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MRCS Part B > Operations > Flashcards

Operations Flashcards

1
Q

Surgical management of duodenal perforation?

A

Midline laparotomy. Close with absorbable interrupted suture if possible, then place overlay omental patch to cover defect. Large volume washout, place drain and close.

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2
Q

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?

A

Not necessarily as rarely malignant Test for H Pylori to guide if eradication needed

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3
Q

Surgical management of bleeding gastric ulcer?

A

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.

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4
Q

Surgical management of perforated gastric ulcer?

A

Laparotomy. Excise for histology, close with absorbable interrupted sutures then overlay omental patch. If extensive ulcer, resect (distal gastrectomy if distal)

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5
Q

Surgical management of bleeding posteriorly sited duodenal ulcer?

A

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

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6
Q

Why don’t anteriorly perforated duodenal ulcers usually cause large volume UGI bleeds vs posterior?

A

Anteriors usually perforate intraperitoneally if D1, vs posterior which erode through gastroduodenal artery posteriorly.

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7
Q

What vessel is usually implicated in posterior duodenal ulcer bleeds?

A

Gastroduodenal artery

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8
Q

Which operation is required for HNPCC-associated colorectal cancer?

A

Panproctocolectomy

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9
Q

Operation of choice for right colon cancer?

A

Right hemicolectomy with ileocolic anastomosis

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10
Q

Operation of choice for transverse colon cancer?

A

Extended right hemicolectomy with ileocolic anastomosis

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11
Q

Operation of choice for splenic flexure cancer?

A

Extended right hemicolectomy with ileocolic anastomosis, or left hemicolectomy with colo-colonic anastomosis

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12
Q

Why is right hemicolectomy with ileocolic anastomosis usually preferred to left hemicolectomy with colo-colonic anastomosis for splenic flexure cancer?

A

Less risk of anastomotic leak with ileocolic anastomosis

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13
Q

Operation of choice for left colonic cancer?

A

Left hemicolectomy with colo-colonic anastomosis

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14
Q

Operation of choice for sigmoid colon cancer?

A

High anterior resection with colo-rectal anastomosis

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15
Q

Operation of choice for cancer of upper rectum?

A

Anterior resection with total mesorectal excision, colo-rectal anastomosis

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16
Q

What is total mesorectal excision?

A

Removal of mesorectal fat and lymph nodes

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17
Q

Operation of choice for cancer of lower rectum?

A

Anterior resection with low total mesorectal excision, colo-rectal anastomosis +/- defunctioning stoma

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18
Q

Operation of choice for cancer of anal verge?

A

APER - abdomino-peroneal excision of colon and rectum with no anastomosis possible.

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19
Q

What is a Hartmann’s procedure? Can it be reversed?

A

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.

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20
Q

Why may Hartmann’s procedure be done for e.g. perforated sigmoid cancer?

A

Risk of anastomotic leak is significantly higher in bowel perforation, especially for colo-colic anastomosis, so high anterior resection and end colostomy formed.

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21
Q

Operation of choice for obstructing rectal cancer? Why?

A

Defunctioning loop colostomy - as high risk of anastomotic leak, surgery harder and danger of positive resection margin in unstaged patient.

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22
Q

How does management of obstructing colonic cancers differ to that of obstructing rectal lesions?

A

For colonic, options are stenting vs resection - rarely defunctioned For rectal, have to defunction with loop colostomy

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23
Q

What is the definitive surgical management for UC? Why might this not be done acutely and what would be done instead?

A

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.

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24
Q

What restorative options are there following subtotal colectomy for UC?

A

Completion proctectomy and formation of ileoanal J pouch (or keeping end ileostomy).

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25
Q

Surgical option of choice for acutely unwell colitic not responding to medical therapy?

A

Subtotal colectomy and end ileostomy

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26
Q

Procedure for debriding an open fracture?

A

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

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27
Q

Outline procedure for DHS?

A

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

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28
Q

What fracture are DHS suitable for?

A

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

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29
Q

What procedure is ideal for head of pancreas cancer if operable?

A

Whipple’s - newer techniques such as pylorus preserving and SMA/SMV resection

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30
Q

What is a Whipple’s procedure? What is taken and what is the result?

A

For head of pancreas carcinoma - pancreaticoduodenectomy, also takes gallbladder. Left with choledochojejunostomy, pancreaticojejunostomy and gastrojejunostomy

31
Q

Potential surgical option for carcinoma of body/tail of pancreas?

A

Distal pancreatectomy

32
Q

What 4 factors affect decision on restoring continuity folllowing colorectal resection?

A

Perforation vs no perforation Vascular supply Mucosal apposition Tissue tension

33
Q

Options for obstructing colonic lesions?

A

Stent vs primary resection Rarely defunction

34
Q

What operation is required for sphincter involvement or very low rectal tumours?

A

APER

35
Q

What clearance margin is required in rectum?

A

2cm distal margin

36
Q

What patients would you offer neoadjuvant radiotherapy to in rectal cancer?

A

Higher grade - T1, 2 and 3 /N0 don’t need and can go straight for surgery

37
Q

How do you manage potentially resectable pancreatic head cancer with obstructive jaundice? What do you avoid?

A

ERCP and plastic stent Avoid metallic stents as these compromise resectability

38
Q

Benefits/risks of total hip replacement over hemiarthroplasty?

A

Better function and prosthetic survivorship But higher risk of dislocation

39
Q

Outline surgical management of extracapsular hip fractures?

A
40
Q

What is most important factor in managing young patients with femoral neck fractures?

A

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

41
Q

Outline surgical management options for intracapsular neck of femur fractures?

A
42
Q
A
43
Q

How would you manage SBO secondary to long termineal ileal strictures in Crohns? How would this differ to short segment strictures?

A

Ileocaecal resection

For shorter segments use stricuroplasty

44
Q

What does the bowel look like in acute Crohns laparotomy? What does the mesentery feel like?

A

Externally inflamed bowel with thick wall that may feel fibrotic

Mesentery is friable and fatty

45
Q

What surgical options would be preferable for Crohn’s? What do you not do?

A

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

46
Q

What layers do you go through in open appendicectomy?

A

Skin

Subcutaenous tissue

Campers then Scarpa’s fascia

External oblique (?) aponeurosis

Internal oblique muscle

Transversalis muscle

Transversalis fascia

Peritoneum

47
Q

Outline how to perform open appendicectomy?

A

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

48
Q

Describe how to do laparoscopic appendicectomy? Specific things to consider?

A

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

49
Q

How would you approach an incorrect swab count at the end of surgery?

A

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

50
Q

What would you do if on operation you found a normal appendix but no other pathology to account for presentation?

A

Usually take anyway - sometimes histological evidence of early inflammation

51
Q

What would you do if on operation you found a normal appendix but alternative pathology e.g. Meckels?

A

Leave appendix and treat pathology if satisfied it would account for symptoms

52
Q

How might you close a regular open appendicectomy at the skin vs a heavily contaminated one?

A

Regular - absorbable subcuticular stich

If heavily contaminated consider interrupted sutures or clips

53
Q

Why are tourniquets used in surgery?

A

Minimise blood loss, improve clarity of operative field

54
Q

How are tourniquets applied and used in surgery? Key safety points?

A

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

55
Q

Roughly how long would you keep tourniquet up for in a well adult for surgery?

A

Max 2 hours

56
Q

Post-inflation systemic affects of applying tourniquet?

A

Increased SVR, CVP and BP

BP gradual increases over time

Induced hypercoagulable state (vascular disruption)

Slow increase in core temp

57
Q

Post deflation systemic effects of tourniqet use in surgery?

A

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

58
Q

4 absolute contraindications to tourniquet use in surgery?

A

Severe PVD

Previous vascular surgery on site

Fracture/thrombosis at site of application

AV fistula in same limb

59
Q

5 relative contraindications to tourniquet use in surgery?

A

Infection at site

Sickle cell disease

PMH of VTE

Skin grafts at site

Lymphoedema in same limb

60
Q

6 complications of tourniquet use in surgery?

A

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

61
Q
A
62
Q

Describe this appearance? What are the issues with it and why may this have happened?

A

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

63
Q

What kind of GI anastomosis is most likely to heal without complications? What areas are at highest risk?

A

Small bowel best

Oesophagus and rectum highest risk

64
Q

Systemic factors increasing risk of anastomotic breakdown?

A

Sepsis,infection

Haemodynamic instability

Jaundice

Diabetes

Poor nutrition

Steroids

Heavy local contamination, poor surgical technique

65
Q

Describe how to do a primary small bowel anastomosis? e.g. following segmental small bowel resection

A

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

66
Q

4 principles of performing vascular anastamoses?

A

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

67
Q

Indications for elective splenectomy?

A

Haematological conditions e.g. haemolytic anaemias, hereditary ellipto/spherocytosis

Malignancy e.g. lymphoma

Cysts/abscesses

68
Q

How would you perform an elective, open splenectomy?

A

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

69
Q

Describe how to perform emergency splenectomy? Why is this different from elective?

A

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

70
Q

4 changes seen post splenectomy?

A

Platelets rise first

Howell Jolly bodies appear over following weeks

Target cells, Pappenheimer bodies

Risk of sepsis to encapsulated organisms

71
Q

When is it best to give platelets in splenectomy surgery for ITP

A

After splenic artery clamped

72
Q
A
73
Q
A

MRCS Part B (25 decks)

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