Operations JB

Question 1

Describe the technique of submandibular sialoadenectomy

Answer 1

Think about the structures at risk when:

• Approaching the gland (marginal mandibular and cervical nerves)
• On the surface of the gland (FA, FV)
• Deep to the gland (LN, CN XII, Rannine veins)

1. Mark out the palpable lesion. Locate incision to avoid the marginal mandibular and cervical branches of the facial nerve; skin crease 4cm below the inferior border of the mandible.
2. Develop flaps; for benign disease lift the SMG fascia with the platysma by suturing together. This ensures protection of the thread-like marginal mandibular.
3. Capsular dissection of the SMG off the anterior and posterior bellies of digastric; facial artery and vein and intimately assoiciated with gland so take separately above and below.
4. Dissect the posterior pole by retracting SMG anteriorly with Babcock’s.
5. Dissect the inferior aspect; identify and preserve the hypoglossal nerve.
6. Dissect the gland supero-anteriorly taking care to identify and preserve the lingual nerve. Pedicalise the gland on the duct and then suture-ligate duct with 3-0 PDS.
7. Layered absorbable closure over 6Fr drain.

Question 2

Describe your technique of thyroglossal cyst excision.

Answer 2

The procedural steps involve:

1. incision and access
2. identification of the cyst and duct; the extent of the duct from the foramen caecum to the pyramidal lobe must be resected.
3. hyoid bone identified, muscles separated and central portion resected
4. closure.

There is a signficant risk of malignancy (10%) in older people

A transverse skin crease incision is made over the location of the cyst. Skin and platysma flaps are created. The median raphe between the strap muscles of the anterior neck is identified and opened — the cyst is located beneath the median raphe.

The strap muscles are retracted laterally to allow dissection of the cyst and the thyroglossal duct down to the pyramidal lobe, which if present is resected, up to the level of the hyoid bone.

Muscles attached to the centre of the hyoid bone are separated and the hyoid is skeletonised out to the lesser cornu.

The hyoid is then transacted with bone-cutters medial to the lesser cornu. The hyoid, grasped with an Allis, then acts as a handle, which when gently retracted can aid dissection of the tract toward the base of the tongue.

Placing a finger transoral to palpate the tongue base and push the foramen cecum toward the operative field can facilitate this dissection although usually retraction on the body of the hyoid if properly mobilized will accomplish the same thing. This dissection passes though the central portions of the mylohyoid and geniohyoid muscles and the foramen caecum is resected. This last part is not as important as a patent connection to the foramen caecum is unlikely.

The opening in the mouth is closed with absorbable sutures and the geniohyoid and mylohoid muscles are re-approximated with absorbable sutures with superficial bites to avoid hypoglossal nerve injury.

A 10Fr Blake’s drain is placed, exiting the right side of the wound. The median raphe is re-approximated with absorbable sutures. The platysma is closed with absorbable sutures and the skin is closed with an absorbable subcuticular suture.

Question 3

Describe how you would perform an emergency fasciotomy for the leg.

Answer 3

• 2 incisions used to release 4 compartments
• Anterolateral incision:
  
  • Longitudinal incision two finger-breadths lateral to the crest of the tibia from the tibial tuberosity to the ankle
  • Incise the fascia covering Tib ant. and extend this fascial incision longitudinally.
  • Undermine the skin to reach intermuscular septum (marked by perforators in swollen leg) and release peroneus fascia
• Medial incision:
  
  • Longitudinal incision one thumb-breadth medial to medial edge tibia
  • Preserve GSV and saphenous nerve where possible
  • Incise fascia at medial tibial shelf
  • Seperate soleus from tibia thus decompressing deep compartment

Alternatively, in an emergency, removing the middle half of the fibula releases all 4 compartments.

Question 4

Describe how to perform a femoral embolectomy.

Answer 4

• Vertical longitudinal incision over the artery
• Dissect down to sheath and incise longitudinally
  
  • The femoral vein lies medially and must be protected
  • The nerve lies laterally and is a plane deeper; excessive retraction is avoided to minimise neuropraxia
• Dissect 2-4cm length of the femoral artery; pass a Lahey around it gently and sling it proximally
• Use the sling to retract and identify profunda femoris
• Dissect profunda and sling this
  
  • Take care to avoid profunda vein
• Make an arteriotomy with an 11-blade
• Extend with Pott’s scissors transversely
• Pass a 4Fr embolectomy catheter proximally; inflate and withdraw
  
  • Control the anticipated bleeding with an assistant holding the sling
• Repeat until clear
• Instil Hep-Saline and clamp proximal vessel
• Repeat procedure distally
• Fill vessels with Hep-Saline and close the arteriotomy directly with 5.0 prolene

Question 5

Describe your operative management of a ruptured abdominal aortic aneurysm

Answer 5

• Permissive hypotension is advocated for patients with a clinical diagnosis of rAAA to maintain an alert patient and systolic blood pressure >70mm Hg is acceptable.
• Immediate transfer to the operating room for patients considered to be surgical candidates
• Supine crucifix position. Skin prep onto the patient while awake. Scrub team ready prior to induction of anaesthesia.
• Maximum access midline incision.
• If actively bleeding; immediate supra-coeliac control via the lesser omentum; blunt dissection on either side of the aorta as it passes between the diaphragmatic crura.
• If haematoma not actively bleeding then obtain supra-renal control; pack the small bowel to the right, lift the transverse colon, mobilise the duodenum to the right, and retract the LRV superiorly. Bluntly dissect either side of the aorta above the renal arteries and apply clamp.
• Get distal control; clamp to distal aorta.
• Talk to anaesthetists; catch up on blood loss.
• Open aneurysm and T the top and bottom; insert self retainer and oversew lumbar back bleeders.
• Insert a Dacron/PTFE tube graft soaked in antibiotic
  
  • 3-0 Prolene double-armed round taper
  • Parachute in top-back wall; in-to-out aorta and out-to-in on graft.
  • Test proximal then sew in distal. Consider embolectomy to iliacs. Flush distally. Complete graft.
  • Notify anaesthetics of release of clamps.
• Consider laparostomy closure to prevent ACS and consider fasciotomies to lower limbs.

Question 6

Discuss your technique of above-knee amputation.

Answer 6

• Most commonly performed for failure of a BKA in the setting of ischaemia and/or diabetic foot sepsis.
• Supine position. Roll under thigh. I mark out a fish-mouth-incision with equal anterior and posterior flaps that are two thirds the diameter of the thigh.
• The corners of the flaps are at the level of the femoral amputation.
• I divide the skin and fascia with diathermy. I then divide the muscle; anterior, then medial, by dissecting with Roberts then cutting down onto the Roberts clamps.
• Anteromedially I identify the femoral artery and vein/s in the adductor canal and suture ligate then proximally tie the vessels with 1-0 prolene.
• I then free muscle and periostium off the femur circumferentially and place a large pack through the defect behind the femur. I use an oscillating saw with water for irrigation to transect the femur. Bone wax for haemostasis if needed.
• The sciatic nerve is identified between the adductor magnus and biceps femoris muscles. The nerve is placed on a gentle traction, ligated proximately with PDS with a long tail, sharply divided, and allowed to retract. The popliteal vessels may need to be taken here separately.
• The posterior muscle group is taken. I irrigate the stump and then check haemostasis. I use a finger to sweep adjacent to the sciatic nerve to make space for the nerve catheter which is placed through skin medially and laid against the nerve in the tunnel created earlier.
• The periosteal flaps are closed over the femur. I place a suction drain beneath the muscular closure. The fascia overlying the muscles is closed to envelop the distal femur.
• I close the skin with 3-0 Nylon vertical mattress sutures.

Question 7

Describe your technique for below-knee-amputation.

Answer 7

Most commonly performed amputation. Because the blood supply is much better on the posterior and medial aspects of the leg than on the anterior or anterolateral sides, transtibial amputation techniques for the ischemic limb are characterized by skin flaps that favor the posterior and medial side of the leg.

• The level of tibial transection is marked out a hands-breadth below the tibial tuberosity . Skin flaps are marked out; short (1-2cm) anterior flap with a long (1cm longer than diameter of leg) posterior flap.
• Sharp division of skin and subcutaneous tissue anteriorly to two thirds of the way down on each side. Incision then taken distally to marked point and completed posteriorly.
• I divide the anterior compartment with diathermy, down to the interosseous membrane, taking care to ligate the anterior tibial vessels.
• I then elevate the periostium of the tibia and dissect around it and pass a medium pack through the defect and transect using an oscillating saw. I divide the fibula 1cm proximal to this. I then bevel the anterior edge of the tibia.
• I then divide tibialis posterior and identify the posterior tibial artery, nerve, and vein/s. The vessels are suture ligated and the nerve is tied, divided, and allowed to retract.
• Soleus and gastrochnemius are divided distally to create a longer myocutaneous flap posteriorly.
• I wash the wound and then place a drain deep to the muscles. Myofascial closure is performed with 2-0 vicryl. The skin is closed with 3-0 Nylon vertical mattress sutures.

Question 8

Describe how you do an emergency thoracotomy.

Answer 8

1. Sharp incision in the 4th intercostal space; below nipple, parasternal to mid-axilla
2. Open chest cavity with heavy scissors
3. Insert rib-spreaders with handles downward-facing
4. Can extend across sternum to contralateral 3rd ICS
5. Don’t forget the internal thoracic artery
6. Mobilize lung by incising inferior pulmonary ligament
7. If bleeding catastrophic - twist hilum
8. Find the bleeders and stop them; optimize workspace
9. Open pericardium with a pinch anterior to phrenic nerve

Question 9

Describe how you perform an FNA of a breast lession

Answer 9

• Verbal consent
• Prepare slides and “cyto-fix” spray
• 23G needle on a 10ml syringe
• Clean the area with an alcohol swab
• Trap the lesion between index and middle finger non-dominant hand
• Warn patient and insert needle into mass
• Several passes (~5-10) whilst drawing back on syringe, should feel the needle enter/exit the lesion
• Release suction and then withdraw needle from skin
• Immediate pressure; ask patient to apply for 5 minutes
• Switch syringe to one with plunger drawn back and apply material onto pre-prepared slide
• Carefully place second slide onto first and use the parallel pull-apart technique to create two ovoid smears; apply cyto-fix to both

Question 10

How do you perform a core biopsy of a breast lesion?

Answer 10

• Verbal consent
• Prepare lab form and pot with formalin
• Use USS guidance + IR when feasible
• Ensure the patient is not on anti-coagulants
• Mark out lump, LA with 5ml of 1% lignocaine with adrenaline
• Prepare area and trolley with sterile gloves etc
• Demonstrate to the patient the sound the gun makes
• 11-blade scalpel to make skin incision
• Introduce core-biospy needle into the incision and advance towards lesion
• Fire gun; inner needle then surrounding sheath fire into mass
• Withdraw and ask assistant to scrape tissue out of groove
• Repeat until 3-5 good cores (sink to bottom) are taken from different directions
• Pressure to 5 minutes.

Question 11

Describe your technique of hook-wire localised excision of a breast lesion.

Answer 11

Wire placed day of surgery by radiology, diagrams from interventionlist noting location of lesion (depth, dimensions), distance of wire tip from skin surface, distance of wire into breast and then into lesion, where tip is in relation to lesion. Diagrams stuck onto OT wall visible to surgeon during procedure. Complete pathology forms and notify radiology when specimen is ready.

• Supine position, remove padding round wire
• Prep & drape care not to dislodge
• Mark curvilinear incision over area or periareolar if feasible
• Incise, & raise flaps with diathermy
• Identify & control wire on underside of flap
• Deliver wire back through the skin
• Littlewood to grasp wire & tissue
• WLE using wire as guidance
• Minimum of 5mm margins; sharp dissection with scissors
• Specimen should be orientated and marked
• Mark specimen with sutures & clips
  
  • Long lateral (3 clips)
  • Medial medium (2 clips)
  • Short superior (1 clip)
  • Loop anterior
  • Specimen for X-ray
• Confirm haemostasis
• Close with 3-0 monocryl
• Wake patient when X-ray confirmed

Question 12

Describe how you perform a mastectomy

Answer 12

• Patient supine, arm free draped and abducted to 80º
• Penny-Farthing incision with smaller circle medially
• Skin sharply incised and (covered) diathermy used to develop plane and flaps, which are taken down to chest wall. Retraction/elevation of flaps with Littlewoods on dermis. Retraction is key.
• Upper limit is usually 2-3cm below clavicle. Place dry pack.
• Lower limit is to the IMF, which should be preserved if reconstruction is planned. Place dry pack.
• Lateral limit is lateral edge of pectoralis major.
• Lift breast off underlying fascia
• Obtain haemostasis
• Performed axillary surgery if planned
• Two-layer closure over 1-2 closed suction drains (12Fr Blakes) using interupted 3-0 monocryl at the dermal layer and 4-0 monocryl subcuticular continuous for the skin.

Question 13

Describe how you perform sentinel node biopsy

Answer 13

• (Warn anaesthetist when injecting blue-dye)
• Pre-operative localisation with both technitium-99 and 3ml of 1% of Isosulfan Blue Dye for intra-operative localisation; inject blue dye into sub-lateral areolar complex/sub-dermis after positioning and massage for 5 min (go scrub)
• Chlorhexidine skin prep and U/square drape the arm
• Mark the maximum signal intensity detected by Gamma probe
• Incise skin 1cm infeior to hair-bearing area of axilla
• Develop skin flaps
• Incise the clavi-pectoral fascia and open the axilla
• Find the blue lymphatic; trace it to find the lymph node/s and dissect them free. Use a Babcock’s to delver the lymph node packet. If the direction of dissection is unclear then use the Gamma probe
• Check the counts; both of the node and background (which must be <10% of the SLN count)
• Obtain haemostasis and perform two layer closure with 3-0 then 4-0 monocryl

Question 14

Describe how you perform an axillary node dissection for breast cancer

Answer 14

• Supine position, arm abducted to 80º and free-draped.
• Use either the lateral portion of the mastectomy incision or use a curvilinear skin incision just below the hairline of the axilla
• Find pec major and lat dorsi
• Raise a superior flap superficial to the clavipectoral fascia
• Incise the clavipectoral fascia medially and dissect pec major and inter-pectoral packet then pec minor up towards the axillary vein; preserve medial pectoral pedicle just lateral to pec minor; dissect pec minor off the chest wall to maximise the exposure of the axillary vein and levels II and III
• Dissect LD and continue superiorly towards axillary vein
• Incise the intervening clavipecctoral fascia between medial and lateral margins then identify axillary vein running transversely; use peanut dissection to dissect vein and tributaries; all fatty tissue and lymph nodes under the vein are swept downwards
• Find thoracodoral vessels and nerve and take down the superolateral corner of the dissection where these vessels meet the axillary vein
• Trace thoracodorsal bundle inferiorly until artery branches into two/at level of angular veins draining into thoracodorsal vein
• Find subscapularis and trace it medially, tunneling bluntly in the avascular plane anterior to subscapularis, to reach the cest wall
• Find the long thoracic nerve medially and meet up with plane in front of subscapularis
• Encircle the axilla and excise it (ensure neuromuscular blockade has worn off)
• Haemostasis, 12Fr Blakes drain(s), two-layered closure with monocryl

Question 15

Describe how you would perform a Hadfield’s procedure

Answer 15

• Patient positioned supine with arm out at 80°
• Chlorhexidine skin preparation and square draping
• Periareolar incision 2/5^ths the circumference of the nipple
• The nipple complex is dissected free of surrounding fat; this is continued around the entire complex and scissors are used to bluntly find this plane behind the ductal complex as it enters the nipple
• Once circumferentially dissected an artery clamp is placed across the distal nipply complex, ensuring that no inversion of the nipple is caught
• A scalpel is used to sharply incise between the clamp and the nipple, bleeding is seen on the undersurface of the nipple.
• Once detached the nipple is retracted and a 3-5cm deep conical excision of the ductal system is excised.
• To prevent nipple retraction a purse-string sutures is placed to close the conical defect. Alternatively the nipple can be re-sited after de-epithlialisation superiorly.
• Layered closure is performed

Question 16

How do you perform single duct excision for nipple discharge/papilloma?

Answer 16

• Identify the candidate duct pre-operatively
• Supine position
• Chlorhexidine skin prep and perforated drape
• Place probe into duct
• Use a circumperiareolar incision and identify the duct with the probe within; ligate the distal aspect of the duct near the nipple and excise a conical cylinder of tissue for 3cm around duct - send for histology
• Obtain haemostasis and close with 4-0 monocryl.

Question 17

Describe your technique of superficial parotidectomy

Answer 17

• Patient positioned head up (until EJV collpases) and head turned away from side of surgery; patient lies near the surgeon’s side of the table
• Protect the auditory opening with vaseline-gauze
• Ask the anaesthetist to maintain hypotension if possible and avoid long-acting muscle relaxants
• Loupe magnification is used
• Use a sinusoidal access incision; pre-auricular to below ear-lobe then back to mastoid then down, at least 2.5cm below ramus of mandible
• Incise skin, fat, and SMAS/platysma
• Anterior and posterior flaps are developed immediately deep to SMAS and platysma respectively. Posteriorly, the greater auricular nerve is identified and protected. Anteriorly, the SMAS is lifted off parotid fascia.
• Release the posterior portion of the gland from the cartilaginous external auditory canal; use Kelly’s retractor for retraction of gland. Create plane with artery forceps and use bipolar for haemostasis.
• Fibres of posterior belly digastric should be visible, dissect this belly.
• The parotid remains attached posteriorly by a thick band of Lore’s fascia containing the artery of the stylomastoid foramen and the accompanying venous plexus. These structures will need to be carefully divided to identify the 3 principal landmarks to the facial nerve:
  1. The triangular process of the external auditory canal cartilage “tragal pointer”
     
     • Nerve 5-10mm deep and inferior
  2. The posterior belly of the digastric muscle
     
     • Nerve ~10mm superior and medial to PBD origin
  3. The tympanomastoid suture.
     
     • Nerve foramen is 10mm inferior to this
• Once nerve is identified; A McCabe facial nerve dissector is used to lift tissue off the nerve and its branches and the bridges between divided with bipolar. Watch for the retromandibular vein tributaries which have a variable relationship within the gland. The gland is reflected forward in this manner; maintain a broad front
• Anteriorly, the nerve dives away over masseter and the superficial layer may be divided with impunity from the anterior border, always checking the back edge of the gland for the plane of dissection.
• In this way, the parotid duct will be pedicled and this is ligated with an absorbable suture.
• Haemostasis is obtained with blood pressure normalised
• A 12Fr closed suction drain is placed parallel to PBD and the wound is closed in layers.

Question 18

Describe how you perform a thyroidectomy

Answer 18

• Patient supine, 1000ml saline bag between scapulae, head on head-ring, table 10° head up and head extended with chin outward pointing
• Skin crease incision marked, usually two finger-breadths above jugular notch in a skin crease, as wide as needed
• Local anaesthetic infiltrated, save some for SCM block
• Knife through skin, protected tip diathermy to divide fat and platysma.
• Superior sub-platysmal flap raised to thyroid cartilage, inferior flap to sternal notch. Two Joll’s retractors placed
• Divide the midline raphe with diathermy to thyroid capsule for the length of the wound
• Use Allis clamps then Kelly’s retractors to lift strap muscles and establish the plane on the capsule of the thyroid gland. Dissect and ligate the middle thyroid vein. Get beyond the equator of the lobe so the carotid sheath structures are identified
• Dissect the upper pole; start medially and establish the plane between medial surface of thyroid and underlying cricothyroid. Use a Dietrich right angle to dissect on lobe and take the vessels with a ligasure
• Look for ESLN on the superior lobe; 50% are Cernea IIa, relatively more are IIb if Goitre is large
• Once the upper lobe has been summited, reflect forward and start to look for para IV on the back of the lobe, preserve this and its blood supply
• Move to inferior pole and mobilise in a similar manner, be aware that para III is more variable.
• Switch sides to dissect around RLN; have the assistant retract the thyroid anteromedially gently with a gauze; use Dietrich right angle to part tissues and identify nerve in T-O groove. Once found, part the tissue superfical to it.
• With the nerve in view, continue mobilising thyroid off the trachea to the midline. Place surgicel and swab and move to other side
• Check all parathyroids
• Check haemostasis with Valsalva, close midline raphe, place local in SCM fascia under vision
• Close wound in layers with monocryl
• Check calcium and PTH 6 hours after surgery

Question 19

How do you prepare for total thyroidectomy for a large MNG?

Answer 19

• Risks of bleeding, damage to nerves, and damage to parathyroids are higher; discuss with with patient
• Obtain cross sectional imaging to assess degree of retrosternal extension and relationship to brachiocephalic veins etc.
• If massive, enlist the help of a senior surgeon and/or cardiothoracic services; have a sternotomy kit available in theatre.
• Most large goitres will be delivered with blunt dissection and finger retraction if the equator is above the thoracic inlet.

Question 20

What are some key points to note during 4-gland exploration for parathyroid adenomata?

Answer 20

• ~85% of the population have 4 glands
• ~13% have 5 glands
• ~3% have 3 glands
• The capsule of the parathyroids moves independently of the thyroid capsule and they are -burnt-butter in colour.
• Always check Calcium and PTH post op and twice daily when abnormal

Parathyroid IV / Superior Parathyroid

• In >80% of patients they are located above and lateral to the intersection of the RLN and ITA
• In ~15% of patients they are behind the superior pole

Parathyroid III / Inferior Parathyroid

• In 45% of patients they are behind the inferior pole
• In 25% of patients they are in the thyrothymic ligament
• In 17% they are anterolateral to the inferior pole of the thyroid
• In 6% they are just below and lateral to the intersection of ITA and RLN

Question 21

Describe minimal access parathyroidectomy

Answer 21

• Pre-localisation is mandatory
• A small laterally based incision is made and platysma divided
• A tissue plane is created between strap muscles and the SCM
• Omohyoid may require division for better exposure
• The gland is identified and capsular excision performed.

Question 22

Describe how a laparoscopic left adrenalectomy is performed

Answer 22

• Position the patient on a beanbag in the lateral decubitus position and flex the table to widen the space between hypochondrium and iliac crest
• Three 10mm ports are used; the first port is placed in the MCL and is used for the camera, the other 2 ports are spaced on either side of the camera port. Occasionally a 4th port is used to retract the spleen and colon.
• Perform a diagnostic laparoscopy
• Mobilise the splenic flexure of the colon so it drops medially. Mobilise the splenophrenic and spleno-renal ligaments so that the spleen falls medially. Identify the inferior phrenic vein.
• Open Gerota’s fascia over the superior pole of the left kidney and continue this up towards the diaphragm; the adrenal should come into view
• Dissect the gland off the superior pole of the kidney laterally and continue this inferiorly and then medially where the renal vein enters the hilum; identify the adrenal vein and dissect it
• Secure the adrenal vein with a vascular stapler and transect it
• Dissect the adrenal off the posterior abdominal wall and place into an endocatch bag
• Obtain haemostasis then close in layers.

Question 23

Describe how to perform a laparoscopic right adrenalectomy

Answer 23

• Position the patient on a beanbag in the lateral decubitus position and flex the table to widen the space between hypochondrium and iliac crest
• Four 10mm ports are used; the most medial port is just lateral to the xiphoid, the most lateral port is in the MAL between the 12th rib and iliac crest; the first port placed is the one 2nd from the midline, via an open approach.
• Perform a diagnostic laparoscopy
• Use a fan retractor through the sub-xiphoid port to retract the liver medially
• Divide the right triangular ligament with a Harmonic scalpel and continue this superiorly; be wary of the right hepatic vein
• Incise Gerota’s over the superior pole of the kidney and extent this up towards the peritoneal reflection of the liver, divide the underlying fat and retract laterally
• Identify the renal vein inferiorly and the IVC medially, using the Harmonic, dissect the fat off the IVC inferior to superior, identifying the right adrenal vein
• Dissect this clearly and secure it with a vascular stapler
• Use the lateral stump to retract and peel the adrenal off the posterior abdominal wall laterally; watch out for the adrenal arteries in this tissue
• Inferiorly, identify the superior renal pole and retract the adrenal superiorly and dissect; again watch for arteries
• Free the adrenal and place into an endocatch bag and remove. Obtain haemostasis. Layered closure.

Question 24

Describe how to perform an open adrenalectomy

Answer 24

• Supine position with a break in the table to widen the distance between hypochondrium and iliac crests
• Extended subcostal incision crossing the midline
• Omnitract retractor then exploratory laparotomy
• I expose the left adrenal by dividing the left lienorenal and lienocolic ligaments and retracting the splenic flexure downwards and spleen and pancreas medially
• I expose the right adrenal by retracting the hepatic flexure of the colon downwards and performing a Kocher’s manoeuvre to mobilise the duodenum. I then divide the right triangular ligament and retract the liver medially exposing its bare area. This provides access to the IVC for proximal and distal slings in cases involving a large tumour.
• The adrenal veins are secured and the gland is resected from its bed and sent for histology.
• Haemostasis is obtained and layered closure is performed.

Question 25

Describe the steps involved in retroperitoneoscopic adrenalectomy

Answer 25

• The patient is placed in the prone jack-knife position
• An open cut-down technique is used for a 12mm port at the tip of the 12th rib; a finger is used to develop the space
• A balloon port is placed and high pressure is used to develop the space (20mmHg CO₂)
• A 12mm port is placed at the mid-portion of the 12th rib (which requires some angulation) and a 5mm port is placed at the tip of the 11th rib
• After the space is developed; the plane just above the kidney is developed; allowing the kidney to drop and the adrenal remains suspended; further dissection here finds the adrenal vein, which is taken with a stapler.
• The upper and lateral attachments of the adrenal are then taken and it is removed in an endocatch bag.

Question 26

Describe how you perform a postero-lateral thoracotomy for a perforated oesophagus

What if you need access to the abdomen?

Answer 26

• A double lumen endotracheal tube is used for these operations whenever possible.
• The patient is positioned and secured in the lateral decubitus with arms in the prayer position and the table is broken to maximise access.
• I place a pillow under the contralateral axilla and a pillow between the legs with the patient strapped to the table.
• I base my incision on the 5th intercostal space, passing through a point 2cm below the inferior spine of the scapula. This can be continued anteriorly and into an upper midline laparotomy incision if needed.
• The muscular layers are divided with diathermy and the top of the 6th rib is scored with diathermy. I ask the anaesthetist to exclusively ventilate the contralateral lung and then enter the pleural cavity sharply and extend this incision for the length of the wound. If the space is tight, I resect the proximal posterior 1cm segment of the 6th rib with rib cutters.
• Finochietto retractors are placed and opened in intervals. Washout and identification of the injury is performed with warmed saline.
• The oesophageal injury is explored, debrided, and extended to ensure the whole injury is seen. I repair this in two layers, and cover the repair with a local tissue flap. If the wound edges cannot be brought together I repair the injury over a wide bore T-tube and bring this out through the chest wall.
• The other side is assessed via the anterior mediastinum and washed out. Haemostasis is secured. I leave 2 x 28Fr chest tubes each side after washout is clear with a Jackson Pratt drain adjacent to the anastamosis. I close the chest in layers and use staples for skin. I discuss the disposition of the patient with the anaesthetic and ICU teams.

This incision may be extened to the upper abdomen and umbilicus for access to the abdomen:

• The subcostal margin has to be divided to link the two incisions
• The diaphragm is divided at its periphery where it attaches to the chest wall until the crus is encountered, this is spared.

Question 27

Describe your operative management of haemorrhoids

Answer 27

• Firstly, exclude SCC of the anus, Crohn’s, and portal hypertension
• Counsel the patient about the risks and post-operative course
• Prepare the patient with 3 days of lactulose prior to surgery and a fleet enema on the day
• Lithotomy position with a headlight
• Diagnostic and planning ano-proctoscopy
• Use a Fansler retractor (or Eisenhammer) for retraction - infiltrate local submucosally
• Address the 3 o’clock haemorroid first
• Grasp the most dependent portion with a Babcock’s and have the assistant retract inferomedially
• Incise the distal-most base of the cushion and create a tear-drop shaped sub-mucosal plane, identifying the sphincter below (transverse white fibres)
• Continue until a (false) pedicle is created and tie this with a vicryl suture; keep the end long for inspection
• Repeat with the other two haemorroids; maintain the mucocutaneous bridges
• Lay an algisite ribbon in the anal canal
• Discharge with stool softeners and metronidazole.

Question 28

Describe how you perform a lateral sphincterotomy

Answer 28

• Lithotomy position with headlight
• Iodine skin prep
• Ano-proctoscopy
• Parks retractor for exposure
• Identify the inter-spincteric groove and make a radial mucosal incision
• Dissect the lower part of the internal anal sphincter free of mucosa and external sphincter and deliver into wound with mosquito forceps
• The proximal extent of the dissection is tailored to the height of the fissure but is never above the dentate line
• Diathermy is used to divide the sphincter muscles under vision
• Apply pressure on the area for 2 minutes and apply a pad for a dressing.
• Discharge with bulk laxatives.

Question 29

Describe the principles and steps of a laparoscopic Heller’s myotomy

Answer 29

The key to a successful Heller’s myotomy is complete muscular division over the affected area of achalasia with confirmation of healthy epithelium intra-operatively.

• The patient is in the split-legs position with the primary monitor at the patient’s left shoulder. The surgeon stands between the patient’s legs following access.
• 5 ports are used; a supra-umbilical 10mm camera port with 4 ports spaced across both hypochondria with a bias to the patient’s left. The right central port is 10mm, the others are 5mm.
• The liver is retracted via the right hypochondrial port and the hiatus is dissected taking care to preserve the vagi.
• Adequate mobilisation of the esophagus before myotomy is begun with mobilisation of the gastric fat pad.
• Scissors on diathermy are used to dissect, elevate, and then divide the longitudinal then circular muscle fibres. As the myotomy extends the edges can be grasped for better exposure. Hook diathermy is used to complete the myotomy on the stomach distally for 3cm. The esophageal dissection is continued proximally for 5-6cm.
• An oesophagoscopy is performed to ensure there is no epithelial injury.
• An anterior wrap (Dor) is used by many surgeons at this point. This is sutured in place with interupted 2-0 Ethibond. A final inspection is performed and the ports are retrieved under vision. The fascia is closed at the 10mm ports and the skin is closed with monocryl.

Question 30

How do you repair a strangulated femoral hernia?

Answer 30

1. Simultaneous assessment and resuscitation of the patient in the emergency room
   
   • History of presenting complaint, surgical and medical history, functional and social history
   • Analgesia, oxygen, supine position with some head-down tilt
2. Establish whether this is a reducible, irreducible, or strangulated hernia
3. If strangulated; requires immediate OT
   
   • Modified McEvedy approach:
   • Transverse skin incision on ipsilateral side above tubercle 3 finger breadths above tubercle
   • Vertical incision in lateral rectus; medial retraction of rectus muscle, Need to divide transversalis fascia, laparotomy through peritoneum
   • Deliver small bowel; combination of internal retraction, external pressure, extra-peritoneal dissection
   • Assess for viability; wrap in warm pack and repair hernia
   • Closure in the A-P plane of femoral ring with 3 interrupted 3-0 non-absorbable sutures
   • Re-assess the bowel; resect or repair
   • Layered closure; anterior rectus then Scarpa’s then skin.
4. Return to ward or HDU depending on physiology

Question 31

Describe how you create a feeding jejunostomy

Answer 31

1. Open approach; small midline incision
2. Identify DJ flexure; select jejunum ~30cm distal with good mobility to abdominal wall
3. Insert 3-0 PDS purse-string suture; clip to ends
4. Create a trephine for the MIC (Kimberly-Clark) jejunostomy and bring the tube through into abdomen
5. Create the enterotomy and feed jejunostomy tube into lumen; close purse-string
6. Make a “Witzel tunnel”, seromuscular bites for 4cm to align tube parallel to lumen; care not to excessively narrow lumen
7. 4 point fixation at anterior abdominal wall; most difficult to reach area first, leave sutures clipped and then tie
8. Fix the bowel to the anterior abdominal wall 10cm proximal and 10cm distal to avoid torsion
9. Close

Question 32

How is “on-table colonic lavage” performed?

Answer 32

1. Mobilise large colon; bring down splenic flexure
2. Excise tumour with oncological resection
3. Transect appendix at half-way and insert 12-14Fr Foley into caecum and inflate balloon
4. Vicryl tie to secure Foley
5. Place additional side square drape
6. Exteriorise bowel and place end into sterile camera-drape and secure with artery forceps; place distal end of camera drape into bucket on floor
7. Lavage with 6-8L of warmed normal saline
8. By now, any devascularised bowel will have demarcated; resect as required and anastomose.

Question 33

Describe your surgical repair of pilonidal sinus disease

Answer 33

• I use a Bascom cleft lift procedure
• The patient is in the prone jack-knife position
• Lines of safety are drawn with the buttocks pushed together
• The buttocks are then splayed with sleek-tape
• Local anaesthetic with adrenaline is injected
• A scimitar shape is drawn out
  
  • The key is to have the lower apex of the scimitar point in a radial fashion to the anus at least a few cm away and move out towards the line of safety
• I use the diathermy on cut to excise the medial skin edge and then undermine the flap
  
  • The key is to make the flap the same width as a mastectomy flap; develop this with diathermy and use skin hooks to lift
  • The apex near the anus must be left a little thicker, I am careful not to damage the sphincter
• Once the flap is raised, I then re-check the lateralisation of the flap and proceed with the remaining skin incision and remove the skin island
• The underlying granulomatous tissue is debrided and scored to release any scars
• The flap is then smeared across and secured with 2 layers of interrupted 2-0 Vicryl sutures over a vascular sling (Bascom himself uses this)
• The skin is closed in an continuous manner using 3-0 monocryl

Question 34

What are the surgical options for pilonidal sinus disease?

What is the evidence?

Answer 34

• The 3 most studies surgical options are:
  
  • The Karydakis flap
  • The Bascom cleft lift procedure
  • The Limberg (rhomboid) flap
• No single operative intervention has been proven superior to another in overall healing, time away from work, or recurrence
• A 2019 systematic review of the existing pilonidal disease literature has revealed a definitive recent trend towards less invasive management, with unacceptably high failure rates seen after traditional wide excision

Question 35

Describe your repair of a Zenker’s diverticulum.

What are the other options?

Answer 35

• I would use an open approach; the patient is supine with a head ring in place and a saline bag between the shoulder blades, the head is turned slightly to the right and the table is tilted to drain the EJV. Place an oro-gastric tube to allow identification of the esophagus.
• I use an anterior SCM incision from the hyoid to 5cm above the SC joint. I incise through skin, fat, and platysma and ligate the EJV if needed
• The exposure needed comes from dissecting the space between the carotid sheath and the visceral column in the midline, three structures cross this space and two of them require routine division; the omohyoid and the middle thyroid vein (+ ITA)
• Exposing the collapsed pouch requires medial retraction of the trachea and oesophagus; the neck of the sack lies at the level of the cricoid cartilage
• The RLN lies in the tracheo-oesophageal groove and I am careful to preserve this. Other nerves at risk is the hypogloassal nerve superiorly.
• The key manoeuvre is division of the cricopharyngeus muscle; I open the sack, insert a right angle into the muscular band and divide it, preserving the mucosa
• I use a 55mm stapler to excise the diverticulum and then insert a small closed-suction drain
• I close the wound in layers with absorbable sutures

The mainstay of treatment of symptomatic Zenker’s diverticula has been surgery. However, nonsurgical minimally invasive methods are being used increasingly. Rigid endoscopy with endoscopic cricopharyngeal division gives excellent results. POEM is also being developed.

Structures to take care of;

RLN

External laryngeal nerve

Descending hypoglossal nerve

Cervical cutaneous nerve

Question 36

Describe the technical considerations when operating on the oesophagus

Answer 36

• The oesophagus lacks a serosal coat except for its short intramuscular portion; serosa forms adhesions readily and is sometimes capable of sealing small leaks; the oesophagus is not privy to this.
• The outer longitudinal muscular coat does not hold sutures well and when it contracts it significantly shortens the oesophagus. This means that anastomoses must be tension free at completion.
• The circular layer when contracted makes the oesophagus appear very narrow, do not anastomose under these conditions as gaps may be left, use stay-sutures or a Foley to improve spacing of anastomotic sutures.

Question 37

What are the options available for oesophageal anastomosis?

Answer 37

• Single layer 3-0 PDS sutures forming an interupted oesophago-jejunal or oesophago-gastric end-to-side anastomosis; use three back wall sutures initially with long ends on clips and then use interupted sutures to close the back wall with the sutures tied on the inside of the lumen. Close the front wall with the sutures on the outside over an NG/NJ tube.
• End-to-side stapled circular anastomosis using a 25mm EEA stapler; insert the anvil into the oesophagus and secure with a purse-string using 2-0 Prolene. Create a temporary gastrotomy or enterotomy and insert the gun and pin of the EEA stapler; trephine the pin out of the lumen at least 2cm from any staple line and then join the pin and anvil. Close the gun and fire and then slowly release and withdraw. Check the donuts. Test the join.

Question 38

Describe an Ivor-Lewis Oesophagectomy

Answer 38

• Performed for distal oesophageal or GOJ tumours
• Combined upper abdominal approach and then right posterolateral thoracotomy; requires double lumen ETT
• Exposure:
  
  • Upper midline incision; diagnostic laparotomy
  • Gray’s retractor, mobilise and retract left liver
• Mobilisation:
  
  • Mobilise the oesophagus at the hiatus circumferentially; divide the vagi and dissect to the left until the cephaled short gastric is encountered
  • Divide the short gastrics and then mobilise the greater curvature outside the gastroepiploic arcade.
  • Lift the stomach anteriorly and divide the coronary vein and left gastric artery.
  • The right gastric artery is divided 3cm from the pylorus and a series of TLC 100 staple lines are fired to create the conduit.
  • Kocherise the duodenum so that the pancreaticoduodenal complex is mobilised cephaled.
  • Perform a pyloromyotomy
  • Ligate the commencement of the thoracic duct
• Lymphadenectomy
  
  • A two-field lymphadenectomy should be performed in an Ivor-Lewis; this varies from centre to centre.
• Closure of the abdomen
  
  • A feeding jejunostomy may be brought up
  • Re-check mobility of conduit and then close the abdomen with 2-0 PDS small bites
• Exposure
  
  • The patient is re-positioned in the right lateral with table break and a gutter for the arm
  • An incision is marked from the spine of the scapula along the 5th ICS anteriorly and up towards to the midline as high as T4 posteriorly.
  • The right chest is opened in the 5th intercostal space; the 6th rib can be taken at the posterior margin to improve access
  • The right lung is deflated and 2 Finochietto retractors are placed and slowly opened
• Mobilisation
  
  • The inferior pulmonary ligament is divided
  • The mediastinal pleura is divided, the Azygous vein is dissected and tied in continuity prior to dividing
  • The oesophagus is mobilised circumferentially down to the hiatus to meet with the previous dissection
  • Thoracic lymphadenectomy is variably practised
• Anastomosis
  
  • The 25mm anvil is introduced into the oesophagus and secured with a 2-0 Prolene purse-string.
  • A temporary gastrotomy is made, the gun introduced per gastrum, and the pin fired through the neo-fundus 2cm away from the staple line
  • The EEA gun is stapled and then fired and removed with a check of the donuts.
  • The gastrotomy is closed and a leak test is performed and an NG tube is placed.
• Closure:
  
  • A J-P drain is placed next to the anastomosis and two 28Fr chest tubes are placed on UWSD
  • The ribs are re-approximated with Z-sutures of 2-0 PDS avoiding the intercostal nerve bundles
  • The muscular layers are closed continuously and the skin is closed with clips.
• Post op
  
  • A water-soluble contrast study is performed on POD-5 and feeding slowly re-introduced if there is no leak.

Question 39

Describe the principles and steps involved in anti-reflux surgery

Answer 39

• The principles of anti-reflux surgery are:
  
  1. To re-establish a length of intra-abdominal oesophagus
  2. Appropriate crural closure
  3. Maintaining the LES within the abdomen
  4. Re-establishing the angle of His
• A 2018 network meta-analysis by Ahmer et al demonstrated that a posterior partial fundoplication provides the best balance of long‐term, durable reflux control with less dysphagia.

7 steps as per Alfred course

Esophageal exposure and mobilisation - caution of aberrant left hepatic artery

Crural delineation, maintaining the epimysium on the crura

Sling esophagus left, ensuring there is adequate intraabdominal esophagus (4cm). Protect the left vagus nerve.

Short gastric mobilisation - lower layers plus posterior gastric artery

Crural repair - tension free with figure of 8 heavy ethibond suture

Fundoplication - partial

• Access:
  
  • Laparoscopic procedure in the supine position with the legs split and secured; surgeon stands between the legs
  • 5 ports are used; a 10mm supra-umbilical port, a 5mm Nathanson port in the epigastrium, two 5mm ports in the MCL below the ribs and a further 10mm port in between the central port and the LUQ port.
• Exposure:
  
  • The liver is retracted with the Nathanson port
  • Divide the lesser omentum close to the hiatus with a Harmonic instrument; identify the right crus
  • Continue the dissection over the arch of the crus towards the left crura; preserve the anterior vagus
  • Dissect between the two crura and preserve the posterior vagus
  • Place a penrose drain for retraction of the distal oesophagus
• Cruroplasty:
  
  • Use 3 interupted, figure-of-8, 2-0 Ethibond sutures for the posterior cruroplasty
• Wrap:
  
  • Divide the short gastrics for more mobility
  • Draw the wrap from the left to the right through the window and shoe-shine to ensure the wrap is loose
  • Use 3 interupted Ethibond sutures to secure the wrap anteriorly; to the fundus if Nissen or to the anterior stomach if a Toupet is being performed
• Closure:
  
  • Note the placement of the NG tube at the end of the case
  • Remove ports under vision and close skin

Question 40

Describe the principles and steps involved in surgical repair of achalasia

Answer 40

• Laparoscopic Heller’s myotomy is the gold standard, however POEM may be reaching equivalence with a meta-analysis of over 7000 patients suggesting improved rates of dyphagia repair albeit with higher rates of reflux for POEM.
• Access:
  
  • Laparoscopic approach with patient supine; legs split and secured
  • 5 ports are used; 10mm supra-umbilcal port, 5mm Nathanson port, two 5mm working ports in the MCLs and a further 10mm port in between the supra-umbilical port and the LUQ port.
• Exposure:
  
  • Retract the liver with the Nathanson
  • Divide the lesser omentum, be aware of accessory left hepatic and the hepatic branch of the vagus; preserve both
  • Dissect the right crus enough to expose the anterior vagus; preserve this
  • Divide the anterior fat pad of the cardia; this is often tricky
• Myotomy:
  
  • Use Maryland’s to divide the muscle of the oesophagus and continue the myotomy for a 3-5cm length, extending to 1cm onto the stomach.
  • Check the myotomy with an on-table endoscopy
• Wrap:
  
  • Suture an anterior wrap across the myotomy.
• Closure:
  
  • Remove the instruments and close the skin.

Question 41

Describe the surgical interventions available for variceal disease and haemorrhage

Answer 41

• TIPS has largely superceded surgical treatment due to the lower complication rate of TIPS
• Emergency shunt surgery is extremely effective in arresting hemorrhage and preventing rebleeding, but it is associated with up to a 50 percent mortality rate

Variceal surgical options are divided into selective and non-selective procedures:

• Nonselective:
  
  • Those that decompress the entire portal tree and divert all flow away from the portal system, such as portacaval shunts.
• Selective:
  
  • Those that compartmentalize the portal tree into a decompressed variceal system while maintaining sinusoidal perfusion via a hypertensive superior mesenteric-portal compartment, such as a distal splenorenal shunt.
• Nonshunt operations:
  
  • Generally include either esophageal transection (in which the distal esophagus is transected and then stapled back together after varices have been ligated) or devascularization of the gastroesophageal junction (Sugiura procedure).

Question 42

How do you arrange PEG placement?

Answer 42

• I use a Cook Pull PEG system
• Endoscopic and percutaneous technique with sedation and LA
• I insufflate the stomach and place a needle through the abdominal wall where the PEG is to be sited
• A guide wire is passed through this, which is snared and brought out via the mouth,
• I then attach the loop end of the guidewire to the loop of the pull-through PEG and lubricate the PEG, especially the inner cuff/flange
• This is delivered into the stomach and out of the PEG site
• The scope is reinserted to ensure the bulb is sitting flush compressing the wall of the stomach to the anterior abdominal wall.
• The exterior flange is snugged down and a dressing is placed.

Question 43

Describe your operative management of a perforated peptic ulcer.

What if it is a gastric ulcer?

What if it cannot be patched?

Answer 43

• Pre-operative preparation:
  
  • NG tube, IDC, consent with family present
  • Broad spectrum antibiotics and PPI
  • GA, supine position
• Access:
  
  • Upper midline incision from patient’s left side
  • Have assistant control contamination and perform preliminary lavage with aspiration of the fluid for M/C/S
  • Check for other ulcers
• Patch repair:
  
  • Use a nearby tongue of omentum
  • Place 3 interrupted 3-0 PDS sutures either side of the ulcer and lay the omentum tongue between them
  • Tie gently so as not to cause ischaemia of the omental patch
• If gastric:
  
  • Biopsy the ulcer with sharp scissor dissection and Debakey forceps
  • Omental patch
• If patch unavailable:
  
  • Use falciform ligament or serosal patch
  • If too large then consider:
    
    • Help from UGI colleague
    • Distal gastrectomy
    • Gastrojejunal bypass and Nissen closure of the duodenal stump. - see notes of difficult duodenal stump closure
• Closure:
  
  • Lavage with 6-8L of warmed saline
  • Place drains and ensure NG is properly located in the stomach
  • Close with loop-0 PDS and staples

Question 44

How do you do a distal gastrectomy?

Answer 44

• The aim of this operation, in the acute setting, is to remove the antrum of the stomach and restore continuity to the GI tract. Marked edema or scarring in the region of the pylorus, pancreas and hepatoduodenal ligaments is a relative contraindiation to gastrectomy.
• Access:
  
  • Good assisstants and good lighting (headlight)
  • Upper midline incision and Gray retractor
  • Retract liver with pack and fish-slice retractor
• Mobilise:
  
  • Enter lesser sac through gastro-colic ligament
  • Mobilise the greater curvature inside the gastroepiploic arcade from the mid-point of the greater curvature to the first part of the duodenum
  • Incise the lesser omentum and clear any posterior adhesion in the lesser sac
  • Identify and ligate the right gastric artery or gastroduodenal pedicle behind D1
• Resection:
  
  • Use a TA stapler to transect the first part of the duodenum - oversew with 3-0 PDS
  • Use a TA stapler to transect the stomach from the incisure to the mid-point of the greater curvature - oversew wiith 3-0 PDS
• Lavage the abdomen and check haemostasis
• Reconstruction:
  
  • Side to side gastrojejunostomy:
    
    • Bring up a loop of jejunum 30cm distal to DJ
    • Continuous back-wall suture with 3-0 PDS left long; place packs around site of join
    • Incise a 5cm gastrotomy and jejunostomy
    • Use a double armed 3-0 PDS at the mid-point of the join and sew a continous seromuscular sutures around to the front wall from either side; complete in the middle
    • Continue the back-wall suture as a front wall suture
    • Check the position of the NG tube and perform a leak test
• Place a J-P drain adjacent to the anastomosis and place a duodenal T-tube exiting far laterally
• Closure:
  
  • Loop-0 PDS to fascia and staples to skin.

Question 45

Describe the principles and steps involved in a oncologic gastrectomy

Answer 45

• Consider sub-total only if 5-10cm margins may be achieved
• D2 lymphadenectomy without splenectomy is the current standard of care in most large western centres
• Access:
  
  • GA, supine position, upper midline incision, Thompson retractor, experienced assistants and good headlight
  • Perform a diagnostic laparotomy
• Exposure:
  
  • Mobilise left triangular ligament
  • Mobilise the entire greater omentum off the transverse colon and mesocolon; lift the stomach up and anteriorly
  • Ligate the right gastroepiploic artery and vein behind D1
  • Kocherise the duodenum to expose the IVC, left renal vein, and aorta
• Dissection:
  
  • Lymph node stations 5 & 6 are taken around the pylorus
  • Dissection continues towards stations 7, 8, & 9 around the CHA and coeliac axis
  • Stations 1, 2, 3, and 4 are taken with subsequent mobilisation of the crus and greater curvature of the stomach
  • Finally, stations 10, 11, and sometimes 12 are taken along the splenic artery towards the CHA branches.
• Resection:
  
  • The duodenum and proximal stomach/oesophagus are divided and the specimen is sent
• Reconstruction:
  
  • For subtotal; a R-E-Y is performed with a side-to-side gastrojejunostomy and distal jejuno-jejunostomy
  • For a total gastrectomy and end to side oesophago-jejunal anastomosis is performed after stay sutures are placed in the distal oesophagus
• Closure:
  
  • Drains are placed adjacent to the anastomosis
  • Washout and closure with loop-0 PDS and staples.

Question 46

Describe the methods available for management of the difficult duodenal stump

Answer 46

Always consider a T-tube duodenostomy exiting laterally to reduce the chance of stump-blow-out

1. Gently pinch off the duodenum distal to the ulcer and secure with a stapler and oversew with 3-0 PDS with the aforementioned T-tube
2. Nissen closure: seromuscular bites of the anterior duodenum taken down onto the distal lip of the ulcer thereby shutting off the lumen. This is reinforced with a second layer of interrupted sutures from the anterior duodenum to the proximal ulcer crater. Kocherisation is mandatory for this.
3. Closure around a large bore catheter or chest tube with external drainage

Question 47

Outline your approach to liver trauma

Answer 47

1. Get temporary control
   
   1. Pack the liver
      
      • Re-approximate the anatomy of the liver by enforcing tissue vectors with packs
   2. Manual compression
      
      • Have an assistant manually compress the liver back into conformation
   3. Pringle manoeuvre
      
      • Use this for arterial bleeding and to provide in-flow control
      • Poke a hole in the avascular lesser omentum and sling a Rummel tourniquet around the portal triad
2. Use adjuncts to haemostasis
   
   • Packs soaked in adrenaline and tranexamic acid
   • Floseal and Tisseel
   • TachoSil sponge or NuKnit with further packs
3. Get the patient to angio-embolisation

Question 48

How do you do a TEP repair for inguinal hernia?

Answer 48

• Supine position, both arms tucked
• Transverse infraumbillical incision on side of pathology, just off-centre ~2-3cm, S-shaped retractors in wound
• Dissect down to anterior rectus sheath, incise transversely 15mm, use the S-shaped retractor to retract rectus laterally; check the yellow fat pad medially
• Use a finger then the balloon to develop the pre-peritoneal space, 25 pumps on the balloon under vision
• Place a stay suture in the fascia, insert the Hasson, insufflate the space
• Place two 5mm ports through the midline between Hasson and pubic symphysis
• Find the pubis, sweep space below it to see bone
• Develop the space below the inferior epigastric pedicle and out laterally
• If direct:
  
  • Reduce the hernia and dissect the peritoneum to the bottom of the field of view
• If indirect:
  
  • Dissect from the top of the chord and laterally and isolate the sac, identify the vessels and eventually the vas
• Insert a Progrip® mesh and cover the myopectineal orifice ensuring 2cm of medial overlap and definite flat mesh beneath the inferior edge of the peritoneum.
• Release the gas under vision, close.

Question 49

How do you do a TAPP repair for inguinal hernias?

Answer 49

• Supine position, ensure bladder empty, both arms in
• Transumbilical Hasson port under vision
• Some Trendeleberg may help reduce the contents of the hernia
• Three 5mm ports; 2 in the midline between symphpysis and Hasson and one on the side of pathology in line with umbilicus
• Confirm the diagnosis; reduce the hernia if needed
• Make a transverse incision above the upper border of the defect and develop the pre-peritoneal space with blunt dissection
  
  • Preserve the inferior epigastrics
  • Create enough space laterally for the mesh without damaging the LFCN or FN
  • Create a pre-vesical space behind the pubis
• Reduce the hernia
• I use a Progrip® 10x15cm mesh with rounded edges to place into the bed of the repair
• I do not tack or cover this (covered) mesh
• Release the insufflation and close the wounds.

Question 50

How do you repair a femoral hernia in the elective setting?

Answer 50

• I use a low approach; GA, supine position, arms out
• I make a skin crease incision over the palpable hernia or below the medial half of the inguinal ligament
• I dissect onto the sac going through the following layers:
  
  • Skin
  • Subcutaneous tissue and fat
  • Cribriform fascia
  • Transversalis fascia
  • Pre-peritoneal fat
  • Peritoneum
• Dissect the hernia free, taking care not to injure the femoral vein laterally; invert into abdominopelvic cavity or tie of if irredicible. Open it and reduce the contents. If not possible, divide medial aspect of the hernia sac. (Noting rare presence of aberrant obturator artery)
• I use three interupted sutures to close the defect:
  
  • Kelly’s on the vein retracting laterally
  • Ethilon 2-0 Prolene on an SH2 needle
  • Inguinal ligament first then pectineal
  • Place all three sutures first then tie
  • Check that vein has room to engorge, leave 4-6mm
• Close in layers

If there was excessive tension on the inguinal ligament, a mesh plug could be inserted. Polypropylene cut 10-12cm by 2cm, rolled into a cigarette shape (2cm long) and placed in to the defect. 2.0 prolene used through inguinal ligament, mesh and pectineal line.

Question 51

What are the principles of component separation for incisional hernia repair?

Answer 51

Ramirez described component separation in the 1990s

• Step 1
  
  • Dissect the subcutaneous fat and skin off the external oblique aponeurosis for 5cm lateral to the rectus sheath
• Step 2
  
  • Divide the anterior rectus sheath at its most medial anterior aspect and develop the retrorectus space
• Step 3
  
  • Divide the lateral external oblique aponeurosis 1-2cm lateral to the lateral border of the rectus muscle, continue this incision for the entire length of the muscle
  • This provides 3-5cm in the upper abdomen, 7-10cm in the mid-abdomen, and 1-3cm in the lower abdomen.

Question 52

Describe your repair of a <5cm umbilical hernia

Answer 52

• Laparoscopic approach; GA, supine, arms in
• Verus needle to Palmer’s point
• 12mm optiport entry to Palmer’s point
• Two 5mm ports to left flank as far lateral as possible
• Diagnostic laparoscopy, identify hernia
• Sharp adhesiolysis, blunt reduction of hernia
• Sweep omentum over bowel
• Mobilise the falciform ligament to clear space for the mesh, mobilise the median and medial umbilical ligaments if fatty
• For a 5cm hernia use a 15cm mesh
• Circumferential ReliaTack™ inner and out crowns
• 4 interupted 3-0 PDS transfacial sutures placed using the Trochar Closure Device via a stab skin incision
• Haemostasis check, ports out under vision, close.

Question 53

How do you site and mature an ileostomy?

Answer 53

Siting an ileostomy:

• Ideally sited pre-operatively with the patient in a sitting position
• Err on the side of a superiorly placed ileostomy near the level of the umbilicus, avoid natural skin creases and the belt line

Maturing an ileostomy:

• Delivered through a trephine through skin and fat with a cruciate incision through the anterior and posterior layers of rectus sheath
• I place 4 interupted 3-0 PDS sutures - left untied
  
  • Full thickness bowel bite distally
  • Seromuscular sutures 4cm proximally
  • Subcuticular sutures
• After eversion these are then tied, eversion can be encouraged with the blunt end of a Debakey’s forceps
• The stoma is then matured circumferentially with 3-0 PDS and an appliance is placed.

Question 54

Describe how you anastomose small bowel to small bowel

Answer 54

I use an end-to-end handsewn anastomosis

• 3-0 PDS II on a taper point SH needle
• I place stay sutures at the mesenteric and antimesenteric ends
• I then take seromuscular bites to perform interrupted sutures half-way between previous sutures
• I then turn the anastomosis over and do the other side
• I close the mesenteric defect with figure-of-8 3-0 PDS sutures.

Question 55

How do you resect small bowel, for example in a Meckel’s diverticulectomy?

Answer 55

• Choose the sites of small bowel excision
• Score the mesentery with diathermy, pinch the fat to make pedicles
• Use Heiss clamps and 2-0 Vicryl ties to secure each pedicle
• Place soft bowel clamps on the bowel outside the area of resection
• Place unfolded large packs around working area
• Place hard bowel clamps on the bowel to be resected; use a scalpel to excise the specimen including the hard clamps
• Clean the lumen with Savlon soaked small gauze
• Place a stay suture at the mesenteric side and at the anti-mesenteric side
• I use a handsewn anastomosis with interrupted 3-0 PDS seromuscular bites
• I close the mesenteric defect and then check the anastomosis.

Question 56

Describe the steps of a laparoscopic right hemicolectomy

Answer 56

• GA, supine position, both arms in, secured to table for Trendelenberg and tilt
• Access:
  
  • 4 ports; 10mm Hasson through the umbilicus, 10mm port left upper abdomen, 5mm port LIF, 5mm port suprapubic region
  • Diagnostic laparoscopy
• Mobilisation:
  
  • I use a medial to lateral approach;
  • The small bowel is swept upwards and medially
  • The omentum is swept over the transverse colon
  • The ileocolic pedicle is bowstringed towards the RIF
  • The peritoneum over the pedicle is incised and gentle disseciton is used to enter the plane between the mesocolon and retroperitoneum, this plane is dissected beyond the ileocolic taking care to identify the duodenum
  • A window is then made on the other side of the ileocolic, this is taken with 3 Hemo-O-Lok clips and divided
  • The embryological plane is then developed up to the hepatic flexure, all the while preserving the duodenum, a swab is placed at the apex of this dissection
  • The omentum is dissected off the right half of the transverse mesocolon and the right branch of the middle colic pedicle is dissected and triply clipped then divided (if wide resection is required)
  • I then continue the dissection around the hepatic flexure and down the ascending colon until the caecum and TI are fully mobilised
  • I check the mobilisation and haemostasis then convert the umbilical port into a small laparotomy with an Alexis retractor
• Anastomosis:
  
  • The right colon is delivered and a side-side T-shaped anastomosis is made with an 80mm GIA and a 60mm TA stapler, I oversew the TA line and place a crotch stitch
  • The bowel is delivered back into the abdomen and the wounds are closed.

Question 57

Describe how you perform a right hemicolectomy.

What are the additional steps required for an extended right?

Answer 57

• GA, supine position, strapped to table, arms out
• Access:
  
  • Stand on the patient’s left, midline incision above and below umbilicus
  • Diagnostic laparotomy; liver, peritoneum, bowel, check for synchronous tumours (3-5%)
• Mobilisation:
  
  • Mobilise the right colon in its embryological plane; start with the caecum and terminal ileum out of the pelvis
  • Medially retracting the colon, I use diathermy to incise the lateral attachments of the colon; I identify the gonadal vessels and more superiorly the duodenum, I do not routinely identify the right ureter if the other landmarks are clear.
  • I then use my left index finger to sweep around the colon and ask my assisstent to diathermy onto my finger and so release the hepatic flexure
  • I am cautious not to avulse a branch of the middle colic vein when mobilising the right transverse mesocolon
• Resection:
  
  • Once the mesocolon is lifted free of the underlying duodenum and pancreas I secure the vascular pedicles;
  • The mesentery of the resection is scored, windows are made on either side of the pedicles with pinching-technique
  • The ileocolic and right colic are secured with Roberts and suture ligated
  • If needed, the right branch of the middle colic may also be secured and ligated then divided
  • Soft clamps are applied
  • Large unfolded packs are laid down
• Anastamosis:
  
  • The bowel is lined up and I make a colotomy and an enterotomy for the GIA 80mm stapler
  • This is fired and the two edges of the common enterotomy are grasped with Babcock’s
  • These are off-set and then a 60mm TA stapler is fired across the two lumens; I use a scalpel to excise the specimen
  • I oversew the TA staple line and place crotch sutures
• I close the mesenteric defect and lavage the abdomen
• I close the midline fascia with 2-0 PDS II on a sharp needle and the skin with monocryl.

Extended right:

• Low-Loyd Davis position
• Mobilise splenic flexure
• Take middle colic pedicle and so anastomosis is likely onto descending colon
• If side-to-side doesn’t line up well then handsew and end-to-end with a Cheatle slit.

Question 58

How do you perform a left hemicolectomy?

Answer 58

• GA, low Loyd-Davis position, arms out
• Bowel prep with Moviprep, Neomycin, and Metronidazole and pre-op fleet
• Access:
  
  • I use a midline incision, perform a diagnostic laparotomy, and then place an Omnitract retractor and pack small bowel into LUQ
• Exposure:
  
  • I mobilise the sigmoid colon in its embryological plane, I identify the gonadal vessels and medial to them the ureter
  • I continue this dissection up to the splenic flexure
  • I then improve the exposure of the LUQ with the Omnitract and get into the plane under the omentum superficial to the left mesocolon, I continue this plane around to my previous dissection
  • I then work from the descending colon level medially, lifting the mobilised colon anteriorly, and identify the IMV from behind, which marks the extend of my mobilisation.
• Resection:
  
  • The appropriate vascular pedicles are identified, the mesentery is score and windows are pinched for passage of Roberts or Heiss clamps
  • The pedicles are suture ligated; I do not perform a high tie on the IMA as there is no oncological benefit
• Anastomosis:
  
  • I perform a stapled anastomosis in continuity
  • The bowel is line up and pack are placed around the working area
  • Colotomies are made and a GIA 80mm is introduced and fired
  • The edges of the common enterotomy are grasped with Babcock’s and offset
  • A TA 60mm is used to cross the two lumens and resect the specimen
  • The TA staple line is oversewn and crotch sutures are placed
• Closure:
  
  • Washout with warmed saline
  • Rectus sheath catheters
  • 2-0 PDS II to the midline fascia and monocryl to skin

Question 59

Outline the operative steps involved in Total Mesorectal Excision

Where is length gained for anastomosis in the pelvis?

Answer 59

• The TME plane is best found by following the glistening posterior surface under the IMA pedicle down into the pelvis
• Experienced assisstants and good lighting are crucial for dissection in the areolar plane
• The plane is best found posteriorly, this is devleoped laterally and then finally anteriorly
• The “lateral ligaments” represent areas of adherence between the mesorectum medially and the plexus laterally and should be spared whilst preserving the TME envelope
• Anterior dissection requires forceful anterior retraction on the seminal vesicle and development of the areolar plane
• The distal extent depends on the tumour level with 5cm of distal mesorectal excision required.
• A high tie on the IMA is not required for oncological reasons but may assist mobility
• True left colonic mobility is gained from a high tie on the IMV combined with splenic mobilisation

Question 60

Describe the perineal component of an APR

Answer 60

• The patient may be in the lithotomy or jack-knife prone position; the latter affords better exposure at increased positional and anaesthetic complexity
• The anal canal is closed with a silk suture
• An elliptical incsion is made just outside the perianal skin; a lonestar retractor is a useful adjunct
• Dissection continues deeply; the coccyx is excised and the levators encountered
• The levators are divided as far lateral as possible and the plane joined with the posterior plane, where a swab has usually been placed
• The anterior margin is the most difficult and is dissected last
• The specimen is then delivered through the wound
• The wound is the either closed primarily or reconstructed with a mesh or myo/fascio/cutaneous flap

Question 61

How do you perform a Delorme’s procedure?

Answer 61

• aka mucosal sleeve resection - use to treat small full thickness prolapse and involves removal of prolapsing rectal mucossa and a mucosal-mucosa anastomosis
• good for small (<5cm) or incomplete prolapse or high risk patients
• confirm dx and exclude rectosigmoid malignancy
• fleet enema
• Spinal or GA, lithotomy position, Lone Star retractor
• I prolapse the bowel with Babcock and then infiltrate the submucosal plane with 0.5% marcaine plus adrenaline to facilitate dissection and limit bleeding
• Using diathermy I incise the mucosa circumferentially 1cm above the dentate line to enter the submucosal plane, which I dissect distally to the apex of the prolapse; where difficult, I use scissors.
• I dissect this on broad front, grasping the mucosa with Debakey forceps
• As I go, I place 4 stay-sutures into the mucosa near the dentate line
• Once I reach the apex of the prolapse, I leave the mucosa hanging on Babcocks and place 8 plication sutures using 3-0 PDS, these are clipped then tied after placement of the 8th suture. 4 of these are left long to improve exposure for the following stiches.
• The mucosa is trimmed off and interrupted 3-0 Vicryl sutures are used to close the mucosal defect.
• The stay sutures are released and the bowel reduces back into the anorectum
• The patient is managed post operatively with laxatives and early mobilisation

Question 62

What are the principles of an Altmeier’s procedure?

Answer 62

• For significant full thickness rectal prolapse
• Aka perineal rectosigmoidectomy - involves resection of the prolapsing rectum via the anus and formation of a coloanal anastomosis with sigmoid colon
• Exclude rectosigmoid malignancy
• Pre-op enema
• GA, lithotomy position.
• Lonestar retractor, prolapse rectum
• Score mucosa with diathremy 1-2cm proximal to dentate line
• Infiltrate submucosal plane with 0.25% marcaine + adrenaline
• Divide all layers of rectal wall anteriorly 1-2 cm above dentate line (ie through mucosa, muscle and seroasa, to reach mesorectal fat; careful not to injure vagina or bladder if concurrent prolapse - place stay sutures in the dentate mucosa
• Continue laterallly; elevate plane with artery forceps to avoid injury to the mesorectum or the inner rectal tube below
• Once outer tube has been fully divided the rectum is mobilised proximally
• Mesorectal vessels are ligated with an energy device or suture ligation; perform circumferential mobilisation until resistance to traction felt
• At this point open the peritoneal cul-de-sac or pouch of Douglas to allow entery into peritoneal cavity - this will allow for palpation of the redundant sigmoid colon, and division of mesorectum and mesosigmoid continues til redundancy adequately reduced
  
  • Care to avoid bleeding vessels retracting and not having access to them
• Can add levatorplasty anteriorly or posteirorly at this point as an addition to the traditional procedure; improves faecal incontinence by restoring angle of pelvic floor which may have become lax over time - ?absorbable or non-absorbable figure 8 2-0 sutures
  
  • hould be able to pass a single finger round rectum
• Once colon adequately retracted through anus, line of proximal dissection marked w cautery and colon transected proximally, beginning anteriorly
• Coloanal interrupted 3-0 PDS sutures placed between cut edge of proximal sigmoid and cut edge of anal canal anteriorly
• then transect posterior aspect and place interrupted posterior sutures
• post-op care involves early mobilisation, laxatives, simple analgesia
• complications
  
  • bleeding
  • anastomotic dehiscence
  • pelvic sepsis
  • coloanal stricture
  • prolapse recurrence
• With the bowel prolapsed; incise the anterior wall and place interupted 3-0 PDS sutures in a segmental fashion, eventually excising all of the redundant rectum.
• Reduce the suture line.
• Post operative care involves early mobilisation, laxatives, and simple analgesia

Question 63

What are the principles of an abdominal resection rectopexy?

Answer 63

• Performed under GA in the low Loyd-Davis position
• Can be done laparoscopically or open:
• A Pfannenstiel incision is used, the fascia is vertically incised and a Balfour retractor is placed
• The TME plane is entered beneath the IMA pedicle and this is developed posteriorly then laterally, the uterus requires retraction as these patients often have a very deep pouch of Douglas.
• If there is redundant sigmoid is is resected and an anastomosis is made.
• The rectopexy is then performed using sutures or tacks to the sacrum, some use a mesh for reinforcement.

Question 64

Describe your method of brachial embolectomy

Answer 64

• 5000IU of Heparin pre op. Consented for neurovascular damage to arm etc.
• I use a longitudinal lazy S incision, medially proximally, and laterally distally over the antecubital fossa
• I identify and divide the biceps aponeurosis
• This exposes the brachial artery with the median nerve located medially
• Dissection on the adventitia of the artery spares the nerve and allows access to the bifurcation into ulnar and radial branches
• I sling all the branches and clamp them
• I make a longitudinal arteriotomy at the bifurcation and check in-flow; should be audible.
• Start with proximal passage of a 3Fr Fogarty balloon then flush with saline. Move onto radial and ulnar arteries; flush with saline.
• Close arteriotomy with continous 5-0 Prolene avoiding raising the intima of the bottom flap.
• Release clamps and check pulses, close over drain.

Question 65

Describe open SFJ ligation and GSV stripping.

Answer 65

• GA, supine position, strapped for Trendelenberg tilt to 30°, leg/s free draped
• Make an oblique incision 2 finger-breadths below and lateral to the pubic tubercle, check for femoral pulse laterally
• Dissect through subcutenous tissue, expect to encounter the SIE, SCI, SEPV, DEPV, AL thigh vein and PM thigh veins
• The GSV will pass through the cribriform fascia into the femoral, which must be seen 1cm proximal and distal prior to ligation of the GSV.
• Note that the superficial external pudendal artery runs across the lower lip of the cribriform fascia.
• Tie the vein in continuity and then use a transfixation suture prior to dividing
• A stripper tip is then introduced into the GSV passed down to the level of the knee where it is retrieved with a stab incision.
• Dissect the distal end of the vein, make a small venotomy to deliver the stripper
• Tie a strong cuff around the proximal bulb at the GSV.
• Tumescent local anaesthesia is placed around the GSV.
• Perform an antegrade strip from knee to groin and apply pressure to the track for 5 minutes.
• Perform stab phelbectomies over pre-marked sites.
• Apply a pressure dressing and then a compressive stocking and elevate the leg post-op.

Question 66

Describe how you do a laparoscopic cholecystectomy

Answer 66

• GA, supine position, right arm out, strapped to table, foot-plate if obese.
• I use a vertical trans-umbilical open entry and place a Maxon suture to the fascia and insert the Hasson port
• After insufflation I place a 10mm epigastric port and two 5mm RUQ ports; one over the fundus and one at the lateral margin at the level of the umbilicus
• After a diagnostic laparoscopy I grasp the fundus of the gallbladder with the fundal grasper and retract it over the liver to the right shoulder
• With my left instrument controlling Hartmann’s pouch I use scissors to incise the gallbladder peritoneum at the anterior edge; this incision is continued on the anterior and then posterior edges of the gallbladder and then hook dissection is used to extend this to the fundus
• I use a peanut to sweep the fat away from the HC triangle and establish the windows, I clear these with hook diathermy if needed
• Once the critical view is demonstrated I triply clip the cystic arterty and duct and divide these
• I then remove the gallbladder from heaptocystic plate with diathermy in the areolar plane and remove it from the abdomen with an endocatch
• After a final inspection I remove the ports under vision and close the fascia then the skin with dissolvable sutures.

Question 67

How do you do an intra-operative cholangiogram?

Answer 67

• I call for radiology and then ensure theatre staff are adequately protected from ionising radiation
• I ensure the theatre table is in a position where IOC can be performed
• I then check the IOC set-up with the nurse; I use a Reddick-Olsen instrument with a 4Fr IOC catheter passed down its length. This is primed with saline and attached to a 3-way stop-cock. I use a 50:50 mix of saline and omnipaque for the IOC.
• After dissecting out the hepatocystic triangle I clip the cystic duct near the gallbladder neck and then make an incision at the confluence of the gallbladder neck and cystic duct and expect to see bile
• I insert the Reddick-Olsen down the RUQ port and feed it into the cystic duct with a Marylands grasper in the right hand, I clamp the Reddick-Olsen and flush some saline down the biliary sytem
• I then remove the instruments and bring in the C-arm and after re-checking coverage, fire a screen shot and adjust as needed.
• I then take a cholangiogram and proceed as required.

Question 68

How do you do an open cholecystectomy?

Answer 68

• I use a sub-costal incision 3 finger-breadths below the costal margin from mid-axillary line to xiphi-sternum
• After safely entering the peritoneal cavity between artery forceps I perform a diagnostic laparotomy and place 2 packs above the liver to deliver it into the wound, two futher packs are used to pack away the stomach and hepatic flexure
• I use a similar approach to my laparoscopic technique;
  
  • The fundus is grasped with Rampley forceps and Hartmann’s pouch is grasped with a Kell’s forceps
  • A right angle Lahey is used to open the peritoneum over the anterior duct, this opening is extended medially and laterally and up towards the fundus
  • The artery is dissected and tied in continuity then divided, the cystic duct may be cannulated here for IOC
  • The gallbladder is then removed from the fundus down to the posterior window and then delived as a specimen
  • After a washout and haemostasis check I close the fascia with a loop-0 PDS
  • The skin is closed with staples

Question 69

What are the steps involved in open CBD exploration?

Answer 69

“Exploration by escalation” - GP 2018

1. Kocherise the duodenum
2. Identify the common hepatic duct by dissecting the cystic duct down to its origin or by cannulation (25G)
3. Place stay sutures with 4-0 PDS and tent the CBD up
4. Use an 11-blade to make a longitudinal choledochotomy and extend with Potts
5. Pick out the stone if possible
6. Massge the stone up if possible
7. Irrigate the stone and retrieve if possible
8. Pass a Fogarty balloon catheter and retrieve after inflation of the balloon
9. Use a 5mm choledochoscope and basket the stone out
10. Open the duodenum and retrieve the stone, cut at 11 o’clock
11. Bypass with a hepaticojejunostomy

Question 70

What are the steps involved in a laparoscopic CBD exploration?

Answer 70

• A trans-cystic or trans-ductal approach may be used; trans-cystic is less likely to be successful when the stone is >8mm or when anatomy (valves, tortuous, angulated duct) hinders the approach.
• Radiologically guided baskets or Fogartys may be used under intra-operative imaging
• Alternatively a choledochoscope may be used and baskets and Fogartys used under direct vision
• My preference is to:
  
  • Attempt flushing first with 50ml saline
  • Then Glucagon 1mg IV
  • Then Buscopan 20mg IV (wait for tachycardia)
  • Then flush again
  • Then place a soft-tip guidewire into duodenum
  • Then railroad a JJ stent into the CBD across the stone and into the duodenum
  • Then arrange post-op ERCP

Question 71

How do you insert a Portacath?

Answer 71

• I insert a Cook Vital Port™ under GA
• The chest and neck are prepared and draped
• The head is turned away from the right side
• I use an USS to identify the IJV
• The skin is incised near the clavicle and a space over the IJV dissected
• I puncture the micropuncture needle into the IJV and thread in the micropuncture needle
• I then railroad a sheath over the wire, and the wire is removed
• A larger wire is then advanced into the sheath and the sheath removed
• I then railroad a peel-away sheath onto the wire, I leave the wire in to occlude the peel-away sheath
• I then inject the area on the chest for port placement with local anaesthetic and adrenaline
• The skin is incised and then a subcutaneous space is developed
• Next, I run a tunneling device with the attached catheter through the subcutaneous tissue to the IJV incision site and draw 15-20cm of catheter through the IJV incision site to be inserted into the IJV
• The wire and inner dilator of the peel-away sheath are removed and the catheter inserted, I check the position with x-ray; the tip should lie in the right atrium
  
  • 2 vertebral bodies below carina
• The peel-away sheath is then removed
• The port locking device is attached to the tip of the catheter and then tested to ensure there is no leak.
• The port parachuted into the pocket with 3 interrupted 3-0 vicryl sutures
• The port and IVC sites are closed and the position is checked again
• The port is locked with Heparin as per the local protocol.

Question 72

Describe your surgical repair of a hydrocoele

Answer 72

• Must have had pre-operative USS.
• GA, supine position, perforated drape
• I make a longitudinal incision down the midline raphe with the testicle and hydrocoele tense underneath the raphe
• I am cautious not to cut the hydrocoele and to dissect the sac for around a half of its size as this facilitates subsequent trimming and stitching
• I then open the hydrocoele and drain the fluid, deliver the testicle, and then trim the sac as needed prior to inverting the sac
• With the edges of the sac on Allis forceps, I align these and use a 3-0 vicryl to continuously suture the edges of the sac together
• The testicle is delivered back into the scrotum and the wound is closed with 3-0 vicryl rapide

Question 73

What are the steps of a Whipple’s procedure?

Answer 73

1. Diagnostic laparotomy and exposure
2. Isolate the SMV and separate the colon and its mesentery from the duodenum and pancreatic head
3. Extended Kocherization
4. Portal dissection including sub-pancreatic tunnel
5. Transect the stomach
6. Ligaments of Treitz are taken down and the jejunum is transected
7. Transect the pancreas and reflect medially
8. Gastrojejunostomy, choledochojejunostomy, and pancreaticojejunostomy.

Question 74

What are the complications of a Whipple’s procedure?

Answer 74

Relate the complications to the THREE anastamoses

• Pancreaticojejunostomy:
  
  • Leak
  • Bleed
  • Pseudoaneurysms
• Hepaticojejunostomy:
  
  • Leak
  • Stricture
• Gastrojejunostomy:
  
  • Leak
  • Stricture
  • Dumping syndrome
• ​Other:
  
  • ​VTE and local thrombosis
  • Malnutrition

Question 75

Why and how do you perform escharotomies?

Answer 75

• Escharotomies are indicated when there are circumferential full thickness burns that are likely to cause compartment syndrome
• The technique is simple:
  
  • Use either scalpel or diathermy through the insensate skin along the lines of fusion between the anterior and posterior surfaces of the limbs
  • Avoid key landmarks:
    
    • Upper - Ulnar nerve, radial nerve
    • Lower - GSV, PT pedicle, Common saphenous

Question 76

Describe a Zadek’s operation

Answer 76

This is performed for recurrent or persistent issues with ingrown toenails (wedge excision usually first line). I first ensure there is no active sepsis; in this case I would merely remove the nail and wait for about 2 months until the sepsis has subsided. I do not perform the operation in the presence of peripheral vascular disease.

I perform a ring block with half 0.5% bupivicaine and half 1% xylocaine (no adrenaline). I prep and drape the forefoot, using a shut-off drape around the instep. I use a glove finger with an artery clip as a tourniquet.

1. I remove the nail, if present, by separating it from the underlying nail bed with a McDonald elevator.
2. I make two incisions 1cm long, extending diagonally from the each corner of the nail to the transverse skin crease just distal to the IPJ.
3. I lift the skin and subcutaneous tissue as a flap and dissect this proximally
4. I carry the dissection under the edges of the skin incisions on either side of the terminal phalanx to the midlateral line to complete the clearance of the germinal matrix of the nail.
5. I cut across the nail bed transversely at the whitish half-moon at the root of the nail and join this tranvserse incision to the dissections under the nail folds
6. I remove the block of nail bed from the surface of the proximal phalanx as far back as the insertion of the extensor tendon.
7. I check for any remaining fragments of germinal matrix
8. I draw the skin flap distally and carefully insert one or two sutures to attach it to the nail bed as well as closing the incisions on either side
9. Dress with gelonet, gauze, stretchy white stuff
10. Elevate foot for 24hrs
11. Remove sutures after 12-14 days

Question 77

Describe a wedge excision for ingrown toenail

Answer 77

• Ring block with 0.5% marcaine/1% xylocaine mix, no adrenaline
• prep foot, drape forefoot
• tournique
• take deep wedge of tissue that includes lateral edge of nail and skin by making 2 incisions;
  
  • dorsal surface with broad 10 blade through nail and skin proximal and distal with blade up
  • 30-45 degree angle to the last around side of toe so meets first
• pull wedge
• check no white shiny nail matrix left, excise any remaining matrix
• ablate
  
  • phenol
    
    • protect skin with petroleum jelly from jelonet
    • dip cotton bud in 80% phenol solution
    • stick into depths of cavity
    • leave for 3 minutes, occasionally twisting
    • wash with liberal methylated spirits
  • cautery
• close with two steristrips, not completely encircling
• jelonet
• gauze and crepe

Question 78

Describe your management of a “can’t intubate, can’t oxygenate” airway.

Answer 78

• CICO mandates emergency surgical airway
• Stand on patient’s left side
• Equipment; Size 10 blade, Bougie, Size 6 ETT
• Iodine; laryngeal handshake; steady with left hand
• Horizontal stab incision into cricothyroid membrane; rotate 90° so blade points inferiorly - switch hands
• Insert Bougie into trachea 10cm
• Thread ETT onto Bougie while rotating
• Inflate, ventilate, confirm, secure.

Question 79

Describe your technique of elective tracheostomy.

Answer 79

• Indicated for long term ventilation, better bronchial toilet, gradual weaning, and sub-acute airway obstruction. Don’t make incision at cricoid cartilage or 1st tracheal ring as high risk of subglottic obstruciton post removal.
• Perform this in theatre under GA
• 10ml 1% Ligno with adrenaline
• Skin crease incision halfway between cricoid and suprasternal notch
• Raise sub-platysmal flaps; divide the midline raphe
• Dissect the isthmus; Heiss clamps across
• Divide and secure with suture ligation 3-0 PDS SH
• Divide or diathermy the pretracheal venous plexus below the cricoid
• It is critical to identify cricoid cartilage and the subsequent tracheal rings. Check the tracheostomy is ready, cuff inflates and it is lubricated.
• Ask for the ETT cuff to be deflated or for the ETT to be advance distally to avoid rupturing the cuff
• Stabilise trachea with cricoid hook
• Horizontal incision between 2nd and 3rd tracheal rings, 1-2cm with a scalpel
• Insert tracheal dilator and insert cuffed tube as the anaesthetist slowly removes the endotracheal tube, they should leave this in the subglottic position until ventilation is confirmed with the tracheostomy.
• Inflate; ventilate and confirm
• Suture tracheostomy tube to skin and close skin loosely over wound.
• Also place circumferential tie and secure around neck, allowing one finger to slide underneath to minimise constriction

In emergency can instead use vertical incision from lower border of thyroid to one finger above suprasternal notch, extending incision between strap muscles. Divide or retract thyroid isthmus and make a vertical incision through 2nd to 4th rings; tracheal dilator; place tube.

Question 80

How do you perform an emergency splenctomy?

Answer 80

• Midline laparotomy in widely prepped patient in crucifix position
• Scoop out blood. Packs to all quadrants.
• Stand on the right hand side of the patient
• Left hand scoop around spleen to medialise:
  
  • Some are more stuck than others, often the haematoma has done most of the dissection
  • These require division of the spleno-renal and spleno-colic ligaments by gently retracting upwards and medially
  • The spleen is then gently pulled downwards and the splenophrenic ligaments are divided with mayo scissors.
  • The short gastric vessels between the greater curvature of the stomach and the spleen must be divided between ligatures. careful not to go too close to the greater curve as this can cause ischaemia. Place packs behind the spleen to bring it forward.
  • Assess the damage;
  • In brisk bleeding, a large artery clamp can be placed across both the main pedicle and the short gastrics and the spleen removed with good haemostasis
• The tail of the pancreas is at risk during clamp application; milk the tail out of the way prior to clamping
• Suture ligate the pedicle under the clamps with 2-0 Prolene.

Question 81

Describe the various methods of splenic preservation

Answer 81

1. Capsular tears - pressure, place haemostatic agent
2. Splenorrhaphy
   
   • Use buttressed sutures to re-approximate a laceration
3. Partial splenectomy
   
   • Use a TA stapler to come across the spleen
   • or ligate segmental vessels, incise capsule in line w ischaemic zone, finger fracture technique, preserve 30% to maintain function
4. Mesh wrapping
   
   • Use a mesh wrap to tamponade the spleen

Question 82

Lap splenectomy

Answer 82

• pre-op vaccines
• patient in right lateral decubitus with table split
• 4 ports in subcostal position with camera port in middle - 2x5mm in midline, 2x10mm in MCL and MAL
• search for ectopic splenunculi (14%) - splenic hilum, gastrocolic ligament, omentum, base of mesentery, left gonadal vein
• mobilise splenic flexure
• enter lesser sac by dividing the gastrocolic ligament and divide the short gastrics
• skeletonise the SA and ligate
• skeletonise the SV and ligate
• divide the avascular splenic attachments
• post-op
  
  • usu have increased leukocytes
  • thrombocytosis can occur immediately post-op but peaks up to 3 weeks
    
    • antiplatelets only indicated for complications or when platelet counts hit 1 million
    • can lead to portal or mesenteric vein thrombosis
  • careful education about OPSI, back-pocket script

Question 83

Elective open splenectomy

Answer 83

• supine, sandbag under LUQ
• either upper midlinen laparotomy or left subcostal incision
• full exploratory laparotomy
• carefully search for splenunculi (14%) - anywhere along splenic vessels, gastrosplenic ligament, splenorenal igament, retroperitoneally, in mesentery, omentum and occasionaly in gonads or path of descent
• ligate splenic artery at beginning of operation if spleen v large or prior to infusing platelets
  
  • enter lesser sac by dividing 10cm of gastrocolic omentum
  • incise peritoneum at superior border of pancreas
  • right angle to pass ligature behind artery
  • ligate in continuity
• divide omental adhesions to lower pole of spleen and splenocolic ligament
• draw spleen medially w left hand and incise periotneum that attaches spleen to lateral sidewall extending incision up along lateral border of spleen towards diaphragm
• divide splenophrenic ligament
• divide peritoneum over front of splenic hilum from lower pole to upper
  
  • stomach can be v close
  • divide short gastrics
• now spleen should only be attached by splenic vessels at hilum
• divide between Roberts, suture ligate
• remove the specimen, check haemostasis, close

Question 84

Hartmanns

Answer 84

• decide whether doing oncological op or not
• stoma marking
• supine, large midline incision, adhesiolysis
• inspect small bowel and retract to right side with moist pack and fixed retractor
• mobilise left colon in its embryological plane
• identify the gonadals and ureter in normal tissue and follow ureter distally, preserving and protecting it
• may elect to dissect omentum off distal transverse colon and mobilise splenic flexure
• select proximal and distal transection points
• linear cutting stapler
• inflammatory vs oncological
  
  • peritoneum overlying mesentery scored w electrocautery and left colic/sigmoid branches identified, double ligated and transected w division of remaining mesentery and removal of specimen
  • IMA ligated near origin from aorta and all associated nodal tissue taken w specimen
• proximal and distal end of bowel marked, sent for histo
• prolene to stump to facilitate reversal
• washout
• ensure prox colon reaches abdominal wall
• create trephine, muscle splitting, enough to accommodate 2-3 fingers
• colon passed out w/o torsion or tension
• drain, close midline
• mature stoma flush with 3-0 monocryl