upper (superior and lingular) and lower segments
Colonoscopy
Sedate with versed and fentanyl DRE and external anal exam Check the scope function: insufflation, wash, suction Insert scope and advance all the way to cecum: need to see TI and appendiceal oriface Withdraw for at least 6 minutes checking everything Retroflex in rectum
Esophagogastroduodenoscopy
Sedate with versed and fentanyl Place bite block device and anesthesize oropharanyx with cetacaine pass scope by staying in midline and following tongue down Advance scope all the way to 3rd portion of the duodenum then withdraw slowly Find the ampulla, examine stomach, retroflex and look for hiatal hernia Desufflate stomach withdraw through esophagus inspecting closely for lesions barrett’s etc
Laryngoscopy
Pick nare that moves air better Check scope Anesthesize with viscous lidocaine Pass scope down nose to pharynx Examine cords as patient phonates and coughs
Proctoscopy and Sigmoidoscopy
Position patient on procto table perform DRE check scope, place obturator in scope introduce scope, insufflate and look for lesions
Axillary Sentinel Lymph Node Biopsy
Radiotracer injection of technicium sulfur colloid with nuclear medicine Methylene blue dye injection right before surgery Do probe mapping to mark out the sentinel node Usually incision is along inferior aspect of hair bearing area, 2cm Open axillary fascia follow blue stained lymphatic channels and use probe to identify sentinel node Remove: palpable nodes, nodes with blue going to them, nodes with activity >10% of the hottest node, ok to stop after 5 nodes
Axillary Lymph node dissection
Incision at inferior edge of hairline, extend from pec to lat Raise flaps to expose pec and lat Open clavipectoral fascia along edge of pectoral muscles Dissect out all the fibrofatty tissue within pec major (under pec minor is level II, medial to pec minor is level I), lat, subscapularis, axillary vein Preserve the intercostalbrachial (numbness), medial pectoral (pec Major), thoracodorsal (supplied lat, pullups), and long thoracic nerves(supplies serratus, winged scapula) Mark specimen (axillary vein margin and lateral margin)
Breast Biopsy with or without Needle Localization
Make incision in skin crease if lesion is superior, make incison radial if lesion is inferior Divide breast tissue to point 1.5cm anterior to breast tissue, raise flaps at depth of tumor as opposed to subcutaneously Excise lesion surrounded by 1-1.5 cm of normal breast tissue Orient the specimen
Breast Cyst - Aspiration
Local antesthic Ultrasound guidance Aspirate: send cytology
Duct Excision
Attempt to express discharge make areolar incision 1/3 circumference encompassing quadrant of discharge insert lacrimal duct probe into discharging duct Excise duct containing probe with margin from just below the nipple dermis into the deep breast tissue (4cm down) If no single secretion-filled duct is identified, entire subareolar duct complex must be excised (4cm down)
Mastectomy - Partial
Make incision in skin crease if lesion is superior, make incison radial if lesion is inferior Divide breast tissue to point 1.5cm anterior to breast tissue, raise flaps at depth of tumor as opposed to subcutaneously Excise lesion surrounded by 1-1.5 cm of normal breast tissue Orient the specimen, x-ray the specimen to confirm abnl if applicable take additional cavity margins Clip the cavity
Mastectomy - Simple, Modified Radical, and Radical
Eliptical incision including nipple areolar complex Raise skin flaps: clavicle, sternum, rectus, lat Incise pec major fascia, remove breast and this fascia off the muscle Place drain Modified radical: Proceed with axillary lymph node dissection Radical: Take pec major and minor
Parathyroidectomy
Basline PTH level Preop ultrasound transverse cervical incision 1cm inferior to cricoid cartiledge subplatsymal flaps, separate straps and dissect them off the thyroid Ligate middle thyroid vein Look parathyroid glands close to inferior thyroid artery and RLN: superior is deep to plane of nerve, inferior is superficial to plane of nerve Excise the adenoma, check an excision, 5 min and 10 min parathyroid level to ensure 50% drop
Thyroidectomy - Partial or Total
transverse cervical incision 1cm inferior to cricoid cartiledge subplatsymal flaps, separate straps and dissect them off the thyroid Ligate middle thyroid vein Take superior pole vessels Take inferior pole vessels Find RLN carefully trace up it Identify and preserve parathyroids by performining capsular dissection divide ligament of berry and remove thyroid from the airway
Ultrasound of the Thyroid
Ultrasound the thryoid parynchema, the central neck, and the lateral neck
Melanoma - Wide Local Excision
Select margins: <1mm= 1cm, no SLNB, 1-4mm=2cm+SLNB, >4mm 2cm margin no SLNB
Pilonidal Cystectomy
isloate the sinsus tract Completely excise down to the sacral fascia pack with WTD
Sentinel Lymph Node Biopsy for Melanoma
Radiotracer injection of technicium sulfur colloid with nuclear medicine Methylene blue dye injection right before surgery Map the tracer: it can go to weird places
Skin/Soft Tissue Lesions - Excisional and Incisional Biopsy
cut it out
Soft Tissue Infections - Incision, Drainage, Debridement
cut it out, pack as necessary
Airway Management/Ventilator Management
Initial vent settings: Mode: SIMV, FiO2: 100%, TV: 7mL/Kg predicted body weight (based on height), PEEP: 5
Arterial Catheter Placement
occlusion test ultrasound guidance cannulate radial artery or femoral artery transduce the signal
Central Venous Catheter Placement
Ultrasound guidance in the LIJ If ultrasound machine is broken L subclavian, identify jugular notch, identify middle of clavicle, 30 degree angle with needle walk down clavicle, get venous blood, thread wire, incise skin, dilate skin and vein, thread catheter in over wire to 17cm order chest xray
Compartment Pressures (Abdomen, Extremity) - Measurement
Hook up pressure line to 20G needle, zero the system, stick the different compartments to get pressure readings Anything above 40mmHg is diagnostic of acute compartment syndrome
Damage Control Laparotomy and Management of the Open Abdomen
Do damage control including packing, shunting, excluding temporary abdominal closure cut an xray-extemity bag, cut vents in it, isolation bag into a sheet and place under fascia Kerlex around fascia wraped 3 times place 2 JP drains rolled into kerlix put ioban on top of everything hook JPs to low continuous suction
Defibrillation and Cardioversion
Synchronized cardioversion: 100J Defibrillation: 200J, manufacturer rec, or max available if unknown
Endotracheal Intubation
Don’t give sux for burn or crush injury Preoxygenate etomidate sux or rocuronium if burn or neuromuscular injury tube the patient confirm end-tidal CO2
Enteral Feeding Tube Placement
pick favorable nare measure tube xiphoid to ear to nare have patient swallow as you place tube inject air and listen to stomach get chest X-ray when done
Invasive Hemodynamic Monitoring
Normal Swan Values
Oxygen Administration Devices
Nasal canula, Face mask, bag-valve mask positive pressure, CPAP, BIPAP, endotrachial intubation
Paracentesis
Ultrasound guidance RLQ replace albumin (how much?) for large volume Send for PMNs, albumin, GS, Glucose
Pulmonary Artery Catheter Placement
RIJ cordis Test balloon Inflate and float the swan Look for waveform changes: RA is short amplitude, RV is wide amplitude, PA is dicrotic, Wedge is short amplitude
Thoracentesis
Sit the patient up with elbows resting on a table Entry point is right below inferior angle of the scapula
Ultrasound Use for Intravascular Access
Put sterile cover on the probe
Urinary Catheterization
pre wash the area, then sterile scrub
Vena cava repair
R Medial visceral rotation: compress cava proximally and distally with large spongesticks, suture with 3-0 prolene
Abdominal Aorta repair
Get proximal control by clamping the distal thoracic aorta through the hiatus: Midline supramesocolic: L Medial visceral rotation: Mobilize descending colon, extend cepalad to mobilize spleen, kidney, pancreas medially and obtain access to aorta Midline inframesocolic: Right-sided Medial visceral rotation: Kocher, extend to white line of toldt, incise small bowel mesentery up to ligament of trietz Aorta: suture repair with 2-0 prolene, if that doesn’t work quickly sew in a dacron interposition graft, damage control other injuries, and get out
Bladder Injury - Repair
Damage control with running suture or just foley and packing bladder is ok Definitive repair: two layers, vicryl inner, pds outer Drain with Foley
Cardiac Injury - Repair
Cut the inferior pulmonary ligament Open pericardium longitudinal to phrenic nerve Deliver heart into open chest Damage control: Staple, side bite clamp, foley in hole Suture repair: 4-0 prolene interrupted, deep but not full thickness Mattress stitch around coronary arteries if necessary Ligate lacerated coronary arteries If heart stops: cross clamp aorta, inject 1mg epi to induce fibrillation, shock with 30 Joules
Carotid Artery Injury - Repair
Prep neck, chest, thigh for vein harvest Position pt with neck extension Incision over anterior border of the SCM Gain anterior border of the SCM Find IJ dissect up to the facial vein, ligate it identify and occlude common, internal and external carotid Do thrombectomy with #3 Fogarty Bovine pericardium patch repair with 5-0 prolene Leave a drain
Duodenal Trauma - Management
Kocherize duodenum Assess injury: easy to access, hard to access, or near-transection easy to access: suture laceration closed transversely: 2 layers: PDS and silk, interrupted hard to access: open duodenum and repairing from inside if hole is in a difficult spot near-transected: try to bring together end to end, last resort is closing around drain to create a controlled fistula pyloric exclusion for combined injuries: longitudial incision in stomach just proximal to antrum, grab pyloric ring and oversew it with 0 PDS, do a gastrojejunostomy
Esophageal Injury - Operation
Left incision anterior border of SCM Divide omohyoid, middle thyroid vein, middle thyroid artery Debride the wound repair in 1 layer with pds If bad injury that can’t be repaired, externalize the esophagus Leave a drain
Exploratory Laparoscopy
Position with foot board and securing straps to allow reverse T supraumbilical hassan two more 5mm in lateral abdomen Inspect for diaphragmatic injury: this is extent of my comfort level with exploratory laparoscopy for trauma
Exploratory Laparotomy
Enter abdomen with generous midline laparotomy: knife and scissors Pack 4 quadrants: liver, spleen, left lower quadrant, right lower quadrant Place a self-retaining retractor Run the bowel for LOT to the rectum Inspect inframesocolic and supramesocolic central retroperitoneum (zone 1), lateral (zone 2) and pelvic (zone 3)
Lower Extremity Fasciotomy
Lateral incision 2cm posterior to posterior tibia Identify septum separating anterior and lateral compartments Incise fascia of anterior compartment longitudinally 5cm Incise fascia of lateral compartment 5cm , limiting amount of proximal fascial incision because superficial peroneal nerve is just beyond head of fibula Medial incision 2cm beyond posterior tibia in soft part of the leg Incise the superfiscial fascia 5cm, retracting gastroc posteriorly Take down attachments of the soleus muscle to the posterior aspect of the tibia (watch out for postierior tibial vessels)
Upper Extremity Fasciotomy
Lateral incision from deltoid insertion to lateral epicondyle find intermuscular septum between anterior (biceps, brachialis) and posterior (triceps), release each compartment with longitudinal incisions, protecting radial nerve as passes through intramuscular septum Forearm: make a dorsal incision and a volar curvilinear including wrist incision: release volar, dorsal, and mobile wad
Focused Abdominal Sonography for Trauma (FAST)
Look at 4 views: Cardiac via subxiphoid, RUQ Morrison’s pouch (hepatorenal recess), LUQ Splenorenal recess, Supropubic bladder
Gastrointestinal Tract Injury - Operation
Debride Repair in 2 layers: PDS inner, silk outer
Neck Exploration for Injury
Left incision anterior border of SCM Dissect down anterior border of SCM, dissect along IJ and ligate the facial vein to access the carotid Divide omohyoid, middle thyroid vein, middle thyroid artery to obtain exposure to the esophagus Repair small airway injuries with interrupted 3-0 pds Put a trach tube in a big injury as a bail out Leave a drain
Pancreatic Injury - Operation
Kocher manuever or even Cattell-Braasch If injury is distal, get at it through lesser sac do stapled distal pancreatectectomy and splenectomy If there is suspicion of a ductal injury, focus on draining it and getting ERCP immediately after If there is a transection, close the pancreatic stumps and drain it Feeding jejunostomy for any major pancreatic head injuries
Hepatic Injury - Packing and Repair
3 options for temorary control: manual compression, temporary packing, Pringle maneuver: poke hole in avascular omentum to left of porta, go around with finger and pinch, replace with vascular clamp Rule out retrohepatic venous bleeding before mobilizing the liver Mobilize liver: divide falciform ligament and release it all the way up to the diaphragm Divide left or right triangular ligament, continue incision into anterior and posterior coronary ligaments Try to cauterize Suture with 0-chromic on large blunt needle Pack and get out, angioembolize Hepatotomy with selective vascular ligation, fill dead space with omentum Resectional debridement
Renal Injury - Repair/Resection
Perform medial visceral rotation on the left or the right Incise gerota’s fascia laterally and lift kidney out of its bed palpate the contralateral kidney prior to nephrectomy Vascular repair artery with 6mm ePTFe interposistion graft Tie the vein, suture ligate the arterty, ligate the ureter between clamps
Splenectomy/Splenorrhaphy
Mobilize the spleen to the midline with fingers and scissors, devide splenorenal and splenophrenic ligaments Decide to repair or excise: repair a kid, everyone else I would just take it out Isolate the vascular pedicle and staple with a vascular staple load
Temporary Closure of the Abdomen
cut an xray-extemity bag, cut vents in it, isolation bag into a sheet and place under fascia Kerlex around fascia wraped 3 times place 2 JP drains rolled into kerlix put ioban on top of everything hook JPs to low continuous suction
Thoracoscopy for Management of Hemothorax
Lateral decubutus position Single lung ventillation Ports: midaxillary line 5th intercostal space and 5th intercostal space near lateral border of scapula Extract clot, Wash out retained hemothorax
Ureteral Injury - Repair
Consider perc neph and getting out Try to primarily, don’t dissect it out much, spatulate, repair over stent, use 5-0 PDS lower 1/3: psoas hitch middle 1/3: transureteroureterostomy upper 1/3: autotransplantation of kidney, bowel interposition
Wounds, Major - Debride/Suture
Wash out wound with saline Debride devitalized tissue Close in layers with interrupted suture
Truncal and Peripheral Vessels - Repair
Hosing groin: generous vertical groin incison start 3cm superior to inguinal ligament, over the pulse or halfway beween tubercle and ASIS. Incise fascia lata and femoral sheath, find inguinal ligament, cut inguinal ligament if you need to get proximal contol at iliac, identify and control common femoral, superficial and profuna femoral, patch or interpostion graft repair, swing sartorius or gracillis over the closure, Shunt and fasciotomy is a good bail out move Superficial femoral repair: medial incision overlying the sartorius, retract sartorius anteriorly and open white roof of Hunter’s canal, do shunt, patch or interposition graft Popliteal: Start with fasciotomy, incision lower medial thigh, Incise fascia posterior to posterior border of femur, palpate pulse back there, gain control of proximal popliteal artery, make separate medial incision 1cm behind border of tibia, beginning at level of knee, cut deep fascia and dissect to the vein, 100u/kg heparinize if no associated injuries, bypass and exclude the injured popliteal segment with reverse saphinous vein graft Below knee arterial injury: one of three leg arteries open to foot is good enough, angiographic embolization is good, RSV interposition graft from contralateral ankle of posterior tibial artery Axillary artery: incise below clavicle, cut pec fascia and go through muscle, identify axillary vein and artery is just deep and superior to it, ligate thoracoacromial artery, reconstruct with RSVG from thigh or bail out with shunt and fasciotomy Brachial artery: medial upper arm incision along groove between biceps and triceps, retract median nerve, repair with ankle saphenous vein or bail with ligation and fasciotomy
AAA Open
Retract t colon cranially, SB Right, and Sigmoid to left Kocherize duodenum find L renal vein, finger dissect to the infrarenal aorta, test clamp it Expose the iliac arteries, femorals if necessary 100u/kg heparin, then apply iliac clamps 1st, infrarenal clamp 2nd Open the aneurysm, evacuate thrombus, over-sew lumbars Place straight or bifurcated Dacron tube graft, sew with 3-0 prolene, flush prior to completing Reimplant IMA if back bleeding pressure is less than 40mm or if the patient has had a previous colon operation Check bowel viability Palpate femoral pulses
EVAR
Confirm adequate aortic neck anatomy: want at least 15mm of length and diameter at most 23mm Obtain access in the bilateral femoral artery with ultrasound, place closure devices and sheaths Heparinize with 100mg/kg Use a comercially available sheath and measurement system and deploy the graft, use additional iliac extensions as necessary Perform balloon angioplasty of the proximal attachement zone, the graft overlap sites, and the distal attachment zones Perform completion angiogram: look for endoleak type I (graft edge) reballoon, place expandable stent, type III defect in fabric or junction: covered stent
Amputations -BKA
BKA: Incise 10cm inferior to tibial tuberosity. Anterior invision is 2/3 leg circumference. Make a big posterior flap Divide muscles, expose fibula 3cm above the incision Identify and divide anterior tibial nerovascular bundle in the lateral leg Identify and divide the posterior tibial and peroneal vessels in the medial leg Saw the tibia and fibula Use amputation knife to cut gastroc and soleus muscles in a tapered fashion on the posterior flap
AKA
Incision: Fish mouth mid thigh Ligate GSV in inner thigh Ligate the femoral vessels medially Expose femur 10cm proximal to incision with periosteal elevator Ligate sciatic nerve in the posterior thigh Divide femur 10cm above the skin incision
Aortofemoral Bypass
Make bilateral groin incisions isolate common femoral artery, superficial femoral artery, and profunda femoris artery bilaterally Midline laparotomy: T colon up, SB right, Sigmoid left, Kocherize duo, follow L renal vein to infrarenal aorta isolate the infrarenal aorta Heparinize Clamp infrarenal aorta proximally and distally Sew graft to side of aorta with 3-0 prolene tunnel the birfurcated graph under the ureters along the native vessels obtain proximal and distal control of the bilateral femorals and sew to the bifurcation bilaterally
Embolectomy/Thrombectomy - Arterial
Patient should be heparinized at time of diagnosis For lower extermity thrombus, start with standard groin incision to access femoral (#4 Fogarty), then go to medial upper calf incision to access below knee popliteal (#3 Fogarty) Obtain proximal and distal control Make transverse arteriotomy Pass a 4 Fogerty (for lower extremity) as far distal as it will go, then inflate balloon and withdraw, repeat until no clot after 2 passages of the balloon Go proximal and distally Close arteriotomy with interrupted 6-0 prolene sutures, flush the closure Perform completion angiogram
Extra-anatomic Bypass
Transverse incision 2cm inferior to the clavicle bilateral vertical groin incisions 2 fingerbreadths lateral to pubic tubercle (Modify this if you are bypassing infected iliac graft and approach from lateral position) Split the pec to get down to the axillary vascular bundle, expose the axillary artery, control with vessel loops Isolate common, superficial and profunda fermorals with vessel loops (if bypassing infection go lateral to sartorius and isolate distal profunda tunnel 8mm ePTFE graft heparinize with 100u/kg Sew in axillary and femoral ends of graft with 5-0 prolene
fem-fem bypass
Vertical groin incisions 2 fingerbreadths medial to pubic tubercle Isolate common femoral, superficial femoral, and profunda femoral with vessel loops tunnel 8mm ptfe graft suprapubically Heparinize with 100u/kg sew in graft with 5-0 prolene, flush before unclamping Doppler the distal pulses
Femoral-popliteal Bypass
Vertical groin incision 2 fingerbreadths medial to pubic tubercle Medial thigh incision just above knee: open facia overlying the popliteal space Separate popliteal artery from the vein and the tibial nerve Harvest GSV from same side, ligating tributaries Reverse it and leave path of vein in-situ Heparinize with 100u/kg Get proximal and distal control of femoral and sew in graft with 5-0 prolene Get proximal and distal control of popliteal and sew in graft with 6-0 prolene Flush prior to completing the anastomosis Unclamp Shoot completion angiogram
Infrapopliteal Bypass
Prep both groins and entire affected leg Dissect out infow: almost always common femoral via standard groin incision Dissect out target: medial calf incision for peroneal and posterior tibial, lateral calf incision for anterior tibial Harvest sapheonous vein Clamp and Sew end-to side to femoral with 5-0 prolene Clamp and sew end-to-side to target vessel Perform completion angiography
Sclerotherapy - Peripheral Vein
Start with conservative therapy: elevation, compression, wound care of statsis ulcers Target refluxing vessel with duplex ultrasound Inject foam sclerosant to destroy endothelium of target vessel
Vena Caval Filter - Insertion
Access femoral vein Place 8.5 Fr sheath Advance catheter and perform cavography to ensure patency of IVC and locate renal veins Advance sheath to region of planned deployment, below the lowest renal vein Advance filter within sheath to sheath end Draw sheath back to expose filter and release the filter hook Perform completion cavography
Venous Insufficiency/Varicose Veins - Operation
Perform small cutdown on source of reflux Anteromedial groin incision: (saphenofemoral junction is just medial to femoral artery below groin crease) (lesser saphenous incision made posterior calf over saphenopoliteal junction) place external stripper through the saphenous system, have it exit through counder incision, attach stripper head distally, strip GSV from groin to knee using inversion technique Remove clusters of varicose veins through stab evulsion technique: tiny stab incision, vein hook
AV Graft
Indication is inability to place AV Fistula Use ultrasound to find and mark the brachial artery and the target vein (cephalic (lateral to biceps) or basilic (medial to biceps)) Transverse incision below elbow in antecubital fossa isolate 4cm of target vein Divide bicep aponeurosis in cruciate configuration Separate bracheal artery from the paired veins and isolate 3cm Select and size a tapered 4 to 7mm PTFE graft, sew 4mm end to arterial inflow (prevents steal), 7mm to the venous inflow Use semicirular tunnelling device to tunnel graft in subcutanous tissue distally to create an oval tunnel Perform venous anastomosis: clamp, venotomy, with end to side 6-0 prolene, use 7mm end of the graft Perform arterial anastomosis: clamp, arteriortomy, end to side 6-0 prolene, use 4mm end of the graft Remove clamps, check for thrill in outflow vein Wait 8 weeks to puncture the graft for dialysis
AV Fistula
Most important vein to remember: cephalic. It is on thumb side and goes all the way up the lateral arm Start with nondominant arm Ultrasound upper extremity physiologic evaluation to rule out arterial insufficiency. Artery must be 2.0mm or greater and have antegrade flow Ultrasound vein mapping to rule out stenosis or thrombosis of cephalic vein. Vein must be 2.5mm or larger for AVF and 4.0mm or larger for AVG Use ultrasound to mark distal forearm course of radial artery and cephalic vein. 5cm longitudinal incision between the radial artery and cephalic vein Isolate cephalic vein for 5-6cm, ligating small branches Isolate radial artery Ligate cephalic vein distally, put clamp on it proximally Proximal and distal radial artery control, 2mm arteriotomy, end-to-side anastomosis with 7-0 prolene remove clamps Feel for thrill in vein
Percutaneous Vascular Access
Access Right IJ, tunnel it
Venous Access Devices - Insertion
Access Right IJ percutaneous access, clamp wire Make subcutaneous pocket, seat port in the pocket to make sure it fits Sew in port with 2-0 prolene to pectoralis fascia Pass tunnelling device from port pocket to the venotomy site (small incision), attach port end of catheter to tunneller and pull catheter into pocket Dilate vein with dilator/peel away sheath, then pass venous end of catheter into the vein, peel away the sheath, use fluro to get it to caval/atrial junction, clamp the catheter at venotomy to prevent air embolism cut catheter close to port and attach to port using the catheter lock sew in the ports, confirm good placement with fluoro Postop chest X-ray
Chest Tube Placement and Management
Select chest tube: trauma: 36Fr, simple pneumo 20Fr Abduct arm Use triangle of safety: Pec, Lat, inframammary fold/nipple= 4th-5th intercostal space in anterior axillary line (incision should be one interspace below) Anesthesize subq and periosteum
Exploratory Thoracotomy
Single lung ventillation on the oposite side Find Sternal Angle and rib number 2, below rib 2 is 2nd intercostal space, count down Anterolateral thoracotomy through 4th intercostal space on side of concern (should be just below the nipple, going just inferior to pec muscle), cut from sternal border to midaxillary line Tie the transected ends of the internal mammary artery Cut the inferior pulmonary ligament Explore Leave chest tubes
Exploratory Thoracostomy
Lateral with exploration side up Single lung ventillation Ports in the middle (7th space), anterior(5th space), and posterior axillary (5th space) lines Explore Leave chest tubes
Partial Pulmonary Resections - Open
Position lateral with lesion side up Single lung ventillation Incision extends from medial scapular border posteriorly to anterior axillay line just below the nipple, following the contour of the 5th intercostal space Grasp lung and wedge it out for a biopsy Lobectomy: 1st dissect out appropriate pulmonary vein and ligate it with vascular stapler, dissect out pulmonary artery and divide it with vascular stapler, finally dissect out and divide lobar bronchus and divide with green load 4.5mm stapler Take lymph nodes with the specimen Perform saline leak test Leave chest tubes
Partial Pulmonary Resections - Thoracoscopic
Lateral with lesion side up Single lung ventillation Ports in the middle (7th space), anterior(3rd space), and posterior axillary (5th space) lines Grasp lung and wedge it out for a biopsy Lobectomy: 1st dissect out appropriate pulmonary vein and ligate it with vascular stapler, dissect out pulmonary artery and divide it with vascular stapler, finally dissect out and divide lobar bronchus and divide with green load 4.5mm stapler Take lymph nodes with the specimen Perform saline leak test Leave chest tubes
Pericardial Window for Drainage
8cm incision made over xiphoid Excise the xiphoid Finger dissect into the retrosternal space till you get to diaphragmatic aspect of the pericardium Grasp pericardium with clamp Sharply open pericardium, aspirate, break loculations with finger, biopsy the pericardium Insert tube into pericardial space through separate stab incision
Inguinal Hernia - Repair
Pediatric inguinal hernias are always recommended to be repaired Incise over the external ring open lateral aspect of the external oblique and carry towards external ring Only divide external ring if you need the exposure Gently dissect out the cord with blunt moves parallel to direction of cord Pass hemostat behind cord to elevate hernia and cord into operating field Incise the cremasteric musles overlying the cord Incise the internal spermatic fascia Find and gently hold the herina sac anteromedially, dissect spermatic vessels and vas deferens off the hernia sac Dissect towards internal ring until preperitoneal fat at neck is exposed Twist the sac, do high ligation with a transfixing 5-0 vicryl suture, excise the redundant sac, allow proximal sac to rectract underneath external ring Close any attenuated external oblique muscle or divided external ring Return testicle to scrotum
Intussusception - Operation
Veress technique at infraumbilical, place 5mm ports infraumbilical, suprapubic, left lower quadrant Insufflate to 10mm Identify intussusception in cecum or descending colon Milk back tip of intussusceptum toward cecum if necessary Gradually distract intussuscepted small intestine from surrounding colon Look to see if you need to resect the bowel Bowel resection: exteriorize bowel through umbilical port, ileocecal resection with 1 layer end to end anastomosis: 2 stay sutures, seromuscular bites for an extra mucosal bowel anastomosis, 5-0 PDS
Malrotation - Operation
Right sided transverse supraumbilical incision Eviscerate bowel Go to root of mesentery, unwrap torsion counterclockwise until duodenum is on the right side of the colon and they are parallel to each other Assess for viability: if entire midgut is dead, close and talk to family, do comfort care Identify Ladd bands from ascending colon to duodenum, divide adjacent to wall of bowel Mobilize entire duodenum with Kocher maneuver Check for duodenal obstruction with a 10Fr NG tube Perform appendectomy Place duodenum in right gutter and cecum on left side of abdomen
Meckel’s Diverticulum - Excision
Veress technique at infraumbilical, place 5mm ports infraumbilical, suprapubic, left lower quadrant Insufflate to 10mm Identify diverticulum in the ileum Exteriorize bowel through infraumbilical port and perform segmental bowel resection with hand-sewn extramucoasal bowel anastomosis, 5-0 PDS, stay sutures at each end, not tied until end, and then interrupted seromuscular sutures 4mm apart all the way around
Pyloromyotomy
Ultrasound confirmation: pyloric channel length >14mm, pyloric muscle width >4mm Resuscitate with saline and replete electrolytes access with infraumbilical veress, place 5mm port there place additional 5mm ports in LUQ and RUQ Locate pylorus, incise with knife set to 3mm depth, start incision just proximal to vein of mayo, extend proximally for 3cm across pylorus onto antrum Use pyloric spreader instrument to spread muscle fibers until mucosa bulges out
Umbilical Hernia - Repair
See if the hernia will close on its own until the child turns 5 Curvilinear incision inferior to umbilicus Take down umbilical stalk Primary repair of defect with 4-0 vicryl
Complex Wound Closure
Irrigate Debride devitalized tissue Close in 2 layers
Skin Grafting
Use lateral thigh as donor area Set dermatome to 12/1000inch thickness Use 45degree angle to harvest skin Mesh the graft Apply graft to recipient site dermal side down Fix edges in place with staples Place xeroform gauze on recipent site and cover with sterile gauze dressing, leave on for 5 days Place tegaderm over donor site
Cystostomy
Percutaneous if ultrasound and kit are available Cut down onto bladder Place a vicryl purse string insert foley, tie purse string Tack bladder to abdominal wall externalize foley drain
Hydrocelectomy
transverse incision across hemiscrotum with hydrocele Open dartos fascia Bluntly develop plane between tunica vaginalis and dartos Deliver testicle into operative field Open tunica vaginalis in the midline and drain the hydrocele fluid, widely open the tunica vaginalis invert edges of cut tunica vaginalis around spermatic cord, sew edges together with 3-0 chromic suture proxima to testicle
Nephrectomy
Perform medial visceral rotation on the left or the right Incise gerota’s fascia laterally and lift kidney out of its bed Tie the vein, suture ligate the arterty, ligate the ureter between clamps Remove kidney from attachments
Orchiectomy
Inguinal incision incise external oblique Isolate spermatic cord Deliver testicle into operative field Identify gubernaculum, and ligate it Ligate the vessels and the vas separately, ligate cord as close to internal ring as possible
Ureteral Injury, Iatrogenic - Repair
Consider perc neph and getting out Try to primarily, don’t dissect it out much, spatulate, repair over stent, use 5-0 PDS lower 1/3: psoas hitch: relaxing incision anterior bladder transversely, sew posterior bladder to psoas, reimplant ureter over stent, close relaxing incision longitudinally middle 1/3: transureteroureterostomy upper 1/3: autotransplantation of kidney, bowel interposition
Hysterectomy
Dorsal lithotomy lower midline laparotomy Incise Left and Right Round ligaments to enter broad ligaments Identify ureters bilaterally Divide ovarian ligaments and suture lig to preserve the ovary Dissect posterior bladder off the uterus Clamp the uterine arteries at the level of the cervix, check position of ureter, then transect the uterine arteries Incise vagina at level of cervix over clamps, remove specimen, suture vaginal cuff closed with locking 2-0 vicryl
Salpingo-oophorectomy
Dorsal lithotomy lower midline laparotomy Incise Left and Right Round ligaments to enter broad ligaments Identify ureters bilaterally ligate infundibulopelvic ligament Make window though mesosalpinx, clamp suspensory ligament of the ovary, ligate mesosalpinx vessels, ligate suspensory ligament of ovary, remove ovary and tube Re-approximate round ligament to cornu of uterus, carrying suture line down to join cut edge of mesosalpinx and broad ligament
Cricothyroidotomy
Stablilize larynx with left hand vertical midline Incision over cricothyroid membrane Incise cricothyroid membrane, dilate with hemostat Place a 6mm ET tube Confirm ET CO2, chest rise Sew tube in place Convert to trach in 24-48 hours
Lymph Node Biopsy
Locate lymph node with ultrasound or palpation Incise along medial border of SCM Get through playtsma and make subplatysmal flaps Develop SCM plane, divide omohyoid if necessary Dissect along jugular, move jugular lymph node medially if necessary find lymph node and get it out
Tracheostomy
Hyperextend neck, use shoulder roll and get donut horizontal incision 1 fingerbreath above sternal notch separate strap muscles vertically down the midline Dissect below thryoid isthmus, if you have to divide the isthmus, oversew it with a runing suture Incise between second and 3rd ring with trap door sides extending down Oxygenate to 100%, Pull ET tube back to subglotic space to make room for the trach tube Insert No 6 Shiley, inflate cuff, hook to circuit, confirm ETCO2 Close skin, suture flange to skin Remove ET tube Get postop chest XRAY
Nerve Block - Digital
Use 25g needle and 1/2%Marcaine NO EPI, 1. Hand palm down 2. Inject into webspace just distal to MP joint on both sides of affected finger
Nerve Block - Intercostal
Landmark: Angle of rib (7cm lateral to spinous process) Insert 22g needle under rib with 30degree cephalad angulation, want tip of needle to be 0.5cm past inferior border of rib Give 5mL of 1/2%marcaine with epi per intercostal level
