Miclsc Flashcards
What is the average length of the rectum and how do you define LAR
The average length is 10 to 15 cm. Proximal one third is intraperitoneal and distal two thirds retroperitoneal
Hi or intraperitoneal anastomosis is greater than 11 cm, low is 7 to 11 cm, very low is less than 7 cm
If you sacrifice the IMA what artery provides collateral
Marginal artery. If you’re going to sacrifice you may want to temporary occlude and then check for a pulse of the marginal artery if the patient has arterial sclerosis, diabetic, smoker
In LAR what arteries to divide in the mesentery?
Superior rectal,
there are collaterals with the middle and inferior rectal which is off the Internal iliac so the victim does not Necrose
How much small bowel can be removed before impairing nutrition?
50%
Where do you find Schiller duval bodies?
Endodermal sinus tumor
Call exner bodies
Granulosa cell tumor
Signet cell
Krukenberg
Hobnail cells
Clear cell
Rokitansky
Teratoma
How to treat necrotizing fasciitis?
Prompt surgical debrident w broad spectrum antibiotics. May use carbapenem and clinda
Type I is polymicrobial
Type II strep A
What are contraindications to pelvic exenteration?
Extra pelvic spread, sidewall disease, pelvic lymph node metastasis(relative), pelvic peritoneum disease (relative)
What are the indications for pelvic exent?
Persistent or recurrent cervical cancer or vaginal cancer,
Primary carcinoma of the cervix stage IV A
Recurrent endometrial cancer confined to the pelvis
Steps to exent?
Explore the upper abdomen and sample para-aortic nodes for frozen section.
2) Incise lateral pelvic peritoneum and enter the retroperitoneal space.
3) Dissect the paravesical space medial to the external iliac vessels.
4) Enter the para-rectal space between the ureter and the hypogastric artery.
5) Examine the parametrial tissue to rule out extension of tumor to pelvic
sidewall.
6) Dissect the parametrial tissue at the pelvic sidewall down to the levator
sling.
7) The sigmoid colon is transected at an appropriate distance from the
pelvic tumor.
8) The areolar space between the sacrum and rectosigmoid is dissected
down to the levator sling.
9) The bladder is dissected free of the pubic ramus.
10) The ureters are transected at an appropriate distance from the tumor.
11) The urethra, vagina and rectum are transected as low as needed to
obtain adequate tumor-free margins.
12) Colostomy, urinary diversion using an intestinal conduit and isolation
of the pelvic cavity is carried out according to personal technique of the
surgeon. Primary low reanastomosis is acceptable in selected cases.
What is the classic triad for recurrent and unresectable disease when considering exent?
Unilateral leg edema, sciatic pain, ureteral obstruction
In selecting patients for exent what should the five-year survival be
20 to 35%
What is a five-year survival for exent?, mortality?
33%
10%
What are the complications for exent and their percentages?
50% of patients will have complications:
Sepsis (10%), fistula urinary or obstruction (6%), intestinal leak (8%),
Sbo(5%), PE (2%), hemorrhage (2.5)
Is TPE the only surgical option for recurrent cervical or vaginal carcinoma?
Radical hysterectomy may be an option. Five-year survival was 62%, fistula rate was 48% it can be considered if tumors size less than 2 cm
What are options for pelvic reconstruction after TPE? Besides sexual function, what are benefits?
Omental J – flap, Gracilis myocutaneous flap, Ram. flap
They can decrease fistula rate and abscess rate.
Describe an omental J– flap to create a neovagina
Divide the omentum from transverse colon, create a cylinder, line it with a split thickness skin graft, and use a vaginal dilator until healing is complete
Gracillis myocutaneous flap What’s the blood supply? What are the disadvantages?
The blood supply is from the medial circumflex femoral vessels. The disadvantages: bulky, flap necrosis
the advantages : it can fill a large defect
Tram flap, blood supply? Contraindications ?
Inferior epigastric for tram
Do not perform if you had a previous maylard or Cherni incision and inferior epigastric was ligated. Can perform arteriography
What conduit is best for the obese?
Transverse
What is the disadvantage of a jejunal conduit
Electrolyte imbalance known as jejunal syndrome, resulting from a resorption potassium and urea and loss of sodium and chloride
What are complications for conduit ?
Urinary leakage and conduit obstruction was most common. Rate increase w time. Transverse conduit w least complication. infection, small Bowel complications, stomal complication
Late: stone formation stenosis electrolyte imbalance
Describe how you do Miami pouch
Transect the distal ileum 10 to 15 cm from the ileocecal valve. Mobilize the cecum,ascending colon, any transverse. Transect t -colon,anastomose ileotranverse. Appy. Open colon along tenia and create U shape. Make pouch, re implant ureters. Insert 14 F into ileum and resect to narrow lumen. Pursestring ileocecal to inc pressure
What are the sizes of staplers and staples for bowel surgery
TA: 30,60,90mm staple size
3.5 mm compresses to 1.5mm. 4.8–> 2mm
GIA 60,90. Staples 2.5–>1.0, 3.8–>1.5, 4.8–>2mm
EEA 21,25,28,31staples: 4.8–>2mm
What is the mechanism for hyperchloremic acidosis in conduits?
Absorption of H+ and ammonium
if ureteral injury < 5cm or below the pelvic brim
Ureteroneocystotomy +/- Baori flap or psoas hitch
if ureteral injury> 5 cm or above pelvic brim or injury is 3-4 cm proximal to ureterovesical junction how to repair
ureteroureterostomy: mobilize ureter for adequate length–>resect until viable tissue–>spatulate w Potts scissor, stent, anastomose (interrupted 5-0 vicryl. place drain near but not next to anastomosis
describe psoas hitch
1.mobilize 2. cystotomy on anterior bladder, away from done 3. anchor bladder to psoas tendon ( avoid gen/fem)4. reimplant ureter, stent 5. close cystotomy vertically
describe boari flap
- mobilize bladder 2. rectangular flap is created on anterior surface of bladder, base 4cm wide, perserve superior vesical 3. suture flap to psoas 4. tunnel ureter thru flap. 5. tubularize flap 6 anastomose ureter, stent
How do you repair a bladder injury?
Reapproximate bladder in the direction that minimizes tension. Close in 2layers. The first layer should avoid going through Mucosa, (invert mucosa into bladder w 3-0). Then, second layer of running 2–0
What is the blood supply of the omentum
Right gastroepiploic off gastroduodenal artery, left gastroepiploic off of splenic artery
What is the laser setting for CO2 laser
Spot size of 2 mm w/wattage of 16 to 18
How do you repair and obturator nerve injury and how does that manifest postop
Repair with 8.0 nylon through epineurium, symptoms are weakness in addiction
Describe how to do a splenectomy
Mobilize the spleen, pull inferior and medial to lyse the splenophrenic and splenocolic ligaments.
Open lesser sac exposing gastrosplenic ligament which contain short gastric.
Divide short gastric’s
Palpate the tail of the pancreas.
Identify splenic artery, ligate these. Identify vein under artery, ligate separately to avoid a fistula
what complications for splenectomy are you worried about, how do you manage? What are the vaccines?
Distal pancreas injury. Used TA staple. Leave drain, check Amylase in drain
Pneumococcal, N meningitis, H influenza
What is blind loop syndrome?
Poor emptying loop of bowel, stasis, bacterial overgrowth, increased bile salts leading to Mal absorption of fats, increased triglycerides leads to more dysmotility, steatorrhea. Hypocalcemia because calcium down but on absorbs fatty acids in the gut
What is short bowel syndrome
Malnutrition, dehydration, electrolyte disturbance. A small bowel is less than 3 m, increased chance of malnutrition
If less than 1 m, likely TPN dependent please more….
How do you treat short bowel syndrome?
Low-fat diet, calcium, vitamin B12, vitamins ADEK, low oxalate
What is it parastomal hernia how do you prevent it and what are the predisposing factors
it is a complication of a colostomy. More often from end colostomy. Herniation is prevented by bringing the stomathrough the rectus muscle. mesh repair while bringing the stoma through the mesh. Predisposing factors obesity, chemotherapy, increased abdominal pressure, Radiation
How do you take down a colostomy?
Start with an elliptical incision around the stoma .mobilize the Colon from adhesions. Dissect the skin and Fascia from colon.Close the stoma with TA
How do you approach radiation damage bowel?
The ideal approach is resection of the affected segment with an anastomosis to non-radiated bowel. However this could lead to shortgut syndrome and it may not be possible to do if the mesentery is immobile. Then you could choose to do a bypass, but this leaves affected segment in situ and could lead to blind loop syndrome. Bypass has lower rate of dehiscence which is likely to be fatal
What type of electrolyte imbalanced you get with conduits
Hyper chloremic acidosis, aggravated by long conduit. Treatment oral sodium bicarbonate
Gracilis flap steps
- Low lithotomy, slight ext rotatation
- Palpate the semitendinosus tendon as it approaches the posterior aspect of the medial tibial condyle and incise above tendon.
- Gracilis tendon identified –it is behind the sartorius muscle and in front of the semitendinosis. and pulled to make the muscle palpable under the skin
- Measure distance and size of graft. Draw skin island, about 6 cm in width x 20 cm long
- A line drawn from the insertion of the adductor tendon on the pubic bone to the insertion of the gracilis on the medial tibial condyle
- Incise. Raise muscle from underlying muscles. Protect saphenous vein
- Delineate skin island
- Suture skin to muscle
- Blood supply is derived from the medial femoral circumflex artery which is located between the adductor longus and magnus, entering the gracilis about 8-10 cm below the pubic symphysis.
- Close leg with staples and nylon retention sutures, closed drain suction
Diaphragm stripping
- Divide falciform
- Incise peritoneum over diaphragm
- Grasp edge w/ allis, develop plane between peritoneum and muscle
- Continue until the point where the anterior leaf of the coronary ligament and its posterolateral extension, the right traingular ligament, reflect on to the surface of the liver.
- Inferior phrenic artery and vein are encountered and clipped.
- This exposes bare area of liver. Just to the right of the falciform ligament, the IVC traverses the bare area.
- The right phrenic nerve penetrates the diaphragm in the bare area of the liver just lateral to the vena cava.
How do you repair hole in diaphragm?
Pursestring suture of O- silk #16 Red robinson catheter attached to suction Have anesthesiologist give big breath, with tube on suction, pull out and tie down pursestring. Test w/ pt in trendelenburg, fill water, give big breath to look for air bubbles.
Tpn
Typical TPN formulation
Standard formula is 500ml D50W and 500ml 8.5% aminoacids 3:1 to 20% lipid emulsion w/ electrolytes, minerals and trace metals and vitamins.
Want about 20-30% of calories as fat. Usually add insulin and cimetidine
Start at 40ml/hr then 80 then 120 over 3 days.
How do you distinguish FTC from OVCA
Main tumor in tube and arising from endosalpinx
Transition between benign and malignant epithelium seen
Ovary and endometrium normal or contain less tumor than tubes
