Operative

Question 1

Find the right ureter

Answer 1

To identify the right ureter, I mobilise the right colon from lateral to medial on its embryonic mesentery. My retraction is strongly up and out of the abdomen to help separate the plane between mesentery and retroperitoneum and protect those structures below. The ureter itself can be visualised as a white tubular structure that vermiculates on stimulation.

1.

Question 2

Find the left ureter

Answer 2

To identify the left ureter, I mobilise the sigmoid and left colon from lateral to medial on its embryonic mesentery. My retraction is strongly up and out of the abdomen to help separate the plane between mesentery and retroperitoneum and protect those structures below. The ureter itself can be visualised as a white tubular structure that vermiculates on stimulation.

1. Identify gonadal vessels at deep ring and trace cranially - ureter lies medially
2. Identify in retroperitoneum overlying bifurcation of iliac vessels at pelvic brim
3. Check that it has not been lifted anteriorly with investing retroperitoneal fascia, if plane is too deep

If concerned for injury - can do on-table IV urogram

Question 3

Find the axillary vein

Answer 3

1. Enter axilla by incising clavipectoral fascia on lateral border of pec minor
2. Identify medial pectoral nerve and bluntly dissect superiorly to find vein in superomedial aspect of dissection
3. Retrograde dissection by identifying thoracodorsal pedicle and tracing superiorly
4. Palpate axillary arterial pulse - vein lies anteroinferior
5. Retract or transect pec minor

Question 4

Shouldice repair

Answer 4

Approach (like regular inguinal hernia)

• Low inguinal incision
• Open external oblique
• Excise cremaster - split in axis of cord, ligate proximal and distal ends of lateral leaflet, excise medial leaflet entirely

Addressing herniae

• Incise posterior wall of inguinal canal from deep ring to pubic crest and search for all herniae
• Thoroughly dissect and reduce sac - can ligate if wish but not essential, but does need to be freely reduced into preperitoneal space

Relaxing incisions

• Relaxing incision in cribriform fascia inferior to incision in EO - from femoral vein to medial aspect of pectineus
• Consider relaxing incision vertically in anterior rectus sheath

Repair - close in 4 layers

• Running suture iliopubic tract to medial transversalis/rectus flap from pubic crest to deep ring
• Return suture along, bringing medial muscles (TA/IO) to shelving edge of inguinal lig
• Third layer of suture is IO/TA to inside of EO
• Fourth layer is same as third, but wider
• Close EO fascia as normal

Essentially, it is multiple double-breasted layered closure

Question 5

Suture repair inguinal hernia

Answer 5

Routine approach

Closure:
- Suture conjoint tendon (TA/IO arch) to iliopubic tract
- Use relaxing incision in deep lamina of rectus sheath, having fully mobilised EO aponeurosis to expose this
-