Operations Flashcards

Question

How is a PEG inserted?

Answer 1

- 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

Answer 2

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.

Answer 3

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

Answer 4

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.

Answer 5

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.

Answer 6

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

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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.

Answer 11

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.

Answer 12

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.

Answer 13

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

Answer 14

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.

Answer 15

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

Answer 16

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.

Answer 17

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.

Answer 18

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

Answer 19

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.

Answer 20

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

Answer 21

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