Non-Cancer Operations

Question 1

Zenker’s Diverticulectomy

Answer 1

1. Extend Neck
2. Incision over ant border of L SCM
3. divide middle thyroid vein
4. retract carotid sheath laterally and tracheal medially to expose esophagus
   (omohyoid gatekeeper)
5. Dissect out diverticulum
6. Place large (60F) bougie
7. Extend myotomy and divide cricopharyngeus
8. Staple diverticulum with TA stapler
9. Test for leak with air insufflation and distal occlusion
10. Close over drain

Question 2

Laparoscopic Nissen Fundoplication

Answer 2

1. Laparoscopic access
2. Steep reverse Trendelenberg
3. Nathanson liver retractor and reflect left lateral segment laterally
4. Incise gastrohepatic ligament and dissect toward hiatus
5. circumferentially dissect both crura and mobilize esophagus - ensure to identify and protect vagus nerves
6. Divide short gastrics with energy device
7. Pass penrose around GE junction, ensureing ~3cm intra-abdominal esophagus
8. Pass 56F bougie
9. Close hiatus with interrupted ethibond sutures to posterior crura
10. Pass fundus posteriorly to create 360 degree wrap
11. Secure wrap with 3-4 ethibond sutures, incorporating esophagus into 1-2 bites
12. ensure hemostasis and close

Question 3

Laparoscopic Heller Myotomy

Answer 3

1. Laparoscopic access
2. Steep reverse Trendelenberg
3. Nathanson liver retractor and reflect left lateral segment laterally
4. Incise gastrohepatic ligament and dissect toward hiatus
5. Incise phrenoesophageal membrane
6. Take care to identify/protect vagus nerves
7. Divide circular muscle fibers of distal esophagus with scissors
8. Divide 5 cm proximally onto esophagus and 2cm onto stomach
9. Muscles split to allow bulging of mucosa
10. Dor Fundoplication
    a. Divide short gastrics
    b. Swing fundus anteriorly and sew to edges of myotomy

Question 4

Lateral internal sphincterotomy

Answer 4

Lateral Internal Sphincterotomy
1. Jack-knife prone or low lithotomy
2. Bivalve speculum
3. Palpate intersphincteric groove
4. Injection of lidocaine with epinephrine
5. Radial incision in anal mucosa over groove on right lateral side; hemorrhoid cushions are left lateral,
and right anterior and posterior so a right incision avoids them
6. Elevate internal sphincteric muscle with Kelly clamp and divide to level of dentate line
7. Close with running absorbable suture

Question 5

Open Hemorrhoidectomy

Answer 5

1. Jack-knife prone or low lithotomy
2. Submucosal injection of lidocaine with epinephrine
3. Elliptical incision in anal mucosa from anal verge to the dentate line
4. Separate internal sphincter muscle from hemmorhoidal tissue with Metzenbaum scissors
5. Ligate pedicle and leave open to heal by secondary intent

Question 6

Femoral Hernia

Answer 6

1. Same exposure as for inguinal repair
2. 5-6cm relaxing incision in anterior rectus sheath
3. Starting at pubic tubercle, sew conjoined tendon to Cooper’s ligament until femoral vein reached
4. Transition stitch, from here laterally conjoined tendon is sutured to anterior femoral sheath

Question 7

CBD Exploration

Answer 7

1. Cholangiogram via cystic duct
2. Cystic duct traced down to junction with CBD
3. CBD opened longitudinally 1-2cm distal to insertion of cystic avoiding 3/9 o’clock blood supply
4. Place stay sutures on side of CBD
5. Explore with 4F Fogarty or basket passed proximally & distally
6. Ductotomy closed over T-tube brought out thru abdominal wall
7. T-tube cholangiogram if time
8. closed suction drain

**if unstable at any time place a T-tube for decompression and get out
** transduodenal sphincteroplasty
a. Pass guidewire down duct through ampulla
b. Kocherize duodenum
c. Longitudinal antimesenteric incision 2nd portion duodenum
d. Insert small mosquito clamp and incise carefully with iris scissors at 10 o’clock to avoid
pancreatic duct (CBD at 11 o’clock, PD at 3 o’clock)
e. 5-0 vicryl traction sutures on ampulla secured to mucosa
f. Pass Fogarty retrograde
g. 2-layer Heineke-Mikulicz duodenotomy closure with drains

Question 8

Carotid Endarterectomy

Answer 8

1. Selective shunt with cerebral oximetry or under local cervical block with squeeze ball in
   contralateral hand
2. Incision along ant border of SCM
3. Divide platysma and laterally retract SCM
4. Divide facial vein (gatekeeper to carotid), enter carotid sheath, and retract IJ laterally
5. Dissect CCA, identify vagus, and dissect hypoglossal nerve away
6. Vessel loop around CCA, ECA, ICA
7. Heparinize (80u/kg)
8. Test clamp ICA to see if changes in pulse oximetry or contralateral squeeze ball
9. Then clamp ICA first, CCA, then ECA (ICE)
10. Longitudinal arteriotomy CCA thru ICA, endarterectomize starting with ICA
11. Tack flap if necessary
12. Patch close arteriotomy, bleed back ICA and re-clamp, then unclamp E then C then I
13. Protamine, hemostasis, and close
14. If stroke, back to OR and reexplore

Question 9

SMA Exposure/embolectomy

Answer 9

1. Cephalad retraction of transverse colon, pack small bowel to right and identify LOT
2. Divide LOT thus exposing SMA with proximal and distal control
3. Heparinize (80u/kg)
4. Transverse arteriotomy
5. Pass 5F Fogarty proximally and 4F distally to remove clot
6. Can milk back clot in arcade
7. Close arteriotomy with interrupted 5-0 prolene
8. Assess distal flow
9. Assess bowel viability for 30mins after with Doppler, palpation, fluorescein and Wood’s lamp
10. Resect frankly necrotic bowel
11. Second look operation 24-36hrs to minimize bowel resection

Question 10

Arm fistula

Answer 10

1. Radiocephalic before brachiocephalic before basilic transposition
2. Make an incision over the cephalic vein in the forearm
3. Identify and tie off any vein branches, and mobilize the vein
4. Expose the radial artery while protecting the nerve, and vessel loop proximally and distal
5. Ensure vein can reach without tension
6. Flush with heparinized saline and anastomose vein to artery
7. Flush before taking arterial clamp off completely
8. Superficialize vein if necessary and close

Question 11

Femoral Embolectomy

Answer 11

1. Heparinize patient preoperatively
2. Prep abdomen to toes
3. Cut down on femoral (anteriorly) or popliteal (medially) with longitudinal incision
4. Proximal & distal control (CFA, SFA, and profunda femoris)
5. Pass 4F Fogarty proximally & then distally until no more clot
6. Completion on-table angiogram & pulse check
7. Close with prolene or venous patch graft from GSV if longitudinal with endarterectomy as needed

Question 12

SFA to Popliteal Bypass

Answer 12

1. Preoperative vein mapping to identify vein >3mm
2. Vertical incision halfway way between pubic tubercle and ASIS
3. Expose CFA, SFA, and profunda femoris proximally and popliteal distally
4. Incision in lower thigh in groove between vastus medialis and sartorius
5. Identify popliteal medially in adductor canal by retracting vastus medialis anteriorly & sartorius
   posteriorly; use femur as landmark
6. Harvest GSV, tie off branches, heparinize
7. Create tunnel
8. Heparinize (80u/kg)
9. Proximal & distal control
10. Proximal anastomosis, flush graft
11. Pass graft through with tunneler, ensure no twisting
12. Distal anastomosis, flush out before completing
13. Close wounds in layers
14. Check Doppler signal and pulses before leave OR
15. Anterior tibial exposure
    a. Use pneumatic tourniquet for exposure and control of bleeding when sewing distal vessels
    b. Longitudinal incision 2cm lateral to tibia
    c. Open anterior compartment
16. Tibioperoneal trunk exposure
    a. Longitudinal incision medial to tibia
    b. Dissect soleus off of tibia, retract posteriorly
    c. Find in deep posterior compartment

Question 13

Ruptured AAA

Answer 13

1. NGT, permissive hypotension, and massive transfusion protocol with good IV access
2. If the patient is bleeding and hypotensive an endovascularly placed aortic occlusion balloon catheter
   (Couda) can be used for rapid proximal aortic control
3. Prep from nipples to knees
4. Midline incision
5. Retract left lateral liver segment and open gastrohepatic ligament to get into lesser sac, then divide
   right crus and move esophagus to left
6. Feel the aorta laterally and pinch against the spine and clamp with a DeBakey aortic clamp
7. Lift up transverse colon, pack small bowel to the right, and mobilize 3rd/4th portion of duodenum
8. Identify neck of aneurysm with gentle dissection up to left renal vein
9. Reclamp here and remove supraceliac clamp
10. Dissect to iliacs and clamp with vascular Satinskies
11. Open aneurysm and evacuate the thrombus and ligate all lumbars/IMA
12. Now heparinize (80u/kg)
13. Proximal anastomosis with 2-0 prolene into tube graft or bifurcated graft if iliacs involved
14. Flush and move clamp distally onto graft
15. Distal anastomosis and flush before unclamping
16. Protamine and close aneurysm sac over graft
17. close RP over aorta and abdomen
18. check pulses before throughout and end

Question 14

BKA

Answer 14

1. Place tourniquet on thigh
2. Anterior incision 10cm below tibial tuberosity
3. Post incision is made and a flap is created
4. Carry anterior incision down to tibia
5. Expose tibia and fibula 2-3cm above incision
6. Saw off at 45 degree angle with Gigli saw
7. Divide posterior tibial nerve on traction and allow it to retract
8. Divide major vessels including anterior tibial artery and tibioperoneal trunk
9. Posterior incision (needs to be a long flap) is then approximated
10. Close in several layers. Leave a drain

Question 15

Fasciotomy

Answer 15

1. Medial incision 1cm to tibial longitudinally down leg and open the fascia with curve Mayos
2. Open and explore to release the deep and superficial posterior compartments being cautious of the
   tibial nerve
3. Lateral incision 1cm from tibia longitudinally and open fascia with curved Mayos
4. Open the lateral and anterior compartments being cautious of the superficial peroneal nerve

Question 16

Subxiphoid window

Answer 16

1. Make a vertical incision over the distal xiphoid and the abdomen
2. Divide the fascia while staying extraperitoneal
3. Remove distal xyphoid if necessary
4. Pick up the pericardium with 2 Allis or 2 stay stitches
5. Incise the pericardium and look for blood
6. If negative close pericardium and then fascia and soft tissues in layers
7. If positive median sternotomy

Question 17

Parathyroidectomy

Answer 17

Supine, arms tucked, neck extended
IV access for monitoring of parathyroid hormone
RLN monitoring ETT
obtain Baseline parathyroid hormone level
collar incision
Raise subplatysmal flaps
Open midline raphe, retract strap muscles
Retract thyroid gland medially
Develop plane between gland and prevertebral fascia
Ligate middle thyroid vein
Look for inferior parathyroid gland
Then excise gland and collect samples

look for drop > 50% in PTH from highest at 10 min(1/2 life 2-4 min)