Operations Flashcards
Surgical management of duodenal perforation?
Midline laparotomy. Close with absorbable interrupted suture if possible, then place overlay omental patch to cover defect. Large volume washout, place drain and close.
Is histology generally required for perforated duodenal ulcers? Do they need resecting at time of surgery? What other piece of non-surgical management is required?
Not necessarily as rarely malignant Test for H Pylori to guide if eradication needed
Surgical management of bleeding gastric ulcer?
If not controlled endoscopically - laparotomy. If distal site of ulcer, consider distal gastrectomy and reconstruction. If unsure or more proximal, consider gastrotomy and underrun + biopsy (because only other resectional options are wedge excision which is difficult to close, and total gastrectomy is much more signifcant operation.
Surgical management of perforated gastric ulcer?
Laparotomy. Excise for histology, close with absorbable interrupted sutures then overlay omental patch. If extensive ulcer, resect (distal gastrectomy if distal)
Surgical management of bleeding posteriorly sited duodenal ulcer?
Laparotomy. Open duodenum longitudinally (vertical duodenotomy). Usually brisk bleeding from posteriorly sited ulcer penetrating through gastroduodenal artery. Apply digital pressure to site and then use large sutures to under run superior and inferior aspect of ulcer, taking deep bites to control bleeding vessel. Once controlled close the anterior duodenotomy in 2 layers transversely to minimise stenotic complications
Why don’t anteriorly perforated duodenal ulcers usually cause large volume UGI bleeds vs posterior?
Anteriors usually perforate intraperitoneally if D1, vs posterior which erode through gastroduodenal artery posteriorly.
What vessel is usually implicated in posterior duodenal ulcer bleeds?
Gastroduodenal artery
Which operation is required for HNPCC-associated colorectal cancer?
Panproctocolectomy
Operation of choice for right colon cancer?
Right hemicolectomy with ileocolic anastomosis
Operation of choice for transverse colon cancer?
Extended right hemicolectomy with ileocolic anastomosis
Operation of choice for splenic flexure cancer?
Extended right hemicolectomy with ileocolic anastomosis, or left hemicolectomy with colo-colonic anastomosis
Why is right hemicolectomy with ileocolic anastomosis usually preferred to left hemicolectomy with colo-colonic anastomosis for splenic flexure cancer?
Less risk of anastomotic leak with ileocolic anastomosis
Operation of choice for left colonic cancer?
Left hemicolectomy with colo-colonic anastomosis
Operation of choice for sigmoid colon cancer?
High anterior resection with colo-rectal anastomosis
Operation of choice for cancer of upper rectum?
Anterior resection with total mesorectal excision, colo-rectal anastomosis
What is total mesorectal excision?
Removal of mesorectal fat and lymph nodes
Operation of choice for cancer of lower rectum?
Anterior resection with low total mesorectal excision, colo-rectal anastomosis +/- defunctioning stoma
Operation of choice for cancer of anal verge?
APER - abdomino-peroneal excision of colon and rectum with no anastomosis possible.
What is a Hartmann’s procedure? Can it be reversed?
Rectosigmoid resection (high anterior resection) with formation of end colostomy and closure of Hartmann’s pouch, which is left in abdomen. Can be reversed via direct anastomosis or with loop ileostomy formation, which will later be closed separately.
Why may Hartmann’s procedure be done for e.g. perforated sigmoid cancer?
Risk of anastomotic leak is significantly higher in bowel perforation, especially for colo-colic anastomosis, so high anterior resection and end colostomy formed.
Operation of choice for obstructing rectal cancer? Why?
Defunctioning loop colostomy - as high risk of anastomotic leak, surgery harder and danger of positive resection margin in unstaged patient.
How does management of obstructing colonic cancers differ to that of obstructing rectal lesions?
For colonic, options are stenting vs resection - rarely defunctioned For rectal, have to defunction with loop colostomy
What is the definitive surgical management for UC? Why might this not be done acutely and what would be done instead?
Panproctocolectomy including removal of rectum, +/- formation of ileoanal J pouch. May not be done in emergency settings due to risk of removal of rectum - may have subtotal colectomy and later proctectomy.
What restorative options are there following subtotal colectomy for UC?
Completion proctectomy and formation of ileoanal J pouch (or keeping end ileostomy).
Surgical option of choice for acutely unwell colitic not responding to medical therapy?
Subtotal colectomy and end ileostomy
Procedure for debriding an open fracture?
Under GA Debride non-viable skin and wound edges as minimum Assess underlying muscle for viability and remove non-viable fat and muscle Remove foreign material and bony fragments Thorough irrigation - at least 6 litres saline Stabilise fracture with ex-fix Usually don’t close wound primarily unless small, uncontaminated type 1 wound - wait for re-look and closure with plastics
Outline procedure for DHS?
Regional or GA depending on patient factors Position on fracture table using II to reduce fracture prior to skin incision Prep and drape Incise over greater trochanter Dissect down to greater trochanter Insert guide wire up into femoral head under II Exchange guidewire for cannulated compression screw to approximate displaced fragments Attach screw to plate running along lateral aspect of upper femur Screw plate to femur to hold reduction Close wound in layers +/- drain
What fracture are DHS suitable for?
Outside of joint capsule - extracapsular pertrochanteric (intertrochanteric). Sometimes suitable for elderly undisplaced intracapsular (valgus impacted subcapital) fractures but risk of AVN so usually go for arthroplasty anyway. Reverse oblique or subtrochanteric may need IM nail
What procedure is ideal for head of pancreas cancer if operable?
Whipple’s - newer techniques such as pylorus preserving and SMA/SMV resection
What is a Whipple’s procedure? What is taken and what is the result?
For head of pancreas carcinoma - pancreaticoduodenectomy, also takes gallbladder. Left with choledochojejunostomy, pancreaticojejunostomy and gastrojejunostomy
Potential surgical option for carcinoma of body/tail of pancreas?
Distal pancreatectomy
What 4 factors affect decision on restoring continuity folllowing colorectal resection?
Perforation vs no perforation Vascular supply Mucosal apposition Tissue tension
Options for obstructing colonic lesions?
Stent vs primary resection Rarely defunction
What operation is required for sphincter involvement or very low rectal tumours?
APER
What clearance margin is required in rectum?
2cm distal margin
What patients would you offer neoadjuvant radiotherapy to in rectal cancer?
Higher grade - T1, 2 and 3 /N0 don’t need and can go straight for surgery
How do you manage potentially resectable pancreatic head cancer with obstructive jaundice? What do you avoid?
ERCP and plastic stent Avoid metallic stents as these compromise resectability
Benefits/risks of total hip replacement over hemiarthroplasty?
Better function and prosthetic survivorship But higher risk of dislocation
Outline surgical management of extracapsular hip fractures?
What is most important factor in managing young patients with femoral neck fractures?
Retaining femoral head - significant sequalae over time with THRs in young (wear, dislocation, revision)
So even displaced intracapsular fractures generally internally fixed despite risks of AVN and non-union but discuss with patient
Outline surgical management options for intracapsular neck of femur fractures?
How would you manage SBO secondary to long termineal ileal strictures in Crohns? How would this differ to short segment strictures?
Ileocaecal resection
For shorter segments use stricuroplasty
What does the bowel look like in acute Crohns laparotomy? What does the mesentery feel like?
Externally inflamed bowel with thick wall that may feel fibrotic
Mesentery is friable and fatty
What surgical options would be preferable for Crohn’s? What do you not do?
Avoid segmental resection
Prefer subtotal colectomy, panproctocolectomy, staged subtotal colectomy and proctectomy
Don’t bother with restorative procedures as can get inflammation of these e.g. ileoanal pouch
What layers do you go through in open appendicectomy?
Skin
Subcutaenous tissue
Campers then Scarpa’s fascia
External oblique (?) aponeurosis
Internal oblique muscle
Transversalis muscle
Transversalis fascia
Peritoneum
Outline how to perform open appendicectomy?
Consent, GA, WHO checklist, prep + drape, supine etc, antibiotics
Transverse incision over McBurney’s point = Lanz - 1/3 from ASIS to umbilicus on right side
Deepen incison down in line of fibres and open peritoneum between clips
Explore RIF and identify appendix, send pus if any there
Ligate mesoappendix incl base of appendicular artery and then base of appendix
Submit appendix for histology
Suction free fluid, washout only if contamination
Run small bowel for co-incidental pathology e.g. Meckel’s
Close in layers
Describe how to do laparoscopic appendicectomy? Specific things to consider?
Consent, GA, supine, prep + drape, WHO checklist, Abx, specifically consider catheter to deflate bladder and reduce risk of iatrogenic injury w trochar (+improve pelvic access in females)
Open Hassan technique to insert port site at umbilicus - infra-umbilical cut down to insert 10mm port with blunt ended tip under direct vision
Air insufflation (10-12mmHg) and insert camera - 10mm 30 degree laparoscope
Insert 2-3 further ports in suprapubic (5mm) and LIF (5 or 10mm) region under direct visualisation
Localise appendix, dissect mesappendix away and ligate base and vessels with loops
Remove with bag and send for histology
Run rest of bowel for Meckels, pelvic region in females
Suction free fluid, washout if contaminated only
Remove port sites under direct visualisation and close
How would you approach an incorrect swab count at the end of surgery?
Stop, don’t wake patient
Recheck swab count and examine operative field/surrounding drapes
If still not found, call senior but consider re-opening wound and re-exploring operative site
If still unable consider II to localise as surgical swabs have radio-opaque markers to identify on XR
What would you do if on operation you found a normal appendix but no other pathology to account for presentation?
Usually take anyway - sometimes histological evidence of early inflammation
What would you do if on operation you found a normal appendix but alternative pathology e.g. Meckels?
Leave appendix and treat pathology if satisfied it would account for symptoms
How might you close a regular open appendicectomy at the skin vs a heavily contaminated one?
Regular - absorbable subcuticular stich
If heavily contaminated consider interrupted sutures or clips
Why are tourniquets used in surgery?
Minimise blood loss, improve clarity of operative field
How are tourniquets applied and used in surgery? Key safety points?
Apply to distal extremity remote to op site
Ensure limb padded, machine checked and facilitates pressure monitoring
Ensure when prepping skin that prep doesn’t run under tourniquet
Inflate only after prophylactic Abx given
Pressure - usually 100mmHg above systeolic
Roughly how long would you keep tourniquet up for in a well adult for surgery?
Max 2 hours
Post-inflation systemic affects of applying tourniquet?
Increased SVR, CVP and BP
BP gradual increases over time
Induced hypercoagulable state (vascular disruption)
Slow increase in core temp
Post deflation systemic effects of tourniqet use in surgery?
Fall in CVP, BP and SVR
Increase end tidal CO2
Increased fibrinolysis
Fall in core temp
Rise in potassium and lactate, reperfusion injury at worst
4 absolute contraindications to tourniquet use in surgery?
Severe PVD
Previous vascular surgery on site
Fracture/thrombosis at site of application
AV fistula in same limb
5 relative contraindications to tourniquet use in surgery?
Infection at site
Sickle cell disease
PMH of VTE
Skin grafts at site
Lymphoedema in same limb
6 complications of tourniquet use in surgery?
Skin injury either from incorrect application or burns if prep accumulates underneath
Damage to muscle at site or distally
Damage to underlying vessels
In those with PVD - plaque rupture, dislodgement and embolization
Damage to nerves - at site (neurapraxia) and distally due to ischaemia
Describe this appearance? What are the issues with it and why may this have happened?
Midline scar which appears to be poorly healed, possibly due to dehiscence and regular redressing
Right iliac fossa stoma - spouted so likely ileostomy - with surrounding skin marks from stoma appliance
What kind of GI anastomosis is most likely to heal without complications? What areas are at highest risk?
Small bowel best
Oesophagus and rectum highest risk
Systemic factors increasing risk of anastomotic breakdown?
Sepsis,infection
Haemodynamic instability
Jaundice
Diabetes
Poor nutrition
Steroids
Heavy local contamination, poor surgical technique
Describe how to do a primary small bowel anastomosis? e.g. following segmental small bowel resection
Drape operative site to prevent local soiling
Apply soft non-crushing bowel clamps to bowel 10cm upstream of resected ends
Meticulous haemostasis
2 stay sutures at mesenteric and antimesenteric borders of bowel with 3/0 round bodied PDS
Confirm orientation and place interupted 3/0 sutures at 5mm intervals along bowel- seromuscular sutures with knots lying externally, then invert mucosa
Once all sutures secured, tie or remove stay sutures and close small mesenteric defects prior to returning bowel
4 principles of performing vascular anastamoses?
Use non-absorbable monofilament e.g. prolene
Round bodied needle
Choose correct size for anastomosis
Continuous suture from inside to outside of artery to avoid raising intimal flap
Indications for elective splenectomy?
Haematological conditions e.g. haemolytic anaemias, hereditary ellipto/spherocytosis
Malignancy e.g. lymphoma
Cysts/abscesses
How would you perform an elective, open splenectomy?
Pre-op liaison with haematologists, ensure pneumo and meningococcal vaccines given (more effective with functioning spleen)
Consent, WHO, supine, GA etc. NG tube insertion to decompress stomach
Midline/left subcostal incision
Mobilise spleen with hilar control if very large
Divide and ligate short gastric vessels, which are in gastrosplenic ligament
Mobilise the colonic splenic flexiure
Idnetify hilum and securely ligate vascular pedicles individually, ensuring not to damage pancreatic tail (which is also in lienorenal ligament)
Divded lienorenal ligaments and remove spleen
If spleen small - can fully mobilise and divide vascular pedicle at end
Haemostase, non-suction drain in bed
Close in layers
Describe how to perform emergency splenectomy? Why is this different from elective?
Haemodynamic control invariably present as this is often indication for splenectomy
Laparotomy
Pack all 4 quadrants and then allow anaesthetics to control haemodynamics
Carefully remove packs and examine quadrants for collateral injuries
Put in self-retaining retractor e.g. Balfour to access LUQ
Remove LUQ pack and inspect spleen
Bring spleen to wound and control hilar vessels - if difficult place atraumatic clamp across hilum taking care not to get pancreatic tail
Once hilum secure, divide short gastric vessels and remove spleen by dividing remaining attachments
If splenic remnants - can implant fragment into omentum
Washout, haemostase, insert NG tube and drain
Close in layers
4 changes seen post splenectomy?
Platelets rise first
Howell Jolly bodies appear over following weeks
Target cells, Pappenheimer bodies
Risk of sepsis to encapsulated organisms
When is it best to give platelets in splenectomy surgery for ITP
After splenic artery clamped
