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ABS > CORE PROCEDURES > Flashcards

CORE PROCEDURES Flashcards

1
Q

Intra-abdominal abscess: drainage

A

Hassan technique
Break into abscess cavity
Culture abscess
Place closed suction drain in cavity, exteriorize

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2
Q

Peritoneal dialysis catheter insertion (LAP)

A

Veress through LUQ
5 mm tracer through R abdomen with placement of 5 mm 30-degree scope
8 mm trocar placed to left of midline (between pubic symphysis and umbilicus)
Catheter passed through 8 mm trocar on stylet and positioned in the pelvis
2-0 vicryl suture placed to anchor deep cuff in place above peritoneum
SQ tunnel created for superficial cuff
Catheter flushed with heparinized saline

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3
Q

Peritoneal lesion - biopsy

A

Access to abdominal cavity
Diagnostic laparoscopy/laparotomy
ID lesion of interest
Excise/biopsy lesion with sharp excision
Mark and send specimen (s) to path

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4
Q

Components separation

A

Midline lap
Reduction of hernia sac/abdominal wall contents
Full LoA
Debride fascia
Create subcutaneous skin flaps
Incise EO fascia
Develop retrorectus/preperitoneal space
Close posterior sheath
Place retrorectus mesh
Bring midline together
Place drains in SQ space

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5
Q

Inguinal hernia - repair

A

Oblique incision along pubic tubercle/ASIS line
Dissect through skin/SQ tissue until EO aponeurosis IDed
Incise external oblique aponeurosis in the direction of its fibers
Encircle spermatic cord with penrose drain
Evaluate and reduce direct, indirect, and femoral hernias, preserving spermatic cord structures
Lichtensein: separate IO from overlying EO aponeurosis. Sheet of polypropylenne mesh fit to inguinal canal with slit or keyhole in lateral aspect for cord. Mesh should overlap pubic tubercle by 2 cm. Inferior and superior edges of mesh sutured to IO, two tails are sutured to inguinal ligament to recreate internal ring. EO closed over mesh and spermatic cord, avoid cord and nerve.
Bassini: conjoint tendon + transversus abdominis to inguinal ligament
Relaxing incision: incise anterior rectus sheath
Reduce testicle back into scrotum

McVay:
Approximate the edge of transverses abdomens aponeurosis to Coopers.
At the medial aspect of the femoral canal, a transition suture is placed to include the Cooper ligament and the iliopubic tract.
Working laterally, the transversus abdominis is secured to the iliopubic tract.
A relaxing incision is made by reflecting the EO aponeurosis superiorly and medially to expose the anterior rectus sheath. The incision is made in a curvilinear direction, 1 cm above the pubic tubercle toward the lateral border of the anterior sheath.
Shouldice:
The floor of the inguinal canal is repaired with running sutures. First, the transverse abdominis aponeurosis is sutured to the iliopubic tract.
The following running suture is used to secure the internal oblique and transversus abdominis to the inguinal ligament.

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6
Q

Femoral hernia - repair

A

Oblique incision along pubic tubercle/ASIS line
Dissect through skin/SQ tissue until EO aponeurosis IDed
Incise external oblique aponeurosis in the direction of its fibers
Encircle spermatic cord with penrose drain
Evaluate and reduce direct, indirect, and femoral hernias, preserving spermatic cord structures
Open inguinal floor (transversus abdominus)
McVay: conjoint tendon to Coopers, interrupted sutures, transition stitct incorporating inguinal ligament at femoral vein
Relaxing incision: incise anterior rectus sheath
Reduce testicle back into scrotum

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7
Q

Chole - OR

A

Infraumbilical hassan, 3 additional ports
Expose triangle of calot to obtain critical view of safety
Perform cholangiogram if indicated through cystic duct ductotomy (hx elevated LFTs, choledocholithiasis or gallstone panc, unsure about anatomy)
Clip and divide cystic duct and artery
Take gallbladder off the cystic plate

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8
Q

Cholecystostomy - OR

A

RUQ incision
Pursestring suture in GB
Enter gallbladder and place Foley catheter, inflate balloon
Tie pursestring secure around foley
Externalize drain

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9
Q

Choledochoenteric anastomosis

A

Identify LoT
10-20 cm distal to LoT, divide jejunum with stapler
Roux limb of 40-60 cm in a retrocolic fashion to the right of the middle colic vessels
Single layer duct to mucosa anastomosis with PDS suture
JJ anastomosis
Secure jejunum to transverse mesocolon, close LoT

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10
Q

Choledochoscopy - OR

A

Incise cystic duct (ductotomy)
Place wire, use balloon dilator to dilate duct
Hook choledochoscope up to saline, advance into duct
Visualize stones, extract with wire basket, drive scope into duodenum if necessary
Administer 1.0 mL glucagon PRN
Withdrawn scope, shoot completion cholangiogram

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11
Q

Splenectomy

A

Vaccinate for encapsulated organisms
45 degree R laterla decub
Hassan supraumbilical port
Look for accessory spleen tissue in hilum, omentum, greater omentum, tail pancreas, groin
Mobilize splenic flexure, divide splenocolic and splenorenal ligaments to elevate spleen anteriorly
Enter lesser sac by dividing greater omentum, divide short gastrics/gastrosplenic ligament
Take hilum with vascular stapler, taking care not to involve the tail of the pancreas
?consideration for drain placement

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12
Q

Partial splenectomy/splenorrhaphy

A

Pledgeted 2-0 Vicryl mattress sutures to repair isolated linear laceration in spleen
Apply topical hemostatic agent/omental plug
Low threshold for splenectomy

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13
Q

“Antireflux procedure”

A

Supraumbilical hassan
Enter lesser sac through pars flaccida
Dissect along R crus, completely reducing/excising any hernia sac
Ligate short gastrics and dissect along left crus
ID and protect anterior/posterior vagus nerves
Repair hiatus with 0 permanent suture
Create 2 cm floppy Nissen wrap (or partial wrap based on manometry), suture with 2-0 permanent suture over 56 Fr Bougie

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14
Q

Zenkers diverticulectomy

A

Incision along anterior border of left SCM
Retract carotid sheath elements/SCM laterally
Perform myotomy in the cricopharyngeus muscle, use right angle to elevate muscularis off of the mucosa
Staple off the diverticulum with a TA stapler fver a 56 Fr bougie or NG tube
Perform leak test

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15
Q

Esophageal perf - repair

A

USe swallow study (GG then barium) to find level of perforation
Anti-fungals, abx
Cervical: left chest incision; mid-esophagus: R chest 4th-6th intercostal space; distal esophagus: L chest 7th intercostal space
Medialize lung by taking down inferior pulmonary ligament
Open pleura over healthy esophagus, perform myotomy to evaluate extent of mucosal injury, debride edges of perforation
Stent esophagus with NGT
Close defect in 2 layers of absorbable suture over NGT
Buttress with strap muscles, pleura, pericardium or intercostal muscle
Place mediastinal/chest drains
If unable to repair, consideration for diverting spit fistula and enteral feeding tube

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16
Q

Paraesophageal hernia - lap repair

A

Supraumbilical hassan
Enter lesser sac through pars flaccida
Dissect along right crus, completely reducing/excising hernia sac
Ligate short gastrics and dissect along left crus
ID and protect anterior/posterior vagus nn
Repair hiatus with 0 permanent suture
Create 2 cm floppy nissen wrap, suture with 2-0 permanent suture over 56 Fr bougie

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17
Q

Paraesophageal hernia - open repair

A

Upper midline/epigastric incision
Enter lesser sac through pars flaccida
Dissect along R crus, completely reducing/excising any herniasac
Liate short gastrics and dissect along L crus
ID and rotect ant/post vagus nn
Repair hiatus with 0 permanent suture
Create 2 cm floppy nissen wrap, suture with 2-0 permanent suture over 56 Fr bougie

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18
Q

Duodenal perf - repair

A

Kocherize duo if necessary
Debride perforation and perform graham patch with silk sutures
Leave NG tube/closed suction drain

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19
Q

Gastrectomy - partial/total

A

Dx lap to ID advanced disease
Completely mobilize omentum off of transverse colon
Kocher maneuver
Ligate L/R gastric aa., R/L gastroepiploic aa., preserve short gastrics if cuff of stomach will remain**
Transect duodenum
Take all celiac, hepatic and splenic nodes with dissection to complete D2 resection
Recon alimentary tract
Place drains at duodenal stump, EJ/GJ anastomosis

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20
Q

Gastrostomy

A

2 box shaped purse strings with 2-0 silk, leave needle on
Incise stomach
Place 12 Fr foley, inflate balloon
Exteriorize foley through LUQ
Tie pursestrings once Foley through abd wall, pexy stomach to the abd wall in 3 places

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21
Q

Vagotomy and drainage

A

Incise pars flaccida and expose distal gus, putting penrose drain around it
ID anterior (coming from L) and posterior (coming from R) vagus nn and elevate iwth nerve hooks
Resect 1 cm of nerve between metal hemoclips, send to path for frozen section confirmation
Kocherize duodenum
Pyloroplasty: 4 cm longitud incision across pylorus, close transversely with interrupted 3-0 vicryl and silk lembert sutures
Alternative is antrectomy with GJ

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22
Q

Adhesiolysis

A

Identify LOT
Run small bowel to cecum, dividing adhesions sharply
Look for enterotomies and deserosalizations and repair transversely

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23
Q

Feeding jejunostomy

A

Elevate transverse colon to identify LoT
ID portion of midjejunum that goes up to anterior abdominal wall comfortably, approximately 30 cm distal to LoT
Fashion 2 concentric box sutures on antimesenteric jejunum, 3-0 silk, leave needles on
Incise jejunum and place 12 Fr red rubber catheter downstream
Exteriorize the red rubber catheter
Tie pursestrings and fix jejunum to anterior abdominal wall in at least 2 places, consider distal fixation at inferio aspect of feeding tube

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24
Q

Ileostomy

A

Preop skin marking avoiding belt line and any other skin lines
Pass penrose through mesentery of desired segment of ileum (20 cm prox to cecum)
Mark proximal and distal with suture
Incise nickle out of RUQ along rectus abdominis muscle
Bring penrose and loop through aperture, exchange for rod
Incise on antimesenteric border clos to the skin on distal side
3 3-0 chromic sutures full thickness to distal skin
Use back of pickup to invert the stoma (brooke)
3 3-0 chromic sutures full thickness to proximal skin

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25
Q

Ileostomy closure

A

Incise 1-2 mm of skin around ostomy
Dissect down to the bowel wall, freeing the bowel from abd wall
Use a 80 mm blue linear stapler on antimesenteric border and a TA-60 blue stapling device to close the opening in the common channel
Drop bowel back into abdomen, loosely close stoma site

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26
Q

Small intestinal resection

A

ID desired area of resection and come through mesentery right under bowel
Transect bowel with 60 mm blue stapler maintaining a bias to avid corner ischemia
Excise mesentery, harvest LN if CA operation
Excise antimesenteric corners of the stapler lines
Introduce a 60 mm blue GIA stapler and fire along antimesenteric border, ensure mesentery not involved, ensure hemostasis of staple lines
Offset staple lines and close common enterotomy with TA 60 stapler
Palpate for patency of anastomosis
Close mesenteric defect

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27
Q

SMA embolectomy/thrombectomy

A

Ignore dead bowel, embolectomy/thrombectomy first
Lift transverse colon, find middle colic and follow it to SMA
Heparinize (80 U/kg)
OBtain prox and distal control
Make transverse incision (embolectomy) or longitudinal incision (thrombectomy) in soft portion of SMA
Pass #4 fogarty until clear of clot x 2 consecutive passes
SHoot completion angio; if still occlusion then bypass from infrarenal aorta or R common iliac a to arteriotomy site
Close arteriotomy with interrupted 4-0 prolene (if embolectomy) or vein/graft patch (if thrombectomy)

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28
Q

Appendectomy

A

Preop foley placement to decompress bladder
Infraumbilical hassan, 5 mm supraumbilical, 5 mm LLQ
Free appy from surrounding structures
Make mesoappendiceal window
Take appendix with bowel load on linear stapler
Take mesoappendix with vascular load on linear stapler
Evaluate for hemostasis of staple lines
Remove appy with spcimen bag

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29
Q

Colectomy-partial

A

Incise white line of Toldt and mobilize colon from RP attachments
Mobilize hepatic/splenic flexure PRN
ID ureter, reflect laterally
Ligate vessels (usually need to take 2 named for formal resection) at base of mesentery, take lots of LN (goal = at least 12)

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30
Q

Colectomy - subtotal

A

Lithotomy position
Transect TI with linear stapler
Incise white line of Toldt on R, mobilize hepatic flexure
Enter lesser sac, take down splenic flexure
Incise white line of Toldt on the L, connect lateral mobilization
Findboth ureters and retract laterally
Ligate vessels and take mesentery
Dissect clearly distal to the rectosigmoid junction at sacral promentory or where teniae coalesce, excising surrounding mesorectum
Transect rectum with contour or TA stapler
Sew anvil into TI
End to end EEA stapler anastomosis
Completion proctoscopy with air leak test

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31
Q

Colostomy

A

Preop stoma site marking, avoiding belt line and any other skin folds
ID piece of colon for creation of ostomy, divide bowel or mark proximal and distal aspects of bowel
Excise 2 cm circular piece of skin along rectus abdominis muscle
Muscle split and make cruciate incision in anterior rectus sheath t accomodate 2 finger breadths
Exteriorize colon and excise the staple line, create ostomy along tenia
Full thickness bites to dermis with 3-0 vicryl, no brooke
size and apply ostomy appliance

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32
Q

Colostomy closure

A

Lithotomy position
Lower midline incision
ID anddissect out distal sigmoid stump
TAke down the ostomy by incising 1-2 mm of skin around stoma and separate from abdom wall
Mobilize splenic flexure if necessary
Freshen edges by restapling
EEA stapler anastomosis: sew anvil in proximally, put stapler through anus
PErform completion proctoscopy and leak test

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33
Q

Anal CA - excision

A

Mark out 1 cm margins around tumor (if >2 cm, need APR)
Remove skin down to SQ flap
Reconstruct with V-Y advancement flap

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34
Q

Anal fistulotomy/seton placement

A

Enema
Prone jackknife
Bilateral pudendal nerve blocks and 4 quadrant perianal block
Use Goodsalls rule and fistula probe/hydrogen peroxide injection to ID fistula tract
Fistulotomy (intersphincteric or transphincteric involving <1/3 internal sphincter): cut down on fistula probe, currett out epithelialized tract
Draining seton (transphincteric >1/3 internal sphincter): place a seton by tying vessel loop to probe and pulling it through then tying it to itself with silk suture

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35
Q

Anal sphincterotomy - internal

A

Enema
Prone jackknife
ID intersphincteric groove by palpation on R side of anal canal
Incise mucosa overlying intersphincteric groove
Develop intersphincteric plane with hemostat
Divide internal sphincter distal to proximal towards dentate, division of muscle to heihgt of fistula
Close mucosal defect with 3-0 vicryl

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36
Q

Anorectal abscess - drainage

A

Prone Jackknife
Elliptical incision overlying area of maximal induration
Send for culture (aerobic, anaerobic, gram stain)
Hemostat/irrigation to divide any loculations
Evaluate for hemostasis
Pack wound

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37
Q

Banding for internal hemorrhoids

A

Enema
Prone jackknife
Locate 3 hemorrhoidal bundles: R anterior, R posterior, L lateral
Load band on device, target vascular bundle just proximal to the hemorrhoid and fire above dentate line *dont do more than one column)

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38
Q

Hemorrhoidectomy

A

Enema
Prone jackknife
Elevate submucosal space with local
Incise perianal skin and undermine hemorrhoid complex, leaving sphincter down
Place clamp across hemorrhoid complex, sharply remove hemorrhoid
3-0 vicryl suture at vascular bundle, run up the clampt owards dentate line, remove clamp
Reapproximate mucosa by running 3-0 vicryl back towards proximal hemorrhoidal complex
Reapproximate anoderm with another 3-0 vicryl, leaving edge open for easy drainage

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39
Q

Perianal condylomas - excision

A

Prone jackknife
Acetic acid
Cut larger condyloma with scissors, mark location of biopsy for pathology
Fulgurate smaller collections with bovie

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40
Q

BAL

A

Place on monitor, pre-oxygenate with 100% O2
Fentanyl/versed for sedation
Insert bronchoscope, ID carina and R/L mainstem based on tracheal rings
Inject 10 cc saline at site of interest
Aspirate into leukin trap and send lavage for aerobic, anaerobic, fungus, cytology

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41
Q

Bronchoscopy

A

Place on monitor, preoxygenate with 100% O2
Fentanyl/versed for sedation
Insert bronchoscope, ID carina and R/L mainstem based on tracheal rings
ID RU (3), middle (2) and lower (5) segments
ID left upper (super/lingular, 5) and lower (5) lobe segments
Bx/lavage any areas of concern

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42
Q

Colonoscopy

A

Left lateral decubitus with knees flexed towards chest
Place on monitor, pre-oxygenate with 100% O2
Fent/Versed for sedation
Confirm colonmoscope functioning (light, suction, irrigation)
External anal exam and DRE
Insert scope and advance all the way to cfecum which is confirmed by identification of TI and appendiceal orifice
Withdraw for at least 6 minutes, bx any areas of abnormality and tattoo any areas concerning for malignancy
Retroflex in rectum to evaluate for hemorrhoids/masses in anal canal

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43
Q

EGD

A

Pisitoion pt on left side, partially elevated head of bed
Place on moniotor, pre-oxygenate with 100% O2
Fent/Versed for sedation
Confirm endoscope functioning (light, suction, irrigation)
Place bite block device
Pass scope by staying in midline, identifying oropharynx and following tongue down
ADvance scope all the way to 2nd portion of duodenum (right and downward motion at pylorus) then withdraw slowly
RAndom bx in antrum to rule out H pylori, any other areas of concern, retroflex to evaluate hiatus for HH/ulcers/masses
Desufflate stomach
Withdraw endoscope throuigh esophagus slowly, Barretts bx - 4 quadrants, 1-2 cm travel

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44
Q

Laryngoscopy

A

Pick nare that moves air better
Check scope
Anesthetize with viscous lidocaine
Pass scope down nose to pharynx with patient in sniffing position
E
xamine cords as patient phonates and coughs

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45
Q

Proctoscopy and sigmoidoscopy

A

Enema
Prone jacknknife
Perform external anal exam and DRE
Check scope (light source, insufflation) place obturator in scope, lubroicate
Introduce scope, insufflate and look for suspicious lesions circumferentially

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46
Q

Duct excision

A

Attempt to express DC in OR
Make periareolar incision 1/3 circumference encompassing quadrant of discharge
Insert lacrimal duct prbe into discharging duct
Excise duct containing probe with margin from just below the nipple dermis into the deep breast tissue (4 cm down)
If no single secretion filled duct identified, entire subareolar central duct complex must be excised (4 cm down)

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47
Q

Parathyroidectomy

A

Extend neck
Baseline PTH level
Collar incision 1 fingerbreadth above sternal notch
SUbplatysmal flaps, separate straps in midline and dissect them off the thyroid
Ligate middle thyroid vein
Look for parathyroid glands, close to inferior thyroid artery and RLN (superior deep/lateral to RLN and inferior anterior/medial to RLN)
Pre-excision PTH level
Excise adenoma, check PTH at 5 min and 10 min post excision for goal 50% drop
If 4 gland hyperplasia: remove 1/2 of first gland, remove 2 full glands,return to remaining 1/2 gland to confirm not ischemic, then remove remaining full gland
Autotransplantation morcellate remaining parathyroid and place into SCM or brachioradialis muscle

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48
Q

Thyroidectomy - partial or total

A

Extend neck
Collar incision 1 FB above sternal notch
Subplatysmal flaps, separate straps in midline and dissect them off the thyroid
Ligate middle thyroid v
Take superior pole vessels
Roll su[perior thyroid lobe to identify RLN
Take inferior pole vessels once RLN identified
Identify and preserve parathyroids by performing capsular dissection
Divide ligament of berry/isthmus and remove thyroid from the airway
Repeat on other side

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49
Q

US of thyroid

A

ultrasound the thyroid parenchyma, central and lateral neck

50
Q

Pilonidal cystectomy

A

Prone, jackknife
Isolate the sinus tract
Ellipse excision down to the sacral fascia
Allow to heal by secondary intention versus flap or off midline closure

51
Q

Compartment pressures

A

Hook up pressure line to 20G needle or use Stryker system
Zero the system
Stick diff compartments to get pressure readings

52
Q

Synchronized cardioversion - indications, joules

A

SVT
Afib with RVR
100J up to maximum manufacturer dose

53
Q

Defibrillation - indications, joules

A

Pulseless vtach, vfib
360J if monophasic or 200J if biphasic

54
Q

Endotracheal intubation

A

Preoxygenate with 100% O2
Induction: etomidate 0.3 mg/kg
Paralytic: succinylcholine or rocuronium 1 mg/kg
Use glidescope to ID epiglottis, vocal cords
Place ETT (7 mm)
Confirm approp placement with ET CO2, condensation in ETT, bilateral chest rise and breath sounds

55
Q

Paracentesis

A

US guidance to vavoid epigastrics
Clean RLQ
Send for PMNs, gram stain, albumin and glucose
If large volume rememer albumin

56
Q

PA catheter placement

A

RIJ cordis
Test balloon
Inflate and float swan
Look for waveform changes: RA is short amplitude, RV is wide amplitude, PA is dicrotic, wedge is short amplitude
Post procedure CXR (PACP should look like smile along heart silhouette)

57
Q

Thoracentesis

A

Sit pt up with elbows resting on a table
Entry point is right below inferior angle of scapula
Send fluid for cx, gram stain, cytology, pH, glucose, LDh, protein
Exudate: high protein/LDH i.e. infection or malig
Transudate: low protein/LDH i.e. CHF

58
Q

IVC repair

A

Right medial visceral rotation (Cattell Brasch)
Compress IVC proximally and distally with large spongesticks
Systemic vs local heparinization if hemodynamics allow
Suture repair injury with 3-0 prolene or place interposition graft (dacron)

59
Q

Abdominal aorta repair

A

Get prox control by clamping distal thoracic aorta through hiatus through pars flaccida
Left medial visceral rotation (mattox)
Progressively move proximal clamp down to site of injury
Suture repair with 2-0 prolene or place interposition graft (dacron)
Temporary abdominal closure to re-evaluate bowel

60
Q

Bladder injury repair

A

Intraperitoneal or concomitant pelvic injuries: 2 layer absorbable suture repair (inner vicryl, outer PDS), foley catheter drainage

61
Q

cardiac injury repair

A

cut inferior pulm ligament
Open pericardium longitudinal to phrenic n
deliver heart into open chest
occlude hole vs definitive repair
suture repair with 4-0 prolene pledget sutures, horizontal mattress to prevent coronary a occlusion
Ligate lacerated coronary aa
Mediastinal drainage/chest tubes

62
Q

Carotid injury repair

A

Position pt with neck extended
Incision over anterior border of SCM
Entrance into carotid sheath
ID IJ vein, follow prox to identify facial vein, ligate for access to CCA
Systemic vs local heparinization if HD allow
ID and occlude carotid vessels: ICE
Do thrombectomy with #3 fogarty until no clot returns x 2 consecutive passes
Bovine pericardium patch repair with 5-0 prolene
Unclamp ECI
Post procedure doppler of all branches of carotid (common, internal, external)
Leave drain

63
Q

Duod trauma mgmt

A

Kocherize duodenum
Assess injury: easy to access, hard to access, or near transection
If easy: suture closed transversely in 2 layers with inner PDS and outer silk, interrupted
If hard: open duodenum and repair from inside as above if hole is in a difficult spot
Near transected: try to bring together end to end , duodenostomy for controlled fistula or pyloric exclusion with GJ anastomosis and enteral feeding tube placement

64
Q

ESophageal injury - operation

A

Anti fungals, abx
Cervical: left chest
Mid esophagus: R chest 4-6th intercostal space
Distal: L chest 7th ICS
Medialize lung by taking down inf pulm ligament
Open pleura over healthy esophagus, perform myotomy to evaluate extent of mucosal injury, debride edges of perf
STent esophagus with NG tube
Close defecti n 2 layers of absorbbale suture over NG tube
Buttress with strap mm, pleura, pericardium or intercostal muscle
Place mediastinal/chest drains
If unable to repair, consideration for diverting spit fistula and enteral feeding tube

65
Q

Trauma ex lap

A

Enter abdomen with midline lap from xiphoidto pubic symphysis
Eviscerate bowel and evacuate hematoma
Pack all 4 quadrants
Obtain hemostasis
Run bowel from LoT to rectum
Evaluate both diaphragms, anterior/posterior aspect of stomach, duodenum
Control spillage/contam
Inspect all zones (zone 2: open if penetrating, zone 3: open if penetrating or expanding)

66
Q

LE fasciotomy

A

Lateral incision one thumb in front of and below fibula to lateral malleolus
ID intermsucular septum separating anterior and lateral compartments
Create H-incision to open anterior and lateral compartments, presrving superficial peroneal nerve
Medial incision one thumb behind and below tibia to medial malleolus
Take care to preserve gr saph v
Incise superficial fascia, retract gastrocnemius muscle laterally
Take down attachments of soleus muscle to posterior aspect of tibia to release deep compartment

67
Q

UE fasciotomy

A

Volar/flexor compartment: biceps groove to antecubital fossa, S incision across antecubital fossa down to carpal tunnel, incise carpal tunnel with extension to palm
Dorsal/extensor comp[artment: straight lin down to hand

68
Q

4 views of FAST

A

Subxiphoid cardiac RUQ (morrisons pouch) LUQ suprapubic (pouch of douglas)

69
Q

Neck exploration for injury

A

Incision along ant border of SCM
Evaluate carotid sheath.- may ligate internal jugular v if injured, repair carotid a
If injury to esophagus/trachea, must eval other side of neck for additional injuries on other side of esophagus and trachea
Tracheal injury: 1 layer absorbable suture +/- trach below site of injury
Esoph injury: 2 layer absorbable suture
Interposition with strap muscles to minimize risk of TEF

70
Q

Pancreatic injury

A

Kocher maneuver
Distal injury/transection distal to neck: distal panc/splenectomy
Anterior injury: debridement iwth large drain placement
If suspicion of ductal injury, wide drainage, post ERCP
Feeding jejunostomy for any major head injuries

71
Q

Hepatic injury - packing and repair

A

Options for temp control: pack, plug (omentum), pringle
Pringle maneuver enter gastrohepatic ligament, place penrose or vessel loop around hepatoduodenal ligament
Rule out retrohepatic venous bleeding before mobilizing liver
Mobilize liver: divide round ligament, falciform ligament, coronary ligaments, triangular ligaments
Options for hemostasis: cautery, argon beam, ligasure, 0-chromic suture with blunt needle tip, topical hemostastic agents, partial hepatectomy, angioembolization

72
Q

Renal injury - repair/resectio

A

Perform medial visceral rotation on left or right
Incise gerota’s fascia laterally and lift kidney out of its bed
Palpate the contralateral kidney prior to nephrectomy
Vascular repair artery if able with 6 mm ePTFE interposition graft
Tie vein, suture ligate the artery, ligate the ureter between clamps as far distal towards bladder as possible

73
Q

Splenectomy/splenorrhapgy

A

Splenic attachments shoudl already be divided from trauma
Mobilize spleen towards midline
Encircle hilum in hand taking care to exclude pancreatic tail
Ligate splenic hilum with linear stapler vascular load
Consdieration for drain placement
Splenetctomy vaccines (meningococcal, strep pneumo, H flu) prior to discharge

74
Q

Temp closure of abdomen

A

Cut vents into extremity xray plastic cover/protector
Place xray plastic above bowel
Place kerlix and large drains above plastic
Cover abdomen with Ioban
Hook large drains up to wall suction

75
Q

Thoracoscopy for mgmt of hemothorax

A

LAteral decubitus
Singel lung ventilation
Ports: mid axillary line 5th ICS and 5th ICS near lateral border of scapula
Extract clot, wash out retained hemothorax, place 1-2 chest tubes

76
Q

Ureteral injury -repair

A

Consdier perc nephrostomy and getting out if HD unstable
Try to repair primarily, dont over dissect periureteral fat, spatulate, repair over stent, use absorbbale suture (5-0 PDS)
Lower 1/3: psoas hitch or boari flap
middle 1/3: transureteroureterostomy (if other ureter not injured)
upper 1/3: mobilize kidney for autotransplantation

77
Q

Groin vessel repair

A

Generous vertical groin incision starting 3 cm superior to inguinal ligament ,overp ulse or halfway between tubercle and ASIS
Incise fascia lata and femoral sheath, find inguinal ligament, cut oinguinal ligament if you need to get prox control at iliac
ID and control common femoral, superficial and profunda femoral
Patch PTFE or interposition graft repair
Swing sarotrius or gracilis over closure
Post repair angiogram, pulse/doppler exam
Consider shunt, fasciotomy

78
Q

Popliteal vessel repair

A

Enter Hunters canal/popliteal fossa
REpair with contralateral GSV, do not ligate vein if can avoid
Post repair angiogram, pulse/doppler exam
Almost always perform fasciotomy

79
Q

Axillary artery injury repair

A

Incision below clavicle
Cut pec muajor fascia and muscle
ID ax vein, artery is SUPERIOR and DEEP

80
Q

Brachial artery injury repair

A

Biceps groove or antecubital fossa

81
Q

R innominate/L carotid at aortic arch repair - access

A

sternotomy

82
Q

Left subcalvian a injury - access

A

left anterolateral thoracootmy

83
Q

Open AAA

A

Elevate transverse colon cephalad, incise LoT for access to RP
Place SB on R side of abdomen, sigmoid to left lateral side
ID L renal V to ID infrarenal aorta
Expose common iliac/femoral vessels depending on landing zone
Heparinize (80 U/kg)
OClamp infrarenal aorta, the ncommon iliac vessels
Open aneurysm sac, evacuate any thrombus, oversew lumbar vessels
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 40 mm or if pt has had previous colon operation
Chekc bowel viability
Plapate femoral/distal pulses
Close aneurysm sac and RP over graft

84
Q

EVAR

A

Confirm adequate anatomy: diameter <32 mm, landing zone 10-15 mm, angulation <60 degrees, adequate iliac vessel diameter
Obtain access in bilateral femoral a with US, place closure devices and sehaths
Heparinize with 80U/kg
Use ocmmerically available sheath and measurement system and deploy graft, use additional iliac extensions as necessary
Perform balloon angioplasty of proximal attachment zone, graft overlap sites, and distal attachment zones
Perform completion angiogram to rul e out endoleaks
Check distal pulses

85
Q

Amp - BKA

A

Incise 10 cm inferior to tibial tuberostity, anterior flap is 2/3 leg circumference, make big posterior flap
Divide muscles, expose fibula 3 cm above incision
ID and divide anterior tibial neurovascular bundle in the lateral leg
ID and divide posterior tibial and peroneal vessels in medial leg
Saw the tibia and fibula
Use amp knife to cut gastroc and soleus muscles in tapered fashion on posterior flap

86
Q

Amp - AKA

A

Fish mouth, mid thigh
Ligate GSV in inner thigh
Ligate femoral vessels medially
Expose femur 10 cm prox to incision with periosteal elevator
Ligate sciatic nerve in the posterior thigh
Divide femur 10 cm above skin incision

87
Q

Aortofemoral bypass

A

Make bilateral groin icnisions
Isolate CFA, SFA and profunda femoral aa bilaterally
Midline laparotomy, elevate T colon cranially to incise LOT for access to aorta
Isolate infrarenal aorta
Heparinize (80 U/kg)
Clamp infrarenal aorta proximally and distally
Sew graft to side of aorta with 3-0 prolene
Tunnel bifurcated graft under ureters along native vessels
Obtain proximal and distal control of bilateral common femorals nad sew to the bifurcation bilaterally
Check distal pulses

88
Q

Embolectomy/thrombectomy

A

Should be heparinized
For LE , start with standard groin incision to access CFA
Obtain prox and distal control
Make transverse arteriotomy for embolus and longitudinal for thrombus
Pass a #4 fogarty as far distal as it will go, then inflate balloon and withdraw, repeat until no clot x 2 consecutive passes
Close arteriotomy with interrupted 6-0 prolene sutures if embolus, graft repair if thrombus, flush the closure prior to completion
Perform completion angiogram, access more distal vessels if ongoing embolus/thrombus

89
Q

Extra-anatomic bypass T

A

Transverse incision 2 cm inferior to clavicle
Bilateral vertical groin incision 2 FB lateral to pubic tubercle
Split pectoralis major muscle to get down to ax vascular bundle, expose axilalry artery, control with vessel loops
Isolate common, superficial and profunda femoral aa with vessel loops (if bypassing infection go lateral to sartorius and isolate distal profunda artery)
Tunnel 8 mm ePTFE graft
Heparinize (80U/kg)
sew in axillary an dfemoral ends of graft with 5-0 prolene
Check distal pulses

90
Q

Fem-fem bypass

A

Vertical groin incisions 2 FB lateral to pubic tubercle
Isolate common femoral, superfiical femoral, and profunda femoral aa with vessel loops
Tunnel 8 mm PTFE graft suprapbuically
Heparinize (80U/kg)
Sew in graft with 5-0 prolene to side of femoral aa, flush before unclamping
Check distal pulses

91
Q

Fem-pop bypass

A

Vertical incision 2 FB lateral to pubic tubercle
Medial thigh incision just above knee, open fascia overlying popliteal space
Separate popliteal a from vein and tibial n
Harvest GSV from same side, ligating tributaries
Reverse it and leave path of vein in situ
Heparinize
Prox and distal control fo femoral artery, sew in GSV graft to side of femoral artery with 5-0 [prolene
Prox and distal control of popliteal artery, sew in graft to side of popliteal artery with 6-0 prolene
Flush prior to completing anastomosis
Perform completion angiogram

92
Q

Infrapop bypass

A

Prep both groins and entire affected leg
Dissect out inflow, almost always CFA via standard groin incision
Dissect out distal target - medial calf for peroneal and posterior tibial aa, lateral calf for anterior tibial a
HArvest GSV, ligating any tributaries
Heparainize
SEw to side fo femoral artery with 5-0 prolene, sew to side of distal vessel with 5-0 prolene
PErform completion angiogram

93
Q

Sclerotherapy

A

Target refluxing vessel with duplex US
Inject foam sclerosant to destroy endothelium of target vessel

94
Q

IVC filter insertion

A

Access femoral ve
Place 8.5 Fr sheath
Advance catheter and perform cavogram to ensure patency of IVC and ID renal vv
Advance sheath to region of planned deployment, below lowest renal vein
ADvance filter within sheath to sheath end
Draw sheath back to expose filter and release filter hook
Perform completion cavogram
Can also perform through IJ vein

95
Q

Venous insufficiency

A

Perform small cutdown on source of reflux
Anteromedial groin incision - saphenofemoral junction is just medial to femoral a below groin crease
Posterior calf - lesser saphenous at saphenopopliteal junction
Place external stripper through saphenous system, have it exit through counter 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

96
Q

AV graft

A

Use US to find and mark brachial artery and target vein (cephalic is lateral to biceps or basilic is medial)
Transverse incision below elbow in antecubital fossa
Isolate 4 cm of target vein
Divide bicep aponeurosis in cruciate configuration
Separte brachial artery from paired veins and isolate 3 cm
Select and size a tapered 4 to 7 mm PTFE graft, sew 4 mm end to arterial inflow (prevents steal), 7 mm to venous outflow
Use semicircular tunneling device to tunnel graft in subcutaneous tissue distally to create an oval tunnel
Heparinize
Perform venous anastomosis: clamp, venotomy, end to side 6-0 prolene (use 7 mm end of the graft)
Perform arterial anastomosis: clamp, arteriotomy, end to side 6-0 prolene, use 4 mm end of the graft
Remove clamps, check for thrill/bruit in AV graft
Palpate distal radial and ulnar pulses

97
Q

AV fistula

A

Start with non dominant arm
Cephalic vein is on thumb side and goes all the way up lateral arm
US the UE to rule out arterial insufficiency and determine adequate diameter of vessels
Use US to mark distal forearm course of radial a and cephalic v (or whatever targeted vessels)
5 cm longitud incision between radial a and cephalic v
Isolate cephalic v for 5-6 cm, ligating small branches
Isolate radial a for 2-3 cm
Heparinize
Ligate cephalic vein distally, put clamp on it proximally
Proximal and distal radial a control, 2 mm arteriotomy, end to side anastomosis with 7-0 prolene
Remove clamps, feel for palpable thrill and audible bruit in fistula
Check distal radial and ulnar pulses

98
Q

Chest tube placement

A

Select size -36 Fr for trauma, 20 Fr for PTX
Abduct arm
ID nipple or IMF for access to 4th/5th intercostal space
Anesthetize SQ tissue and periosteum
Enter at superior aspect of lower rib to avoid intercostal neurovascular bundle
Post proc CXR

99
Q

Exploratory thoracotomy

A

Lateral decub, single lung ventilation on opposite side of interest
ID 4th ICS
Anterolateral thoracotomy from sternal border to midaxillary line
Tie transected ends of internal mammary artery
Divide inferior pulm ligament
Explore chest
Leave chest tubes

100
Q

Exploratory thoracostomy

A

Lateral decub, single lung ventilation on opposite side of interest
Ports in middle (7th space), anterior (5th space) and posterior axillary (5th space) lines
Explore chest
Leave chest tubes

101
Q

Open partial pulm resection

A

Lateral decub with lesion side up, single lung vent other side
Incision extends from medial scapular border posteriorly to anterior axilalry line just below the nipple following contour of 5th ICS
Grasp lung and wedge it out for a biopsy
Lobectomy: 1st dissect out appropriate pulm vein nand ligate it iwth vascular stapler, dsisect out pulm a and divide with vascular stapler, then dsisect out and divide lobar bronchus and divide with green laod 4.5 mm stapler
Take lymph nodes with specimen (9, 11-14)
Perform saline leak test, re-insufflatel ung under direct visualization
Leave chest tubes

102
Q

Partial pulm resection - thoracoscopic

A

Lateral decub with lesion side up, single lung vent other side
Ports in middle (7th space) anterior (3rd space) and posterior axillary (5th space) lines
Grasp lung and wedge it out for biopsy
Lobectomy: 1st dissect out appropriate pulm vein and ligate with vascular stapler, dissect out pulm a and divide with vascular stapler, the ndissect out and divide lobar bronchus and divide with green load 4.5 mm stapler
TAke LN with specimen (9, 11-14)
Perform saline leak test, reinsufflate lung under direct visualization
LKeave chest tubes

103
Q

Pericardial window for drainage

A

8 cm incision over xiphoid
Excise xiphoid process if needed
Finger dissect into retrosternal space to identify pericardium
Grasp pericardium with tonsil/clamp
Sharply open pericardium aspirate, break loculations with finger, biopsy the pericardium
Insert tube into pericardial space through separate stab incision Inguinal hernia repair

104
Q

inguinal hernia repair

A

Incise over external ring
Open lateral aspect of EO and carry towards external ring
Only divide ext ring if you need exposure
Gently dissect out the cord with blunt moves parrallel to direction of cord
Pass hemostat behind cord to elevate hernia and cord into operating field
Incise cremasteric muscles overlying the cord
Incise the internal spermatic fascia
Find and gently hold the hernia sac anteromedially, dissect spermatic vessels and vas deferns off the hernia sac
Dissect towards internal ring until preoperitoneal fat at neck is exposed
Twist the sac, do high ligation with transfixing 5-0 vicryl suture, excise redundant sac, allow prox sac to retract underneath external ring
Clsoe any attenuated ext oblique muscle or divide ext ring
Return testicle to scrotum

105
Q

Endoranal advancement flap

A

opening the fistula tract, performing a curettage of it, suture closing the internal os, and advancing the mucosa, submucosa, and muscle from proximal to distal to cover the internal os. This can result in seepage and the patient may feel like they’re experiencing incontinence or a wet-anus but this will resolve the fistula in most cases.

106
Q

LIFT procedure

A

when you make a curvilinear incision along the fistula tract, curettage the tract, and ligate the fistula in between the internal and external sphincters. You then close the external os and reapproximate the mucosa over the fistula tract. There’s a small chance of incontinence with these as well so I would talk to the patient about that.

107
Q

Open placement of PD Cath

A

3-5 cm paramedian skin incision (minimizes risk of pericatheter leak and hernia)
2-3 cm incision through anterior and posterior rectus sheath to reach peritoneum
Purse string of 4-0 absorbable suture placed around peritoneal opening
Stylet placed into catheter and inserted into peritoneal cavity, directed to pelvis to the R side of rectum
Purse string around catheter, BELOW Dacron cuff, and fascia closed around Cath with interrupted NONabsorbable suture
SQ tunnel amde, catheter is tunneled, leaving superficial Dacron cuff 1-2 cm deep to skin
Catheter flushed with heparinized saline

108
Q

Traumatic Diaphragmatic Hernia Repair

A

Meticulous inspection of the diaphragm intraoperatively is necessary.
Debridement of devitalized tissue
Small defects can be repaired primarily with nonabsorbable suture, using interrupted, running, or figure-of-8 suture techniques.
Larger defects may require repair with prosthetic mesh (consider biologic)
Chest tube placement (minimize postop complications of PTX or effusion)

109
Q

Repair of parastomal hernia

A

Both open and laparoscopic parastomal hernia repair adhere to the general principles of hernia repair:
Reduction of the hernia contents
Excision of the hernia sac
Tension-free closure of the fascial defect (if possible)
Possible mesh reinforcement
Mesh placement, in a retrorectus or intraperitoneal underlay position, reduces recurrence rates. In emergent or contaminated cases, suture repair alone with or without absorbable/biologic mesh placement may be the preferred option.
A “keyhole” mesh can be fashioned, allowing passage of the stoma conduit through the mesh. Alternatively, a modified Sugarbaker-type mesh repair can be used, where the ostomy is lateralized using a noncircumferentially secured underlay mesh.

110
Q

Repair of spigelian hernia

A

In a frankly contaminated field, placement of a permanent mesh should be avoided. Primary repair should be performed or a biologic or absorbable synthetic mesh should be used.
The best outcome in terms of reducing hernia recurrence involves placement of a permanent prosthetic mesh. Synthetic absorbable and biologic meshes are most often used in contaminated fields where infection is a concern but are associated with higher recurrence rates.
Mesh reinforcement can be performed as an onlay, sublay, or underlay repair. In general, sublay or underlay mesh placement has been associated with lowest hernia recurrence rates.

111
Q

Repair of obturator hernia

A

A preperitoneal or intraperitoneal approach is best (either laparoscopic or open).
Reduction of hernia contents and sac
The obturator foramen can be opened posterior to the nerve and vessels.
Repair with placement of a pre-peritoneal mesh

112
Q

Repair of perineal hernia

A

Can be approached through trans-abdominal and/or perineal
Reduction of sac and contents
Repair with suture (for small defects) or mesh (for larger defects)

113
Q

Anterior release

A

The anterior release involves creation of subcutaneous flaps, division of the external oblique aponeurosis lateral to the semilunar line, and development of the plane between the external oblique aponeurosis and the internal oblique muscle laterally. Mesh reinforcement can then be placed in an underlay or overlay position.

114
Q

Posterior release

A

The posterior release involves opening the retrorectus space medially and creating the posterior plane between the rectus muscle and the posterior rectus sheath. The posterior rectus sheath is then incised again just medial to the laterally perforating neurovascular bundles. The underlying transversus abdominis muscle can be divided (TAR), and dissection is carried laterally to mobilize the transversalis fascia and peritoneum off of the overlying muscle.

115
Q

Lap trans cystic CBD exploration

A

Perform a cholangiogram.
After establishing the stone burden, replace the cholangiogram catheter with either a basket extraction implement or choledochoscope.
Use glucagon to relieve sphincter pressure along with transcystic flushing of the duct with saline to force debris into the duodenum.
In cases of stone impaction, use Fogarty balloon catheters to help free the stones.
Place the retrieved stones in a safe spot in the abdomen and eventually in a specimen bag with the gallbladder.

116
Q

Lap transductal CBD exploration

A

Perform a cholangiogram.
Forcefully flush through the transcystic catheter to distend the CBD.
Make a distal, vertical, supraduodenal choledochotomy with sharp scissors or hook cautery on cut mode.
Use a cholangiogram catheter to flush the stones.
Perform a choledochoscopy with a flexible scope.
Retrieve the stones using a basket retrieval device through the working port of the choledochoscope.
In cases of stone impaction, use Fogarty balloon catheters to help free stones.
Close the choledochotomy primarily or over a T tube at least 14F in size using absorbable monofilament suture.

117
Q

Open CBD exploration

A

Perform an extensive Kocher maneuver such that the area of the ampulla can be palpated.
Make a distal, vertical, supraduodenal choledochotomy approximately 1.5 cm in length.
Pass Fogarty catheters superiorly to extract stones from the common hepatic duct and inferiorly through the ampulla to extract CBD stones.
Irrigate generously with saline.
Ensure that the CBD is clear of stones using either choledochoscopy or a cholangiogram.
Close the duct primarily or over a T tube at least 14F in size.

118
Q

Transduodenal sphincteroplasty

A

Perform an extensive Kocher maneuver.
Make a transverse or longitudinal duodenotomy on the lateral duodenal wall at the junction of the lower one-third and upper two-thirds of the duodenum.
Identify the papilla.
Cut the ampullary sphincter in the 11 o’clock position on the papilla using cautery or scissors. Extend this to include the entire common tract of the sphincter of Oddi.
Extract all stones.
Suture the wall of the CBD to the duodenal mucosa using interrupted fine absorbable sutures.
Close the lateral duodenotomy.

119
Q

Distal pancreatectomy

A

Supine (esp if tumor closer to portal-SMV) vs modified “lazy” right lateral decub
Thorough dx lap –> MIS or open
Enter lesser sac via dividing gastrocolic ligament, ensuring adequate control of the short gastric vessels with clips, electrocautery, or ultrasonic scalpel. If the spleen is to be removed with the distal pancreas specimen, the short gastric vessels are similarly divided to allow splenic mobilization. The stomach is retracted anterosuperiorly toward the abdominal wall. The splenocolic ligament is similarly divided to allow caudal retraction of the transverse colon and splenic flexure.
The distal pancreatic body should be entirely visualized at this time. The distal aspect of the gland is then mobilized from the posterior retropancreatic fat using a combination of blunt dissection and bipolar electrocautery or ultrasonic scalpel, either from lateral to medial or medial to lateral.
The splenic vein is directly posterior to the pancreas and comes into view before the artery as the gland is dissected posteriorly. Early preparation of the transection plain is critical if urgent vessel ligation is required in the event of hemorrhage during dissection.
The splenic artery, vein, and pancreas may be ligated/transected in any order as dictated by the flow of the operation and anatomy. The splenic vessels should be ligated with vascular stapler or combination of clips and ties, and the vessel stumps should be kept as short as possible; long vascular stumps increase the risk of thrombosis or rupture. The pancreatic gland itself is transected using a stapler, or energy device, with or without oversewing or use of an omental pedicle flap over the stump.
The distal pancreas (with or without spleen) specimen is then removed. For laparoscopic procedures, this is typically performed via an endoscopic retrieval bag and enlargement of a laparoscopic port site or Pfannensteil-Kerr incision.
The surgical bed is then inspected for adequacy of hemostasis, and the choice of operative drain placement is at the discretion of the operating surgeon.

120
Q

Splenectomy

A

Use a midline incision, which is optimal for exposure when the spleen is ruptured or massively enlarged.
Understand that a left costal margin incision is preferred in most elective procedures.
Mobilize the spleen by dividing ligamentous attachments, beginning with the splenocolic ligament.
Enter the lesser sac.
Realize that in patients with significant splenomegaly, early ligation of the splenic artery along the superior border of the pancreas is an option and may be preferred.
This allows safer manipulation of the spleen and dissection of the hilum.
This allows for some shrinkage of the spleen itself.
This provides an autotransfusion of red blood cells and platelets.
Incise the lateral peritoneal attachments, most importantly the splenophrenic ligament, and gently develop a plane deep to the spleen and tail of the pancreas.
Next perform individual ligation and sequential division of the short gastric vessels.
Identify the tail of the pancreas and protect it from harm. The tail of the pancreas often lies within 1 cm of the splenic hilum.
Ligate the splenic artery and vein before dividing them.
Remove the spleen.
Look for accessory spleens. Common locations are the splenic hilum, splenic pedicle, greater omentum, the tail of the pancreas, and splenocolic ligaments.
Close the abdomen without drainage.

ABS (23 decks)

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