Core Procedures Flashcards

Question

Lower eso perforation

Answer 1

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 3. 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. 4. 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. 6. I’d place two sterile chest tubes (one basilar and one apical). 7. 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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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)

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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

Answer 40

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.

Answer 41

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.

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

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

Answer 46

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