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CORE PROCEDURES Flashcards

1
Q

Hiatal Hernia Repair

A

Position patient supine w/ footboard
Gain access, place liver retractor
Incise gastrohepatic ligament (watch for replaced L hepatic a off L gastric a)
- Continue until you can see R crus of diaphragm
- Bluntly mobilize esophagus circumferentially, taking care not to injure vagus nn.
o Watch for inferior phrenic vein when dissecting around the posterior esophagus
- Need to see both crura of diaphragm – with clear plane between esophagus and crura
- Put penrose around esophagus to aid retraction
- Perform mediastinal mobilization so you get at least 3cm of intra-abdominal esophagus
- Reapproximate crus with NONABSORBABLE suture +/- mesh for reinforcement
- Perform fundoplication based on manometry
** If 360 degree – take down short gastrics, perform “shoeshine maneuver” + make sure fundus of stomach is posterior to esophagus)
 Fundoplication anteriorly with non-absorbable sutures (make sure 2-3 cm long, 1cm apart)
 Make sure you have brought all contents down from chest
 Resect hernia sac

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2
Q

Open Lichtenstein repair

A

o position supine, prep and drape in usual sterile fashion
o Make oblique incision 2 fingerbreadths above inguinal ligament
o Carry down through the external oblique (cut in direction of fibers, taking care not to damage ilioingunal nerve)
o Clean off shelving edge of inguinal ligament down to the pubic tuberacle
o Isolate cord structures from the hernia sac down to the inguinal ring
o reduce hernia sac and contents back into the abdomen
o use piece of split mesh and secure to pubic tubercle (cooper’s ligament)
 inguinal ligament inferiorly(running) and internal oblique/transversus (conjoint
tendon) superiorly (interrupted)
o close external oblique fascia

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3
Q

Open Femoral Hernia Repair

A

o Incise inguinal floor –> convert femoral hernia into direct hernia
o Use interrupted silk sutures to approximate conjoint tendon to coopers
 starting medially, down to lacunar ligament running laterally to close femoral
canal
o Transition stitch – last stitch in cooper’s ligament that includes the inguinal ligament
o Continue to run conjoint tendon to inguinal ligament
o Close external oblique

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4
Q

Open LAR

A

Ask urology to place stents
Lithotomy, prep abdomen and perineum, trendelenberg
Mobilize sigmoid colon along white line of toldt, bluntly mobilize off abdominal wall
Make sure to ID the URETER
Mobilize left colon so it reaches to the pelvis without tension (may need to perform splenic flexure mobilization, making sure to stay close to colon to decrease the risk of splenic or pancreatic injury)
Score sigmoid mesentery medially from sigmoid to rectum along the superior
rectal a
Ligate superior rectal a
Elevate the rectum, which will show an areolar plane
Use energy device to free the rectum circumferentially, staying in a plane close to the rectum
Do your anterior dissection last
(holds rectum in place to help with posterior dissection)
dissect 2cm past tumor (can use endoscopy to ensure at right place if no tattoo)
use articulating stapler to divide the rectum distally and a linear stapler to divide colon proximally
pass off the specimen
perform an EEA anastomosis through rectum and perform a leak test

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5
Q

Left adrenalectomy

A

o Mobilize lateral attachments to the spleen
o Take down pancreas
o Identify inferior phrenic vessels as they trace down on top of adrenals
o Identify L adrenal vein on inferior-medial aspect of adrenal
o Use energy device to encircle adrenal and separate from surrounding Gerotas fascia and
peritoneal attachments (nothing distinct about arterial supply)

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6
Q

Right adrenalectomy

A

R supine position w/ bump on R side
o Mobilize hepatic flexure and triangular ligament of liver to point of inferior phrenic vessels
o Trace inferior phrenic vessels down to adrenals
o Secure adrenal vein as it enters IVC
o Use ligasure to encircle adrenal

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7
Q

Neck exploration for trauma

A

 Incision along anterior boarder of SCM
 Incise platysma
 Retract SCM laterally
 Identify IJ & divide facial vein
 Open carotid sheath – deal w/ any vascular injury
 Explore esophagus – ID w/ NGT/OGT
 Look at trachea +/- bronch
 Leave a drain
 If injury to one side of esophagus/trachea, probably have injury to the other side
o Either do CL incision or endoscopy
o Use strap muscle to buttress

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8
Q

Thyroidectomy

A

Set up to use a nerve stimulator
 Supine, bump under shoulder, arms tucked
 Collar incision
 Raise subplatysmal flaps, retract superiorly & inferiorly
 Separate strap muscles bluntly & place self-retaining retractor
 Start at upper pole and bluntly separate avascular plane
o Carefully ID upper pole vessels & divide close to thyroid
 Using harmonic scalpel or harmonic, separate thyroid from surrounding tissues, bringing
anteriorly and medially
o Divide inferior thyroid vessels and middle thyroid vein
 Identify RLN in tracheoesophageal groove and protect throughout dissection
 Continue dissection medially, incise ligament of berry, separate thyroid from larynx & trachea

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9
Q

Duodenal perforation

A

 Upper midline laparotomy, evacuate contamination and irrigate abdomen
 ID perforation & debride necrotic tissue
 Take biopsies for H.pyori culture/cancer
 Loosely reapproximate edges of hole with 3.0 PDS, leaving tails long and place tongue of
omentum over, tying down with long ends
 Leave drain
 Treat w/ PPI, amoxicillin 1000mg BID (or metronidazole500mg BID), clarithromycin 500mg
BID until you get H.Pylori results
 If patient already on PPIs, consider doing truncal vagotomy
o Markedly reduces cholinergic stimulation and gastric acid secretion
o Also denervates the pylorus, so need pyloroplasty or antrectomy to ensure drainage

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10
Q

Truncal vagotomy

A

Left hepatic lobe lifted superiorly and laterally
o Divide triangular ligament to expose hiatus
o Dissect esophagus circumferentially
o Identify and dissect anterior and posterior branches of vagus
o Place proximal and distal clips 2cm apart on nerve and resect section
 Send to pathology to confirm
o Perform cruroplasty as needed to prevent hiatal hernia
o Place NGT

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11
Q

Bleeding duodenal ulcer

A

 Upper midline incision
 Can use EGD to find ulcer or just
make incision over D1
 Place sutures superior and inferior to bleeding ulcer (and medially to prevent backbleeding)
o Make sure not to place too deep so you don’t injure CBD
o Protect by placing red rubber catheter into ampulla or watch for bile before closing
 If patient has refractory disease, extend incision superiorly through pylorus
o Perform pyloroplasty by closing transversely
o Perform vagotomy at conclusion of the case

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12
Q

Distal gastrectomy

A

o Perform Kocher Maneuver
o Divide gastrocolic ligament to enter lesser sac
o Divide stomach halfway up greater curvature
-Ligate and divide R gastroepiploic vessels near GDA
-Incise gastrohepatic ligament
o Divide R gastric artery at level of pylorus
o Divide duodenum & stomach with a stapling device
o Oversew duodenal stump to minimize bowout
o Reconstruct with B1 or B2
o Leave drains

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13
Q

Total gastrectomy

A

Midline laparotomy and full exploration.
o Mobilize GE junction and esophagus, taking a margin of diaphragmatic crura.
(Look for accessory left hepatic artery when dividing the gastrohepatic ligament)
o Separate the omentum and lesser sac lining en bloc from the transverse colon.
o Divide the short gastric vessels, and skeletonize the celiac, splenic, and common
hepatic arteries, taking their lymph nodes.
o Ligate left and right gastric and gastroepiploic arteries at their bases.
o Divide esophagus, stomach, and jejunum.
o Reconstruction with esophagojejunostomy and jejunojejunostomy.

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14
Q

Sleeve gastrectomy

A

Mobilization of the greater curvature of the stomach
Proximal and complete mobilization of the fundus with exposure of the left crus
Evaluation of the hiatus and hiatal hernia repair PRN
Assessment and lysis of retrogastric adhesions
Passage of the bougie with placement along the lesser curvature of the stomach
Longitudinal gastrectomy using a linear cutting stapler
Removal of the specimen

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15
Q

Radical cholecystectomy

A

If there is no peritoneal disease, proceed
 Take 3-4cm of normal surrounding liver in a non-anatomic fashion
 Perform regional lymphadenectomy
o Choledochal, hilar, peri-portal and high peripancreatic lymph nodes
 If previous lap chole –> excise all port sites full thickness

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16
Q

CBD stone

A

 Flush with saline
 1ml glucagon, flush again & repeat cholangiogram
 Transcystic CBD exploration
o Place wire under fluoroscopy, balloon dilate cystic duct, place sheath

o Place flexible choledochoscope, retrieve stone via basket
 Convert to open, Kocherize duodenum, try to milk stones back
o If still stuck, make choledochotomy just past cystic duct comes off CBD via scope
 Transduodenal sphincteroplasty via lateral duodenotomy (D2)
o Close transversely & leave drain
 complete cholecystectomy
o Last resort if can’t get stone out, choledochojejunostomy

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17
Q

Inguinal lymphadenectomy

A

 Frog-leg patient
 Slight S-shaped incision from ASIS to below femoral triangle
 Raise flaps until you can identify nodal tissue surrounding femoral vessels
o Boundaries: superior – inguinal ligament, medial – adductor longus, lateral- sartorius

 Deep dissection
o Divide inguinal ligament
o Mobilize peritoneum (place superiorly)
o Mobilize fatty tissue around the iliacs
o Protect with muscle flap (sartorius flap)
 Divide at proximal insertion site and rotatme medially
 Lay drain for both

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18
Q

SMA embolectomy for acute mesenteric ischemia

A

 Ex-lap, elevate transverse colon, follow middle colic a. down to SMA
 Palpate for pulse at base of transverse colon & expose SMA
 Take down ligament of treitz & open peritoneum over the artery
 Get proximal & distal control w/ vessel loops
 heparinize patient (80u/kg)
 Make transverse arterotomy
 Use #3-2Fr balloon and perform embolectomy distally & proximally
 Make sure you have good back bleeding and close enterotomy transversely w/ interrupted prolene
 Examine bowel for necrosis, palpate/doppler at antimesenteric border
 Place abthera & re-examine 24h later

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19
Q

Zenkers diverticulectomy

A

 L neck incision, dissect medial to carotid sheath, make sure not to injure RLN
 Identify diverticulum
 Place large bougie (60F)
 Perform stapled diverticulectomy if >2 cm (if <2 cm PEXY)
 Perform 2-3cm myotomy on cricopharyngeus muscle
 Leave drain, close in layers

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20
Q

Sub-xiphoid window

A

 Incision just over and extending below the xyphoid process
 Blunt dissection to dissect under xypoid and sternum, at angle 45 degrees after 1st few cms
 Resect xyphoid in most cases
 Feel heart against fingers, grab pericardium w/ toothed pickup or allis clamp
 Incise with mets
 If blood comes out, do median sternotomy (likely heart injury)
 If clear – done, washout and close

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21
Q

Whipple procedure

A

I always start with a diagnostic laparoscopy first to look for any lesions. If there’s no lesions, I would proceed with a vertical midline incision, place a bookwalter to facilitate exposure, takedown the hepatic flexure, kocherize the duodenum all the way to the IVC, at which point I would divide the stomach. I would then perform a portal dissection by starting with a dome-down approach for a cholecystectomy, down towards the triad and ducts. I would then ligate the GDA, make a tunnel behind the pancreatic neck making sure not to injure the SMA or SMV, and divide the pancreatic neck with a stapler. I would then perform a proximal division of the jejunum, remove the specimen and make the first anastomosis which is a pancreaticojejunostomy, which I would do over a stent. I would then perform a choledochojejunostomy, followed by a gastrojejunostomy. I would leave drains by the anastomoses and finish the operation.

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22
Q

Ruptured AAA

A

 prep from neck to knees (do not induce until prepped and anesthesia ready)
 ex-lap, get supraceliac control
o open gastrohepatic ligament and push esophagus laterally (left)
 eviscerate bowel and pack to the right outer abdomen
o further mobilize mesentery from peritoneum to get additional visualization
 open retroperitoneum & ID left renal vein
o lift L renal vein to help identify renal arteries
o move aortic clamp down to infrarenal location
 dissect out both iliac arteries and clamp
o heparinize patient w/ 80u/kg
 open aneurysm sac – evacuate out all old clot
 perform anastomosis using 3-0 prolene (proximal and then distal)
 Re-implant SMA if there is poor back-bleeding and patient is stable enough
o Don’t re-implant if pulsatile or thrombosed
 Close aneurysm sac over graft
 Check for distal pulses & close

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23
Q

Hepaticojejunostomy

A

Hepaticojejunostomy
 Enter abdomen, place self-retaining retractor
 Identify CBD
 Create roux-n-y
 End to side choledochojejunostomy
o Interrupted5-0 PDS sutures
 Leave drain

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24
Q

Transhiatal Esophagectomy

A

 Completely mobilize stomach preserving right gastric and right gastroepiploic arteries
 Perform kocher maneuver and pyloromyotomy (extramucosal)
 Place penrose around esophagus at GE junction & elevate up out of the chest
 Use clips and cautery to take all small vascular branches as far into the mediastinum as
possible
 Use hand to bluntly dissect around anterior and lateral aspects of the esophagus as high as
possible
 Make L neck incision at the anterior boarder of the SCM
o Get behind the carotid sheath and encircle esophagus with penrose
o Staple off the esophagus
 Using a kissing hands technique – mobilize superior aspect of the esophagus until it is
completely freed from the mediastinum
o Remove specimen through the abdomen
 Inspect mediastinum for bleeding and pack as needed
 Transect stomach ~5cm distal to GE junction making sure you have good margins for cancer
 Transpose gastric conduit through mediastinum into L neck
 Perform side to side stapled cervical esophagogastric anastomosis
 Place penrose drain next to anastomosis and close
 Place J tube for feeding
 Get post-op CXR to make sure no PTX

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25
Q

Resuscitative thoracotomy

A

 Splash betadine prep; L arm up

 Enter chest in 4-5 th intercostal space from sternum to table

 Place retractor

 Sharply take down inferior pulmonary ligament (just enough to get lung to elevate)
o Don’t hit inferior pulmonary vein

 Grab pericardium and incise with scissors (anterior to phrenic nerve)
 Deliver heart out of pericardium and do open cardiac massage
 Chase ribs down toward spine and open pleura
 Use fingers to dissect around aorta (place NGT to ID esophagus) & clamp

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26
Q

Lower ext fasciotomy

A

 Lateral incision (releases anterior and lateral compartments)
o 2cm posterior to tibial edge (between fibula and tibia)
o Identify septum separating anterior and lateral compartments and incise fascia

o Incise less in lateral compartment to avoid injury to superficial peroneal nerve
 Medial incision (releases deep posterior and superficial posterior compartments
o 2cm posterior (medial) to tibia
o Incise fascia
o retract gastrocnemius posteriorly and take down attachments of soleus to posterior tibia

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27
Q

Open bassini repair

A
  1. Oblique incision 2 finger breadths above inguinal ligament, down to external oblique
  2. Incise external oblique, identify and preserve ilioinguinal nerve
  3. Encircle cord w/ penros and separate sac
  4. Open sac and assess bowel viability - can either resect if possible through this or perform
    lower midline laparotomy
  5. No mesh, so after returning contents perform primary repair with 2-0 proline by sewing
    conjoint tendon to inguinal ligament (can do relaxing incision above conjoint tendon if too much tension)
  6. Closure of external oblique aponeurosis, SubQ, and skin
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28
Q

sublay ventral hernia repair

A

Sublay ventral hernia repair
1. Peritoneal entry and complete adhesiolysis
2. Retromuscular dissection by incising posterior rectus sheath
3. Reconstruction of posterior sheath and dissection lateral to develop space for mesh
4. Mesh placement - polypropylene, leave drains above mesh
5. Reconstruction of anterior layer and closure

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29
Q

Laparoscopic ventral hernia repair

A
  1. LUQ Hasson entry w/ 12mm trocar placement, additional 2 5mm trocars on ipsilateral
    abdomen
  2. Adhesiolysis and reduction of hernia contents with minimal thermal use to avoid missed
    hollow viscus injury
  3. Mesh placement w/ 4cm fascial overlap, Parietex mesh, anti-adhesion barrier down
  4. Mesh fixation via trans-fascial sutures in 4 spots and circumferential tacs
  5. Remove trocars under direct vision and close 12mm trocar fascia with figure of 8 suture
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30
Q

Component separation

A
  1. Midline laparotomy
  2. Remove all prosthetic material and address any bowel issues
  3. Elevate lipocutaneous flaps 2cm lateral to linea semilunaris (lateral edge of rectus)
  4. Incise external oblique fascia and separate internal and external oblique muscles to 3-4cm
    above costal margin and to inguinal ligament inferiorly
  5. Release posterior rectus sheath by incising 1cm lateral to linea alba
  6. Develop retro muscular plane to lineament semilunaris but preserving neurovascular bundles
    of Rectus
  7. Place appropriately sized (large usually) biologic mesh underlay below muscle and above
    posterior sheath, place drains over mesh to improve incorporation
  8. Reapproximate midline fascia w/ interrupted figure of 8 sutures (2-0 or 0 PDS, can also do
    vicryl)
  9. Remove excess/devascularized skin and close subQ/flaps over drains
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31
Q

CBD exploration

A
  1. Conver to open and perform cholangiogram through cystic duct or CBD hole
  2. Kocherize duodenum and trace cystic duct to CBD then place 2 stay sutures of 5-0 PDS at
    ends of planned ductotomy
  3. Make 2cm dichotomy and flush duct with saline via red rubber, then choledochoscope
    proximally and distally
  4. Pass size 4 Fogarty or basket in both directions and then close over adequate sized T tube,
    closing ductotomy around T tube w/ interrupted 5-0 PDS
  5. Completion IOC and leave drain and close
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32
Q

Distal pancreatectomy + splenectomy

A

Vaccinate preop
1. Midline incision and enter lesser sac, completely divide short gastrics
2. Mobilize peritoneal attachments to spleen (splenorenal, splenocolic and splenophrenic)
3. Dissect distal pancreas and spleen away from transverse colon and identify plane/tunnel
between IMV and pancreas at level of Treitz
4. Ligate splenic artery, then splenic vein away from SMV confluence both with vascular stapler
5. Transect pancreas with stapler (TA Green) at SMV/Splenic confluence
6. Leave drain and close

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33
Q

Cystgastrostomy

A

Ensure wall 6mm thick
1. Upper midline and then anterior gastrotomy approx 5cm
2. Aspiration of cyst for cultures and cytology, then entry into pseudocyst with cautery
3. Explore cavity and debride/evacuate everything
4. Anastomosis of at least 5cm w/ locking 2-0 PDS suture
5. Close gastrotomy in 2 layers, leave NGT and drain and close

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34
Q

Lap Nissen

A
  1. Gain laparoscopic access and place assistant trocars including 5mm subxiphoid liver retractor
  2. Incise gastrohepatic ligament and bluntly dissect between esophagus and crus and
    mediastinal dissection to obtain 3cm esophagus into abdomen
  3. Complete mobilization of fundus and pass posteriorly
  4. Creation of 2cm long fundoplication (Nissen or Toupe) over 60fr Bougie
  5. EGD to ensure not too tight
35
Q

Esophageal perforation + repair

A
  1. Appropriate thoracotomy and mobilize intercostal muscle from anterior attachment while
    entering for future use
  2. Incise inferior pulmonary ligament and incise mediastinal pleura, identify leak site
  3. Debride devitalized tissue and extend myotomy to expose all damaged mucosa
  4. Perform repair in 2 layers with inner absorbable and outer permanent suture
  5. Leave chest tubes, NGT above injury and perform gastrostomy tube
36
Q

Heller myotomy

A
  1. Laparoscopic access and place assistant ports w/ subxiphoid liver retractor
  2. Mobilize distal esophagus and remove anterior fat pad over GE junction but preserve vagus
    nerve
  3. Divide the longitudinal and circular muscle fibers 6cm up esophagus and 2cm onto stomach
    then insufflate under saline to air leak test for mucosal defect
  4. Perform Dor (180 anterior partial) fundoplication to cover defect
  5. EGD and close
37
Q

Graham patch

A
  1. Upper midline incision and washout, identify site of perforation, culture fluid
  2. Mobilize tongue of omentum
  3. Debride eges and place 3 interrupted 2-0 silk seromuscular stitches, then tie down over
    tongue of omentum to secure it into place
  4. Leave drain, consider pyloric exclusion or J tube if necessary
38
Q

Ileostomy creation

A
  1. Identify appopriate loop of ileum and choose site - through rectus muscle and not w/in skin
    crease
  2. Excise disk of skin and incise fascia in cruciate fashion to allow passage of 2 fingers
  3. Bring ileum out through defect in appropriate orientation
  4. Mature in standard Brooke fashion, and prior to closing abdomen ensure no twisting
39
Q

Subtotal colectomy

A
  1. Begin at sigmoid and divide @ upper rectum w/ stapler, ligating mucosa closer to colon
    (unless c/f cancer)
  2. Mobilize descending colon along white line and splenic flexure, dividing mesentery aft er this
  3. Mobilize hepatic flexure and separate all omentum from transverse colon
  4. Mobilize cecum and right colon, divide TI several cm distal to IC valve
  5. Bring specimen out extraction incision and create end ileostomy
  6. Leave drain near rectal stump and close
40
Q

Subtotal gastrectomy

A
  1. Midline laparotomy
  2. Define proximal margin w/ 5cm margin, then take down gastrocolic omentum and enter
    lesser sac, exposing right gastroepiploic artery and dividing it
  3. Retract stomach to right and expose and ligate left gastric @ lesser curve, then short gastrics
  4. Kocherize duodenum and ligate right gastric artery, and transect duodenum 2cm past pylorus
  5. Mobilize jejunum 30cm distal to LoT and transect, then 45cm distal to this create J-J w/
    stapler and close common enterotomy
  6. Bring proximal Roux limb through transverse mesocolon and create stapled G-J, closing
    common enterotomy
  7. D1/2 lymph node dissection along lesser and greater curve, hepatic artery nodes
  8. Leave NGT, air leak, and leave drain and close
41
Q

Lap Sigmoid colectomy

A
  1. Identify IMA and incise peritoneum and dissect it free circumferentially and perform high ligation
  2. Mobilize lateral attachments of sigmoid and descending colon, mobilize splenic flexure
  3. Divide IMV at inferior border of pancreas, then divide mesentery and divide upper rectum
    with linear stapler
  4. Extra-corporealize proximal margin and pursestrings EEA, then perform EEA colorectal anastomosis
  5. Air leak and Leave drain if concerned and close
42
Q

LAR

A
  1. Laparoscopic access and place assistant ports
  2. Medial-lateral dissection of upper rectum and identify both ureters (stents), then perform
    high ligation of IMA and IMV
  3. Completely mobilize descending colon and splenic flexure
  4. Perform total mesolectal excision by entering avascular presacral space and identify distal
    resection margin (2cm if you can) and divide with linear stapler
  5. Bring out proximal colon and place pursestring with anvil, perform EEA anastomosis, air leak
    leave drain
  6. Diverting loop ileostomy and close
43
Q

APR

A
  1. Supine lithotomy midline laparotomy and perform total mesolectal excision, mobilize
    descending colon for colostomy creation
  2. Pelvic dissection - identify lateral and posterior perirectal spaces, carry down past prostate
    and uterus
  3. Perineal dissection - pursestrings anus closed and excise ellipse of skin including external
    sphincter and dissect through both ischiorectal fossae and through anococcygeal ligament using
    coccyx and ischial tuberosities as guides
  4. Rendezvous perineal and abdominal dissections and close perineal wound in sequential
    layers with 2-0 vicryl, skin with interrupted Nylon vertical mattress sutures
  5. Create end colostomy, place omentum and drain in pelvis, and close laparotomy
44
Q

Lateral internal sphincterotomy

A
  1. Prone jackknife, choose right or left based on hemorrhoidal tissue
  2. Incise anoderm over intersphincteric groove and dissect out internal sphincter
  3. Perform sphincterotomy up to level of fissure (tailored sphincterotomy)
45
Q

Partial thyroidectomy

A

Neck extended

  1. Incision along skin lines and divide platysma, then making subplatysmal flaps and separating
    the strap muscles
  2. Take upper pole vessels first, then mobilize the superior lobes anteriorly and medially to
    identify RLN in tracheoesophageal groove
  3. Dissect inferiorly staying close to thyroid, identifying parathyroids and preserving their blood
    supply
  4. Divide through middle of gland w/ ligasure device
46
Q

Central neck dissection

A
  1. Dissecting out both RLNs and removing all fibroadipose tissue between carotid sheaths and
    hyoid bones superiorly and brachiocephalic vessels inferiorly
  2. Lymph node tissue from anterior and posterior triangles, defined by submandibular gland
    superiorly, IJ medially, trapezius laterally and clavicle inferiorly is removed
  3. Reapproximate medial aspect of SCMs to sternothyroid muscle, then close platysma and skin
47
Q

Parathyroidectomy

A

Neck extension
1. Baseline PTH prior to incision
2. Neck incision and subplatysmal flaps, separate strap muscles
3. Identification of RLNs, then identifying abnormal parathyroid glands and excision without
breaching capsule of the abnormal glands
4. Intraop PTH monitoring with reduction by >50% or normalization) at 10 minutes after gland
resection
5. Auto-implant into non-dominant brachioradialis If concerned about devascularization or in
patient with renal failure
Location of parathyroid glands?
Inferior: inferior to inferior pole, anterior to RLN
Superior: Within 1cm of RLN as it mercies cricothyroid membrane, posterior to superior pole

48
Q

REBOA

A
  1. Obtain femoral artery access and insert a 5-8fr sheath over a wire under US guidance
  2. Insert a large compliant balloon and position in zone 1 (left subclavian to celiac artery) for
    abdominal or pelvic hemorrhage source, or zone 3 (infrarenal) if pelvic source
  3. Inflate with 1/2-1/2 saline and contrast mixture, then secure balloon in place
  4. When balloon ultimately removed, repair arrteriotomy with cutdown and repair
49
Q

Zone 2 neck exploration

A
  1. Neck incision along anterior border of SCM, open carotid sheath and divide facial vein and
    middle thyroid veins to expose carotid
  2. Obtain proximal and distal control if carotid injury present, same for jugular injury (can ligate
    jugular or primary repair)
  3. Mobilize esophagus and place penrose to rotate circumferentially to inspect
  4. Palpate and visualize larynx and trachea
  5. Perform esophagoscope and bronchoscopy on the table
50
Q

Trauma laparotomy

A

Fluoroscopic table if possible, supine and arms out, prep chin to knees
1. Xiphoid to pubis incision
2. Pack all 4 quadrants and start from area that does not appear to be bleeding
3. Digital or clamp occlusion of arterial bleeding sources for initial control
4. Explore penetrating retroperitoneal injuries
5. GI Contamination: run bowel quickly and systematically, check both hemidiaphragms, close
simple injuries to stomach/duo/SB in single layer, and resect nonviable segments
6. Drain pancreatic injuries, can do distal pancreatectomy if complete disruption to left of SMV
7. No anastomoses during damage control laparotomy

51
Q

Duo injury repair

A
  1. Midline lap and packing of all 4 quadrants
  2. Do trauma lap until you get to duo, then do kosher maneuver to expose
  3. Damage control vs definitive repair –primary repair for simple lacs, Roux en Y duodenojejunostomy for larger holes or serial patch
  4. Consider pyloric exclusion with TA stapler, would then need GJ
  5. Decompression with integrate or retrograde duodenostomy tube if warranted
52
Q

Open AAA repair

A
  1. Midline Laparotomy, reflect small bowel to right and lift T colon superiorly
  2. Incise RP by LoT and reflect duodenum to right, find infrarenal aorta for clamp site
  3. Dissect distal aorta and proximal common iliac arteries
  4. Heparinize with 80u/kg and furosemide then clamp iliac arteries and THEN clamp aorta
  5. Open sac and oversew bleeding lumbars with silk interrupted suture
  6. Sew in graft with 2 or 3-0 prolene
  7. Close sac and retroperitoneum over graft, check distal pulses
53
Q

Ruptured AAA repair

A
  1. Midline laparotomy and open gastrohepatic ligament and compress aorta at level of diaphragm, get clamp here
  2. Lift SB and T colon away and incise RP and expose infrarenal aorta
  3. Get proximal and distal control of iliacs
  4. Heparinize and clamp, open sac and evacuate thrombus, oversew lumbar bleeders
  5. Sew in graft with 3-0 prolene
  6. Close RP and sac over graft
  7. Unclamp and check pulses
54
Q

Open femoral thrombectomy

A
  1. Heparinize patient with 80u/kg
  2. Prep both groins and make vertical incision over inguinal ligament dissecting layer by layer until you identify CFA
  3. Obtain control of CFA, SFA and Profunda and heparinize to ACT over 250
  4. Transverse arteriotomy over bifurcation, and pass 4 or 5fr Fogarty for multiple sweeps proximal and distal
  5. Close arteriotomy with interrupted 5-0 Prolene and close incision in layers
  6. Consider fasciotomy given ischemia time
55
Q

CEA

A
  1. Anterior SCM incision, retract SCM laterally and identify IJ, divide facial vein, identify vagus lateral to IJ
  2. Get control of CCA, ECA w/ superior thyroid and ICA with care to avoid hypoglossal nerve
  3. Heparinize and clamps placed in this order: ICA, CCA, ECA (ICE)
  4. Arteriotomy is made from CCA onto the ICA and shunt is placed into ICA and CCA and secured with Rommel tourniquets, use doppler to interrogate shunt
  5. Endarterectomy performed, tacking sutures with interrupted proline when needed, and closure with bovine pericardium patch angioplasty with shunt removal
  6. Backbleeding is performed in all vessels
  7. Clamps removed: ECA first, then ICA and then CCA
  8. Intraop US to look for flap and close
56
Q

Fem Pop Bypass

A
  1. Exposure inflow artery (vertical groin incision) and outflow vessel (popliteal, medial incision)
  2. Expose and dissect contralateral saphenous vein, prepare for bypass with heparinized saline and repair leaks
  3. Create bypass graft tunnel, heparinize, clamp and perform proximal anastomosis in reverse fashion (reverse GSV)
  4. Bring graft through tunnel and perform distal anastomosis
  5. Confirm flow through graft and outflow arteries with doppler and pulse exam
  6. Shoot completion angiography
57
Q

AV fistula

A
  1. Antecubital incision and identify cephalic vein, dissect free and surround with vessel loop, mobilize adequate distance to reach brachial artery
  2. Identify brachial artery medially and surround with vessel loop
  3. Ligate and divide cephalic vein, bring to artery and heparinize
  4. Clamp artery, make arteriotomy and do anastomosis
  5. Unclamp and check pulse
58
Q

GSV ablation

A
  1. Frog leg affected side and access distal GSV
  2. Pass RFA catheter up to saphenofemoral junction under US guidance
  3. Tumescent around GSV w/ epinephrine and saline
  4. Ablate vessel starting 3cm distal to saphenofemoral junction
59
Q

Pediatric inguinal hernia

A
  1. Incise over external ring and open external oblique aponeurosis
  2. Dissect cord and separate cord from hernia sac
  3. Twist and suture ligate the sac with a 4-0 or 5-0 vicryl
  4. Close attenuated external oblique muscle or divided external ring
60
Q

Intussusception operation

A
  1. Transverse supra umbilical incision
  2. Identify intussusception and milk back tip of intussusceptum toward cecum
  3. Assess for resection and perform if needed
  4. Close
61
Q

Malrotation

A
  1. Transverse supra umbilical incision
  2. Eviscerate bowel and go to root of mesentery, then perform counterclockwise detorsion (turn back hands of time) until duodenum on right side of colon
  3. Assess for viability and resect what is necessary and divide Ladd’s bands
  4. Straighten line from duodenum to ICA
  5. Perform appendectomy
62
Q

Pyloromyotomy

A

Remember to resuscitate with normal saline and replete electrolytes
1. 3cm RUQ incision extending laterally from lateral border of rectus
2. Incise pylorus just proximal to vein of mayo (prepyloric vein), extend proximally for 2cm across pylorus and onto antrum
3. Split with hemostat until mucosa bulges
4. If full thickness injury, close in 2 layers and perform contralateral myotomy

63
Q

Open pulm resection

A

Position with lateral lesion side up and single lung ventilation
1. Posterolateral thoracotomy through 5th ICS
2. Dissect out appropriate pulmonary vein and ligate it with vascular stapler, then pulmonary artery and ligate with vascular stapler, then finally dissect and divide lobar bronchus with green load TA stapler
3. Take lymph nodes with specimen
4. Perform saline leak test
5. Leave chest tubes and close

64
Q

Penetrating Injury To Groin

A

Prep both legs
1. Vertical incision overlying starting superior to inguinal ligament
2. Proximal and distal control of CFA, SFA and Profunda
3. Perform repair/shunt/patch angioplasty
4. Completion angiogram
5. Consider fasciotomy

65
Q

BKA

A
  1. Incise 10cm inferior to tibial tuberostomy, 2/3 leg circumference and make big posterior flap
  2. Divide muscles and expose fibula 3cm superior to incision
  3. Identify and divide anterior tibial neurovascular bundles, posterior tibial and peroneal neurovascular bundles
  4. Saw tibia and fibula and close muscles over stump and then skin
66
Q

AKA

A
  1. Fish mouth incision mid thigh
  2. Ligate GSV in inner/medial thigh and incise muscles at level of skin incision
  3. Ligate femoral vessels medially
  4. Highly ligate sciatic nerve in posterior thight
  5. Expose femur 10cm proximal to skin incision and divide with saw and close fish mouth incision over bone, can use muscles as flaps
67
Q

Extra-anatomic bypass

A
  1. Bilateral vertical groin incisions and transverse incision 2cm inferior to the clavicle
  2. Split pec to get down to axillary artery, dissect and obtain control w/ vessel loops
  3. Isolate CFA, SFA and Profunda
  4. Tunnel 8mm PTFE graft
  5. Heparinize with 80u/kg
  6. Sew axillary and femoral grafts w/ 5-0 prolene
  7. Completion angiogram
  8. Consider fasciotomy
68
Q

Skin graft

A
  1. Use lateral thigh as donor area
  2. Set dermatome to 12/1000 inch and use 45 degree angle to harvest skin
  3. Mesh graft 3:1 (unless face)
  4. Apply graft dermal side down and fix edges with staples
  5. Place xeroform gauze over recipient and donor site
69
Q

IVC filter insertion

A
  1. Access femoral vein and place 8.5 fr sheath
  2. Advance catheter and perform cacography to ensure patency of IVC and locate lowest renal vein
  3. Advance sheath to planned deployment below renal veins and advance filter
  4. Draw back sheath to expose filter and release the filter hook
  5. Completion cavography
70
Q

BAL

A
  1. 100% FiO2
  2. Insert bronchoscope
  3. Inject 10cc saline and aspirate into leukin trap and send for: diff count, microbology, virology, cytology
71
Q

Hysterectomy

A
  1. Lower midline laparotomy
  2. Incise left and right round ligaments to enter broad ligaments
  3. Identify ureters bilaterally
  4. Divide ovarian ligaments and suture ligate to preserve the ovary
  5. Dissect posterior bladder off the uterus and clamp uterine arteries at level of cervix, then divide arteries
  6. Incise vagina at level of the cervix over clamps and suture vaginal cuff closed
72
Q

Colonoscopy

A
  1. Sedate with versed and fentanyl
  2. Left lateral decubitus and perform DRE, check scope function
  3. Insert scope and advance to cecum identifying TI and AO
  4. Withdraw for at least 6 minutes
  5. Retroflex in rectum
73
Q

EGD

A
  1. Sedate with versed and fentanyl, bite block
  2. Insert scope by staying midline and following tongue down
  3. Advance all the way to third portion of duodenum, identify ampulla and withdraw slowly
  4. Examine stomach and retroflex in stomach to identify hiatal hernia
74
Q

PAC placement

A
  1. Test balloon and inflate and float swan after gaining RIJ access/Cordis w/ US
  2. Look for waveform changes: RA is short amplitude, RV is wide amplitude, PA is dicrotic, Wedge is short amplitude
75
Q

Normal swan values (MVO2, PA pressure, PCWP, SVR, CI)

A

MVO2: 70%
PA Pressure: 20/10
PCWP: 10
SVR: 1000
CI: 3 (2-4)

76
Q

Highly selective vagotomy

A

Phrenoesophageal ligament overlying esophagus incised and encircled with Penrose
ID main vagal trunks in posterior mediastinum
Examine lesser curvature to ID nerve of Latarjet
Dissect 6 cm proximal to pylorus at incisura – LEAVE crows foot (maintain innervation to antrum and pylorus)
Divide lesser momentum from lesser curve and continue to divide vagal branches to 6 cm proximal to GEJ (divide as close to stomach as possible)

77
Q

Pyloroplasty

A

ID pylorus by palpation of muscular ring
2 cm proximal to pylorus, incise gastric wall and extend incision distally parallel to long axis of bowel for 5 cm using electrocautery

78
Q

Open GJ

A

Upper midline incision
ID pylorus then ID 5 cm proximal to pylorus as gastric site of anastomosis
Next ID LoT and select jejunum 15-30 cm distal
Double layered side to side isoperistaltic anastomosis

79
Q

Subtotal gastrectomy

A

Staging lap
Midline ex lap, preserving falciform (can be used to buttress duodenal closure)
Mobilization of Gr curvature of stomach using a Ligasure, stopping short of short gastrics
Mobilize hepatic flexure and expose GASTROCOLIC TRUNK (R gastroepiploic v + colonic v –> SMV) and divide trunk using vascular stapler
Divide R GASTROEPIPLIC A
Mobilize lesser curvature by dividing lesser omentum
R GASTRIC A(arising from CHA) divided and including lymphatic tissue with specimen
Encircle duodenum 2 cm distal to pylorus and divide with a stapler (AVOID BILE DUCT HEPATIC ARTERY OR PORTAL V)
Oversew stapled duo line with 3-0 silk Lembert and buttress with falciform
L gastric a divided at origin
Divide stomach 4-6 cm proximal to gastric cancer using green load of GI stapler
Roux en y gastrojejunostomy

80
Q

Roux en y gastrojejunostomy

A

Loop of jejunum distal to LoT that reaches stomach pouch without tension identified and divided using blue load GIA stapler
Oversew staple line of the Roux limb with 3-0 silk
Roux limb needs to be >40 cm (level of stomach –> JJ)
Defect is created in transverse mesocolon to L of middle colic
Stapled side to side anastomosis between BP limb and jejunum using GIA stapler and closing common enterotomy with TA stapler
Two layered anastomosis between anterior surface of gastric pouch and Roux limb (hand sewn)

81
Q

PEG tube

A

EGD
Fully insufflate stomach
Advance snare the withdraw 2 cm
Transilluminate
Carefully palpate and choose spot with brightest area of transillumination
Infiltrate with local, make a skin incision
Advance angiocath with the needle, remove needle and loop snare around the catheter
Advance wire via catheter and close snare around wire
Withdraw scope
Connect looped wire to wire at tapered end of PEG tube
Pull suture from abdominal wall and follow with scope
Confirm thickness of abd wall, ensure bolster is able to move/spin and is not too tight

82
Q

Open gastrostomy – OR

A

Upper midline
ID an area on anterior surface of mid portion of stomach close to greater curvature
Using 3-0 Vicryl, sew circular purse string around site with diameter of about 1 cm
Place a 2nd purse string, diameter of approx 2 cm
Grasp. left linea alba with clamp and pick area through middle of L rectus muscle where tube will exit – make incision on overlying skin and pass Kelley through abdominal wall and out skin
Grasp end of catheter and bring it through abdominal wall
Make small gastrostomy in center of purse string and confirm entry into stomach, place catheter through gastrostomy and tie purse strings dow
Inflate balloon
Can fixate using 3-0 Vicryl through seromuscular layer of stomach and peritoneum of abdominal wall x 4 –secure all sutures first and then tie them at the end

83
Q

Feeding jejunostomy

A

Incision in midline at level of LoT
Retract momentum and transverse colon to identify segment of small bowel chosen in LUQ
Run small bowel LoT to ileocecal valve to r/o other pathology
Identify insertion site and make incision
Retract abdominal wall and pass Kelley from inside abdomen to skin incision
Tube brought through abdominal wall
Segment of jejunum 30 cm from LoT and use 3-0 vicryl to place purse string suture
Maintain orientation of proximal/distal jejunum
Create small enterotomy using cautery, place distal end of feeding tube through enterotomy and direct distally at least 10 cm
Tie down purse string
Imbricate tube entry site using 3-point triangular technique
Imbricate small bowel over feeding tube for about 5 cm (witzel tunnel)
Secure to parietal peritoneum

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