Operations

Question 1

How would you prepare for an operation?

Answer 1

—Consent
Before entering theatre, I would ensure the patient had been appropriately consented and had been informed of the risks and benefits of the procedure and any alternatives with a focus on the patients priorities in line with the 2015 Montgomery ruling and the recent NICE guidelines on shared decision making.

—Brief
I would make sure that a Team Brief and the WHO checklist had been completed.
Specific significant risks relevant to this situation would include risk of ……….

—Setup
I would position the patient supine and level. I would make sure the patient was catheterised with large bore IV access inserted, with an arterial line and central access. I would ensure appropriate equipment was available including for this case
Retractors, Vessel sealers, Stapler (TLC 75, Eschelon Flex Blue/Gold/Green)

—Approach and why
‘I would adopt a minimally invasive approach’

Question 2

How would you perform a stapled small bowel resection?

Answer 2

• I would exteriorise the bowel using a wound protector and inspect for a suitable transection point
• Signs of suitable viability to make that decision would include colour of the bowel, peristalsis and pulsation in the mesentery
• I would then ligate the mesentery in a shallow v shape with diathermy, clips and ties.
• I would use a linear stapler to excise the specimen by dividing both ends. In my practice that would normally be a TLC 75 with a blue cartridge
• I would then position the bowel in a side-side configuration and place an anchoring 3-0 PDS stitch at the far end of my proposed staple line
• I would then make enterotomies in both segments of bowel and create the anastomosis
• I would assess its patency, check for any excessive bleeding from the staple line and close the enterotomy with 3-0 PDS. I would then oversew the entire distal staple line with 3-0 PDS. I would then double check for flow and no obvious leaks, close the mesenteric defect with 2-0 vicryl and return the bowel to the abdomen

Question 3

How would you perform a hand-sewn small bowel resection?

Answer 3

• I would exteriorise the bowel using a wound protector and inspect for a suitable transection point
• Signs of suitable viability to make that decision would include colour of the bowel, peristalsis and pulsation in the mesentery
• I would then ligate the mesentery in a shallow v shape with diathermy, clips and ties.
• I would apply soft and crushing bowel clamps and excise the specimen. I would control any excessive bleeding with cautious diathermy
• I would then position the bowel in a end-end configuration and perform a single-layer, interrupted, hand sewn anastomosis using 3-0 PDS

I would then double check for patency and no obvious leaks, close the mesenteric defect with 2-0 vicryl and return the bowel to the abdomen

Question 4

How would you perform a right hemicolectomy?

Answer 4

My approach to this as a non-specialist would generally be with a mid-line laparotomy. I would ensure a linear stapler and energy device was available.

I would start by packing the small bowel to the left of the abdomen to expose the ileocolic pedicle.

I would mobilise the right colon from lateral to medial, taking care to identify and preserve both the right ureter and the duodenum. I continue dissection around the hepatic flexure dividing the gastrocolic ligament up to the point of transection

I would then divide the colonic mesentery starting by performing a high ligation of the ileocolic pedicle and then use the energy device to divide the rest of the mesentery to the point of division. I would ensure sufficient mobility of the small bowel to reach the transverse colon

I would then perform a stapled side-side anastomosis using the Barcelona technique with three firings of a linear stapler, usually a TLC 75 with blue cartridge. I would oversew the distal staple line with 3-0 PDS, close the mesenteric defect with 2-0 vicryl and return the colon to the abdomen

I would then washout the abdomen and if there was significant contamination I would leave a 30 french drain in the pelvis.

Question 5

How would you close a laparotomy in an emergency setting?

Answer 5

Usually I would use at least 2 x 1 Loop PDS sutures

Making sure the suture length was at least 4 times the wound length.

I would then do a mass closure with 1cm bites at 1cm intervals

Question 6

How would you close a laparotomy wound in the elective setting?

Answer 6

Usually I would use at least 2-0 PDS sutures in line with the 2015 STITCH trial

Making sure the suture length was at least 4 times the wound length.

I would then do a continuous small bite closure of 5mm intervals and 5mm width, ensuring only the aponeurosis was included

Question 7

How would you perform a subtotal colectomy?

Answer 7

As a non-specialist, I would do this with a generous midline laparotomy and the patient supine.

I would ensure that a linear stapler and an energy device was available and place a retractor, either a Golligher or ideally an omnitract

I would start by packing the small bowel to the left of the abdomen and mobilising the right colon from lateral to medial along the white line of Toldt. I would then mobilise up past the hepatic flexure identify and preserving the right ureter and duodenum.

I would continue to mobilise the transverse colon by dividing the gastrocolic ligament. I would then pack the small bowel to the right and mobilise the left colon from lateral to medial and approach the splenic flexure from below

I would identify and preserve the left ureter, then I would divide the left colon with the linear stapler leaving a long rectal stump. I would ligate the colonic mesentery close to the bowel with the energy device and continue the dissection to a suitable part of terminal ileum that would reach the abdominal wall.

I would create an opening for the ileostomy using a cruciate fascial incision and muscle splitting technique, preferably in an area marked by the stoma nurses, in the RIF.

I would then was the abdomen, leave a drain in the pelvis and secure the rectal stump in the lower part of the laparotomy so that if it gives way there is a mucuos fistula. I would then formally close the rest of the laparotomy using a mass closure and mature an end ileostomy with 3-0 vicryl rapide of a length of at least 2.5cm above the skin.

Question 8

How would you perform a Hartmanns procedure for perforated diverticular disease?

Answer 8

As a non-specialist, I would do this with a generous midline laparotomy and the patient supine.

I would ensure that a linear stapler and an energy device were available and place a retractor, either a Golligher or ideally an omnitract. I would inspect the abdomen for any abscess and drain this and inspect the bowel to ensure that it is safely resectable

Assuming this was the case, I would pack the small bowel to the RUQ and start mobilising the left colon. I would identify and preserve the left ureter and gonadal vessels and continue dissection anterior to gerotas fascia up to and including the splenic flexure to ensure I had enough length on the colon remaining.

I would divide the colon proximal to the pathology using the linear stapler and divide the mesentery close to the bowel using an energy device. I would then perform a distal division at the recto-sigmoid junction and perform a thorough washout and place a 30fr drain in the pelvis.

I would then create an opening for an end colostomy, preferably in an area marked by the stoma team, in the LIF, using a cruciate fascial incision and splitting the muscle.

I would close the abdomen using a mass closure and mature an end colostomy using 3-0 vicryl rapide.

Question 9

How would you perform a CBD exploration?

Answer 9

I would start with a standard cholecystectomy setup, with 2 10mm and 2 5mm ports.

I would elevate the gallbladder cephalad and dissect out the cystohepatic triangle to gain a critical view. I would confirm the presence of choledocholithiasis by performing an on table cholangiogram. If this was confirmed I would first assess if a transcystic approach would be possible.
- only possible for distal stones <7mm (cannot retroflex)

If not then proceed to formal CBD exploration if CBD >8-10mm. Dissection of supra duodenal CBD bluntly and with scissors. Transverse incision made over duodenum, avoiding the arteries at 3/9 o/c and insertion of choledochoscope.

In my practice we use a single use ureteroscope for this. Then use a dormer basket to extract any stones, passing it through the ampulla to exclude ampullary stones. Make sure CBD/CHD clear of stones

Closure with interrupted 3-0 PDS transversely and leave a 20fr drain next to the choledochotomy. If no bile then remove at 48 hours

Complete cholecystectomy and washout

Question 10

How would you perform a laparoscopic hernia repair?

Answer 10

In my practice I perform an extraperitoneal approach (TEP). I would not routinely give antibiotics in line with recent guidelines

I would position the patient supine and slightly trendelenberg and make a subumbilical incision down to the fascia. I would incise the rectus sheath on the side of the hernia and elevate the rectus muscle with a Lagenback retractor. I would insert a 10mm tracer and insufflate the exztraperitoneal space

I would then bluntly dissect a plane inferiorly to the public tubercle and laterally underneath the inferior epigastrics using the endoscope. I would then insert 2x5 mm ports into the midline and continue dissection widely to at least the ASIS laterally and across the pubic symphysis medially. I would take care with dissection in the triangle of doom, medially to the spermatic cord where the iliac vessels are located and the triangle of pain laterally

Any direct hernia I would reduce primarily and then inspect the spermatic cord. I would bluntly dissect any indirect sac from the spermatic cord and reduce it so that the entire peritoneal reflection is visualised. I would then place a shaped mesh ideally into the preperitoneal space ensuring that it crosses the midline, widely to the ASIS and the peritoneum is superior to it.

I do not routinely tack the mesh but if necessary I would place a medial tack and avoid tacking inferiorly. I would then hold the mesh in place and desufflate the abdomen.

Question 11

How would you perform a midline incisional hernia repair?

Answer 11

I would ensure the patient had been prepared adequately preoperatively - weight loss, smoking cessation etc.

I would perform this with an open approach, however I am aware of lap and robotic techniques.

I would reopen the existing excision and excise the scar. I would identify the sac and reduce its contents. I would then clear the fascia back to the edges of the defect. I would open and excise the sac if not already done and widely clear the peritoneum of adhesions to identify any smaller defects.

If the defect was <2cm I would repair the defect with 1 Nylon - as suggested by recent consensus guidelines published in Annals of Surgery in 2017.

Otherwise I would open the rectus sheath bilaterally and dissect behind the rectus muscle to make a large plane for mesh placement. I would want at least 5cm overlap on each side, but practically I would dissect out as much rectus sheath as possible.

I would then close the posterior sheath with a loop 1 PDS and insert a large, synthetic , large pore, non-absorbable mesh into the retrorectus space. I would secure this with a few radially placed 2-0 Prolene sutures. I would then close the anterior sheath with 1 PDS and leave two redivac drains, one in the rectus sheath and on in the subcuticular space.

If the fascial defect was too big to close primarily I would perform a posterior component separation by incising the posterior rectus sheath at the lateral aspect of my retrorectus dissection and a transversus abdominus release by incising this along its medial attachment.

Question 12

How would you perform a subtotal gastrectomy?

Answer 12

• Laparoscopic approach with 4 ports and liver retractor
• Dissection of greater omentum from transverse colon running from 1st short gastric to right gastroepiploic pedicle which is ligated with clips
• Division of posterior gastric adhesions including splenic artery nodes (11p)
• Division of gastrohepatic ligament and isolation/ligation of right gastric artery
• Mobilisation of 1st part of duodenum and division with a linear stapler
• Dissection of lymphatic tissue from CHA, coeliac axis and hepatoduodenal ligament (8/9/12)
• Left gastric artery then ligated at its origin (7)
• Dissection along lesser curve including pericardiac nodes
• Division of specimen 5cm proximal to tumour
• Reconstruction with roux-en-y technique
  —- Division of jejunum at 50cm (BP Limb)
  —-50cm further jejunum taken and anastomosis of BP limb to jejunum at this level with linear stapler and closure of enteroenterostomy
  —-Antecolic, ante gastric Gastrojejunostomy created with linear stapler and closure of gastroenterostomy
  —-Closure of mesenteric defects with permanent suture
  —-Drain to duodenal stump

Question 13

How is the oesophagus approached in the neck?

Answer 13

• Left side of neck with head extends and turned to right
• Incision on anterior border lower 1/2 of SCM
• SCM dissected free from sternohyoid to identify internal jugular vein
• Anterior Omohyoid belly identified and divided
• Middle thyroid vein ligated and deep cervical fascia opened
• Carotid sheath retracted laterally
• Blunt dissection onto oesophagus via NGT.

Question 14

How would you perform an Ivor-Lewis Oesophagectomy?

Answer 14

Minimally invasive approach
—- Abdominal phase - 4 ports, liver retractor
- Mobilisation of greater omentum with careful preservation of gastroepiploic arcade and division of short gastrics above this to hiatus
- Partial Kocherisation of duodenum to mobilise pylorus to hiatus
- Dissection of lymphatic tissue and ligation of LGA at origin
- Mobilisation of lesser curve of stomach including lymph nodes and wide dissection hiatus
- Sling oesophagus with Jaques catheter and dissect up into mediastinum as far as possible including pleural strip
- Divide stomach 5cm distal to tumour creating tubularised conduit
- Suture divided specimen to conduit
- Feeding jejunostomy and close
—-Thoracic phase - 4 ports, single-lung ventilation, semi-prone right chest
- Continue pleural strip superiorly to azygos vein and divide between hemoloks
- Dissection of oesophagus including paraoesophagheal and carinal lymph nodes until free
- Ligate thoracic duct if identified
- Divide oesophagus proximally with linear stapler
- Open chest, extract specimen, prepare conduit
- Circular stapled anastomosis using Orville 25mm
- Passage of NGT past anastomosis and fixation at nose
- Gastrostomy excised with linear stapler and removed
- 2 x chest drain close

Question 15

How would you perform a feeding jejunostomy?

Answer 15

If not part of another procedure, I would place 1 10mm and 2 5mm ports.

I would reflect the transverse colon cephalad to find the DJ flexure and identify a segment of proximal jejunum that will come to the anterior abdominal wall in the LUQ.

I would then loosely secure the jejunum to the abdominal wall using 3-0 monocryl on a straight passed through the abdominal wall and retrieved with an endoclose in 3 places . Then I would introduce a Freka type feeding tube without a balloon into the bowel passing distally about 15cm before securing at the skin and in a 4th place on the bowel.

I would start water infusion on extubation and follow the advice of a dietician on a suitable feeding regime

I would secure this at the skin then perform a 4th suture on the bowel

Question 16

How would you perform a staging laparoscopy for OG cancer?

Answer 16

Usually with 2 5mm ports.
I would assess for any peritoneal or liverdisease or large pools of ascites. I do not routinely perform washings unless there is an obvious problem.
I would then look for a hiatus hernia and assess for tumour respectability - fixity to surrounding structures mainly along with lymphadenopathy outside the surgical field

I would also liaise with the anaesthetist about the patients stability for resectional surgery

Question 17

How would you perform a wedge resection for GIST?

Answer 17

I would ensure the patient had been worked up appropriately and was aware that the operation could proceed to a major gastrectomy.

I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would assess the tumour to make sure an adequate excision margin could be obtained with a wedge type resection, then I would divide the gastro-colic ligament and short gastrics with an energy device. I would then use a laparoscopic stapler with a reinforced green cartridge to excise the tumour with a 2cm margin.

I would perform an air leak test and ensure haemostasis, removing the specimen in a bag

Question 18

How would you perform a sleeve gastrectomy?

Answer 18

I would ensure the patient had been through a bariatric MDT and was suitably prepared for surgery
I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would divide the gastro-colic ligament and short gastrics with an energy device up to the gastro-oesophageal junction I would carefully ensure there was no hiatus hernia and repair if one was found. I would then use a laparoscopic stapler with a reinforced cartridges starting about 5cm from the pylorus to excise the sleeve of stomach. I would aim to maintain a 4cm remnant stomach, taking extra care around the incisura and the GOJ

I would perform an air leak test and ensure haemostasis, removing the specimen in a bag

Question 19

How would you perform a gastric bypass?

Answer 19

I would ensure the patient had been through a bariatric MDT and was suitably prepared for surgery
I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would start by dividing the greater omentum and performing the Jejunojejunostomy. I would identify the DJ flexure and walking the bowel for 50cm for my BP limb. I would window the mesentery and divide the small bowel with a stapler and blue cartridge before continuing to walk the small bowel for another 100cm for my alimentary limb, being careful to maintain orientation.

I would then perform stapled side-side jejunojejunostomy and close the enterotomy with 2 layers of 3-0 PDS.

I would then make my gastric pouch by tunnelling under the lesser curve and a green stapler. Aiming for around 20ml or 1 x 5cm. I would then perform a stapled side-side gastrojejunostomy over a 30fr bougie to ensure an anastomosis diameter of around 1cm or more. I would then do methylene blue test occluding after the GJ and close both the mesenteric and Petersons defects

Question 20

How would you perform a LARS?

Answer 20

I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would start by opening the Pars Flaccida and dissecting the oesophagus from the whole of the right crus. I would then continue my dissection anteriorly and divide the phreno-oesophageal ligament. I would then dissect down the left crus and sling the oesophagus with a Jaques catheter. I do not routine divide the short gastrics. I would make sure I have identified the anterior vagus and ideally posterior vagus and preserve these.

I would mobilise at least 2-3cm of oesophagus into the abdomen and then perform a crural repair. Typically I would place 3 1 Ethibond posteriorly and 1 anteriorly. I would then ensure I had sufficient fundus to perform a Dor wrap.

I would then place 1 suture to recreate the angle of His and Suture the fundus anticlockwise around the clock face 3, 1, 11, 9, 7.

I would then ensure haemostasis and close.

Question 21

How would you perform a Heller Myotomy?

Answer 21

I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would start by opening the Pars Flaccida and dissecting the oesophagus from the whole of the right crus. I would then continue my dissection anteriorly and divide the phreno-oesophageal ligament. I would then dissect down the left crus and sling the oesophagus with a Jaques catheter. I would make sure I have identified the anterior vagus and ideally posterior vagus and preserve these.

I would mobilise the oesophagus so I could perform my myotomy up to 6cm superior to the GOJ. I would mark my myotomy for 8-9cm starting 3cm distal to the GOJ and divide the serosa/muscularis with a hook. I would then perform an air leak test.

I would then close the hiatus with 1 ethibond and perform an anterior Dor wrap and close

into the abdomen and then perform a crural repair. Typically I would place 3 1 Ethibond posteriorly and 1 anteriorly. I would then ensure I had sufficient fundus to perform a Dor wrap.

I would then place 1 suture to recreate the angle of His and Suture the fundus anticlockwise around the clock face 3, 1, 11, 9, 7.

I would then ensure haemostasis and close.

Question 22

How would you approach repairing a giant hiatus hernia?

Answer 22

I would position the patient supine, split legs, reverse trendelenberg, 4 ports and a liver retractor

I would start by assessing if the contents of the hernia could be reduced primarily, but with the expectation of them springing back immediately. I would start dissection outside of the hernia sac so as to reduce the entire sac by identifying the loose areolar tissue suggesting I’m in the correct plane. I would preserve the vagi.

I would reduce the entire hernia sac and contents into the abdomen and then close the hiatal defect with 1 Ethibond. I do not routinely place a mesh as evidence does not support this technique. If the defect was large I would selectively place a biosynthetic mesh designed for use at the hiatus.

If unable to close the defect without undue tension I would consider a left lateral diaphragmatic release +/- permanent mesh reconstruction. I would then perform a Dor wrap if possible or if not then a sutures 3 point gastropexy.

start by opening the Pars Flaccida and dissecting the oesophagus from the whole of the right crus. I would then continue my dissection anteriorly and divide the phreno-oesophageal ligament. I would then dissect down the left crus and sling the oesophagus with a Jaques catheter. I do not routine divide the short gastrics.

I would mobilise at least 2-3cm of oesophagus into the abdomen and then perform a crural repair. Typically I would place 3 1 Ethibond posteriorly and 1 anteriorly. I would then ensure I had sufficient fundus to perform a Dor wrap.

I would then place 1 suture to recreate the angle of His and Suture the fundus anticlockwise around the clock face 3, 1, 11, 9, 7.

I would then ensure haemostasis and close.

Question 23

How would you perform a laparotomy for trauma?

Answer 23

I would ensure the patient was promptly transferred to the theatre and the massive transfusion protocol had been activated.

If there was time and expertise I would want a cell saver set up although my experience with these is mixed.

I would prep and drape the patient awake and be prepared to make a rapid midline laparotomy with a knife.

After entering the abdomen I would rapidly evacuate any clots and then sequentially pack the abdomen, starting from the area of most suspicion, including packs above and below both spleen and liver, quadratically and in the pelvis. I would make sure the scrub team were accurately counting the packs in and out.

Any ongoing bleeding I would try and control with direct pressure to allow the anaesthetists to catch up and restore the patients physiology.

I Would also place a self retaining omnitract retractor to aid visualisation

Question 24

How would you perform a splenectomy in a trauma setting?

Answer 24

I would perform a trauma laparotomy (as previous card).

If the spleen was the source of bleeding I would then proceed to splenectomy. I am aware of splenic conservation techniques, but I have no experience of them and I think the safest option is to perform a formal splenectomy.

I would start by retracting the spleen medially and dividing its inferior, lateral and superior attachments (spleno-colic, splenodiaphragmatic and lienorenal ligaments)
I would then dividing the gastrocolic ligament with an energy device near the spleen to enter the lesser sac
and continue along to divide the short gastric arteries.

I would then ligate the vessels close to the spleen avoiding damage to pancreas. I would leave a drain in the pancreatic bed

Question 25

How is a PEG inserted?

Answer 25

• Endoscopic transillumination of abdominal wall two fingers beneath costal margin
• Local anaesthesia
• Cannulation of stomach and passage of guide wire by Seldinger technique, grasped using snare and pulled through mouth.
• Dilator with following G-tube passed through mouth and fed through abdominal wall until resistance met (bumper at abdominal wall)
• Check position and secure in place

Question 26

How is an oesophageal dilatation performed?

Answer 26

I would give the patient sedation, in my practice this would usually be 2.5mg of midazolam and 50ug of fentanyl, although I would tailor that to patient size and age

I would perform a diagnostic OGD to identify the problem and consider if further biopsies are necessary. If happy then I would proceed . In my practice I perform balloon dilatation rather than rigid dilatation. If the stricture was impassable I would initially dilate with a small balloon of 10-12mm and limit my procedure three successive increments. For achalasia, the BSG recommend 30-35-40mm.

I would inflate the balloon to the atmosphere specified on the dilator to achieve the diameter, while pushing the scope into the balloon to visualise the mucosa and holding for 30s before releasing. I would generally perform a repeat endoscopy at 2 weeks until 15mm is reached.

I would make sure the patient was on a PPI, was observed for at least 2 hours and was drinking before discharge.

I would be concerned about perforation if the patient develops increasing pain, fever, tachycardia or crepitus. I do not routinely screen for dilatations and would do this only where the stricture was high risk - post caustic, multiple strictures, previous perforation.

Question 27

How would you perform an ER thoracotomy?

Answer 27

Generally this will be for penetrating chest trauma critically unstable or with a witnessed loss of output or loss of output for <15minutes or evidence of cardiac tamponade.

Patient is supine with both arms out. I would prep and drape the patient if there was time, but otherwise start an incision in the left chest in the 4th/5th interspace beneath the nipple from the sternum to the mid-axillary line. I would cut down to the intercostals then enter the chest laterally avoiding the heart on the superior border of the rib. I would continue this anteriorly and evacuate any obvious haematoma. I would perform the same procedure on the right side and cut across the sternum with heavy scissors. I would then insert rib spreaders and maximise exposure.

I would evacuate any clot and attempt to control any bleeding with direct pressure. I would make a T-shaped incision in the pericardium to exclude a tamponade avoiding the phrenic nerve. I would try to control any bleeding from the heart with sutures, or I could use an inflated Foley catheter if this fails.

If there was cardiac activity I would consider internal cardiac massage with a two handed technique

Question 28

How would you perform a primary survey?

Answer 28

I would initially perform a primary survey aiming to identify any life threatening injuries. While this was happening others would be obtaining observations and gaining IV access etc.

I would first assess the airway and ensure the patient had cervical spine protection with a collar and blocks or inline stabilisation. I would try and talk to the patient and a coherent response strongly suggest a patent airway. (IF not then GCS<8 or non purposeful movements –> intubation) I would consider airway adjuncts such as a Guedel if there was a concern before endotracheal intubation.

I would then move to breathing and obtain oxygenation/resp rate and examine the chest looking for injury, chest wall movement, asymmetry and auscultate for breath sounds. Looking to identify airway obstructions, tension/open pneumothorax, massive haemothorax, flail chest and cardiac tamponade. This patient should receive oxygen regardless.

I would then move on to circulation, reviewing BP and HR and looking for obvious signs of bleeding in the chest, abdomen, pelvis and long bones. With inspection for bleeding bruising or injury in these areas. I would examine the abdomen for tenderness. I would ensure that 2 litres of warmed crystalloid had been started and appropriate blood and cross match had been sent.

I would then assess the GCS, pupils and glucose, and fully expose the patient to look for other injuries.

Question 29

How would you perform a secondary survey?

Answer 29

I would obtain an AMPLE history (Allergies, medication, PMH, last ate, events).

I would then performa head-toe examination, examining the eyes, maxilla facial structures and C-spine.
I would repeat a Chest and abdominal inspection/examination and also examine the perineum including a digital rectal examination.

I would palpate long and small bones of the limbs and a full neurological examination.

Question 30

How would you place an endo-sponge?

Answer 30

I would position the patient supine and under general anaesthetic. I would endoscope the patient to identify the perforation, confirming that is localised. I would washout the cavity and decried any necrotic or inflammatory tissue or food residue

I would then fashion the sponge which usually we make adhoc rather than using the commercial kit. We shape a piece of vacuum sponge like for a vacuum dressing to the shape of the cavity. I then secure it to the tip of a nasogastric tube that has been passed through the nose and brought out the mouth using a heavy silk. This is then positioned in place using the endoscope and a rat-toothed grasper. The tube is secured in place with a bridle and attached to wall suction. I would change this at 3 days

Question 31

How would you repair a perforated PU?

Answer 31

I would position the patient supine, arms tucked and slightly head up. If the patient was stable I would start with a laparoscopic approach with 4 ports, otherwise I would perform an upper midline laparotomy.

I would identify the defect and if the hole was <2cm, attempt a primary repair with a 3-0 PDS if possible. Although the WSES guidelines suggest that a omental patch is not indicated, it is my practice to place one at the time of surgery. I would perform a thorough lavage of the abdomen and place a single 20fr drain at the site of injury.

I would make sure the patient continued on broad spectrum antibiotics, antifungals and IV PPI, and an NGT was placed at the end of the procedure. If the perforation was gastric I would take biopsies and consider excising the ulcer primarily.

Postoperatively I would prescribe the patient eradication for H.Pylori, and cautiously start fluids orally on d2-3. I don’t routine arrange a contrast swallow but would do so if concerned.

Question 32

How would you repair a giant perforated PU?

Answer 32

I would position the patient supine with arms tucked. I would go straight to laparotomy as I will not be able to manage this laparoscopically.

For gastric perforations I would strongly consider a distal gastrectomy and roux-en-y reconstruction if the patient was stable enough to withstand this. Otherwise I would resect the affected stomach and place a NGT and feeding jejunostomy with a view to returning at a later date.

For duodenal perforations these can be challenging and I would ask for help form a Hepatobilary colleague. If they were not available, Ideally I would perform Kocher maneouvre to fully mobilise and assess the duodenum. Options I would consider would include wide drainage, pyloric exclusion and gastrojejunostomy or closure of the defect around a T-Tube to create a controlled fistula.

I would ensure I had an enteral access route at the end of the operation, the stomach was decompressed and drains were placed.

Question 33

How would you approach a perforated thoracic oesophagus operatively?

Answer 33

I would initially perform an OGD with the patient supine to fully characterise the defect. Assuming it was in the distal oesophagus I would then position the patient in the right lateral decubitus position and perform a left posterolateral thoracotomy in the 7th intercostal space.

I would lavage the chest and debride any devitalised tissue. I would then tackle the defect by first extending the myotomy to fully expose the mucosal defect before closing it in 2 layers with an inner absorbable 3-0 PDS and outer non-absorbable suture. I would buttress my repair with intercostal muscle or pericardium. I would ensure that a draining NG and feeding jejunostomy were placed at the end of the procedure and the chest was drained bilaterally

If >50% of the oesophagus was destroyed or the tissue was not healthy enough to support a repair, my options would then be to place a T-Tube or either resect or exclude the oesophagus. If there was significant underlying pathology the WSES guidelines suggest that a resection would be the best treatment but this can be very challenging.

Question 34

How would you approach an incarcerated femoral hernia?

Answer 34

I would perform a modified McEvedy procedure.

I would make a transverse skin crease incision about half way from the umbilicus to Pupbic symphysis from the midline to the side of hernia.

I would then open the lateral edge of the rectus sheath and distract the rectus muscle medially and insert large retractors into this space. I would then dissect the extraperitoneal plane down to the femoral canal and place a self retaining retractor like an omnitract to aid visualisation.

I would then identify the hernia site and reduce its contents by stretching the defect or dividing the lacunar ligament. I would open the sac and inspect its contents and if viable return to the abdomen. If not viable, I would perform a small bowel resection.

I would then repair the hernia by placing a flat mesh into the extraperitoneal space and securing it in place with 2-0 prolene, making sure it adequately covers the defect. If I had done a bowel resection I would repair the defect primarily with a 1 Ethibond suture, suturing the inguinal ligament to the pectineal ligament avoiding placing any sutures laterally

I would then close my incision in layers.

Question 35

How would you repair an inguinal hernia by an open approach?

Answer 35

I would make an angled groin crease incision, deepened through campers and scarpas fascia to the EOA.

I would then clear the EOA down to visualise the Inguinal ligament. I would then open the EOA with a knife and then divide it in the line of its fibres using scissors and being careful to avoid injuring the ilioinguinal nerve.

I would attempt to encircle the cord an identify the sac by blunt dissection.

In an acute setting I would open the sac early to identify the contents and if they require resection, if not then I would reduce them to gain space.

I would then make sure the cord structures are protected and either reduce or excise the sac.

I normally reinforce the posterior wall with 2-0 Vicrly and then place a flat mesh in a Lichtenstein configuration, secured with 2-0 prolene. I would then close in layers.

Question 36

How would you perform a laparoscopic appendicectomy?

Answer 36

Using a 3 port technique I would identify the caecum and follow the Taenia coli down to the base of the appendix. I would then mobilise the appendix laterally. I normally skeletonise the mesoappendix to the base and place 2 vicryl endoloops.

I then put a Burt bag into the abdomen, divide between the loops and place the appendix in a bag. I usually remove this then finish cleaning.

I do targeted suction and aspiration unless there is generalised peritonitis in line with the Jerusalem WSES guidelines.

If I was unable to satisfactorily close the base with loops I usually suture it with a 3-0 vicryl. I do not routinely place drains.

Question 37

How would you operate on a patient with mesenteric ischaemia?

Answer 37

I would perform a midline laparotomy and inspect the whole abdominal contents.

I woud identify any obviously necrotic segments of bowel and if there was contamination I would resect these now. Otherwise I would lift the colon and palpate the SMA at the root of the mesentery. I can find this by following the middle colic artery down. If there was no palpable pulse then I would consult a vascular surgeon who may consider performing an embolectomy or SMA bypass. I have no experience in these procedures.

An embolectomy would require proximal and distal control of the SMA, heparinisation, opening longitudinally and then insertion of a small foggarty catheter e.g. 2/3 proximally and distally. The artery is then closed with a vein patch to avoid narrowing the artery.

I would then resect any obviously dead bowel and usually plan for a relook at 24-48 hours. I would place an Abthera if available or op site sandwich and return the patient to ITU

Question 38

how would you insert a chest drain?

Answer 38

I would identify the safe triangle just anterior to the mid axillary line and the 4th and 5th interspaces. I would prep and drape the patient and anaesthetise the area with 10mls of 1% lidocaine with adrenaline.

I would the incise on the upper border of the rib in the 5th interspace and deepen my incision with a large clip like a Roberts down through the intercostals to the pleura. I would then open then pleura bluntly and insert a finger to clear any adhesions. I would then position a chest drain through the hole, aiming up for air and down for fluid. I would secure this with a silk suture and connect it to an underwater drain.

Question 39

How would you make an opsite sandwich?

Answer 39

I would start by getting a large pack and 2 op sites. I would then place the first op site sticky side up on a trolley, place the large pack on this and then cover it with a second op site, this time with the sticky side down. I would ensure that there was no exposed adhesive.

I would then make multiple holes in the sandwich on both sides through the posit using a blade. I would then position this in the patients abdomen making sure it extends well beyond the midline incision. I would then connect this to a Vacuum pump device

Question 40

How would you operate for small bowel obstruction

Answer 40

If there was a single transition point and the patient had 2 or fewer previous laparotomies I would consider a laparoscopic approach starting with an open cut down at Palmar’s point. Otherwise I would perform a midline laparotomy.

I would divide any adhesions to the anterior abdominal wall and walk the small bowel from the healthy collapsed distal segment at the TI to the the point of transition. I would then use sharp dissection to divide any band or adhesion present here. Having decompressed this area I would continue assessment proximally to exclude any further areas of obstruction. Any areas of necrotic or dubious viability bowel I would resect and perform a primary anastomosis.

I do not routine place any anti-adhesion agents - although the Bologna guidelines recommends Adept liquid for lap procedures and Seprafilm for open procedures.

Question 41

How would you perform a subtotal cholecystectomy?

Answer 41

If it was not possible to safely dissect out the cystohepatic triangle, I would perform a subtotal cholecystectomy.

To do this I would create a plane behind the gallbladder at a safe area on the liver bed and continue the dissection anteriorly to the gallbladder fundus. I would then proceed distally as far as was safe to free as much as the gallbladder as possible. I would then open the gallbladder, carefully collecting any stones and identify the cystic duct orifice, which I would perform a cholangiogram through.

I would excise as much of the gallbladder as possible and close the cystic duct orifice with 2 layers of slowly absorbable suture like a 3-0 PDS or V-loc. I would then leave a 20fr drain next to the gallbladder remnant and washout and close.

If there was a persistent bile leak I would arrange an ERCP and sphincerotomy which is usually enough to resolve this.

Question 42

How would you perform a distal pancreatectomy in the trauma setting?

Answer 42

I would position the patient supine and perform a upper midline laparotomy. I would open the gastrocolic ligament to enter the lesser sac, divide any posterior gastric adhesions and distract the stomach cephalad and the colon/mesocolon caudad.

Generally I would perform an enbloc splenectomy and start by mobilising the lateral attachments of the spleen and the lienorenal ligament in which the hilum and pancreatic tail lie.

I would then divide the splenic hilum and pancreatic tail using a vascular load stapler

Question 43

What would you do if a patient suffered cardiovascular collapse upon induction of pneumoperitoneum?

Answer 43

I would communicate clearly with the anaesthetist, evacuate the abdomen of CO2 and begin searching for a potential cause.

The differential diagnosis would include a CO2 embolism, major vascular injuries and pneumothorax/mediastinum but massive PE, MI and malignant hyperpyrexia are possible.

A CO2 embolus would be suggested by a machinery type heart murmur in addition to hypotension, cyanosis and cardiovascular instability. If I suspected this I would make sure the patient was ventilated with 100% oxygen and put the patient head down in the left lateral decubitus position. A CVC could be used to aspirate the CO2

I would expect to see blood in ports if there was a visceral injury, but this may not be present and I may need to convert to a laparotomy. If blood was spurting from the ports I would occlude it without removing it, alert the anaesthetist and scrub team and rapidly convert to a laparotomy. I would identify the injured vessel which is most likely to be the iliacs, and obtain proximal and distal control of this.

I would contact the on call vascular surgeon to help me reconstruct the artery which would most likely be with a interposition vein graft.

Question 44

How would you perform a McKeown Oesophagectomy?

Answer 44

I would start my dissection in the chest and mobilise the oesophagus from the diaphragmatic hiatus to the thoracic inlet. Key steps here would include ligation of the Azygous with a vascular stapler or hemoloks, identification and preservation/ligation of the thoracic duct, dissection of the meso-oesophageal lymph node packet and preservation of the airway. A single chest drain is left at the end of the chest phase

I would then move to the abdomen and create my gastric conduit in the usual fashion, which is supplied by the right gastroepipolic artery and arcade. I would perform an extensive Kocher maneouvre as I need enough length to get the conduit to the chest. I would take the LGA at its origin with surrounding tissue and connect to my chest mobilisation. I would then fashion my gastric conduit using a linear stapler. I would create my feeding jejunostomy.

I would then open the left neck down to the oesophagus and divide this at a suitable level before joining my dissection to the top of the chest. I would then attach a nylon tape to the top of the oesophagus and pull that through into the abdomen. The specimen can then be removed through the abdomen and the conduit attached to the tape. The tape is pulled up into the neck and then a single layer handsewn anastomosis with 3-0 PDS is fashioned with an NGT visualised passing through. A corrugated drain is left in the neck

Question 45

How would you perform a lower leg fasciotomy?

Answer 45

Mark tibial spine and fibula, identified from lateral malleolus.

Generous incision of skin midway between tibia and fibula and raising of flaps to expose deep fascia. The Anterior and lateral compartments can then be incised vertically to open the anterior and lateral compartments of the leg and the bridge divided for further exposure.

For the posterior compartment, the medial border of the tibia is marked and then longitudinal superficial incision is made 1cm posterior to medial tibial border with care to preserve long saphenous vein. Again flaps are raised until fascia exposed and incision made over gastrocnemius/soleus muscles (Sup post compartment). Exploration of the deep posterior compartment can then be done by blunt and sharp dissection to take gastroc/soleus off the bone