Core Procedures

Question 1

Rectus Sheath Hematoma Exploration

Operatively ligate inferior epigastric a

Answer 1

Exploration:
-prep patient widely from knees to chest
-include both groins
-longitudinal incision over the hematoma and extend it 5cm proximal and distal
-open rectus sheath
-evacuate hematoma
-identify bleeding vessels and oversew them
-leave drain in rectus sheath
-subq drain before closing the skin

Operatively ligate inferior epigastric a:
-make oblique incision in groin, just under inguinal ligament
-follow ligament down to femoral artery
-identify branches off the proximal cfa, the inferior epigastric should come off medially
-test clamp and if improved bleeding, ligate them with silk sutures

Question 2

Ventral Hernia

Answer 2

1. Access to abdomen outside of hernia
2. LOA to free bowel from anterior abdominal wall, working towards the hernia and fascial defect
3. Reduce the hernia by place gentle traction on the distal, non-dilated portion. Extend fascial defect (if needed) to reduce the bowel
4. I would then connect my laparotomy incision with the hernia defect and fully mobilize bowel and inspect for viability
5. If viable and stable patient, perform definitive repair
6. excise hernia sac
7. assess if fascial edges come together without tension
8. place macroporous polypropylene mesh in either underlay or retrorectus space (pending on prior repairs and what planes have been previously violated)
9. if well incorporated, leave old mesh in place. If not, excise
10. If tension, then perform fascia release with either anterior component separation or transversus abdominis release
11. If nonviable, resect necrotic bowel, perform primary anastomosis ensuring good perfusion and tension free.
12. In contaminated setting, do not place mesh or open any fascial planes, attempt primary closure, if available, would reinforce my primary closure with underly of biologic mesh
    If can’t bring together, bridge with biologic mesh or vicryl mesh, close skin over self-suctioning drains, need more definitive repair in the future

Question 3

Paraesophageal hernia

Answer 3

I would perform a minimally invasive, transabdominal approach.
1. gain access with optiview technique, camera port 15 cm below the xiphoid and other ports triangulated on the hiatus
2. I would utilize self-retaining liver retractor
3. with gentle traction I would reduce the hernia contents, open gastrohepatic ligament beginning my dissection of hernia sac along the inner border of the cura, completely excising the hernia sac
4. perform high mediastinal circumferential dissection in order to obtain 3cm of intra-abd esophagus, taking care to preserve both the anterior and posterior vagus nerves
5. divide short gastrics to the fundus in order to construct the fundoplication, I would then close the cura defect over a large bougie with a plegdeted non-absorable suture, construct a partial 270 degree posterior wrap

Unable to get 3cm of intrabdominal eso
first, maximally mobilize the esophagus with a high mediastinal dissection to the level of pulm veins
if esophagus foreshortened, gastropexy, collis gastropexy

Question 4

Eso perf after hiatal hernia

Answer 4

early with leak- return to OR
lap exploration with egd, source control by draining mediastinum, identify and try to repair, leave drains, advanced endoscopist to place a stent, consider distal feeding access

Question 5

Inguinal Hernia

Answer 5

1. fingerbreath above the inguinal ligament
2. Dissect through soft tissue until I reach the EO, incise it in the direction of it’s fibers to open the inguinal canal, taking care to identify and protect the ilioinguinal nerve
3. After identifying hernia sac and spermatic cord, I would circle the cord structures at the internal ring with a penrose drain
4. At this point, I would dissect the sac away from the cord structures, open the sac and assess the viability of the contents
5. As long as bowel appears viable, I would reduce the contents, ligate the sac at the internal ring and perform mesh repair using a light weight, marcoporous polypropylene mesh secured to the conjoint tendon superiorly and the shelving edge inferiorly with 2cm of overlap medially

If necrotic bowel, if I can mobilize enough bowel through the groin incision to perform a resection and primary anastomosis, I would do that
Otherwise I would perform a laparotomy thorugh a lower midline incision
No permanent mesh in this contaminated setting, so I would perform a basini repair by approximating the conjoint tendon to the inguinal ligament with a prolene suture

If hernia below the inguinal ligament, femoral hernia
Require mckvay repair by approximating the conjoint tendon to cooper’s ligament with a transition stitch under the inguinal ligament before arriving at the femoral vein
Relaxing incision: incise anterior rectus sheath

If hernia spontaneous reduces on induction, still check bowel with diagnostic lap. Gross contamination, tissue repair through groin incision
If bowel viable without contamination, lap tapp repair with synthetic mesh

Question 6

How do you perform a bladder pressure?

Answer 6

patient lies supine, connect three way stop cock to foley, one port to aline setup, zero transducer at iliac crest, drain bladder, 25cc saline into bladder, measure at end expiration

Question 7

Approach to early presentation, lower eso perforation in s/o achalasia

Answer 7

1. post lat thoracotomy in 6th intercoastal space
2. take down infeior pulm ligament
3. mobilize distal eso
4. visualize a 2cm perforation, just above the ge junction
5. edges appear healthy, nonfriable
   extend myotomy to make sure you have complete visualization of the defect
6. debride any nonviable tissue
   7.two layer repair
7. use flap coverage
8. need to do a myotomy 180 degrees opposite perforation if for achalasia
9. leave drains, washout
10. g-j tube

if intraabd leak, laparotomy incision and fundoplication

Question 8

Distal panc and splenectomy

Answer 8

min invasive, lap approach
1. supine, steep reveserse trendelberg with a footboard
2. start by mobilizing the stomach by transecting the short gastric
suspend stomach
3. fully mobilize splenic flexure to expose inferior edge of pancreas
4. then make a retro pancreatic tunnel 2cm to the right of the mass
transect pancreas with gradual compression with a blue load stapler
transect splenic artery at roughly the same area
5. bring lymph nodes and artery with the specimen
6. identify and transect vein with vascular load stapler
7. then dissect pancreas off the RP in a plane outside the peripancreatic fat so that I can take that tissue with the specimen
8. mobilizing spleen off it’s lateral attachments
9. remove specimen in a bag and leave 19fr blake drain in splenic fossa

Question 9

Bleeding gastric or duo ulcer

Answer 9

midline laparotomy
anterior gastrotomy
identify and oversew the ulcer to get control of the bleeding
where is ulcer located posterior wall of antrum 3cm proximal to pylorus
acid hypersecretion and nsaid use

bleeding duodenal ulcer
mildine laparotomy
kochar maneuver
longitudinal incision in duodenal bulb and identify lesion
gda usually source of bleeding and control iwth 3 point ligation (superiorly, inferiorly and medially) taking care to identify and avoid the common bile duct
then close duodenal incision transversely

Question 10

Ileal pouch won’t reach the anus

Answer 10

sb mesentery fully moblized off rp all the way to LOT
high ligation of ileocolic pedicl
assess different points of TI as to which apex would be best in terms of reach
if not adquate reach, relaxing incision on both sides of small bowel mesnetery perpendicular to mesenteric vessels
if still no, selectively divide vessels in mesenteric arcade but would be cautious to not devascularize the pouch
final options include creating s shaped pouch or leaving a defunctional pouch in pelvis with plans to reoperate in 6 months

Question 11

LAR with DLI

Answer 11

1. medial to lateral dissection of rectosigmoid colon starting at the sacral promonatory
2. develop a plane between the retroperitonium and colon mesentery
3. identfy ima and isolate it at the take off from aorta
4. identify left ureter before divide ima
5. continue medial to lateral disseciton until I reach the paracolic gutter
6. i would then mobilize the splenic flexure by dividing all atachments to the colon and medialize the descdenidng colon
7. i would then start the tme dissection posteriorly and make sure I’m identifying and protecting the hypogastric nerves
8. I would fully mobilize the rectum down to the pelvic floor and identify a point of transection 2cm distal to the tumor
9. I would divide the colon proximally and distally and perform a tension free stapled end-to-end anastomosis
10. I would then perform a leak test
    Finally if this was negative, I would create a DLI at a site that was marked preoperatively by a stoma nurse

Question 12

Right colectomy for colon ca

Answer 12

1. diagnostic lap
2. after clearly identifying the duodenum, I would perform medial to lateral dissection of ascending colon taking care to protect duodenum, right kidney and ureter in RP plane
3. incise white line of toldt and take down gastro colic ligament to enter into lesser sac
4. high ligation of ileocolic pedicle and right colic artey
   (5. If extended right for hepatic flexure lesion, I would also divide the middle colic vessels)
5. once colon completely mobilized, periumbilical incision to extracorporalize specimen
   divide ileum 5cm prox to ilecocecal valve and transverse colon near splenic flexure with preservation of left colon base on left colic a
6. tension free side-side ileocolic anastomosis

Question 13

Subtotal colectomy and end ileostomy for c.diff

Answer 13

1. stoma marked preoperatively
   anestheisa team
2. midline laparotomy, assess abdomen and confirm no other pathology
3. mobilize colon starting with ascending colon, divide mesentery with ligasure device close to bowel wall and not attempt any high ligation of mesenteric vessels
4. once mobilize, divide TI and distal colon and rectosigmoid junction
5. perform leak test of rectal stump to ensure staple line intact
6. I’d also oversew the staple line with a 2-0 pds suture
7. create end ileostomy and place drain in the pelvis

Question 14

Sigmoidectomy for diverticulitis

Answer 14

1. perform midline laparotomy
2. washout the abdomen thoroughly
3. mobilize the descending colon and splenic flexure, taking care to identify and avoid my ureter
4. identify my transection margin
   proximal margin would be my most distal healthy, uninvolved colon
   distal margin would be proximal rectum
5. I would then perform a tension free colon to proximal rectum anastomosis with eea
6. perform leak test with sigmoidoscope
   once anastomosis complete, I would create a diverting loop ileosotmy

Question 15

Lateral Internal Sphincterotomy

Answer 15

1. prone position
2. make 2cm radial incision at intersphincteric groove in the right lateral position away from hemorrhoidal tissue
3. I would dissect into the intersphincteric groove and isolate the internal sphincter muscle with a kelly clamp the length of the fissure
4. I would then divide the internal sphincter muscle with bovie electric cautery
5. I would then close the skin incision with a 3-0 chromic suture

Question 16

Procedures for hemorrhoids

Answer 16

Rubber band ligation
Identify apex of hemorrhoidal pedicle and that it is well above the dentate line

Excisional hermorrhoidecotmy
Minimize the amount of anoderm excision
Dissect hemorrhoidal tissue off the internal sphincter muscle
Suture ligate the hemorrhoidal pedicle
Close mucosal defect with 3-0 chromic suture while leaving an edge of the wound open for drainage

Question 17

Flex sig for volvulus

Answer 17

I’d perform this procedure with propofol sedation with anesthesia
After containing consent and a timeout, I would introduce the scope under visualization through the anus to the rectum. I would use minimal insufflation of co2 until I reach an area of narrowing and twisting in the sigmoid colon. I would then gently advance the scope past this area until I reached dilated colon proximally. I would then suction as much gas and stool proximally and then leave a decompressive rectal tube.

Question 18

Whipple

Answer 18

1. Diagnostic laparoscopy, examining surface of liver, peritoneal cavity and sb/mesentary for any e/o occult metastatic disease.
2. If negative, I would perform a midline laparotomy and start by taking down the attachments between the greater omentum and transverse colon, entering the lesser sac.
3. I’d trace the middle colic vein up to identify the smv at the inferior border of the pancreas and develop the plane behind the neck of the pancreas and encircle the pancreas with an umbilical tape.
4. I would next mobilize the hepatic flexure and perform a complete kocher maneuver. This allows me to palpate the course of the sma.
5. I would next perform a cholecystectomy and portal dissection and division of the common hepatic duct and identification and ligation of GDA.
6. Next I would transect the distal stomach and divide the small bowel distal to the LOT mobilizing the distal duodenum from the mesentery.
7. I would then divide the pancreatic neck and send the distal duct margin for frozen section analysis.
8. Finally I would divide the uncinate process attachments, adjacent to the sma adventitia.
9. Once this resection is complete and pathology has confirmed a negative distal margin, I would proceed with reconstruction consisting of a tension free duct to mucosa pancreaticojejunostomy, hepaticojejunostomy and gastrojejunostomy. I would leave closed suction drains near the pancreatic and biliary anastomoses.

Question 19

Ivor Lewis Esophagectomy

Answer 19

1. in operating room, start with abdominal portion of the operation
   patient would start supine
2. mobilize greater curve of stomach taking care to protect gastroepiploic arcade as that will be blood supply to conduit
3. perform kochar maneuver to help conduit reach into chest
4. mobilize stomach and ligast the left gastric artery at the base keeping lymphatic tissue with the specimen
5. the mobilize the remainder of the stomach and perform a hiatal dissection and keeping lymphatic tissue with spcimen
6. create gastric conduit by transecting stomach at least 5cm distal to the tumor creating a long conduit based on the greater curvature of the stomach
7. i would then suture the conduit to the specimen so it can be pulled into the chest
8. patient would then need to be repositioned for a right thoracotomy
   in my practice, we would involve thoracic surgery for this portion of the case
9. right lateral thoracotomy and then mobilization of eso and surrounding soft tissue up to the azagus vein
10. the esophagus would then be stapled and specimen removed
    the gastric conduit is then brought up into the chest
11. a circular staple is use to make the anastomosis
12. i would leave two chest tubes for drainage and close

Question 20

Lap Heller Myotomy and Dor Fundoplication

Answer 20

48h liquid diet
ngt prior to induction
1. triangulate port to hiatus
perform hiatal dissection and expose the ge junction and anterior esophagus
2. identify and protect the vagus nerve
3. divide by longitudinal and circumferential muscles being sure to completely divide and separate the muscle fibers from the underlying mucosa for a length of 6cm onto the eso and 2cm onto the stomach
4. upper endoscopy and air insufflation leak test
5. finally, I’d construct an anterior 180 degree fundoplication

Question 21

Internal hernia after bypass

Answer 21

position patient supine with arms tucked
gain access via hassan technique
place 3-4 additonal 5mm ports to triangulate to allow me to run the bowel
start at TI where bowel is decompressed and run common channel proximally until I reach the point of obstruction at the jj
assess viability of bowel
close mesenteric defect with permanent suture

if needed to reconstruct, make a larger incision and extracoporalize the jj
based on weight loss, nutritional status, and measuring all the limbs, decided length
side to side roux and common, plug in bp 30cm proximal

locations of internal hernia following bypass:
most common is mesenteric defect at jj
peterson’s defect behind the roux limb mesentery
through the rent in the transverse mesocolon if rny was constructed in a retrocolic fashion

Question 22

APR with flap closure of perineal wound

Answer 22

I perform these with my plastic surgery collegues to help with optimal flap coverage and make sure that stoma marked preop
1. lap medial to lateral mobilization of rectosigmoid junction and descending colon
2. I would make sure to identify the left ureter
3. ligate the superior rectal artery
4. I would then divide the colon at the rectosigmoid junction and proceed with dissection of the rectum
5. following the principles of a mesorectal excision making sure to preserve the hypogastric nerves
once I get down to the pelvic floor, I would then perform the perineal dissection
6. I would makes sure I’m taking wide margins, keeping in mind the location of the tumor prior to treatment
7. I would perform the dissection circumferentially by diving the anococcygeal ligament posteriorly until I met up with the abdominal dissection
8. Once the perineal dissection is complete, I would remove the specimen
9. I would then create the aperture of the end sigmoid colostomy and the site of preoperative stoma marking
10. I would then ask my plastic surgery colleagues to join me for flap coverage of the perineum
and once complete and all incisions closed, I would then mature the colostomy

Question 23

Embolectomy

Answer 23

heparinize patient 80u/kg
broad spectrum antibiotics
call OR for open case with vascular set including fogarty for embolecotmy, catheters

1. midline laparotomy, enter peritoneum and examine bowel
2. if grossly perforated, clamp and resect, otherwise pack in ruq
   elevate transverse mesocolon and follow middle colic artery to sma
   feel for a pulse proximally then carefully expose loop valve
3. act >200
4. clamp prox and distally and make transverse arteriotomy
5. use 2 3 embolectomy catheter to retrieve clot proximally and distally
6. once good inflow and outflow, close arteriotomy with interrupted prolene sutures
7. doppler
8. place warm irrigation, 20 minutes before re-evaluating the bowel
   if some bowel dusky but no definitely dead, temporary abd closure and plan second look

Question 24

Thrombectomy

Answer 24

different patient, chronic vasculopath, more insidous onset
not a candidate for embolectomy
if can identify healthy portion of sma, can do iliac sma bypass with greater saphenous vein or ptfe or if vascular surgeon available and had endovascular options, transfemoral stenting or retrograde stenting

Question 25

Lower eso perforation

Answer 25

1. position patient in right lateral decub position preferably with single lung ventilation if tolerated then perform thoracotomy through 7th intercoastal space harvesting intercoastal muscle flap on the way in later to be used as a repair buttress, 2. I would mobilize the esophagus, debride necrotic tissue and perform a vertical myotomy to fully expose the mucosal injury
2. I’d perform a two-layer repair with a vicryl inner layer and a silk outer layer using my previously harvest intercoastal flap to buttress the repair.
3. would perform a leak test via an ngt inserted by anesthesia just proximal to the injury and then have the ngt passed into the stomach. 5. I would then irrigate the thorax with warm sterile saline.
4. I’d place two sterile chest tubes (one basilar and one apical).
5. And then close the thoracotomy. 8. Prior to leaving the OR, I would establish entero access with a feeding jejunostomy performed through a separate small upper abdominal incision

proximal: left neck exploration
mid eso: right thoracotomy in 4-6th intercoastal space
upper midline abd if leaking into abdomen

bail out procedures in the event of perforation from ca, mid-eso from achalasia, caustic injection, devitalized eso
resection, exclusion and proximal diversion
if cannot primary repair, place t-tube through the injury to control the leak
still need wide drainage and distal feeding access

Question 26

Horseshoe abscess drainage (modified Hanle procedure)

Answer 26

1. Place patient in lithotomy position
2. Perform anoscopy to see if we can identify an internal opening c/w perianal fistula (I would anticipate that this would be in the posterior midline)
3. I would carefully examine the entire anal canal to see if I can appreciate any fullness to suggest abscess
4. Drain post anal space by making a skin excision at the point of maximal fullness in the posterior midline and divide the analcoccygeal ligament
5. I would then try to see if I can pass a probe from this space into the internal opening to see if I can place a seton
6. Next I would make counter incisions over the points of maximal fullness overlying the bilateral ischiorectal fossa and place setons from the posterior midline to keep the cavities open and allow the area to drain
7. I would then use a tonsil clamp to break up all loculations and irrigate all the cavities until the effluent is clear

Question 27

fistulotomy

Answer 27

highest risk of incontinence, only used for intersphincteric fistulas that count as <30% of intersphincteric muscle anteriorly and <50% posteriorly
divide skin and muscle overlying the fistula tract
fistula tract and its edges are debrided until there’s healthy tissue
hemostasis obtained and wound left open
can also consider marsupilizing the edges of the track to prevent the skin from closing prematurely and allow the wound to heal from the base

Question 28

LIFT procedure

Answer 28

1. performed by exchanging the seton for a fistula probe
2. Make an incision externally in the intersphincteric groove
3. dissect out the fistula track between the internal and external sphincter so that all is left is the fistula probe
4. suture is used to tie of the internal and external track within the intersphincteric groove
5. peroxide is then injected in the external fistula track to confirm the fistula has been fully disrupted

Question 29

anorectal advancement flap

Answer 29

1. performed by dissecting out the mucosal flap distal to the internal opening of the fistula
   this can include partial or even full thickness flap
2. a U shaped flap is approximated so that it’s 2x the length of it’s width
3. the internal opening of the fistula is identified and closed with suture
4. the mucosal flap is then secured one centimeter distal to the internal opening

Question 30

Colonoscopy

Answer 30

1 balloon golytly split dose prep and cld the day before colonoscoy, npo mn
confirm no blood thinners and no allergies
consent and timeout
DRE, insert scope and pass under direct visualization from the anus all the way to the ileocecal valve, noting the appendiceal orifice, the ileocecal valve and the crowsfoot of the cecum
I would then carefully withdraw the scope spending at least 6 min on the withdraw

difficultly advancing: reduce scope to make sure no loops, abdominal pressure, stiffen scope, pediatric scope, position patient, senior partner, virtual or low dose ct colonosocpy that same day

5mm pedunculated polyp in transverse colon: cold snare polypectomy

8mm sessile polyp in descending colon: cold snare polypectomy

1.5cm pedunculated polyp in sigmoid colon: hot snare polypectomy and close mucosal defect with a clip

1.5cm sessile polyp: endoscopic mucosal resection (lift the polyp up off the submucosa with an injectate)

endoscopic submucosal dissection: polyps >2cm and when c/f malignancy to remove the polyp en bloc with adequate margins

Question 31

Breast abscess drainage

Answer 31

ellipitical skin incision from directly over the abscess cavity
leave a large enough aperture of patient to do dressing changes
and allow the cavity to heal from the inside out before the skin closes over the top of the cavity
evacuate all purulent fluid and break up all loculations
I would be sure to thoroughly irrigate the abscess cavity thoroughly
also excise a small portion of cavity wall itself and send to pathology
pack wound at completion and allow to heal by secondary intention

Question 32

Left adrenalectomy

Answer 32

1. position in right lateral decubitus position, place ports along the coastal margin
2. Begin by assess the abdomen for any signs of metastatic disease
3. if negative, incise lateral attachments to the spleen and begin to mobilize the spleen and pancreas medially to develop the avascular plane between the pancreas and gerota’s fascia,
4. I would then open gerota’s fascia. I would identify the inferior phrenic artery as it traces down on top of the adrenal and ligate it.
5. I would then identify the left renal vein and trace this medially until I encounter the adrenal vein, the adrenal vein would be carefully dissected and divided between clips,
6. I would continue to mobilize the adrenal gland off the kidney and away from the diaphragm using an energy device, place the adrenal gland in an endocatch retrieval device and remove it from the abdomen, I would confirm good hemostasis before closing

Question 33

Right adrenalectomy

Answer 33

left lat decub
periumbilical, 3 additional ports
mobilize the hepatic flexure access kidney
sometimes need to mobilize liver taking down the triangular attachments
open up gerota fascia
finding adrenal vein as it empties into ivc, ligate between two clips
dissect adrenal gland with rim of fat

Question 34

Total thyroidectomy for Graves

Answer 34

repeat thyroid function tests two weeks before surgery to confirm free T3 wnl
pretreatment with lugols iodine solution for one week prior to surgery to decrease vascularity of thyroid gland
1. supine, arms tucked with neck gently extended
2. intubated with a tube that has recurrent laryngeal nerve monitoring capabilities
3. collar incision, raise sub-platsymal flaps, open the midline raphe, retract strap muscles to gain access to the thyroid gland
4. I would retract the thyroid gland medially and develop the plane between the thyroid gland and the pre-vertebral fascia
5. I would identify and ligate the middle thyroid vein, then mobilize the upper and lower pole of the thyroid gland taking the vessels with an energy device making sure the parathyroid glands were preserved with their vascular pedicles
6. I would then identify the RLN in the tracheoesophageal nerve and complete the mobilization by taking the ligament of berry
7. I would perform a similar procedure on the contralateral side
8. I would check for hemostasis, check viability of parathyroid glands and autotransplant any parathyroid gland that appeared compromise
I would then close

Question 35

Total thyroidectomy with central neck dissection

Answer 35

1. supine, arms tucked with neck gently extended
2. intubated with a tube that has recurrent laryngeal nerve monitoring capabilities
3. collar incision, raise sub-platsymal flaps, open the midline raphe, retract strap muscles to gain access to the thyroid gland
4. I would retract the thyroid gland medially and develop the plane between the thyroid gland and the pre-vertebral fascia
5. I would identify and ligate the middle thyroid vein, then mobilize the upper and lower pole of the thyroid gland taking the vessels with an energy device making sure the parathyroid glands were preserved with their vascular pedicles
6. I would then identify the RLN in the tracheoesophageal nerve and complete the mobilization by taking the ligament of berry
7. I would perform a similar procedure on the contralateral side
8. I would perform a central lymphadenectomy by removing all the soft tissue between the carotid arteries, sternal notch and hyoid bone, taking care to make sure I preserved the parathyroid glands.
9. If unable to preserve parathyroid’s vascular pedicle, I would confirm parathyroid tisse on frozen section and autotransplant them to the sternocleidomastoid muscle
10. I would check for hemostasis
    I would then close

Question 36

FNA biopsy

Answer 36

using ultrasound to localize the nodule
anesthetize the skin over the needle trajectory
under ultrasound guidance, I would perform multiple passes within the nodule using a 25g needle
I would ask for cytopathology on standby to confirm adequate sample

Question 37

Thyroid lobectomy

Answer 37

1. supine, arms tucked with neck gently extended
2. intubated with a tube that has recurrent laryngeal nerve monitoring capabilities
3. collar incision, raise sub-platsymal flaps, open the midline raphe, retract strap muscles to gain access to the thyroid gland
4. I would retract the thyroid gland medially and develop the plane between the thyroid gland and the pre-vertebral fascia
5. I would identify and ligate the middle thyroid vein, then mobilize the upper and lower pole of the thyroid gland taking the vessels with an energy device making sure the parathyroid glands were preserved with their vascular pedicles
6. I would then identify the RLN in the tracheoesophageal groove and complete the mobilization by taking the ligament of berry
7. I would then divide the thyroid just lateral to the isthmus
8. confirm hemostasis and close incision

Question 38

Open left adrenalectomy

Answer 38

1. left subcostal laparotomy and access LUQ of abdomen
2. Mobilize splenic flexure of colon, spleen, tail of pancreas medially to expose the left adrenal mass and kidney
3. En bloc excision of left adrenal mass and surrounding L RP adipose tissue
4. If involvement of left upper pole of kidney, would need L nephrectomy
5. Avoid rupture of tumor capsule at all cost
6. Any RP LN that look suspicious should also be removed

Question 39

Lap R adrenalectomy

Answer 39

1. Left lateral decubitus position with R side up
2. I’d begin by mobilizing the R lobe of the liver by dividing the posterior peritoneal attachements of the triangular ligament and coronary ligament exposing the bare area of the liver
3. I would continue to dissect the RP posterior to the R lobe of the liver to identify the vena cava
4. I would continue to dissect along the right lateral, anterior aspects of vena cava until the R adrenal vein is identified, which I would then clip and divide
5. Once adrenal vein is ligated, I would mobilize the right adrenal gland away from the RP adipose tissue, posterior diaphragm and posterior musculature using an energy device
6. I would then ligate the fatty attachments of the adrenal gland to the upper pole of the kidney taking care to avoid the renal hilar vessels until the adrenal and rp adipose tissue is completely dissected
7. place specimen in endocatch bag, confirm hemostasis, and close incisions

Question 40

SLNB for melanoma

Answer 40

inject isosulfate blue dye and radiotracer around the lesion 1-2h prior to the procedure
after excision of the primary lesion, I would use a gamma probe to identify my sentinel ln and make an incision that takes into account further ln excisions, excise all nodes that are identified via gamma probe or uptake of blue dye

Question 41

Melanoma excision guidelines

Answer 41

melanoma in situ <0.5cm margins
<1mm thickeness, 1cm margins
1-2mm, 1-2cm margins depending on ability to close the defect
>2mm, 2cm margins
slnb for any tumor >1mm thickness or 0.8mm thick with ulceration

Question 42

Pilonidal surgery

Answer 42

1. prone, jack-knife position
2. mark area of incision and spread buttocks with tape
3. plan an elliptical incision that encompasses the entirety of diseased area, taking incision deep enough to normal tissue, including all inflamed sinus tracks
4. if sinuses track lateral, will debride with curettage to ensure complete removal of diseased tissue
5. once excised, i would gauge tissue approximation; my options include primary closure with drain, secondary intention with possible wound vac

Question 43

bascom cleft lift

Answer 43

1. mark the buttock lines prior to taping the buttocks apart
2. excise the disease in an off midline triangle with the apex above and lateral to the wound
3. remove all disease tissue down to the base of the pre-sacral fascia
   create a skin flap opposite the apex of the triangle direction and move it toward the midline
4. close the tension free incision off midline with drain

Question 44

va ecmo

Answer 44

team and equipment
1. access contralateral fem artery and vein under ultrasound guidance
2. administer heparin
3. insert appropriately sized arterial and venous drainage canulas over wires under flouroscopic guidance
venous drainage canula to just below the RA
arterial drainage canula to descending ao
4. with circuit primed, initiate flow and adjust for patients cardiac function
5. when stabilized, insert distal perfusion catheter just below the arterial catheter insertion site

Question 45

Neck injury

Answer 45

MTP
anesthesia intubate him in the OR
1. Prep widely to include neck, chest, abd, pelvis, thighs
2. Begin with incision on anterior border of SCM starting at angle of mandible down to sternal notch
3. I would then divide the platsyma, retract the SCM and IJV laterally
4. Get proximal control as low as needed on common carotid to stay out of the hematoma
5. Once I have proximal control of carotid and IJ, I would follow them into the hematoma making sure to stay on top of the vessel to identify injuried area
6. I would get control with a finger or clamp as I continue to dissect around it to get distal control internal and external carotid
7. Before clamping, I would have anesthesia administer heparin
and place an argyle shunt into the common carotid into the internal carotid

8. nearly transected IJ, divide and ligate
   20% injury common carotid but once debride to viable margins, the defect is actually 40%
   for <50% injure, I would perform a patch angioplasty with bovine pericardium

if external carotid complicating your repair, just ligate it

9. make sure to check repair with doppler (ICA, biphasic with long diastolic because low resistance in the brain)
10. after my repair and removal of the shunt, I would continue to explore the neck for evidence of aerodigestive injury
11. if carotid transected just distal to carotid bulb, use reverse gsv interposition graft or if no vein is available, a 6mm ptfe
12. no back bleeding for distal internal carotid a stump, pass a 2 fogarty, inflate and pull back until adequate back bleeding. This should be done prior to a shunt being placed
13. injury just above the clavicle, and on ct scan with large pseuoaneursym with extravasation at base of common carotid artery, would see if vascular surgery is available for endovascular control and/or stenting or proximal common carotid artery; if not available, would prepare to do complete or partial sternotomy to get control of the base of the common carotid artery
14. intimal flap from blunt injury neurologically intact, antiplatelets and re-image in a week to make sure injury does not become a pseudoaneurysm

Question 46

IVC injury

Answer 46

1. Trauma laparotomy, expect large vessel injury so eviscerate bowel to examine the RP
2. if continued bleeding, I would pack all 4 quadrants and then slowly withdraw those packings systematically to identify the injury
   large zone 1 hematoma on R side of abdomen
   suspicion for ivc injury
3. start by right medial visceral rotation to expose RP
   take down white line of toldt at the cecum and following this all the way up
4. kochar maneuver of doudenum to expose the ivc superiorly
5. once i have proximal and distal control with either a sponge stick or umbilical tape
   I would open the hematoma, evacuate the blood and identify my injury
   through and through injury to ivc below renal veins with proximal and distal control
6. longitudinal veinotomy of anterior wall of ivc through the injury segment to allow me to repair the back wall of the ivc
7. evaluate the extent of injury of both anterior and posterior segments
   if posterior segment is easy to approximate with 3-0 prolene, I would do this now
8. I would then evaluate my anterior portion of ivc and see if it could be close without significant stricture
   if stricture, would use a patch of bovine pericardium to close anterior wall of ivc once it’s been debrided to healthy edges
9. if completely destructive ivc that could not be repair primarily, depends on patients hemodynamic stability and state of other injuries
   ligate the ivc and perform ppx fasciotomies in the operating room
   if stable, would attempt to reconstruct the ivc with a ringed ptfe graft slightly smaller than the diameter of the ivc to keep the flow rates high

penetrating injury at the confluence of the ivc but having difficulty visualizing it because ao is in the way
right to left medial visceral rotation and try and expose the bifurcation
if deep in pelvis, I may have to divide the R iliac artery to expose the problem

Question 47

LE trauma

Answer 47

1. prep abdomen, groin creases and contralateral extremity
2. longitudinal incision just below the inguinal ligament and follow this down to the common femoral artery and place a vessel loop around it for proximal control and then dissect distally to get control of my sfa and profunda
3. heparinize patient and clamp all three inflow vessels
4. make a long incision over the area of concern based on trajectory of bullet
5. get proximal control with sfa and get distal control; control of femoral vein
   2cm defect with small portion of back wall intact, distal vessel is thrombosed; femoral vein is uninvolved
6. interposition bypass of sfa with contralateral reversed gsv
   prior to repair, place shunt to regain perfusion to my extremity
   fogarty embolectomy of outflow track, #3
7. good inflow, place argyle shunt into outflow and tie silk sutures to hold it in place
8. after harvesting, remove the shunt and confirm good back bleeding
9. debride vessel to healthy portion and spatulate the end of the vessel
   reverse the vein at anastomose wtih 5-0 prolene once the shunt is removed
10. check pulses and determine total time to revascularization to determine whether fasciotomies are needed

if palpable PT/DP, you’re done
not good outflow or c/f embolus, use butterly need to shoot angiogram
at and peroneal had thrombus at origins but good PT and foot perfused
stop operation, place patient on low dose heparin gtt
if needed to intervene, perform below knee pop cutdown and selective tibial embolectomy

Question 48

ED Thoracotomy

Answer 48

1. position patients left arm above their head
2. make an incision from lateral aspect of sternum all the way down to the bed at level of nipple or inframammary fold
3. use a pair of heavy scissors to cut across intercostal musculature staying along superior aspect of rib to avoid neurovascular bundles
   place fitoshetto retractor and open the chest widely
4. once in the chest, open the pericardial sac avoiding the phrenic n in the process
5. examine the heart for other injuries and begin cardiac massage
6. i would also cross-clamp the ao and address any injuries to the lung

Question 49

Massive hemothorax

Answer 49

get control of hilum, with a clamp
tractotomy, suture ligating, or non-anatomic resection with a stapling device
patient with brisk bleeding and starting to decompensate
as a last resort, total pneumonectomy
or pack the chest and go to the icu

Question 50

3cm ballistic injury to second portion of duodenum and large zone 1 hematoma

Answer 50

wait of anesthesia, appropriate instruments and second surgeon prior to unpacking
superceliac ao at hiatus and have vascular clamp on hand
right to left medial visceral rotation, which is accomplished by taking down white line of toldt and performing a kochar maneuver on the duodenum
dime size whole in ivc
sponge sticks above and below the injury
update anesthesia collegues that obstructing venous return to the heart
attempt to repair with running 3-0 prolene sutures if that doesn’t work or bleeding is too brisk, I could use a side biting satinsky clamp
regarding duodenum, need to first assess if common bile duct is involved and then decide if can close the defect primarily after non-viable tissue is debrided
if can’t identify cbd, it may be that it is injured, so would pass a fogarty catheter in the duo via the cystic duct
if unable to close primarily, duoduodenostomy or rny duodenojejunostomy and then leave drains adjacent to the repair, and while still intraop, pass a ndt distal to the repair
no pyloric exclusion

if mass disruption of pancreatic head and duo, likely need whipple in staged approach
at this operation, control bleeding, spillage of bile/enteric contents, leave numerous drain and place abthera

Question 50

Eso injury from penetrating neck wound

Answer 50

repair eso defect
1. position the patient with a bump under his shoulders and his head turned away from the injury
2. I would prep the entire neck and chest
3. I would make my incision along the anterior border of the SCM
4. To get access to the eso, I would incise the platsyma, retract the scm laterally and open the carotid sheath to allow for visualization of the IJV, carotid a and vagus n
5. I would then medialize the thyroid and trachea complex by ligating the middle thyroid vein, inferior thyroid a and omohyoid muscle
6. at this point, I should be able to visualize the esophagus but could also place an ngt to help with identification

2cm full thickness injury to lateral esophagus

7. insert 40fr bougie or egd scope and perform a two layer primary repair using absorbable suture
   I would be sure to expose the entire mucosal defect, which may require me to enlarge the muscular defect to do so
8. I would also leave multiple drains in the area
9. If concomitant tracheal injury, I would repair the injury with absorbable suture
   Because of proximity to esophageal injury, I would use a muscle flap to buttress and separate my repairs

Question 50

Liver Injury

Answer 50

manual compress liver, give anesthesia time to catch up
next I would get adequate exposure by extending my incision just above the xiphoid process, take down falciform, and then place a self-retaining retractor like an omni or bookwalter

continues to bleed
options depend on whether bleeding is arterial or venous
electrocautery, energy devices, argon beam, topical hemostatic agents, vessel clips, tissue staplers, omental packing, suture ligation of vessels, capsule approximation, anatomic or nonanatomoic liver resections can be considered, for extensive liver injuries, I would call an experienced colleague for assistance

still bleed, pringle maneuver, get control but now

pringle maneuver: clamping of portas hepatas
open the avascular plane of lesser omentum
find the foramen of winslow
place an avascular clamp or mal tourniquet across the portal structures

still bleeding, c/f retrohepatic ivc injury, I would need to get control of the suprahepatic ivc (can always open the diaphragm or get access via the R chest) and the infrahepatic ivc

Can consider packing a going to IR
Take gallbladder
Leave drains

Question 51

Pre-peritoneal packing

Answer 51

lower midline incision that does not violate the peritoneum
retract the bladder, and pack the pre-peritoneal space with laparotomy pads, typically can fit 3 on each side of the bladder and the close the skin

if continues to bleed,
zone 3 roboa
ligate the hypogastric a
re-engage IR for embolization

Question 52

Bladder Repair

Answer 52

First, carefully examine the bladder to rule out other injuries, specifically looking at bladder neck and urethral orfices
If no other injuries present, I would close the defect in two layers with absorbable sutures
Foley catheter remains in place for two weeks

If yes to injury at bladder neck, call urology

Question 53

Trauma splenectomy

Answer 53

I would start by placing laparotomy pads behind the spleen to elevate and medialize the organ
carefully taking down attachments to the diaphragm, kidney and colon
once medialized, I would identify, control and transect the hilar vessels with a laparoscopic stapler
If one wasn’t available, I would clamp and suture ligate the vessels individually
Next, I would transect the short gastrics with a vessel sealer
Then I would take time to examine the hilar vessels and short gastrics to confirm hemostasis

Question 54

LE Escaratomoies

Answer 54

do this bedside after assuring patient patient is sedated
prep out lower extremities and determine the proximal and distal extent of my full thickness burns
using bovie electrocautery, I would incise the skin down to the level of the dermis completing two long medial and lateral incisions from bilateral medial and lateral malleolus up through the full thickness burn
I would also release the medial and lateral tissue of the foot following the same incisions
I’m looking for dermal separation and releasing the skin bridges within the incision without excising the subcutaneous fat

36h
excision of deep partial and full thickness burns
tangentially excise the areas that are full thickness and deep partial thickness
take incision down to healthy tissue
plan to temporarily place mesh allograft to cover these burns

7d after admission
allograft taken nicely
now stsg
dermatome set to 0.011 inches (3:1 or 4:1 mesh)
cover grafts with kerlix an
soak in 2% mafeinide acetate for several days with daily dressing changes

Question 55

emergent R common fem to below knee pop bypass with gsv and possible fasciotomy

Answer 55

expose common fem a and below knee pop a
longitudinal incision from inguinal ligament caudal about 10cm
I would then dissect down to the vessel and loop it proximally as well as identify and localize the sfa and profunda with a vessel loop
I would then place a bump under the distal thigh and make a medial incision about 1 fingerbreath behind the tibia to expose the below knee popliteal artery by retracting the gastrenemius posterioly
I would then harvest saphenous vein from the contralateral leg to use as my conduit
I would then create a tunnel in the anatomic plane and leave the tunneler in position
I would sew the vein in reverse orientation
I would start just by beveling it
I would then ensure the patient is heparinized adequately
then clamp his common femoral a both proximally and distally and make an arteriotomy and sew the anastomosis with 5-0 prolene
I would then pressurize the vein and look for any bleeders and identify the correct orientation of the vein
I would then bring the vein through the tunnel and sew it to the below knee popliteal artery in a similar fashion with a 6-0 prolene
shoot angio
+/- fasciotomy (if >6h)

Question 56

cea

Answer 56

standard fashion with bovine patch angioplasty and routinely shunt
I would place a shoulder roll and extend his neck and make an incision along the anterior border of the scm
I would take that down through the platysma, identify the facial vein and ligate it
I would then retract the internal jugular vein laterally
I would identify the common carotid proximally, taking care to identify and protect the vagus nerve
I would dissect out the common carotid distally and place a vessel loop around the external and internal carotid arteries
I would then heparinize the patient
and then clamp in ICE order (internal, common, external)
and perform a longitudinal arteriotomy and place and argon shunt using shunt clamps to hold it in place
I would perform my endarterectomy and then perform a patchy angioplasty with bovine pericardium
and sew it into place with a 5-0 prolene
I would remove the shunts and flush the carotid
I would perform a good repair with intraoperative ultrasound, looking for intimal flaps

in pacu, re-develops symptoms, ultrasound
if fully thrombosed, heparinize and return to OR
consider saphenous vein patch instead of bovine pericardium
abciximab

now in pacu, patent flow
cta to evaluate for distal emboli that could potentially be treated by interventional neuro

Question 57

CFA to pop bypass

Answer 57

CFA to pop bypass
Prep both legs circumferentially
I would start the case by harvesting the gsv on ipsilateral extremity and reversing it and prepping it and placing it in a vein solution
I would then expose and control the CFA with a longitudinal incision beginning at the inguinal ligament
I would then expose the popliteal artery below the knee at the take off of the anterior tibial artery
I would then pass my tunneler from the knee to the groin in an anatomic fashion and tunnel my vein graft, being sure to keep it correctly oriented
I would heparinize the patient with 80U/kg and check ACT every 30 minutes
I would clamp the common femoral and sew an end to side anastomosis with 5-0 prolene
I would sew my distal anastomosis in a similar fashion
I would perform an angiogram to confirm no kinks in my vein graft
I would check my pulses and close

Question 58

greater saphenous vein ablation

Answer 58

in the operating room, I would use an ultrasound to access the gsv just below the knee and use a micropuncture needle and wire
I would then place a 7fr sheath and place the ablation catheter through this and follow it to the saphofemoral junction
I would inject tumescence around the gsv throughout its course in the leg
then I would pull the catheter back 2cm distal to saphofemoral junction and begin ablating down the gsv
I would remove the catheter and the sheath and evaluate the saphofemoral junction and make sure no e/o dvt in common femoral vein

Question 59

Brachialcephalic fistula creation

Answer 59

1. Axillary block
2. Mark the artery and vein with a duplex
3. Make an oblique incision incorporating both of them over the antecubital crease
4. Then I will focus on dissecting adequate vein both proximally and distally
5. Then I will open the brachial sheath and isolate the brachial artery and free it for a 4cm segment
6. I would heparinize the patient and then clamp proximally and distally and make an arteriotomy
7. And sew the vein with an end to side fashion with a 6-0 prolene
8. I would feel for a thrill in the vein and confirm no kinks or restrictive bands of tissue are present
9. I would also then check for pulses in the hand
   I would then close the incision after hemostasis

Question 60

Ped open R inguinal hernia repair

Answer 60

Perform a R inguinal dissection and locate the hernia sac on the anter-medial side of spermatic cord
I would separate the sac from the cord contents, making sure to identify and preserve the ilioinguinal nerve, vas deferens and testicular vessels
I would separate the sac from the cord structures and free it all the way to the external inguinal ring
I would perform a double high ligation of the sac with a silk suture
Finally, I would remove any excess sac, including any non-communicating hydroceles

If testicle very mobile and comes into operative field, perform orchiopexy

If inadvertently divide vas deferens, call urology and repair

Question 61

Delorme procedure

Answer 61

1. rectal mucosa is removed circumferentially from the prolapsed rectum over its length
2. the underlying muscle is then plicated with a series of sutures such that when tied, the rectal muscle creates a ring of muscle above the anal canal that helps prevent prolapse
3. the anal canal mucosa is then sutured circumferentially to the rectal mucosa remaining at the tip of the prolapse

Question 62

lymphoscintigraphy for melanoma

Answer 62

Pt reports to nuc med for intradermal injection of technetium sulfur colloid to biopsy/tumor site. LSG defines drainage pattenr. In OR, gamma probe used to confirm location of sentinel nodes. Isosulfan blue dye injected around biopsy/tumor site. Targeted dissection using gamma probe and visualization of blue dye. Nodal excision complete once only background signal detected by probe without residual visible blue or suspicious nodes.

Question 63

inguinal LN dissection for melanoma

Answer 63

I would frog-leg the patient in the operating room, make a curvilinear incision from just under the ASIS to the midline of the inguinal ligament and go beyond it several centimeters. I would retract the peritoneum cephalad and remove all the lymph nodes in this region. I would then find the most superficial lymph node to the iliac artery which would be Cloquet’s node. I would send this for a frozen biopsy, and if that’s positive I would proceed with a deep inguinal lymph node dissection which would include all the lymph nodes posterior to Cloquet’s node. If it’s negative, I would stop.

Question 64

deep ILND

Answer 64

Deep dissected can be performed by creating a separate incision in EO aponeurosis or by dividing inguinal ligament
Peritoneum and ureter are retracted medially to expose iliac fossa. Iliac nodes are dissected off common and external iliac vessels. Obturator nodes dissected off the posterior surface of the external iliac vein
After closure over a deep drain, sartorius mobilized and transposed to sit over exposed femoral vessels
Superficial drain placed and incision is closed

Question 65

radical cholecystectomy

Answer 65

laparoscopy to rule out peritoneal metastasis
I would then perform a liver resection taking 2 cm of liver around the cystic plate, resecting parts of 4B and 5
I would then perform a portal lymphadenectomy by skeletonizing the hepatic artery starting at the common hepatic node moving distal down the artery and resecting all fibrofatty tissue off the vessels.
I would also skeletonize the portal vein and resect the lymphatic tissue around the bile duct being careful not to disrupt the blood supply
To be safe, I would also resect the residual cystic duct down to its junction at the cbd, being sure not to narrow the cbd

Question 66

open AAA

Answer 66

elevate transverse colon cephalad, incise LoT for access to RP, place SB on R side of abdomen sigmoid to L lateral side, ID L renal v to ID infrarenal ao, expose common iliac/femoral vessels depending on landing zone, heparin (80u/kg), Oclamp infrarenal ao and common 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 40mm or if patient has had previous colon operation, check bowel viability, palpate fem/distal pulses, close aneurysm sac and RP over the graft

Question 67

Altemeir’s procedure

Answer 67

Consists of excision of the prolapsed rectum and associated sigmoid colon from below, and construction of a coloanal anastomosis

Question 68

transabdominal approach for rectal prolapse

Answer 68

resect redundant sigmoid and ventral mesh rectopexy pre-sacral fascia at sacral promontory (want to go low, miss all the nerves)

preop: colonoscopy
If uterine prolapse, do the same thing at the same time