Operative

Question 1

Oblique subcostal incision (Kocher’s on right, spleen access on left)

Answer 1

• can be etended across midline as a roof top incision if required eg for liver and pancreas surgery
• incision about 2 finger breadths below subcostal margin and towards xiphi
• deepen incision to expose the external oblique and the anterior rectus sheath
• divide these layers and the rectus muscle and incise the internal oblique muscles with diathermy
  
  • helpful to insert a long artery forceps such as a Robert’s or Kelly’s under the muscle belly to facilitate this
• divide the posterior rectus sheath and transversus abdominis aponeurosis to expose the pre-peritoneal fat and open the peritoneum in line with the incision picking it up with artery forceps initially
• take care to spare the 9th costal nerve, which is visible at this stage
• a midline superior extension through the linea alba to form a ‘Mercedes Benz’ incision provides further access if required

Question 2

Trauma splenectomy

Answer 2

• widely prepped, crucifix, wear a headlight, stand on pt’s right
• midline laparotomy
• eviscerate the small bowel, scoop out clots, pack to all quadrants
• use an omnitract, ask anaesthetist to provide trendelenburg and left-side up
• with my left hand scoop around spleen to medialise (may be mobile in trauma or stuck)
• if stuck, divide splenorenal and splenocolic ligaments by gently retracting upwards and medially; spleen is then gently pulled downwards and the splenophrenic ligaments are divided with mayo scissors so the spleen can be brought to midline
  
  • may have short and unyielding splenorenal ligament - retract medially and beyond tip of fingers can make a nick in stetched ligament posteriorly with your scissors; enlarge the nick with scissors or your fingers up and around the spleen
• once spleen is mobilised and in my hand, can control bleeding by pinching the vascular pedicle, including both the gastrosplenic ligament containing the short gastrics in front and splenic hilum behind
• place packs behind spleen to bring it forward and assess damage
• decide whether to remove or repair depending on
  
  • pt’s trauma burden, age of patient, severity of injury, surgeon experience
• removal
  
  • identify and clamp vessels at hilum of spleen with Roberts clamps and divide between the clamps, taking care to avoid injury to tail of pancreas - ligate all vessels that are clipped using 0 vicryl ties
  • divide the short gastrics between ties or clips (automatic clip applier), being careful not to get too close to the greater curve which can cause ischaemia
  • (in brisk bleeding and if have other things to do also, a large artery clamp can be placed across both the main pedicle and short gastrics to control, and spleen later removed)
• check: haemostasis, damage to stomach (repair), pancreas tail (repair/divide/leave drain)
• occasionally may find ruptured spleen stuck to abdo wall and diaphragm and rapidly developing a plane behind it not realistic; in this case can
  
  • quickly control splenic artery by entering lesser sac through gastrocolic omentum, and isolate artery along the upper border of pancreas
  • or go straight at hilum - gently pull stomach towards you to put the gastrosplenic ligament on tension and divide it between clamps
  • immediately behind it you will find the splenic hilar vessels - clamp them then start dissection to mobilise the devascularised spleen

Question 3

Methods of splenic preservation

Answer 3

• Capsular tears
  
  • Pressure
  • Place haemostatic agent
• Lacerations
  
  • Mesh wrap with polyglycolate (to tamponade)
  • Liquid haemostatics ie fibrin glue
  • Repair with synthetic absorbable sutures on long blunt needle using pledgets, or a strip of Teflon on each side, or omentum as a bolster
• 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

Question 4

Lap splenectomy

Answer 4

• pre-op vaccines
• patient in modified right lateral decubitus at 45 degrees, appropriately secured with a beanbag and all pressure points padded, with the table flexed to open up the space between the costal margin and iliac crest
  
  • modified at 45 degrees cf 90 bc can then roll the table to get 90, so if you have to convert to open its easier than if they are in true lateral decubitis
  • well secured so I can ask the anaesthetist to move the table to use gravity to assist my dissection
• optical entry or open Hasson technique in MCL, total 4 ports in the subcostal position with camera port in the midline
  
  • 2x 5mm in midline, 2x12mm in MCL and mid axillary line
  • occasionally an additional port is required for retraction towards the midline, near the xiphoid process
• extensive search for ectopic splenunculi (14%) - splenic hilum, gastrocolic ligament, omentum, base of mesentery, along left gonadal vein - need to do this at beginning of case bc if start to mobilise tissues will get some bleeding espec if platelet disorder then harder to find
• mobilise splenic flexure as required and divide any attachments or adhesions between the colon and spleen or omentum and the spleen (omental attachments to lower pole of spleen often contain one or two vessels which supply lowermost segment of the spleen, so care required when dividing these)
• two common approaches to lap splenectomy are
  
  • initial dissection of hilar vessels followed by splenic mobilisation
  • or division of the posterior leaf of the splenorenal ligament first which allows teh spleen to fall medially under its own weight, facilitating further posterior dissection, which progresses til spleen is fully mobilised, revealing a ‘mesentery’ which contains the panc tail and the splenic vessels
• i prefer to leave the posterior and superior attachments initially so that the spleen remains retracted while i’m dissecting out the hilar vessels
  
  • i start with the inferior pole and work my way up towards the hilum, taking small vessels and the peritoneum over the hilum
  • when that becomes difficult I enter the lesser sac by dividing the gastrocolic ligament and take the gastrosplenic ligament and short gastrics with a ligasure or haemoloks; I continue up to the level of the left crus (til there are no short gastrics left), and the stomach can be retracted to the right
  • now I’‘m left with the hilum of the spleen and the tail of the pancreas medially; I dissect out the vessels at the hilum and take the artery and vein using a vascular load on an endoscopic linear stapler
  • I’m careful to avoid injuring the tail of the pancreas so I hug the spleen and might end up taking branches of the splenic vessels closer to the hilum
• I then further divide the inferior and lateral attachments, and lastly the splenophrenic ligament
• I place the spleen in a bag and check haemostasis and again for splenunculi
• If it’s for benign disease, morcellate it to allow extraction without extending my port sites

Specific post-op care

• monitor for haemorrhage, atelectasis, infection
• know that pts will usu have an increase in leukocytes post-op; physiologic
• infectious complications include subphrenic abscess and OPSI
• give vaccinations 2wks post-op if didn’t get pre-op
  
  • if compliance a concern then give prior to d/c
  • if immunocompromised, wait 3m
• careful education about OPSI, back-pocket script
• thrombocytosis can occur immediately post-op but peaks up to 3wks
  
  • antiplatelets only indicated for complications or when platelet counts hit 1 million
  • portal or mesenteric vein thrombosis = serious, reported in up to 14%, some studies reporting higher rate in lap spleens

Question 5

Elective open splenectomy

Answer 5

• supine, sandbag under LUQ
• either upper midline laparotomy or left subcostal incision
• full exploratory laparotomy
• carefully search for splenunculi (14%) - anywhere along splenic vessels, gastrosplenic ligament, splenorenal ligament, retroperitoneally, in mesentery, omentum and occasionally in gonads or path of descent
• ligate splenic artery at beginning of operation if spleen is 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 (careful as often quite thin)
  • ligate in continuity
  • can then find splenic vein further laterally in splenic hilum or revert to posterior approach which is to divide the posteiror leaf of the splenorenal ligament which allows spleen to be gently mobilised medially
  • w v large spleens can be difficult approaching splenic artery by anterior approach & the operation can be difficult; consider embolising splenic artery under rad control pre-op - can lead to much smaller and more pliable spleen
• divide omental adhesions to lower pole of spleen and the splenocolic ligament
• draw spleen medially w left hand and incise peritoneum that attaches spleen to the lateral sidewall extending incision up along lateral border of spleen towards diaphragm

Question 6

Perforated gastric ulcer

Answer 6

• preparation: NG, IDC, broad spectrum abx, PPI
• GA, supine, headlight
• access
  
  • upper midline from pt’s right
  • on entering, suction free fluid and ligate falciform
  • exploratory laparotomy; expect to find the perforated ulcer in the first part of the duodenum, the prepyloric region of the stomach or along the lesser curve of the stomach
  • check mesentery, peritoneum and liver for any evidence of metastatic disease
  • if gastric, biopsy ulcer with sharp scissors and Debakey forceps
    
    • 4% overall risk of malignancy; 30% for ulcers >3cm
• options for gastric ulcer:
  
  • freshen edges and primary closure
  • omental patch repair
  • distal gastrectomy
• patch repair
  
  • use a nearby tongue of omentum - may need to mobilise right omentum from transverse colon to achieve this
  • 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 omentum unavailable use falciform ligament or ?serosal patch
• distal gastrectomy
  
  • aim is to remove antrum of stomach and perform an appropriate reconstructoin
  • marked oedema or scarring in the region of the pylorus, pancreas and hepatoduodenal ligament is a relative contraindication to gastrectomy
  • landmark for my proximal resection is a line between the incisura of the lesser curve and the terminal branches of the right gastroepiploic on the greater curve; distal resection margin will be proximal D1 (~2cm past pylorus)
  • careful not to injure pancreas
  • begin dissection inferiorly, incising gastrocolic omentum near terminal branches of right gastroepiploic to enter lesser sac
    
    • mobilise greater curvature and ligate the branches of the right gastroepiploic until I reach the distal pylorus and main trunk of right gastroepiploic artery which I ligate wiht 0-vicryl
  • my assistant now elevates the stomach carefully, retracting it proximally while I divide any congenital adhesions between the stomach and pancreas
  • next I mobilise the lesser curve; I incise the lesser omentum near the incisura and dissect distally, ligating the descending branch of the left gastric artery and the right gastric artery; GDA should be preserved
  • on reaching pylorus my assistant elevates distal stomach and I mobilise any final attachments between pylorus/prox D1 and pancreas if safe to do so; branches of GDA may need to be divided)
  • having confirmed the position of the NGT I divide the stomach proximally (incisura to greater curve) with a linear cutting stapler; I underrun this with 3-0 PDS for haemostasis
  • next I divide D1 ~2cm distal to the pylorus (linear cutting stapler) - remove specimen and bury stump staple line with 3-0 PDS if duo isn’t thickened/oedematous
    
    • if duo retracted and fibrous may need to place a malecot through the duo stump or protect it with a side duodenostomy T tube at the junction of D2 and D3
    • Kocher manoeuvre not required for Bilroth II or REY
  • abdominal lavage
  • side-to-side gastrojejunostomy in antecolic fashion
    
    • bring up loop of jejunum that will reach stomach w/o tension but short (~20-30cm distal to DJ)
    • continuous back-wall suture (~3cm proximal to staple line) with double-armed 3-0 PDS left long; place packs around site of join
    • 5cm gastrotomy and jejunotomy
    • use double armed 3-0 PDS at midpoint of join and sew a continuous suture around to front wall, coming around the corners with Connell sutures and positioning the NG in afferent jejunum beyond anastomosis before completing it in the middle
    • continue the back-wall as a front-wall suture
    • leak test
  • final lavage, 2 drains (24 Fr silicon drain next to duodenal stump and blakes drain near gastrojejunostomy); close abdomen
  • post-op: HDU, NBM 48hrs w NGT free drainage, IV abx, PPI BD, DVT prophylaxis, H pylori eradicatoin, gastroscopy in 6wks

Question 7

Repair of perforated duodenal ulcer

Answer 7

• patch repair if small
• >2cm shouldn’t be managed with patch repair - risk of leak, nonhealing, stricture; and hazardous to dissect out and close the duodenum; options
  
  • if unstable, damage control with tube duodenostomy: kocherise duodenum, debride ulcer wall, place malecot catheter directly into ulcer defect and close duodenum around Malecot (?pursestring suture) then place a pedicle of omentum around the pursestring at the base, and a closed suction drain nearby
    
    • NG and consider feeding jejunostomy
    • malecot left for 6wks, feed through tube jejunostomy as soon as ileus resolves and start oral feeds on day 5-6; prior to removing Malecot do a 2-3 day clamp trial
    • or consider above with pyloric exclusion + gastrojejunostomy rather than feeding jej
    • consider lateral T tube
  • or Nissen closure of duodenum - if anterior duodenal wall is soft and pliable, duodenum can be left attached to the ulcer posteirorly and anterolateral duo wall mobilised (Kocher manoeuvre) so that it can be sewn down to distal fibrotic edge of ulcer crater (Nissen’s manoeuvre); a second layer of Lembert sutures are inserted between the anterior wall of the duodenum and the proximal edge of the ulcer
  • or jejunal patch
  • or Roux-Y drainage of perforation
  • or resection of perforation bearing duo and gastric antrum with partial gastrectomy & Billroth II reconstruction - but resection of these large ulcers risks CBD injury
• post-op: >90% have H pylori infection - eradicate & 8wks PPI

Question 8

Trauma laparotomy

Answer 8

• GA, abx, SCDs, IDC, supine, prep and drape from nipples to knees
• Skilled assistance, headlight, 2 large suckers, multiple rolled large packs, vascular instruments, haemostatic agents, omnitract available
• Good communication with team
• Goals:
  
  • Arrest haemorrhage
  • Control peritoneal contamination
  • Definitive repair of injury only if stable; early termination of surgical intervention before the development of irreversible physiological changes (lethal triad)
• Rapid midline entry from xiphi to pubic symphysis
• Eviscerate SB, evacuate clots by hand, pack all 4 quadrants
  
  • assistant elevates the abdominal wall of each quadrant in turn
  • begin with RUQ by placing by left hand over dome of liver, pulling it gently towards myself and placing packs over my hand above and then below the liver
  • pack right paracolic gutter
  • pull spleen towards me with left hand then pack over my hand above the spleen and left lobe of liver; create sandwich by packing medial to spleen
  • pack left paracolic gutter then pelvis
  • check swab covering the eviscerated bowel; if blood accumulating deal with mesenteric bleeder
  • while packing am feeling for any obvious injury
• Once packs in, communicate with anaesthetics and allow them to catch up with resuscitation & place omnitract
• Assess each quadrant carefully by removing packs and methodically assessing all organs and vascular structures to find the source of bleeding, beginning with the quadrant least likely to be source of haemorrhage (removing packs frees up space)
• I systematically assess the entire abdominal contents, paying particular attention to the liver, spleen, small and large bowel in blunt abdominal trauma
  
  • supramesocolic compartment: liver, GB, right kidney, stomach to GOJ, duodenum (kocherise if need full exposure), spleen, left kidney, diaphragm, lesser sac incl posteiror wall of stomach and body/tail of pancreas
    
    • bleeding from spleen in unstable pt: splenectomy
    • bleeding from liver: pack
  • inframesocolic compartment: small bowel, colon, bladder, reproductive organs
    
    • hollow organ injuries: staple off (but bleeding takes priority over contamination)
  • retroperitoneum: I perform medial and lateral visceral rotation to access the major vessels and retroperitoneal structures as indicated
• Major arterial haemorrhage originating from below thoracic aorta: supracoeliac clamp
  
  • Retract stomach caudally, retract left lobe of liver upwards and open pars flaccida of gastrohepatic ligament to access the lesser sac
  • Retract oesophagus to left and separate the muscle fibres of the aortic hiatus of the diaphragm
  • Apply aortic clamp above the origin of coeliac trunk
  • Remove clamp as soon as definitive control achieved
• Washout
• Temporary closure

Question 9

Left-sided medial visceral rotation (Mattox manoeuvre)

Answer 9

• to get to midline supramesocolic sector - contains suprarenal aorta and its branches (if try to get to this from front have to transect stomach and pancreas then struggle through dense connective tissue and nerve plexuses)
• mobilise lower descending colon from retroperitoneum, heading toward splenic flexure, and continue upward along same line which extends lateral to spleen - enables you to rotate the spleen, pancreas and left kidney in a medial direction toward the midline
• plane is directly on the muscles of the posterior abdominal wall - can feel it with fingertips
• continue medial rotation all the way up to the diaphragmatic hiatus - can then cut left diaphragmatic crus laterally and bluntly dissect around aorta with finger to gain access to distal thoracic aorta as high as T6 which is a quick and easy way to get proximal aortic control w/o opening chest
• gives access to abdominal aorta & most of its branches incl celiac, superior mesenteric, left renal and left iliacs
• if target is aorta itself or its anterior branches, rotate the left kidney w the other left-sided organs - if leave it in place & develop plane anterior to it, left renal vein and artery will be in the way so access to anterolateral aspect of aorta will be restricted, and left ureter will be vulnerable to injury
  
  • in front of suprarenal aorta is thick periaortic tissue; easier to get into the periaortic plane at infrarenal level then proceed upwards
• but if target is left kidney or renal vessels, leave kidney in place
• afterwards check for:
  
  • splenic injury - common w this manoeuvre
  • avulsion of left descending lumbar vein while mobilising left kidney - comes off left renal vein and crosses over left lateral aspect of aorta immediately below the left renal artery; if you plan to work on the aorta around the level of the renal vessels, good idea to identify, ligate and divide this lumbar vein to avoid avulsion during retraction of the mobilised kidney

Question 10

Elective tracheostomy

Answer 10

• preparation
  
  • usually ventilated in ICU; discuss choice of tracheostomy wiht ICU and anaesthetics; usually use tracheostomy tubes size 5-7, one size above and one size below the ETT size
  • in theatre under GA, sandbag under shoulders with extended neck (not too much), tie placed under pt’s neck ready to secure trache tube with once it’s in
  • this procedure requires careful coordination with anaethetics and nursing team - careful time out and discuss plan; pt will need to be pre-ventilated prior to entering trachea
  • check all necessary equipment available and checked, including testing cuffs of tube and ensuring ventilator extension tubing is available
  • palpate and mark if possible thyroid notch, cricoid cartilage and suprasternal notch
  • infiltrate 1% lignocaine w adrenaline
• procedure
  
  • skin crease incision 2cm above sternal notch, subplatysmal flaps
  • check for high-riding brachiocephalic in suprasternal notch
  • divide midline raphe and retract straps laterally
  • divide isthmus - ligate thyroid ima artery, clamp isthmus between artery forceps, divide and oversew edges with 2/0 vicryl (makes reinsertion safer and easier in setting of accidental dislodgement)
  • divide or diathermy pretrachal venous plexus below cricoid
  • identify space between 2nd and 3rd tracheal rings by palpation with artery clip
  • check in with anaesthetist who will have been pre-ventilating the patient and ask if they are ready for me to enter the trachea; before doing so I ask that they deflate their cuff or advance the tube distally
  • horizontal incision between the 2nd and 3rd ring with a scalpel and can be extended laterally in each direction using scissors
  • I place an 0-maxon suture around the 3rd ring and leave it long and subseuqently use this to retract the trachea anteriorly as I place my tube (can also be used to help reintroduce tube later if accidentally dislodged)
  • I communicate with the anaesthetist who will pull out their ET tube slowly til just above the newly created tracheotomy (should leave in subglottic position til ventilation confirmed with tracheostomy)
    
    • tracheostomy tube then placed through opening into trachea
    • inflate
    • confirm placement with CO2 monitor or ventilator
    • oral ETT removed
  • secure trache tube to skin with 2-0 silk then close skin
  • secure neck tie to tube (allowing at least 1 finger to slide underneath to minimise constriction)
  • flexible extension tube used to connect tube to ventilator circuit to minimise unnecessary movement of tube in immediate post-op period

Question 11

Tracheostomy indications

Answer 11

• Prolonged ventilation
  
  • Better bronchial toilet
  • Gradual weaning
• Sub-acute airway obstruction (supraglottic infection or inflammation)
• Pts requiring protection of their airway (vocal cord paralysis, stroke)
• Pts requiring permanent airway access – oropharyngeal tumours/resection
• As an emergency procedure for airway obstruction, although cricothyroidotomy is usually preferred if endotracheal tube (ETT) placement is unsuccessful
• Increasingly, percutaneous trache is performed, espec in ICU in pts requiring prolonged ventilation or intubation; relative contraindications to this include: obesity, short neck, cervical spien injury, enlarged thyroid
• Don’t make incision at cricoid cartilage or 1^st tracheal ring as high risk of subglottic obstruction post removal

Question 12

Tracheostomy complications

Answer 12

• Tracheoesophageal fistula
• Bleeding – can occur from thyroid or jugular veins or from a trachea-innominate fistula
• A dislodged tube
• Creation of a false passage – can occur if tube not placed into trachea correctly or if there is inadvertent removal and blind replacement
• Infection – uncommon
• Obstruction – can occur due to drying of mucus secretions; therefore good tracheostomy toilet and humidified air is important; obstruction can also occur following dislodgement of the tube
• Subglottic tracheal stenosis – due to pressure effects of the cuff and may require corrective surgery if trache is to be removed
• Vocal cord dysfunction – uncommon
• Tracheo-innominate fistula – uncommon (~1%) – may be preceded by a sentinel bleed, due to erosion of any part of the tube into the brachiocephalic trunk – rapidly fatal
  
  • tube tilts forward eroding into innominate arterial trunk
  • manage with finger in stoma and inflated endotracheal balloon

Question 13

Emergency tracheostomy

Answer 13

• Vertical incision from lower border of thyroid cartilage to one finger breadth above suprasternal notch, extending incision between strap muscles
• Palpate first tracheal ring with left index finger
• Divide or retract thyroid isthmus to expose anterior tracheal wall
• Vertical incision through 2nd-4^th rings
• Tracheal dilator
• Tube

Question 14

Emergency cricothyroidotomy

Answer 14

• Indications: CICO
• Stand on pt’s left side
• Equipment: size 6 ETT
• Iodine, laryngeal handshake, steady with left hand
• Horizontal stab incision into cricothyroid membrane; rotate 90 degrees so blade points inferiorly – switch hands
• Insert bougie into trachea 10cm
• Thread ETT onto bougie while rotating
• Inflate, ventilate, confirm, secure
• (?or needle cricothyroidotomy done with 14G)

Question 15

Femoral hernia - low approach (Lockwood)

Answer 15

• GA, supine, arms out
• Stand ipsilateral side
• Incision and dissection
  
  • 4-5cm skin crease incision below medial half of inguinal ligament
  • dissect onto the sac going through: skin, subcut tissue and fat, cribriform fascia, transversalis fascia, pre-peritoneal fat, peritoneum
  • look out for small veins running into the GSV; ligate and divide them as necessary
  • expose fat covered hernia sac and dissect it free so it can be traced proximally beneath the inguinal ligament, taking care not to injure femoral vein laterally
• Manage sac
  
  • Open sac between artery forceps
    
    • Bladder may be forming medial wall
  • Sweep away fat within sac to expose neck (deep)
  • Identify femoral vein and preserve
  • Empty sac, transfix and ligate neck with 2/0 absorbable suture excising sac 1cm distal to ligature
• Repair
  
  • The inguinal and pectineal ligaments meet medially through the arched lacunar ligament; the aim of the repair is to unite the ligaments for about 1cm laterally, w/o producing constriction of the femoral vein
  • I use three interrupted sutures to close the defect:
    
    • Kelly’s on the vein retracting laterally
    • 2-0 Prolene on an SH2 needle
    • inguinal ligament first then pectineal – insert a stitch deeply into the inguinal ligament and use this to draw the ligament upwards, while the needle is insinuated behind it, to take a good bite of the pectineal ligament
    • place all three sutures first then tie
    • check that vein has room to engorge, leave 4-6mm
    • if excessive tension on inguinal ligament, a mesh plug could be inserted; polypropylene cut 10-12cm by 2cm, rolled into a cigarette shape (2cm long) and placed into defect
      
      • three sutures of 2-0 prolene through inguinal ligament, mesh and pectineal line
      • less likely to result in compression of femoral vein and ?less prone to recurrence
• Close in layers

Question 16

Torn femoral vein during low femoral hernia approach

Answer 16

• If femoral vein is torn, control bleeding with pressure from gauze packs and request blood, arterial sutures, tapes, bulldog clamps and heparin solution, and summon assistance
  
  • expose vein; don’t hesitate to approach it from above and below the inguinal ligament
  • apply bulldog clamps and tapes above and below damaged segment
  • insert fine 5/0 sutures set 1mm apart, 1mm from the torn edges, to evert them and close the hole
  • flush with heparin at intervals
  • release, then remove the clamps and tapes

Question 17

Acute femoral hernia - modified McEvedy

Answer 17

• use for strangulated hernias as provides excellent access for assessment of bowel and if necessary for resection
• IDC preop to reduce risk of damage to the bladder
• Transverse skin incision on ipsilateral side 3 finger breadths above tubercle
• Incise lower rectus sheath vertically 1-2cm medial and parallel to lateral border
• Lift lateral edge of sheath and incise thin transversalis fascia from 2.5cm above pubic tubercle to mobilise lower lateral edge of rectus medially
• Ligate and divide inferior epigastric vessels which cross this line low down
• In this preperitoneal space I move inferiorly towards the pubic tubercle to expose the entire myopectineal orifice; this may require a deeper inferior retractor eg a Deaver
  
  • If the sac is heading above the iliopubic tract, it’s an inguinal hernia; the inferior epigastric vessels provide a clue to the position of the deep ring and superficial ring
  • If the sac is heading below the iliopubic tract, it’s a femoral hernia
• In the acute setting I would like to inspect the contents of the neria, so I open the peritoneumand follow the small bowel loop down to the femoral canal; I would gain control of it before reducing it to avoid potential peritoneal spillage and contamination either with soft bowel clamps or nylon tapes
• Reduce the sac, manipulating it from above and below
• If small bowel is compromised, resect
• Close peritoneum with 2/0 vicryl
• ?transfix, ligate and divide the neck of the sac
• For a femoral hernia, repair the canal from above – options
  
  • Suture repair if strangulated
    
    • Suture iliopubic tract anteriorly to Cooper’s ligament posteriorly (ie close in AP plane of femoral ring), with a permanent monofilament suture – usually 3 interrupted 2-0 nylon or prolene; care to avoid injuring or narrowing femoral vein bc it is the lateral border of the repair
    • Or transversalis fascia can be fixed to Cooper’s ligament medially and iliopubic tract laterally
  • Mesh – usually not in acute strangulation setting
• For an inguinal hernia, I would place a polypropylene mesh in the pre-peritoneal plane to cover the myopectineal orifice
• Close in layers; anterior rectus with 0 PDS, then Scarpa’s, then skin

Question 18

Can’t reduce sac during McEvedy approach

Answer 18

• Having gently dilated the neck of the hernia with a finger alongside the sac, I would push gently over the hernia externally (from the groin) whilst applying gentle traction from within the (pre-) peritoneal surface
• Next, formally dissect the sac to free the surrounding tissue with blunt and sharp dissection in both the pre-peritoneal and subcutaneous planes, whilst leaving the neck of the sac adherent to the crural canal; occasionally it is necessary to open the sac layer by layer in the subcut plane if it is particularly thickened and oedematous
• If these measures are unsuccessful I would formally divide the lacunar ligament medially, having first made sure that there is not an aberrant obturator artery present
• Manually reduce externally with preperitoneal tension
• In rare circumstances in which the contents still can’t be reduced, inguinal ligament can be transected
• Hernia sac can be reduced through the femoral defect to transition it into an inguinal defect

Question 19

High approach to femoral hernia (Lothieson)

Answer 19

• advantage = can be used for repairing coexisting inguinal and femoral hernias
  
  • for femoral hernia alone it has the disadvantage that it damages the inguinal canal and could lead to a subsequent inguinal hernia
• expose inguinal canal and dislocate cord, as for inguinal hernia ops
• incise transversalis fascia
• identify neck of sac and external iliac vein
• isolate neck of sac and gently withdraw the fundus; if there is difficulty, have the lower skin flap retracted downwards, incise the cribriform fascia and isolate, open and empty the sac from below
• ensure the sac is empty & bladder is not adherent, then transfix, ligate and divide neck of sac
• with index finger, feel margins of femoral canal; in front is inguinal ligament, medially lacunar ligament, posteriorly pectineal ligament and laterally femoral vein
• narrow the triangular gap by inserting non-absorbable sutures of 2/0 prolene between the pectineal ligament and inguinal ligament
• if upper approach was selected bc there is also an inguinal hernia, deal w an indirect sac now
• either close the incision in the posterior wall transversalis fascia w a non-absorbable suture or carry out a mesh Lichtenstein repair
• close the inguinal canal, subcut tissue and skin as for an inguinal hernia

Question 20

Local anaesthetic for inguinal hernia repair*

Answer 20

• Inject 20mL along the line of the proposed incision using a fine needle to raise a continuous bleb within the epidermis
• Replace the needle with a larger one to inject deeply and along the same line superficial to the anterior wall of the canal
• Blunt the needle to improve the ‘feel’ of passage through the aponeurosis and inject 5mL of fluid 2cm above and medial to the ASIS deep to the external oblique to block the iliohypogastric and ilioinguinal nerves
• Reserve about half the volume of anaesthetic to inject under the external oblique aponeurosis, around the neck of the sac and into other sensitive areas during the operation

Question 21

Open inguinal hernia repair - tension free mesh repair (Lichtenstein)

Answer 21

• Skin crease incision based on the internal ring
• Dissection through subcut fat and Scarpa’s, controlling superficial epigastric vein with 2-0 vicryl ties
• External oblique aponeurosis exposed and incised sharply; incision extended along fibres of external oblique aponeurosis to external inguinal ring, to expose inguinal canal
• Identify and isolate iliohypogastric and ilioinguinal nerves
  
  • IH typically found lying on int oblique abdominal muscle after edges of external oblique aponeurosis elevated
  • II nerve runs along spermatic cord through superficial inguinal ring & terminates at skin of upper and medial parts of thigh
  • I divide them if there is a risk of entrapment (studies suggest similar incidence of chronic pain whether nerves are intentionally transected or preserved; regardless of approach, identification critical to prevent inadvertent entrapment)
• Place artery on the 2 leaves of the external oblique and reposition the self-retainer
• Spermatic cord mobilized at pubic tubercle with blunt dissection and encircled with Penrose drain
• Retract cord laterally and inferiorly to complete dissection to deep ring and identify a direct hernia
• Separate cremaster muscle from spermatic cord with blunt dissection and identify indirect hernia sac if present
  
  • Usu ant and superior to spermatic cord in indirect hernia
  • Separate sac from spermatic cord down to level of internal inguinal ring
• If any concern that a femoral hernia may be present, incise the transversalis fascia to expose the upper aspect of the femoral canal; if a femoral sac is present, deal with it via a high approach (Lothiesen procedure)
• Pick up the sac with 2 artery forceps and open it with scissors between them; return any contents to the peritoneal cavity (look out for slider) then transfix neck with Vicryl and excise the sac 1cm distal to the ligature and reduce it (alternatively fully mobilise and simply invert the sac; need not be ligated for this)
• If lipoma of cord with retroperitoneal fat herniating through internal inguinal ring, ligate and excise it
• If margins of int ring have been stretched by the indirect hernia, narrow the gap in the posterior wall using a non-absorbable suture to approximate the attenuated margins of the transversalis fascia medial to the cord
• If large indirect sac, isolate proximal portion up to the internal ring, divide the sac within the inguinal canal, transfix and ligate the neck and leave the distal portion open
• If sliding hernia
  
  • If sac intact, don’t open it; if sac has been opened, mark the fringe of peritoneum on the viscus with artery forceps and close the sac
• If distinct funicular direct sac, resulting for a localized defect in posterior wall, isolate it, empty it then transfix, ligate and divide it at the neck; define the margins of the posterior wall defect; if the hole is small and can be closed w/o tension, suture it with non-absorbable material on a fine, curved, round-bodied needle
• If diffuse direct sac and associated with a general weakness of posterior wall, don’t open it; push it inwards and maintain the invagination (plicate) with a running suture of 2/0 vicryl, carried across the stretched transversalis fascia to flatten the bulge wo tension; sutures mustn’t bite deeply or bowel or bladder may be damaged
• Using a nonabsorbable synthetic mesh cut to shape, a slit is cut in distal lateral edge to accommodate the spermatic cord
  
  • Lower medial corner of mesh is slightly rounded; the upper medial corner more so; mesh is then incised from its lateral margin, placing the cut 1/3 of the distance from the lower edge, extending for approx. half the length of the mesh, depending on the size of the pt
  • Mesh is first secured to PT with 2-0 prolene with 2cm overlap medially then inferolaterally, suture is run along shelving edge of inguinal ligament to a point 2cm lateral to the internal ring (remembering to be careful of femoral vessels which run directly below inguinal ligament in femoral sheath)
  • Overlap the tails of the mesh by bringing the lower edge of the upper portion in front of the lower tail and securing it to the inguinal ligament with two interrupted sutures (or by including it in the lateral part of the continuous suture); the resulting opening in the mesh should be a snug, but not a tight, fit around the cord
  • 4 ish interrupted sutures in superior part of mesh (to transversus abdominis muscle/conjoint tendon)
• Close external oblique with 2-0 vicryl (during which external ring is recreated), taking uneven bites
• Close scarpa’s fascia
• Continuous monocryl to skin

Question 22

Spigelian hernia

Answer 22

• Repaired because of risk of incarceration associated with a relatively narrow neck (most 1-2cm diameter)
• Mark site preop
• Transverse incision made over defect and carried through ext oblique aponeurosis
  
  • Can extend the incision medially to open the anterior rectus sheath (?why)
• Hernia sac dissected free; invert sac or open and excise, and develop pre-peritoneal space – can check along lateral edge of rectus for other defects
• Place a mesh extra-peritoneally
• Close layers of abdo wall (transversus abdominis, int oblique muscle then external oblique aponeurosis with 0 prolene
• Lap can also be used but care to completely reduce all contents prior to repair

Question 23

Nerve damage during open inguinal hernia repair

Answer 23

• II & IH nerves relatively superficial & usu seen w/o difficulty, though if cord layers incised (or removed) II nerve is at risk & must be dissected free in order to protect it
• II also at risk when superficial ring being repaired at end of procedure – can get caught in suture closing ext oblique
  
  • Supplies sensation to scrotal or labial skin & skin pubic region
• IH may only be seen if upper ext oblique flap mobilized for ≥2cm; if a darn or mesh is used, nerve at risk of being picked up by superiorly placed sutures, or if relaxing incision made in rectus sheath nerve may be divided
  
  • Supplies motor to conjoint tendon & sensation to suprapubic region
• Genital branch of genitofemoral nerve at risk unless identified running w cremasteric vessels – at risk when cleaning region of deep ring
  
  • Division can lead to some loss of labial/scrotal skin sensation & in male low-lying testicle

Question 24

Lap TAPP repair

Answer 24

• GA
• Supine, both arms tucked, positioned head-down
• Transumbilical Hasson entry
• 2x 5mm ports placed, one at lateral border of each rectus muscle (avoid inferior epigastrics)
• Inspect both inguinal areas for hernias
• Identify following landmarks: medial umbilical ligament, testicular vessels, inferior epigastric vessels, external iliac vessels
• Ensure that any contents of the hernia sacs are reduced
• transverse incision made in the peritoneum, starting at the medial umbilical ligament 1-2 cm above the hernia orifice and continuing out laterally just short of the ASIS – this line parallels arcuate line (dissect down vertically at the lateral aspect to create an L shape) – be cautious of inf epigastrics
• peritoneum grasped at edge and peeled down from transversalis fascia to expose the entire myopectineal orifice and create a ‘pocket’
  
  • when creating flap, care to avoid injury to epigastric vessels and to sweep all layers toward the anterior abdominal wall, except the thin peritoneal layer
• dissect the pocket medially to expose pubic symphysis and Cooper’s ligament, a white glistening structure along superior pubic ramus
• dissect laterally, continuing exposure to 3-5cm lateral to opening of internal inguinal ring and inferiorly until the edge of the psoas muscle is visible
• dissection of indirect hernia sac, if present, performed by placing inward traction on peritoneum & carefully separate sac from cord structures
  
  • as sac is reduced, look for gonadal vessels posterolaterally and vas deferens medially
• if direct hernia present, sac must be separated from transversalis fascia within Hesselbach’s triangle
• once peritoneal sac completely reduced and pocket enlarged to expose entire myopectineal orifice, pocket is ready for placement of mesh
  
  • check for any peritoneal defects that will result in mesh being exposed to abdominal cavity; will need to be repaired (eg if sac transected) or mesh with barrier coating used
• mesh then introduced through umbilical port, placed into preperitoneal pocket in the preperitoneal position and unrolled to cover entire myopectineal orifice
• peritoneum then reclosed with suture or tacks, thus excluding mesh from intraabdominal contents to prevent bowel adhesions and minimize risk of bowel being ‘trapped’ in preperitoneal space

Question 25

Lap TEP repair

Answer 25

• GA
• Supine with both arms tucked
• Lap tower at foot of bed
• 20cm incision inferior and slightly lateral to the umbilicus, through the anterior rectus sheath
  
  • rectus muscle retracted laterally to allow visualization of posterior rectus sheath
  • S retractor or finger to develop preperitoneal plane
  • Dissecting balloon then passed into the space and insufflated under direct lap visualization – 30 pumps
  • care not to injury inferior epigastrics
  • dissecting balloon deflated and replaced with blunt-tipped trocar after placing 0-maxon suture in anterior sheath
  • gas connected & turned on and camera introduced
• Two 5mm ports placed in lower midline 2cm and 5cm above PT
• Dissection similar to TAPP repair
• Clarify anatomy – note pubic bone medially, identify inf epigastric vessels
• Often a direct hernia, if present, will reduce spontaneously with pneumoperitoneum
• Unlike TAPP technique, indirect space must always be dissected out bc a hernia here may not be readily apparent in a TEP approach
• Peritoneum must be gently dissected from anterior abdominal wall, from level of ASIS to below iliopubic tract; don’t start at internal ring but dissect laterally and medially first
• Identify pubic bone medially and gently strip peritoneum down from this area; the bladder will be seen below the pubic bone near the midline and is gently stripped downwards and backwards; look for the sac of a direct inguinal hernia which will be seen attached to white fold of transversalis fascia
• Move to ASIS & dissect laterally; ensure epigastric vessels don’t come down and strip peritoneum downwards and backwards to reveal a portion of the psoas muscle
• Note an indirect sac as it passes forwards into the internal ring close to lower end of inferior epigastric vessels/look for it by carefully dissecting the tissues in the region of the internal ring; grasp the sac and pull it backwards, stripping tissue away from it with the right-hand instrument
• As the indirect sac is gradually withdrawn, look for the vas deferens or round ligament (passing medially) and the gonadal vessels (passing laterally); these structures are applied to the deep surface of the peritoneum at the internal ring and need to be separated from the sac
• Once hernia sacs reduced, ensure the peritoneum is well down – at least 3-4cm distant from the int ring
• Insert the mesh
  
  • Whether or not to use tacks depends on surgeon preference; most will recommend one or two in Cooper’s if direct hernia component present
• Once positioned, insufflation released as graspers hold lower edge of mesh in place

TEP vs TAPP

• no significant difference been found re length of surgery, return to normal activity, or rate of recurrence
• some studies suggest higher incidence of port-site hernias and visceral injuries with TAPP, whereas more conversions may occur w TEP
• regardless of approach, failures of lap repair occur at the inferior border as the viscera ‘sneaks in’ under the inferior edge of the mesh – so sufficient dissection of the pocket along the inferior border is paramount to reduce recurrence (some also use fibrin glue to fixate inferior edge of mesh)

Question 26

Obturator hernia

Answer 26

• Key principles
  
  • Rare hernia through obturator canal, presents as a lump in medial thigh
  • Most occur in females >50, generally presents w SBO
  • Howship-Romberg sign – pain medial thigh on hip extension, internal rotation and adduction of thigh
  • If diagnosed in elective setting can be repaired lap via TEP or TAPP approach
  • Acute repair typically via laparotomy
• Specific preop preparation
  
  • Urinary catheter
• Operation details
  
  • GA, supine
  • IDC, NG if not already present
  • IVAB on induction
  • Stand on pt’s right side
  • Lower midline laparotomy as per SBO, run SB
  • Identify hernia and reduce bowel, inspect and resect as required
  • Reduce peritoneum and any preperitoneal fat within the obturator foramen
  • If necessary, obturator foramen is opened posterior to nerve and vessels and obturator nerve can be manipulated gently with a blunt nerve hook to facilitate reduction of the fat pad
  • Generally either repair w interrupted sutures (can make lateral relaxing incision) or place mesh and cover with peritoneum – avoid injury to obturator nerve and vessels
  • Alternative is lap TEP approach as per inguinal hernia, however dissection needs to be continued down to pelvis and mesh placed in pre-peritoneal position

Relative anatomy

• Obturator canal is passageway from pelvis to medial thigh and is formed by obturator foramen (between ischium and pubis) and the obturator membrane
• Normally transmits obturator NAV which pass medially
• Hernia typically between pectineus and obturator externus muscle

Intra-op issues

• If unable to reduce – incise neck of hernia in posteromedial direction to avoid obturator NAV

Question 27

Open umbilical hernia repair

Answer 27

• Make a curved incision in the groove above or below the hernia
  
  • May need to excise umbilicus if skin compromised
• Deepen incision, identify aponeurosis and expose it around the adjacent half of the circumference of the hernia
• If the hernia is small, preserve the umbilical skin by dissecting it off the hernia as a flap
  
  • If the hernia is large, make a spindle-shaped incision to include the umbilicus, excising the stretched skin
• Expose 2cm of aponeurosis around the remainder of the margin of the hernia
• Separate the peritoneum from the under-surface of the rectus sheath all round, without tearing it
• Open sac if need be then close it at neck with a continuous 2/0 vicryl
• Insert a ventral patch 2cm larger in diameter than the defect and at each quadrant insert a 2/0 prolene suture through the flap
• Close the fascia with 1 nylon
• If skin over fundus was preserved, pick up under surface of navel with a vicryl and sew it to the rectus sheath to produce a dimple

If peritoneum breached, can consider onlay mesh (though ventral patch is coated?)

Question 28

Ventral hernia repair

Answer 28

• lap good for obese pts with small to medium-sized defects, to avoid extensive subcutaneous dissection and potential mesh infections
• open repair
  
  • synthetic sublay (retrorectus) mesh
• principles
  
  • gain safe access to reoperative abdomen
  • complete adhesiolysis of anterior abdominal wall
  • preparation of abdominal wall for prosthethic mesh placement
  • mesh deployment
  • reconstruction of a dynamic abdominal wall with reapproximation of the linea alba
• preparation
  
  • consider patient, hernia, repair factors; optimise patient; CT for planning; consider botox/progressive insufflation
• midline incision to encompass all prev incisions if possible, enter abdomen sharply
• completely free anterior abdominal wall of adhesions to lateral gutters
  
  • to avoid injuring visceral contents during dissection of lateral abdominal planes and to allow these structures to slide to midline during eventual abdominal wall reconstruction
• remove all prior prosthetic materials from abdominal wall
• create retrorectus space
  
  • grasp linea alba with Kocher clamps and incise posterior sheath approx. 0.5cm lateral from its edge; typically begun just above umbilicus
  • visualization of rectus muscle confirms retrorectus space is entered
  • create the plane with diathermy, avoiding injury to underlying rectus muscle
  • retromuscular plane then developed in a cephalad and caudal direction
  • below the arcuate line, the peritoneum and transversalis fascia are present posterior to the rectus muscle; these layers are dissected away from it
  • inferior and superior epigastric vessels are visible at most cephalad and caudad portions of dissection before coursing within rectus abdominis
  • dissection carried laterally to linea semilunaris
  • laterally perforating neurovascular bundles travelling between int oblique and transversus abdominis muscle pierces the posterior lamella of int oblique to enter the retrorectus space just medial to the linea; these are seen as the retrorectus dissection approaches the linea semilunaris and should be salvaged to preserve innervation of rectus abdominis muscle
  • this anatomic plane is localized by identifying the perforating intercostal nerves and vessels (see photo); typically 1cm lateral to inferior epigastric vessels
• if rectus muscle relatively well preserved and sufficiently wide, dissection is complete -> posterior components closed, mesh placed
• this is where Rives-Stoppa retrorectus dissection stops – lateral dissection ends at linea semilunaris
• in larger hernias requiring more overlap or in atrophic narrowed rectus muscles, can continue dissection laterally with TAR
  
  • enter pre-peritoneal space ~1cm medial to perforating nerves at linea semilunaris by dividing lateral posterior rectus sheath and transversus abdominis in the upper third; aponeurosis of transversus abdominis in middle third
  • using blunt dissection, develop preperitoneal space to psoas muscle
  • below the arcuate line, preserve the inferior epigastric vessels
  • continue dissection inferiorly to pubis and enter space of Retzius (expose pubis and bilateral Cooper’s ligaments)
  • superiorly divide the costal insertion of the posterior rectus sheath as it approaches xiphoid process - makes preperitoneal subxiphoid fat plane contiguous with retrorectus space
  • close posterior rectus sheaths along midline with 2-0 PDS
  • close any defects in posterior layer with interrupted figure-of-eight sutures or buttressed with omentum or Vicryl mesh to bridge
  • place large piece of mesh often in a diamond shape and fix it superiorly and inferiorly to Cooper’s but not laterally
  • (drains in retromuscular space above messh controversial - remove rapidly if synthetic mesh)
  • close anterior rectus sheath with 1-0 PDS
  • if unable to close fully, close proximally and distally and in the centre suture the fascial edges to the mesh

Question 29

Scrotal exploration

Answer 29

• GA, supine, IV abx
• Sterile prep and drape of whole scrotum
• Median raphe incision
• Displace testis medially so that soft tissues on appropriate side are divided using diathermy including dartos, external spermatic fascia, cremasteric fascia, internal spermatic fascia
• Cautiously open parietal layer of tunica vaginalis by picking it up between two artery forceps & widen incision to deliver testis; avoid damage to epididymis
• Viewed from below an anti-clockwise rotation is required for the right side and a clockwise for the left side – away from midline somewhere between 180-720 degrees
• If testis is dusky or black, it is placed in a sponge moistened with warm saline and left for 10min
• While waiting for torted testis to recover, deliver the contralateral testis through the midline septum
  
  • Inspect it carefully and fix it as below
• If after this the testis remains black, then an orchidectomy is required
  
  • Clamp cord with two large arteries
  • Double tie the proximal cord with an 0 Vicryl transfixing suture then 0 Vicryl tie, then cut the cord leaving both ties
  • Contra-lateral exploration and fixation then required
• If testis is viable then perform bilateral fixation
• To perform fixation, use 3/0 prolene suture; evaginate scrotum and place a suture in the parietal layer of tunica vaginalis and then a suture in corresponding place in testis
  
  • place 3 sutures, one at lower pole, one at right and left sides; tie all sutures only after placed
  • through same incision dissect into contralateral sac and perform fixation as above
• if dx not torsion, look for another cause
  
  • presence of hydrocele fluid when tunica vaginalis is opened may suggest an intrascrotal pathology
  • in acute epididymitis, epididymis appears inflamed and engorged - washout with saline

Question 30

Epididymal cyst excision

Answer 30

• Appraise
  
  • Excise only when they become uncomfortably large
  • Relatively contraindicated in young males as may cause epididymal damage leading to reduced fertility
  • Warn pts that recurrent cysts are likely
• Preparation
  
  • Check imaging and mark side to be operatived on
  • Incise scrotal skin as for hydrocele; deepen incision though scrotal layers using a handheld diathermy point or knife
  • Deliver the testis along with its appendages, including the cysts; remember that cysts are often multiple and commonly occur in upper pole of epididymis
  • Combine blunt and scissor dissection; hold testis w one hand or have an assistant hold it, while you clean off all the adventitial tissue surrounding the cyst
  • With scissors, completely excise the cyst or de-roof it by cutting off the whole protruding surface
  • If there are lots of cysts, excise the part of the epididymis bearing them
  • Oversew the raw area left following this, using fine absorbable sutures
  • Return testis to scrotum and close as per hydroceles

Question 31

Hydrocele

Answer 31

• must have had pre-op USS
• GA, supine, perforated drape
• 3 commonly practiced surgical repairs:
  
  • Lord’s plication, Jaboulay procedure and hydrocele excision
    
    • there is minimal dissection of the hydrocele sac w Lord’s plication, resulting in a relatively bloodloss procedure; works well w thin-walled hydroceles that aren’t too large
    • Jaboulay eversion and excision of the hydrocele sac requires more dissection of the sac w more opportunity for bleeding but more suited to thick-walled hydroceles
• I make a longitudinal incision down the midline raphe with the testicle and hydrocele tense under the raphe and dissect through the dartos layer
• Dissect through deeper layers by picking up between artery clips sequentially until tunica vaginalis (hydrocele) reached
• Jaboulay:
  
  • I am cautious not to cut into the hydrocele sac which is dissected from overlying layers and the hydrocele and testis delivered through the incision
  • Incise the tunica vaginalis, drain the fluid, deliver the testicle then evert the sac behind the testis
  • I hold the edges of the sac with Allis forceps and trim the sac are required then re-approximate the edges around the cord and epididymis posterior to the testis, using continuous 3-0 vicryl (may need to be trimmed)
  • testicle is delivered back into the scrotum
• Lord’s procedure:
  
  • Incise the tunica to drain the hydrocele fluid then extend the incision in the tunica using scissors
  • In Lord’s procedure, hydrocele sac isn’t dissected from dartos layer
  • To perform plication, use interrupted absorbable sutures to gather together the redundant tunica in several small bites circumferentially, starting from cut edge and working towards testis
  • Avoid placing the suture through the epididymis
  • After all the sutures have been placed, the tunica vaginalis appears bunched around the testis, thus obliterating the hydrocele
• Excision
  
  • Alternatively, excise the tunica vaginalis close to the testicle and achieve haemostasis by running a fine continuous absorbable suture round the cut edge
  • Before returning testis to scrotum, apply meticulous haemostasis using diathermy or ties where appropriate
• Closure
  
  • close dartos using a continuous absorbable suture, taking large bites of the muscle to aid haemostasis
  • close scrotal skin with 3-0 vicryl rapide
  • scrotal support to minimise swelling/haematoma

Question 32

Simple orchidectomy

Answer 32

• Indications:
  
  • Severe or recurrent attacks of acute epididymitis
  • Chronic epididmymitis, including any tuberculous epididymitis
  • Severe testicular trauma when testis not salvageable
  • Testicular infarction from a neglected torsion
  • Hormonal treatment for advanced prostate (though a subcapsular orchidectomy often preferred in this situation)
• Preparation
  
  • Discuss possibility of inserting testicular prosthesis if appropriate, but avoid inserting a FB in an infected/inflamed area; delay inserting til inflammatory process has resolved
  • Check imaging and mark side
• Action
  
  • If condition is inflammatory and involves the skin, then make the incision in the scrotum so as to excise the overlying attached infected skin if necessary
  • Leave involved skin attached to underlying structures and enter scrotal sac away from inflamed area
  • Deliver testicle w overlying attached are of skin (don’t worry about taking skin regenerates well
  • Apply gentle traction to the testicle and clean the cord structures to free ~5cm of cord
  • Cross-clamp cord at this level w 2 strong artery forceps, dividing it between them
  • Tie the clamped upper end w strong absorbable suture, but don’t release the forceps before applying a second tie; if cord is v thick, tease it into two structures and cross-clamp each, to avoid creating a bulky pedicle w a tie that’s not secure
  • Use finger dissection and traction on the lower divided cord to remove the testicle
  • In the presence of severe infection, leave scrotal wound unsutured to drain freely; otherwise place corrugated Yates’ drain through most dependent part of scrotum and insert a few interrupted absorbable sutures to approximate the skin edges
• Loose dressings only

Question 33

Inguinal orchidectomy

Answer 33

• Appraise
  
  • Removal of a testis through a groin incision is indicated where a malignancy of the testis has been diagnosed or is suspected; this approach is taken to prevent potential seeding of tumour cells into the scrotal skin
  • USS and tumour markers (but normal tumour markers don’t exclude malignancy)
  • Pre-op offer pts opportunity for cryogenic sperm banking, since subsequent oncological treatment may render the pt infertile
  • If pt requests testicular prosthesis, this can be inserted at time of orchidectomy or delayed until a later opportunity
• Preparation
  
  • Check imaging and mark
  • Position supine, prepare lower abdo and external genitalia
• Action
  
  • Make incision 1-2cm superior to surface markings of inguinal ligament from above the PT extending laterally to a point just beyond the deep inguinal ring
  • Clear external oblique, allowing clear demarcation of inguinal ligament and external inguinal ring
  • Use a knife to make a small incision in external oblique aponeurosis in direction of fibres and, using scissors, open inguinal canal from deep ring to superficial ring, exposing the spermatic cord; locate and preserve the ilio-inguinal nerve
  • Bluntly dissect the spermatic cord from the floor of the inguinal canal; doubly clamp the cord close to the deep ring and testis can then be manipulated safely
  • Apply traction on the cord w simultaneous pressure on the scrotum to deliver testis through the incision with its surrounding tunical coverings
  • The most inferior part of the testis is attached to the scrotum by the gubernaculum; divide and tie it
  • Divide the cord between the double clamps thus excising the testis and cord
  • Transfix the stump of the cord; leave an artery clip on the surgical tie so the the stump doesn’t retract into the abdominal cavity before complete haemostasis is achieved
  • Control any points of bleeding in the wound and scrotal cavity to minimize the risk of scrotal haematoma
  • Close external oblique with a continuous 2/0 Vicryl suture and reconstruct the superficial ring; be careful not to catch the ilio-inguinal nerve in your suture line
  • Close scarpas and skin; scrotal support will help to tamponade any intrascrotal bleeding

Question 34

Vasectomy

Answer 34

Key principles

• Counsel patient and partner. Should be considered irreversible
• May be initial failure rate, need to ensure 2 negative semen analysis prior to unprotected sex
• Late failure rate 1:500 due to recanalization

Preparation

• Examine scrotum and cord preop to assess accessibility of vas; a short cord length may make a LA procedure difficult espec in a nervous pt in a cold operating theatre

Operation details

• Perform under GA. Supine
• Shave area in operating room. Time out. Sterile prep and drape.
• Grasp vas at neck of scrotum and work it towards skin
• Hold vas close to skin using non-dominant hand
• If doing under LA, inject into scrotal skin and subcut tissues over the vas
• Place two Allis forceps either side of a 1cm segment of vas to be excised
• Make a vertical incision of skin between Allis forceps
• Divide through coverings layer by layer using scalpel in line of wound til glistening white muscular coat of Vas is seen
• Use another Allis to grasp the vas and free it to deliver a segment ~3cm in length and deliver into wound
• Both ends of vas clamped with artery forceps & vas cut between the ties and a short segment sent for histology
• Each end is tied with 3/0 Vicryl & then stump of vas doubled over and tied again to form a loop (some alternatively cauterize the cut ends and replace the two cut ends in the scrotum in separate tissue planes by suturing the loose adventitial tissue over one of the ends (fascial interposition)
• I push the lower end back into the scrotum
• I close the incision with 3/0 Vicryl interrupted sutures
• I incorporate the upper end into the subcut tissues to keep the ends widely separated
• I perform the same on the opposite side and apply a scrotal support

Post-operative complications

• Early – bleeding/bruising, swelling, pain, skin infection, epididymitis/vas-it is
• Late – granulomas, failure and need for re-excision, chronic scrotal pain (1 in 20 – often caused by small sperm leaks leading to local inflammation and irritation; sperm granulomas may cause palpable lumps as well as chronic scrotal pain

Specific post-op care

• Sterilisation is not immediate; do semen analysis at 3-4/12 post-op (verify that no sperm are present in ejaculate)
  
  • 2 consecutive negative sperm count within a month required to pronounce sterility
  • This also identifies the small proportion of pts w early failure due to incomplete vassal occlusion
  • if counts equivocal, re-exploration required

Question 35

Circumcision

Answer 35

• GA, supine, IV abx
• Before draping retract foreskin & clean any material underneath. Sterile prep and drape
• Mark proximal extent of incision base around glans penis; make a V-shape at the frenulum
• Place 2 artery forceps on foreskin (may need to stretch open foreskin with artery clip first)
• Incise marked skin in a circumferential manner, taking into account the frenulum posteriorly
• Incise the skin between the forceps down to the glans and incise the inner layer 3-5mm from edge of corona
• Hold up foreskin with artery and using scalpel divide loose areolar tissue; any substantial vessels should be ligated
• When I reach the frenulum I clip and tie the frenula artery
• Foreskin then disconnected
• Bipolar diathermy for any bleeding; this can be from dorsal veins or frenula artery
  
  • May choose to encircle frenula artery with a U stitch of 3-0 undied vicryl or clip and tie
• Place circumferential interrupted 3-0 vicryl rapide; do ventral part then can do U stitch at frenula and cut it long to use on a clip for retraction to place other sutures
• Cover suture line with jelonet and gauze, followed by combine with a hole in it then folded back around the penis

Complications

• Bleeding (frenula vessel usu)
• Infection
• Injury to head of penis or urethra
• Removal of too much skin
• Adhesions (penile skin can stick to head of penis)
• Poor cosmetic result
• Change of sensation during intercourse

Question 36

Ureteric stent

Answer 36

• Prepare
  
  • Review imaging and mark side to be stented
  • Arrange for a radiographer to be present in the operating theatre to operate an image intensifier for on-table fluoro
• Action
  
  • Pass a cystoscope and carefully insert into bladder
  • Locate the ureteric orifice on obstructed side
  • Pass the floppy tip of a guide-wire through the working channel of the cystoscope and direct it into the distal end of the ureter
  • Advance guide-wire slowly into ureter using the image intensifier to screen the wire as it is advanced
  • Resistance will be met when the pt reaches the obstructing stone; gently probe the stone with the guide-wire until it slides pass the stone
    
    • Advance wire into renal pelvis, where you will see it curl
  • Confirm you are in the kidney by passing a 6Fr catheter over your guidewire; again, use Xray guidance to observe catheter advancing over to your side
  • When catheter is near tip of wire, now remove the guide-wire
  • Attach a 10-20mL syringe to the end of the ureteric catheter and aspirate urine; send for culture
  • Inject radiological contrast into the ureteric catheter to outline the renal collecting system
  • Replace guide-wire through ureteric catheter then remove the catheter leaving just the guide-wire in the collecting system
• Use a double J stent based on height of the patient (26cm if tall; 24cm if average; 22cm if short)
• Feed stent over guidewire and advance it towards the kidney
• Keep cystoscope close to ureteric orifice so you do this and direct the radiographer to screen the stent as it passes up the ureter; insert a stent pusher over the wire to advance the stent through the cystoscope
• When there is an adequate length of stents in the renal pelvis, remove the wire completely, which will allow the prox end of the stent to curl in the renal pelvis and the distal end to curl in the bladder
• If your guidewire is unable to advance beyond the obstructing stone:
  
  • Pass ureteric catheter over wire to level of stone and continue to probe stone gently w the wire; the ureteric catheter will provide some stiffness to the wire and prevent it from curling beneath the stone
  • Failing this, exchange the wire for a hydrophilic ‘slippery’ wire; remember to prime the slippery wire by flushing it w saline
  • If you are unable to pass a guidewire beyond the stone, insert a nephrostomy rather than cause ureteric damage w repeated attempts at retrograde passage
• Follow-up
  
  • Leave stent for 4-6wks before attempting stone removal – will also allow any infection to be treated completely and ureteric inflammation to settle
    
    • A stent will also result in ureteric paralysis and dilatation facilitating subsequent ureteroscopy
  • Prior to stone surgery, obtain a plain KUB xray to locate position of stone alongside stent
  • Ureteroscopy should be performed by a urologist
    
    • Semi-rigid ureteroscope is used for ureteric stones w laser stone fragmentation
    • Occasionally, a ureteric stone is pushed back into kidney during stent insertion and will require flexible ureteroscopy for fragmentation and removal

Question 37

Lateral sphincterotomy

Answer 37

• Lithotomy position w headlight
• Iodine skin prep
• Ano-proctoscopy
• Parks retractor for exposure
• Identify intersphincteric groove by palpation and make a mucosal incision with a 15 blade along the groove (not radial)
• Use a mosquito forceps to spread parallel to the muscle and develop the groove deeper
• Use left hand to find the band and guide your mosquito in to deliver lower portion of int anal sphincter into the wound
• Prox extent of dissection is tailored to height of fissure but never above dentate line
• Diathermy used to divide sphincter muscles under vision
• Apply pressure on area for 2 mins and apply a pad for dressing
• Discharge w bulk laxatives

Question 38

Initial management of fistula in ano

Answer 38

• acutely: drain sepsis only (meta-analysis of trials looking at acute fistulotomy or seton found reduced risk of recurrence at final f/u but this was assoc w tendency to higher risk of flatus incontinence & soiling (RR 2.46)
  
  • exception would be an obvious chronic tract in context of recurrent abscess formation
• then early elective EUA
  
  • define anatomy
  • if simple fistula, fistulotomy
    
    • in general, may lay open if encompasses
      
      • half of ext sphincter posteriorly in a man, 1/3 in a woman
      • 1/3 of ext sphincter ant in a man, never anteriorly in a woman
  • if not simple, want sepsis eradicated & well-formed chronic tract; place seton

Question 39

How is an endoanal/endorectal advancement flap performed?

Answer 39

The endoanal and endorectal advancement flaps preserve the anal sphincter by closing off the internal opening of the fistula with a mobilised flap of healthy tissue consisting of mucosa and submucosa, w or w/o the internal sphincter. The flap provides tissue coverage of the tract’s internal opening and allows it to heal and close.

These are the preferred approach for complicated anorectal fistulas w/o coexisting incontinence. Not all anorectal fistula pts are candidates for mucosal flap advancement - v high fistulas technically challenging; relative contraindications = anal stenosis, active proctitis, IBD (due to high complication and failure rates).

• GA, enema, lithotomy if posterior or prone if anterior. Lonestar retractor
• external opening: core out fistulous tract from external opening to external sphincter
• locate internal opening
• infiltrate 0.25% marcaine with adrenaline
• excise the internal opening down to the underlying muscle
• prepare the flap:
  
  • curvilinear incision around the dentate line that includes the mucosa, submucosa and a portion of the circular muscular fibres that is sufficient to cover the internal opening
  • base of flap proximally should measure at least twice its width at apex, and the base should be no more than 1/3 of the anal canal circumference to prevent stricture formation
  • ensure the flap isn’t too thin
• curette and debride the fistula tract
• advance the flap distally beyond the internal opening and suture in place; prefer to anchor the centre & most cephalad portion of the underside of the flap first; then the lateral portion of the flap is secured w a running or interrupted suture

Outcomes: cure rates ?75%, low-to-moderate recurrence in experienced hands (0-40%), tolerable incontinence rates (0-12.5%)

Question 40

LIFT procedure*

Answer 40

Ligation of the intersphincteric fistula tract - a sphincter-sparing procedure for complex transsphincteric fistulas.

• performed through the intersphincteric plane (ie with a separate intersphincteric incision) and is based on the secure closure of the internal opening & removal of infected cryptoglandular tissue
• GA, lithotomy (or prone depending on location of internal opening)
• identify external and then internal opening; place a lockhart-mammary probe into the tract
• identify the intersphincteric groove and incise down to the probe and isolate the intersphincteric fistula tract; hook it with a small, right-angled clamp
• place a lonestar retractor to facilitate dissection
• ligate the tract with 3-0 vicryl close to the internal sphincter then divide distal to this
• hydrogen peroxide is injected through the external opening to confirm division of correct tract
• external opening and remnant fistulous tract are curetted to level of proximity of external sphincter complex
• finally, intersphincteric incision is loosely reapproximated with an absorbable suture
• curettaged wound is left open for dressings
• a modification to the LIFT technique unroofs the fistula from the internal opening, therefore eliminating the intersphincteric wound - in one study this was as effective but faster than original LIFT
• can also cauterise the internal opening then close it with interrupted 3-0 sutures
• can be used to treat both simple and complex fistulas; tract >3cm, previous procedures and obesity have been assoc w LIFT failure
• healing in 61-94% in 4-8wks (low fistulas 80-90%, more complex 57%), faecal incontinence rare (1.4%)

Question 41

Anal sphincter repair*

Answer 41

• Grades of tears:
  
  • 1st degree = skin and subcut tissue of perineum & vaginal epithelium only; perineal muscles remain intact
  • 2nd degree = extend into fascia & musculature of perineal body, which includes deep and superficial transverse perineal muscles and fibres of pubococcygeus and bulbocavernosus muscles; anal sphincter muscles remain intact
  • 3rd degree = complete or partial disruption of sphincter complex
    
    • 3a - <50% of EAS thickness is torn
    • 3b - >50% of EAS thickness is torn
    • 3c - both EAS & IAS are torn
  • 4th degree = both EAS & IAS & anal mucosa torn
• 3rd & 4th degree tears should be repaired in operating room within 8-12hrs (ideally sooner)
• no specific advantage to end-to-end approximation vs overlaping technique (latter requires more extensive mobilisation of EAS & therefore only possible for injuries that involve >50% of EAS
• can use PDS or vicryl
• aim is
  
  • to restore continuity of both external and internal anal sphincters, with a thick perineal body and rectovaginal septum created to provide muscular and structural support in the thin area between the anterior anorectum & vagina
  • proper recon will also result in lengthening of the anal canal and restoration of a functional HPZ within it
  • goal = recon of a muscular cylinder ≥2cm thick & 3cm long
• GA, prone jackknife or lithotomy
• acute:
  
  • if 4th degree, repair torn anal mucosa with continuous 3-0 or 4-0 vicryl or PDS
  • identify IAS and repair as a separate layer (often retracts laterally & superiorly) - continuous 3-0 vicryl or PDS
  • identify and grasp ends of EAS with Allis clamps - repair with either end-to-end or overlapping plication of disrupted EAS & its capsule with interrupted or figure-of-8 sutures (2-0 or 3-0 PDS or 2-0 vicryl on cut tapered 1 or 2 needle)
    
    • usually place at least 4 or 5 interrupted sutures
  • rebuild distal rectovaginal septum & perineal body - helps to maintain spacial distance between anus & vagina & may prevent suture erosion from deeper layers; also takes tension off underlying sphincter repair - interrupted 2/0 vicryl on cutting needle
• elective (LH)
  
  • GA, prone jackknife
  • make an incision 5mm distal to the anal verge, centered at the point of injury and extend for 120 degrees
  • dissect into the ischiorectal fat
  • mobilise the anus from the vagina by placing two fingers into teh vagina and two Allis forceps on the anal margin wound
  • incise the full thickness scar and sphincter complex
  • dissect this away from the anal mucosa
  • mobilise the sphincter to allow for 2cm overlap and fix with 2-0 PDS
  • close the skin

Question 42

Loop ileostomy formation

Answer 42

• Siting:
  
  • Ideally sited pre-op with patient in sitting position
  • Err on side of a superiorly placed ileostomy near level of umbo; avoid natural skin creases and belt line
• Having completed the initial part of the operation I stand on the patient’s right with my assistant on the left
• Choose site of bowel – usually 20cm proximal to IC valve and check it reaches skin without tension.
• Make trephine – I place a large pack over the abdominal contents and place two littlewoods on the edge of the fascia for my assistant to retract medially on
• With diathermy I make a circular incision in the skin and remove a disc of skin. I dissect down to the anterior sheath and make a cruciate incision in this, split the rectus muscle bluntly and incise the posterior sheath; I perform this step with my hand behind the abdominal wall and a large pack over the bowel
• I recheck that the piece of bowel I have selected reaches through the trephine without tension. I make a small incision in the mesentery adjacent to the bowel, ensure it isn’t twisted and thread a nelaton catheter through this with the black port on the medial side to keep track of my orientation. I bring the bowel through the trephine and secure the catheter on the outside
• I close the midline
• Maturing:
  
  • I make a transverse incision in the bowel
  • I spout the mucosa (if loop then proximal limb only)
  • I place 4 interrupted 3-0 PDS sutures – left untied
    
    • Full thickness bowel bite distally
    • Seromuscular bite 4cm proximally
    • Dermal bite
  • 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 43

Sacral nerve stimulation

Answer 43

• This is done in two stages; the first is a testing phase and the second is permanent if benefit is gained from the testing phase
• GA, prone jack knife with anus and toes exposed
• Mark out landmarks for S3 foramina, 1cm cephalad to crest of sacrum and 1cm lateral to midline
• 20G spinal needle into S3 on each side and find the best response to stimulation using an external handheld neurostimulator
• look for lifting and flattening of the buttock groove and flexion of the big toe; change for the temporary pacing wire
• once patient awake, attach the external stimulator for a 3 week test phase
• insert the permanent device if a 50% improvement in symptoms is seen
  
  • place the permanent wire with barbs and tunnel it subcutaneously and place the stimulator in the buttock

Question 44

Abdominal (resection) rectopexy*

Answer 44

• GA in low Lloyd-Davis
• Can be done open or lap
• Pfannenstiel incision used, fascia vertically incised and a Balfour retractor is placed
• TME plane entered beneath IMA pedicle and this is developed posteriorly then laterally then anteriorly to mobilise the rectum; the uterus requires retraction as these pts often have a very deep pouch of Douglas
• If redundant sigmoid it 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 45

Altmeier’s procedure

Answer 45

• 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
• Lonestar, prolapse rectum
• Score the mucosa with diathermy 1-2cm proximal to dentate line
• Infiltrate submucosal plane with 0.25% Marcaine & adrenaline
• Anteriorly dissect through mucosa, muscle and serosa to reach mesorectal fat; careful not to injure vagina or bladder if concurrent prolapse
• Continue laterally; 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 mobilized proximally
• Mesorectal vessels are ligated with an energy device or suture ligature; perform circumferential mobilization until resistance to traction felt
• At this point open the peritoneal cul-de-sac or pouch of douglas to allow entry into peritoneal cavity – this will allow for palpation of the redundant sigmoid colon, division of mesorectum and mesosigmoid continues til redundancy has been adequately reduced
• Care taken as dissection proceeds as retraction of bleeding vessels may need ur
• Can add levatorplasty anteriorly or posteriorly at this point as an addition to the traditional procedure; improves faecal incontinence by restoring the angle of the pelvic floor which may have become lax over time – ?absorbable or non-absorbable figure 8 2-0 sutures. Should be able to pass a single finger around the rectum
• Once colon adequately retracted through anus, line of proximal dissection is marked with cautery & colon is transected proximally, beginning anteriorly
• 3-0 PDS placed between cut edge of proximal sigmoid and cut edge of anal canal – place anterior coloanal sutures
• then transect posterior aspect and place interrupted posterior sutures
• postop care involves early mobilization, laxatives and simple analgesia

Complications

• bleeding
• anastomotic dehiscence
• pelvic sepsis
• coloanal stricture
• prolapse recurrence

Question 46

Delorme’s procedure

Answer 46

• Also known as a mucosal sleeve resection, this is to treat small full thickness rectal prolapse and involves removal of prolapsing rectal mucosa 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, Lone star retractor
• Prolapse the bowel with Babcocks 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 (?identify white annular fibres of rectal wall lying deep to submucosa), which I dissect distally to apex of prolapse; where difficult I use scissors
• I dissect this on a broad front, grasping the mucosa with Debakey forceps
• ??As I go, I place 4 stay-sutures into the mucosa near the dentate line – is this necessary?
• Once I reach the apex of the prolapse, I leave the mucosa hanging on Babcocks and place 8 plication sutures in a linear fashion through the muscularis from the apex of the prolapse to the distal edge of the mucosa just proximal to the dentate line using 3-0 PDS, with 3-4 bites; these are clipped then tied after placement of the 8^th suture
  
  • 4 of these are left long to improve exposure for the following stitches
• the mucosa is trimmed off and interrupted 3-0 Vicryl sutures are used to close the two cut edges of mucosa which are now adjacent to each other
• the stay sutures are released and the bowel reduces back into the anorectum
• I use the rest of my local as a pudendal block and place a spongostan dressing
• post-op laxatives and early mobilization

Question 47

Anterior resection*

Answer 47

• Bowel prep with pico prep, metronidazole and ciprofloxacin
• mark stoma sites
• GA, modified Lloyd Davies, stand on patient’s right
• Midline laparotomy
• Diagnostic laparotomy
• Omnitract
• Pack small bowel to right
• Mobilise the sigmoid colon from the lateral side in its embryological plane, identifying and protecting the gonadal vessels and ureter
• Mobilise the splenic flexure from lateral to medial, until the IMV
• I divide the IMV just below the pancreas
• I then have my assistant elevate the mesentery of the colon superiorly and I open the peritoneum to the right of the IMA parallel to the vessel and dissect it out to encircle it with my left index finger
  
  • (I keep close to the back wall of the IMA and sweep away any hypogastric plexus (sympathetic) fibres posteriorly)
  • I divide the IMA 1cm distal to its origin to protect para-aortic autonomic nerves, and just proximal to the left colic artery
• I then pack away the sigmoid colon and proceed with my TME dissection
• I enter the mesorectal plane posteriorly behind the inferior mesenteric vessels, dissecting the plane between the presacral fascia and mesorectum, using the St Marks retractor in my left hand with my assistant retracting the rectum superiorly
• I continue this posterior dissection until I am below the tumour and continue this laterally and anteriorly
  
  • I preserve the so-called ‘lateral ligaments’ which represent areas of adherence between the mesorectum medially and the plexus laterally
  • In a male, unless the tumour is anterior, I keep my anterior resection posterior to Denonvillier’s fascia
• I use a contour stapler to divide the rectum
• I have my assistant size the EEA stapler from below (29-33mm)
• I prepare the anvil in the proximal bowel and then perform and end-to-end stapled anastomosis
• leak test
• close with 1 PDS on CT1 needle

Question 48

APR

Answer 48

• Bowel prepped, stoma site marked
• GA, modified Lloyd Davies, stand on patient’s right
• Midline laparotomy
• Alexis wound retractor
• Pack small bowel to right
• Mobilise the sigmoid colon from the lateral side in its embryological plane, identifying and protecting the gonadal vessels and ureter
• I then have my assistant elevate the mesentery of the distal sigmoid under slight tension and open the peritoneum to the right of the IMA parallel to the vessel and dissect it out to encircle it with my left index finger
  
  • (I keep close to the back wall of the IMA and sweep away any hypogastric plexus (sympathetic) fibres posteriorly)
  • I divide the IMA 1cm distal to its origin to protect para-aortic autonomic nerves, and just proximal to the left colic artery
• I divide the distal sigmoid just proximal to the first sigmoid branch, after checking for pulsatile flow in the marginal artery
• I don’t routinely mobilise the splenic flexure or take the IMV high unless this is required for length
• I then pack away the sigmoid colon and proceed with my TME dissection
• I enter the mesorectal plane posteriorly behind the inferior mesenteric vessels, dissecting the plane between the presacral fascia and mesorectum, using the St Marks retractor in my left hand with my assistant retracting the rectum superiorly
• I continue this posterior dissection as far as I can go, ultimately stopping my dissection at the tip of the coccyx near the level of the origin of the levators. I perform a cylindrical APR and avoid ‘coning in’ which may compromise the circumferential margin of the tumour
• I extend my dissection laterally to each side until I reach the anterior peritoneal reflection, preserving the so-called ‘lateral ligaments’ which represent areas of adherence between the mesorectum medially and the plexus laterally
• In a male, unless the tumour is anterior, I keep my anterior resection posterior to Denonvillier’s fascia. I continue my anterior dissection as far distally as possible, to the pelvic floor
• I perform the perineal dissection with the patient in lithotomy
• I close the anal canal with a 2-0 silk and make an elliptical incision just outside the perineal skin
• I use a Lonestar retractor
• The margins of my dissection are determined by anatomy and tumour location; in general my posterior margin is the palpated coccyx, the lateral margins the ischial tuberosities, the anterior margin the urethra in men and posterior vaginal wall in female
• I first dissect posteriorly and enter the ischiorectal fossa on each side
  
  • I divide the anococcygeal ligament and my dissection joins the abdominal dissection, just anterior to the coccyx
• I then continue my lateral dissection, dividing the lateral origin of the levator muscles in an extra-levator plane by placing my finger into the pelvis and hooking it behind the levators, then dividing them with diathermy
• The anterior margin is the most difficult and is dissected last
  
  • A finger in the female vagina or palpating the Foley catheter in a male can help
• I then deliver the specimen through the perineal wound and close the wound in layers
  
  • (or reconstruct with a mesh or flap with the help of Plastics; flap options include posterior thigh/gluteal flaps, anterolateral thigh flaps or vertical rectus abdominis flaps)
• I then rescrub, check haemostasis in the pelvis and create my end colostomy
• I leave a pelvic drain (?) and close the midline

Question 49

Hartmanns

Answer 49

Key principles

• Inflammatory v oncological - decide on purpose of procedure pre-op
• Resect to healthy bowel
• Protect ureter
• Minimize retraction on spleen

Specific preop preparation

• Consider JJ stent in difficult cases if concern of ureteric involvement
• Stoma nurse marking; or if not then I would mark prior to scrubbing – avoid bony areas, creases, previous scars; in presence of panus the stoma will need to be sited above it
  
  • Usually position stoma within a triangle formed by the ASIS, umbilicus and pubic symphysis; ideally the colostomy should be brought out through the fibres of the rectus abdominis

Operation

• Supine, large midline incision
• Adhesiolysis
• Inspect small bowel and retract to right side using moist pack and fixed retractor
• Mobilise the left colon, initially dividing the congenital sigmoid adhesions and then mobilizing it in its embryological plane
• Identify the gonadals and ureter, the latter which can be reliably identified as it crosses the common iliac vessels; once found the gonadals and left ureter are displaced posteriorly and mobilization continues towards the midline
• Ideally it is best to avoid mobilization of the upper rectum as this makes subsequent reversal more challenging; however, in some instances, it will be necessary to permit distal transection
• Upon adequate mobilization, the limits of the resection are marked at the mesenteric border of the sigmoid and the peritoneum between the 2 sites is scored in preparation for vessel ligation
  
  • The mesentery is then transilluminated and the vessels individually isolated, ligated and divide using 0 or 2/0 vicryl, as appropriate
• The diseased sigmoid colon is then resected with a 80mm GIA stapler
  
  • The distal margin of resection is usually at the rectosigmoid junction
• Now check there is adequate mobility on the descending colon proximally to allow the colostomy to be fashioned without tension
  
  • Formal mobilization of the splenic flexure is seldom necessary
  • If do need to take the splenic flexure, often have to take the IMV high as well
• NB 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 with specimen
• The stump is oversewn with 3-0 PDS and marked with prolene to facilitate its identification during the reversal procedure
• Washout
• Consider drain
• Create trephine in LIF
  
  • Skin and fascia firmly grasped and the skin at the proposed stoma site is grasped with an Allis forceps and a circular incision made with cutting electrocautery; a disc of skin ~3cm diameter is then excised; I usually preserve the subcut fat
  • Using retractors I dissect down to the anterior rectus sheath and excise this in a cruciate fashion
  • I have a pack in the abdomen and elevate the abdominal wawll with my hand to protect the underlying viscera
  • The rectus muscle is spread transversely and longitudinally to identify the posterior rectus sheath; I protect the inferior epigastric arteries during this step
  • A similar cruciate incision is made in the posterior sheath; the resulting defect should be large enough to easily accommodate 2-3 fingers
  • Two babcocks are placed through the defect to grasp the colon which is brought up, avoiding any twists or constriction of the mesentery
• Close midline
• Maturation of flush stoma with 3-0 monocryl

Question 50

Intra-operative ureteric injury

Answer 50

• Ureteric injury
  
  • Prevention
  • Attempt to minimize further harm; confirm that it’s the ureter, assess the level of injury, any evidence of tissue loss and viability of the cut ends
  • After assessing the severity I would contact a urologist for help
  • The options may include:
    
    • Uretero-ureterostomy repair over a stent when injury is to the mid or upper ureter above the bifurcation of the iliac vessels
    • If injury is distal enough to allow the proximal ureter to be mobilized and inserted into the dome of the bladder w/o tension, a uretero-neocystostomy without psoas hitch would be appropriate
  • If a urologist can’t attend, I would be guided by him/her over the phone as to how to salvage the situation until it can be definitively repaired by an expert; options may include placement of a drain tube, a stent or exteriorization of the cut end

Question 51

Small bowel resection

Answer 51

• Examine entire small bowel from DJ flexure to TI to ensure there is no other pathology
• Choose the sites of small bowel excision and make mesenteric windows adjacent to the bowel at this point
• 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 bowel outside the area of resection
• Place unfolded large packs around working area
• Place crushing bowel clamps on the bowel to be resected; use a scalpel to excise the specimen including the crushing 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 seromuscular bites, using a 3-0 PDS II on a taper point SH needle
• I perform interrupted sutures halfway between previous sutures; then turn the anastomosis over using the stay sutures and do the other side
• I then revert the bowel back to its normal alignment using the stay sutures
• I remove the soft bowel clamps
• I close the mesenteric defect with figure-of-8 3-0 PDS sutures

Question 52

Transanal excision of a rectal polyp*

Answer 52

• indications: rectal polyp, or T1 tumour that is <8cm from anal verge with no high risk features, <3cm and <1/3 circumference, no LVI, no PNI, well differentiated, absence of mucinous or signet ring
• aim is to resect full thickness down to mesoretal fat with 1cm margin
• preop: full bowel prep
• operation
  
  • lithotomy (posterior lesions) or prone (anterior lesions)
  • parks retractors to expose the lesion
  • traction sutures can be placed distal to the lesion to improve mobility and visualisation
  • 1cm margin marked out with diathermy and full-thickness excision done
  • irrigation
  • defect can be left open or closed transversely with absorbable sutures

Question 53

Total abdominal colectomy for colitis

Answer 53

• mark ileostomy site
• Lloyd davies, catheterise bladder
• midline incision
• omnitract
• exploratory laparotomy
  
  • the colon is hyperaemic, thickened & oedematous - don’t handle it excssively and don’t pull away adherent omentum or lateral pelvic wall adhesions as these may be the site of sealed perforations
  • note any free gas or fluid; if perforation this can be used as a point to decompress the colon proximally and distally then try to close w purse-string before proceeding; oversew serosal tears that could progress to full thickness defects
  • typically the colon is massively dilated and visualisation difficult; decompression useful
  • examine SB for skip lesions and the SB mesentery for enlarged LNs which might suggest Crohn’s disease
• gently dissect the colon from its lateral attachments, starting at the caecum and mobilising it completely round to the rectum, taking care to avoid too much traction
  
  • if colon is fixed to lateral abdominal wall, remove a disc of peritoneum with it rather than risk opening a sealed perforation
  • if the omentum is uninvolved and moves freely it can be separated from transverse colon and will prevent adhesions between the small bowel and laparotomy wound, but if difficult to dissect just remove it with the colon (also gets in the way later if trying to do a lap pouch)
• transilluminate the mesentery and divide the vessels at a suitable place near to the bowel
  
  • take care to preserve terminal ileal arcades/ileocolic artery which may provide blood supply for a subequent ileal pouch
  • preserve superior rectal artery to decrease possibility of rectal devascularisatoin
  • if suspicion there could be malignancy, need to be down at pedicles but also sometimes this can be quicker because there are only 3-4 vessels to deal with
• mobilise TI and transect it using a linear cutting stapler 1-2cm proximal to IC valve
• divide lower sigmoid colon with a stapler (rectosigmoid at lowest but may be further up in lower sigmoid depending on what you want to do with the stump)
  
  • bring out through lower end of wound as a mucous fistula or tack the corner above the fascia
  • if not enough length oversew, mobilise omentum to cover it and leave malecot but better to not divide it too low instead (if leaving a closed rectal stump irrigate the rectum prior)
• bring ileum through ileostomy trephine and close abdomen
• mature ileostomy/mucous fistula

Question 54

Total colectomy with ileorectal anastomosis

Answer 54

• colon mobilised, preserving omentum
• preserve superior rectal artery and vein and avoid damaging pre-sacral nerves
• right-angled clamp across rectosigmoid junction and irrigate the rectum through the anus
• soft bowel clamp on ileum then crushing; divide the ileum excising the crushing clamp
• divide the rectosigmoid below the right-angle clamp with a long-handled scalpel and remove the specimen; hold up the rectum with Babcock’s
• antimesenteric slit in ileum to match its size to the rectosigmoid
• single layer seromusuclar inverting sutures with PDS (or staple across rectosigmoid and use a 28mm CEEA stapler for the anastomosis

Question 55

Total proctocolectomy

Answer 55

• if previous colectomy and mucous fistula, mobilise the mucous fistula when teh wound is reopened and staple or oversew the lumen of the sigmoid
• otherwise perform colectomy as previously described
• mobilise rectum with peritoneal incision on both sides close to the rectal wall, joined anteriorly just above the peritoneal reflection
  
  • preserve the superior rectal artery + the presacral fat and nerves; clamp, divide and ligate the individual sigmoid and rectal arteries close to the rectal wall with fine ligatures
  • alternatively, excise the mesorectum as for anterior resection of the rectum but don’t breach the presacral fascia or damagge the presacral nerves
• dissect posteirorly as far as the coccyx
• dissect anteriorly between the rectum and vagina in female or between the rectum and prostate
• laterally preserve the lateral ligaments
• place strong purse-string suture around anus close to anal margin; aim to remove minimal perianal skin
• make circumferential incision and deepen it to expose the intersphincteric plane between the pale fibres of the internal sphincter and the darker voluntary muscles fo the external sphincter - Lonestar retractor
• deepen dissection bilaterally, separating internal sphincter from puborectalis and levator muscles to establish a plane into pelvis then dissect posteriorly up to puborectalis sling
• deepen anterior part of dissection behind superficial and deep transverse perineal muscles then continue the dissection upwards, in the female between the vagina and rectal wall
  
  • in the male, the external sphincter decussates in midline to merge w fibres of rectourethralis muscle - cut the strap-like rectourethralis to expose posterior aspect of prostate gland and divide visceral pelvic fascia laterally on each side wher eit is condensed on to lateral lobe of prostate
  • seminal vesicles then seen in upper part of wound
  • divide Waldeyer’s fascia posteirorly to meet abdominal dissection
• divide any remaining lateral attachments and remove specimen through perineum, leaving a small wound with the external sphincter and the whole of the levator muscles intact
• approximate puborectalis and levator muscles with interrupted vicryl
• close subcut tissue in two layers with interruptetd vicryl
• close skin with interrupted 3/0 nylon on cutting needle

Question 56

Restorative proctocolectomy + IPAA

Answer 56

• divide anorectal junction at level of puborectalis sling, preserving int and ext sphincters
• construct a stapled ‘J’ pouch from a 40cm loop of TI using multiple firings of a linear cutting stapler to produce a pouch 20cm in length
  
  • if the apex of the pouch can be brought to 6cm below the inf margin of the symphysis pubis then a tension-free anastomosis can usually be constructed
  • freeing mesentery up to duo should be undertaken routinely and extra length can be achieved by making relaxing incisions in teh preitoneum of the mesentery
  • sometimes necessary to divide one of the main arteries of supply eg ileocolic or major continuation of the SMA - always precede with trial of vascular occlusion with appropriate clamps
• ileoanal anastomosis is usually constructed using a 25mm diameter CEEA circular stapler, the anastomosis lying 1-2cm above the dentate line
• avoid leaving a cuff of residual rectum below the anastomosis as this will result in persistent inflammation, bleeding and urgency (‘cuffitis’) which may result in failure of the pouch
• defunction with loop ileostomy

Question 57

On-table colonic lavage

Answer 57

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

Question 58

Open right hemi

Answer 58

• Pre-op
  
  • Ensure full work-up with clinical and pathological staging complete
  • No bowel prep
  • Ensure stoma site marked if acute or Crohns
• GA, supine, strapped to table, arms out
• Steps:
  
  • Entry/laparotomy
  • Mobilization of right colon and terminal ileum off duodenum
  • Ligation and division of blood vessels
  • Resection
  • Anastomosis
  • closure
• Access:
  
  • Stand on pt’s left, midline incision above and below umbilicus
  • Diagnostic laparotomy; liver, peritoneum, bowel, check for synchronous tumours (3-5%) or free fluid/contamination or bowel ischaemia if acute
  • Pack small bowel towards pelvis/LLQ with moist pack
  • In the case of a caecal volvulus I would consider deflation of the caecum with a 16-18G needle on a 5mL syringe with the plunger replaced with suction tubing through a taenia coli
• Mobilization:
  
  • (in the case of a caecal volvulus the caecum and ascending colon will usually be drawn medially)
  • Mobilise the right colon in its embryological plane using a lateral approach
  • Medially retracting the colon, I use diathermy to incise the lateral attachments of the colon
  • I am looking to identify, dissect, free and preserve the retroperitoneal structures from the right mesocolon; the 2^nd part of the duodenum is the key structure as the right ureter/gonadals are only infrequently seen
  • I then use my left index finger to sweep around the colon and ask my assistant to diathermy onto my finger and so release the hepatic flexure
  • I am cautious not to avulse the fragile mesocolic veins at the hepatic flexure with excessive traction on the specimen, particularly when the mesocolon is short; there are often vessels in the hepatocolic ligament that need to be formally divided
  • I facilitate mobilization from the transverse colon end by dissecting the anterior leaf of the greater omentum off the proximal transverse colon and meeting up with my previous dissection plane
  • Finally, any terminal ileal bands/adhesions are divided so the whole of the right colon can be lifted towards the midline
• Resection
  
  • Once the mesocolon is lifted free of the underlying duodenum and pancreas I secure the vascular pedicles
  • With adequate mobilization of the duodenum away from the mesocolon, identification of the ileocolic artery at its origin from the SMA is usually obvious
    
    • The mesentery of the resection is scored, windows are made on either side of the pedicle with pinching-technique
    • Roberts are applied and the pedicle is divided and ligated with 0 vicryl
  • With my assistant elevating the specimen I can transilluminate the mesentery to identify the ileal, right colic and other mesenteric vessels prior to their ligation and division; the right colics if present and the marginal artery or sometimes the right branch of the middle colic are divided
  • Extent of resection will usually include approximately 10cm of TI and the colon to the mid-third of the transverse colon
  • Prior to ligation of marginal artery/right branch of middle check for pulsatile flow
  • Soft clamps are applied
  • Large unfolded packs are laid down
• Anastomosis:
  
  • The bowel is lined up and I make an antimesenteric colostomy and enterotomy for the GIA 80mm blue stapler
  • This is fired ensuring the mesentery is well clear and the two edges of the common enterotomy are grasped with Babcock’s
  • As I remove the stapler I check the internal staple line for bleeding
  • I off-set the staple lines 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 with 2-0 PDS II on a sharp needle and the skin with monocryl

Extended right hemi:

• Low-Lloyd 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 59

Lap right hemi

Answer 59

• GA, supine, both arms in, secured to table for Trendelenberg and tilt
• Access:
  
  • 4 ports; 10mm Hasson through umbilicus, 10mm port left upper abdomen, 5mm port LIF, 5mm port suprapubic region
  • diagnostic laparoscopy
• Mobilization
  
  • 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 dissection 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 and this is taken with 3 Hemolok 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 required)
  • I then continue the dissection around the hepatic flexure and down the ascending colon until the caecum and TI are fully mobilized
  • I check the mobilization 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 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 60

Stricturoplasty

Answer 60

• Usually in the context of Crohn’s disease (chronic structuring/fibrosing disease) of the small bowel in order to relieve obstruction and preserve bowel length
  
  • Advantage lies in preservation of the intestinal absorptive capacity of the normal segments of bowel located between strictures
  • Stricturoplasties can either be performed alone or in conjunction with a resection, but they are best performed in the presence of either long segments of stricturing disease or multiple short strictures in which a resection would result in the loss of a lengthy segment of bowel or in pts w multiple prior resections
  • Also indicated when they offer a simpler alternative to resection, as is the case w short recurrent disease at a previous anastomotic site
  • Contraindicated in presence of generalized, intra-abdominal sepsis, acutely inflamed phlegmonous intestinal segments, fistulas, abscesses or long, tight strictures with thick unyielding intestinal walls
  • The choice of when to perform a stricturoplasty and what technique is used depends on number of strictures, length of each stricture and distribution of strictures and the intervening normal small bowel
• For strictures 2-3cm in length I perform this in a modified Heineke-Mikalicz fashion
• Pre-op preparation
  
  • Confirm diagnosis
  • Confirm strictures and position/degree of obstruction
    
    • If areas of stenosis are suspected but not evident on serosal inspection, a Foley catheter with a balloon inflated to 2cm and inserted through an enterotomy can be used to assess these sites
  • Exclude active sepsis or inflammation
  • Several strictures in short period or active inflammation is usually better served with a small bowel resection
• Supine under GA
• Lap or open; if open, midline laparotomy
• Identification of stricture and examination of rest of SB
• Assess tightness to ensure stricturoplasty required
• Longitudinal full thickness enterotomy with diathermy through stenotic area and onto healthy normal bowel either side for a distance of 1-2cm
• Frozen section if any concern about malignancy?
• Consider passing a foley catheter through the enterotomy
• Apply stay sutures to middle of incision on each side and retract in opposite directions; this marks the new ends of the transverse closure
• Close incision in a transverse fashion with interrupted full thickness single layer 3-0 PDS
• Test air and water tight

Alternative for longer strictures: Modification of Finney stricturoplasty vs resection

Finney stricturoplasty:

• Appropriate for strictures up to 15cm in length
• A stay suture is placed in midportion of strictured site
• The strictured segment is then folded onto itself into a U shape
• A row of seromuscular sutures is placed between the two arms of the U, and a longitudinal U-shaped enterotomy is then made, paralleling the row of sutures
• The mucosal surface is examined and biopsies with frozen section if concern for malignancy
• Full-thickness sutures are then placed in a continuous single layer beginning at the posterior wall of the apex of the stricturoplasty and continued down to approximate the proximal and distal ends of the enterotomy
• This full-thickness suture line is continued anteriorly to close the stricturoplasty
• A row of seromuscular Lembert sutures is then placed anteriorly
• One drawback of this procedure is that a very long Finney stricturoplasty may result in a functional bypass with a large lateral diverticulum which can be at risk for bacterial overgrowth

Michelassi Stricturoplasty = side-to-side isoperastaltic stricturoplasty

• In general, repeated Heineke-Mikulicz or Finney stricturoplasties should be separated from each other by at least 5cm to avoid forming a bulky segment of intestine and placing tension on each suture line
• Pts w multiple strictures that are grouped close together or a long segment of structuring disease (>20cm in length) are best managed w an isoperistaltic side-to-side stricturoplasty
• Mesentery of strictured segment is first divided at its midpoint and the diseased loop of SB is severed between atraumatic intestinal clamps
• The proximal and distal ends of bowel are then placed in an isoperistaltic side-to-side fashion
• Stenotic regions of one loop are placed adjacent to dilated areas of the other loop
• Division of some of the mesenteric vascular arcades may facilitate the positioning of the two limbs over each other
• A layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 suture is used to approximate the two loops of bowel
• Longitudinal enterotomies are then performed on both loops, with the intesetinal ends tapered to avoid blind stumps
• After obtaining adequate haemostasis with suture ligation or electrocautery, an internal row of full-thickness 3-0 absorbable sutures is placed anteriorly as a running Connell stitch and reinforced with an outer layer of interrupted seromuscular Cushing stitches using nonabsorbable 3-0 suture

Question 61

ED thoracotomy

Answer 61

• Indications:
  
  • penetrating chest trauma with signs of life in past 10-15mins
    
    • best evidence for survival from a thoracotomy = pts w single penetrating stab wound to chest
    • while ED thoracotomy primarily performed in pts in cardiac arrest, pts that are peri-arrest with hypotension (SBP <70mmHg) unresponsive to chest decompression and blood products with penetrating chest trauma could be considered for resuscitative thoracotomy in ED if an operating room isn’t immediately available
  • controversial indications
    
    • penetrating extra-thoracic trauma with cardiac arrest
    • blunt (thoracic) trauma w signs of life on arrival to ED who then have cardiac arrest
      
      • USS evidence of cardiac tamponade may indicate pts w a potentially favourable outcome
• Contraindications
  
  • penetrating trauma with CPR in progress >15mins and no signs of life
  • blunt trauma w no signs of life on arrival to ED
  • other injuries incompatible w survival (eg severe TBI)
• Signs of life being: pupillary response, spontaneous ventilation, presence of a carotid pulse, any measurable BP, spontaneous limb movement, cardiac activity seen on USS or ECG
• Instrument requirements
  
  • scalpel with 20 blade
  • forceps
  • Finochietto chest retractor
  • Lebsche knife and mallet or Gigli saw for sternum
  • large vascular clamps such as Satinsky vasc clamps (large and small)
  • Mayo scissors
  • Metzenbaum scissors
  • long needle-holders
  • internal defibrillator paddles
  • sutures, swabs, Teflon pledgets, sterile skin prep and drapes
  • ideally lung retractor (whisk type)
  • good light
• aims:
  
  • release cardiac tamponade and control cardiac haemorrhage (primary role)
  • internal cardiac massage and defibrillation
  • control intrathoracic haemorrhage (eg pulmonary or great vessels) - may need to perform hilar twist or clamp
  • control air embolism or bronchopleural fistula
  • cross clamp thoracic aorta
    
    • preferentially increase blood flow to coronary arteries and brain
    • decrease downstream (eg abdominal) bleeding

1. Ensure someone is intubating and the other side has been decompressed with a finger thoracostomy
2. PPE + rapid antiseptic solution
3. Left anterolateral thoracotomy in 5th ICS through muscle, periosteum, parietal pleura from costochondral junction anteriorly to posterior axillary line laterally following the upper border of the rib; use 20 blade then heavy scissors, care to avoid int mammary artery
   
   • Can extend as bilateral incision (clamshell) requiring horizontal division of sternum (with heavy scissors or Gigli saw) & ligation of int mammary vessels bilaterally - sternum may have some adhesions to pericardium which can be gently dissected with flunt tipped scissors or forceps
   • Can extend cranially in midline by dividing sternum for penetrating wounds involving mediastinal structures
4. Use your hands to spread ribs and insert Finochietto retractor with handles downwards facing
5. Open pericardium in cranial to caudal direction - pinch it in front of phrenic nerve and cut with scissors - stay anterior and parallel to phrenic nerve
   
   • completely open pericardium and deliver heart out of sac - scoop out pericardial blood/clot
   • identify any myocardial laceration and close
     
     • place finger on laceration if ventricle or Satinsky clamp if atria or great vessels
     • close with sutures (3-0 or 4-0 nylor staples
     • if heart beating, repair should be delayed til initial resus measures have been completed; if not beating, suturing precedes resuscitation
   • this is main goal of ED thoracotomy; if main injury is a laceration to myocardium, this may now result in ROSC; transfer to OT for formal operative repair

Other interventions

1. If haven’t opened other side yet and any doubt push your hand anteiror to pericardium to create a window into the other hemithorax
2. Internal cardiac massage
   
   • grasp heart in hands with wrists opposed and milk heart from apex
   • ?adrenaline can be injected directly into left ventricle
3. Internal defibrillation using internal paddles - 10J
4. Control of lung parenchymal bleeding
   
   • mobilise lung by incising inferior pulmonary ligament
   • clamp site of bleeding, can use mattress sutures to repair
   • consider hilar clamping or twist 180 to control severe pulmonary bleeding (last resort - poorly tolerated)
5. Aortic cross clamping
   
   • open the parietal pleura on either side of the aorta with finger or Mayo scissors and dissect aorta away from prevertebral fascia posteriorly and oesophagus anteriorly just enough to accommodate a clamp
   • ensure aorta is clamped, not oesophagus
   • alternatively can compress against spine manually

Question 62

Median sternotomy*

Answer 62

• vertical incision in stenral midline extending from 2cm above sternal notch to 3-4cm below xiphoid
• deepen incisoin to anteiror table of sternum, keeping to midline
• define superior border of manubrium and bluntly develop retrosternal plane from above with your finger
• then go to inferior part of your incision and open linea alba immediately caudal to xiphoid to bluntly develop same plane from below
• ask anaesthetist to stop ventilating momentarily, divide sternum in midline with vertical sternal saw
• hook toe of saw beneath sternum and pull on it to elevate bone as it is being cut to reduce the risk of iatrogenic injury to substernal structuresuse cautery to control oozing from cut edges of bone
• insert a sternal retractor adn gradually open it w/o cracking sternum
• look ofr left innominate vein - extending across the anterior aspect of the upper mediastinum, is the first structure you have to deal with when dissecting in thoracic outlet; in trauma situation, identify, clamp, divide and ligate it

Question 63

Open drainage of pancreatic cysts

Answer 63

• within 4-5wks of pancreatitis onset, cyst wall unlikely to be sufficiently mature to take sutures & external drainage required
• even after that stage, endoscopic/transgastric and percutaneous drainage common
• surgical drainage more appropriate for large, mature or recurrent cysts and for those that communicate with the pancreatic duct - cystgastrostomy or or cystduodenostomy or cystjejunostomy
• be aware of other causes of cystic mass in or adjacent to pancreas - fully investigate pre-op, always get biopsy of cyst wall at operation and arrange frozen-section if suspicion of malignancy
• always do CTA preop to check for pre-existing pseudoaneurysm
• cystgastrostomy
  
  • only indicated for effusions into lesser sac that have been present for long enough to have developed a fibrous wall; stoma will probably close once cavity has collapsed following drainage
  • pack off stomach
  • longitudinal incision through anteiror gastric wall fairly close to greater curvature and opposite incisura angularis; suck out gastric contents
  • incise posterior gastric wall for a short distance opposite the anterior gastrotomy
    
    • if cyst difficult to palpate, 19gauge needle on 10mL syringe to localise it
    • deepen incision and enter cyst; get samples of fluid for culture and biochem
  • evacuate contents of cyst and gently break down any loculi with finger
  • insert a running Vicryl suture round the margins of the posterior gastrotomy, ensuring a stoma at least 4cm diameter
  • close anterior gastrotomy in 2 layers and close abdomen with drainage
• cystduodenostomy
  
  • reserved for small cyst in head of panc close to duo loop
  • make longitudinal duodenotomy opposite cyst
  • insert needle into cyst; aspiration of bile warns you bile duct nearby and shouldn’t proceed
  • if aspirate clear, leave needle in place and incise duo wall to enter cyst
  • suture margins of opening as above
  • close duo in 2 layers, taking care not to narrow lumen
  • close abdo with drainage
• cystjejunostomy
  
  • applicable to all types of cyst with walls thick enough for suturing
  • most likley method to obtain dependent drainage and avoid the potential problem of food debris contaminating the pseudocyst cavity
  • mobilise pancreas
  • incise anterior wall of cyst, sample and drain its contents and explore its recesses for any obvious ductal communication
  • create a Roux loop of jejunum and close the end
  • approximate the upper end of the Roux loop to the front of the cyst w/o tension
  • create a generous side-to-side anastomosis between the opening into the cyst and a longitudinal jejunotomy
  • use 1 or 2 layers of suture according to thickness of cyst wall, but use Vicryl for inner layer
  • restore intestinal continuity by jejunojejunostomy at the base of the Roux loop

Question 64

Pancreatic body and tail trauma

Answer 64

• open lesser sac through gastrocolic ligament and if any sign of injury open posteiror peritoneum overlying the injured area
• damage control:
  
  • haemostasis and drainage
  • pack lesser sac for haemostasis
  • drain converts potentially uncontrolled panc leak into a controlled fistula
• definitive management
  
  • stop bleeding from superficial lacs and contusions with local haemostatic means
  • leave drains
  • if obvious ductal injury or strong suspicion, distal pancreatectomy
    
    • if happen to come across pancreatic duct, ligate it
    • otherwise mobilise spleen and pancreas to midline, and use a linear staple (black reinforced endo-GIA or TA 60 or vascular endo-GIA) across the pancreas and splenic vessels
    • control any bleeding from splenic vessels with haemostatic stitch
    • underrun staple line with 3:0 monofilament

Question 65

Whipples

Answer 65

Involves removal of pancreatic head, duodenum, gallbladder and bile duct with or without removal of gastric antrum; indicated for tumours of the pancreatic head and peri-ampullary region

1. Diagnostic laparotomy and exposure
2. Isolate SMV and separate colon and its mesentery from duo and panc head
   
   • enter lesser sac by taking greater omentum off transverse colon
   • mobilise hepatic flexure
   • incise visceral peritoneum along inf border of panc from pt’s left of middle colic vessels to the pt’s right and inferiorly, towards junction of D2/D3 to expose junction of MCV and SMV - expose SMV
   • may need to mobilise retroperitoneal attachments of SB & R colon mesentery to expose 3rd & 4th parts of duo if venous resection or access to posterior SMA needed
3. Extended kocherisation
   
   • begin at transverse (3rd part) of duo by finding anterior aspect of IVC
   • all fibrofatty & lymphatic tissue medial to R gonadal vein & anterior to IVC is elevated, along w panc head & duo
   • manoeuvre is continued to left lateral edge of aorta, w exposure of ant surface of left renal vein
   • extended superiorly to widely open foramen of Winslow
4. Portal dissection and cholecystectomy
   
   • expose CHA proximal and distal to RGA & GDA
   • ligate and divide RGA then GDA
   • mobilise hepatic artery proper off underlying PV
   • expose PV
   • perform cholecystectomy and transect CHD at its junction w cystic duct; place bulldog clamp
5. Transect stomach
   
   • Ligate and divide terminal branches of LGA along lesser curvature of stomach
   • Divide with endo GIA at level of 3rd or 4th transverse vein on lesser curve & at confluence of gastroepiploic veins on greater curve
   • Divide omentum at level of greater curvature transection
   • Can consider pylorus preservation in pts w small periampullary neoplasms
6. Ligament of Treitz taken down and jejunum transected
   
   • endo-GIA, 7-10cm distal to ligament of Treitz; ligate and divide its mesentery continuing proximally, mobilising 4th and 3rd parts of duo & dividing duodenal mesentery to level of aorta
   • reflect this devascularised segment of duo and jejunum beneath the mesenteric vessels into the RUQ
7. Transect pancreas and reflect medially
   
   • stay sutures on superior and inferior borders of pancreas then transect at level of PV (or more distally if adherent to PV/SMV and will need to do venous resection)
   • separate panc head and uncinate process from PV/SMV confluence
   • expose SMA
   • remove all mesenteric soft tissue and perineural tissue to right of SMA
8. Pancreaticojejunostomy
   
   • bring transected jejunum retrocolic through transverse mesentery and do 1 or 2-layer end-to-side, duct-to-mucosa pancreaticojejunostomy, with stent in panc duct, usign 4-0 or 5-0 PDS
   • if panc duct not dilated and/or panc substance is soft, can do an anastomosis that invaginates the cut end of the pancreas into the jejunum
   • or can do pancreaticogastrostomy (better if soft gland and nondilated duct?)
9. Hepaticojejunostomy
   
   • single-layered interrupted end (bile duct) to side (jejunum) anastomosis with interrupted 4-0 or 5-0 PDS
10. Gastrojejunostomy
    
    • antecolic, end-to-side in 2 layers, with efferent limb adjacent to greater curve
    • starting from lesser curve, ~6cm of gastric staple line removed
    • distance between biliary and gastric anastomoses ≥50cm alllowing jejunum ot be antecolic w/o tension and also preventing bile reflux into liver
    • antecolic to prevent possible GOO caused by colonic mesentery

+/- feeding jejunostomy

Question 66

Complications of a Whipples procedure

Answer 66

• pancreaticojejunostomy
  
  • leak
  • bleed
  • pseudoaneurysm
• hepaticojejunostomy
  
  • leak
  • stricture
• gastrojejunostomy
  
  • leak
  • stricture
  • dumping syndrome
• other
  
  • VTE and local thrombosis
  • malnutrition

Question 67

Open necrosectomy

Answer 67

• midline incision
• explore abdomen
• ascitic fluid sent for amylase
• evaluate bowel
• necrotic cavity usually posterior to stomach - enter through gastrocolic omentum w blunt dissection
  
  • some collections may require drainage through transverse mesocolon or through lateral approach after mobilisign lef tor right colon as necessary
• aim for limited dissection - adequate debridement w minimal intervention
• encounter murky, purulent or green fluid on entering necrosectomy cavity - aspirate and send for micro
• thorough debridement of necrotic debris - safest to do manually w fingers
• irrigate cavity and pack temporarily; remove packs & if haemostasis is an issue can leave packs in place & reexplore in 24-48hrs
• consider feeding tube access and cholecystectomy
• 2 large bore sump drains placed in cavity and brought out of abdomen through separate stab incisions in RUQ
  
  • drains secured to wall suction, can flush if become occluded with debris
  • as pts recovers, gradually withdraw sump drains & remove many wks after surgery

Question 68

Minimally invasive necrosectomy

Answer 68

• access through anterior abdominal incisions or flank and retroperitoneum, usu along tract of a pre-existing perc drain catheter
• commonly used as part of a ‘step-up’ strategy for pts who fail perc drainage alone
• advantages over open
  
  • effective, small incisions, avoid laparotomy & asosciated complications eg abdominal wall defects & bowel fistulas
  • direct access to necrotic cavity prevents contamination of the peritoneal cavity that is assoc w open necrosectomy
  • decreased systemic inflammatory responsees/physiologic effects on pts cf open
• 3 types described
  
  • anterior lap necrosectomy - rarely done
  • transgastric ‘endoscopic’ necrosectomy - out of date
  • retroperitoneal necrosectomy w or w/o video assistance - preferred
• anterior lap necrosectomy
  
  • similar to open but access through ports w peritoneal insufflation
  • collect large pieces of debris in endocatch
  • can be difficult visualisation in critically ill pts who may be swollen and on high levels of ventilatory support + risk of peritoneal contamination
• transgastric ‘endoscopic’ essentially a variation of transoral endoscopic and involves putting a perc gastrostomy tube - but now would just do standard endoscopic
• retroperitoneal approach
  
  • retroperitoneal incisions, usu on left side through a previously placed image-guided perc catheter tract
  • can be performed through single port or multiple adjacent ports, w or w/o video-assisted guidance (ie with direct visualisation or directly through the ports w intermittent inspection of cavity w laparoscope
  • when finished debridement, place large drain catheters through tract and suture to skin eg 32 French chest tubes - allow for continued drainage, postop irrigation of cavity and access for additional procedures when necessary

Question 69

Zenker’s diverticulum

Answer 69

• supine, head ring, shoulder bolster, head turned slightly to right and table tilted to drain EJV
• orogastric tube to aid identification of oesophagus
• anterior SCM incision from hyoid to 5cm above SCJ
• incise through skin, fat and platysma and ligate EJV if needed
  
  • try and preserve a branch of a cervical cutaneous nerve seen in upper part of incision
• dissect space between carotid sheath and visceral column in midline divide omohyoid and middle thyroid vein +/- ITA (but try and preserve if possible)
  
  • may need to divide straps
• retract trachea and oesophagus medially to expose collapsed pouch - neck lies at level of cricoid cartilage
  
  • gently dissect it off the oesophagus preserving RLN which lies in TOG
  • also look out for hypoglossal nerve superiorly
• key manoeuvre = division of cricopharyngeus; insert right angle into muscular band and divide it towards teh midline posteriorly, preserving the mucosa
  
  • often need to include lowermost fibres of thyropharyngeus
  • mucosa will bulge w/o restriction from oesophagus or neck of sac when complete division is achieved
• use a 55mm stapler to excise the diverticulum
• small closed-suction drain
• close wound in layers with absorbable sutures

Question 70

Antireflux surgery

Answer 70

• principles
  
  • mobilise lower oesophagus and reduce hiatus hernia
  • re-establish a length of intra-abdominal oesophagus
  • appropriate crural closure
  • maintain the LOS within the abdomen
  • re-establish angle of His
  • avoid dysphagia
• access
  
  • supine with legs split and secured, surgeon between legs, assistant on pt’s left, reverse Trendelenburg
  • 5 ports used; 12mm supraumbilical optiport, 5mm Nathanson port in epigastrium, two 5mm ports in MCL below ribs and further 10mm port in between the central port and the LUQ port
• exposure
  
  • left lobe of liver retracted with Nathanson
  • divide the pars flaccida to identify the right pillar of the right crus
    
    • care to avoid the hepatic branch of the vagal nerve (go just above it) and accessory left hepatic artery
    • bluntly separate the right pillar from the oesophagus and develop plane between the hernia sac and mediastinal structures with a pledget (leaving healthy endoabdominal fascia overlying the pillars of the crus)
  • divide the phrenooesphageal membrane transversely (careful of anterior vagus nerve)
  • approach left pillar by mobilizing the greater curve of the stomach – may need to take some short gastrics but not always
    
    • dissection begins at level of inf pole of spleen, about 1cm from greater curve (10-15cm from angle of His); extra care to make sure short gastric vessels are divided haemostatically as left pillar is approached bc bleeding here can be difficult to control
    • also divide posterior gastric attachments to pancreas here to ensure adequate gastric mobilization
  • separate oesophagus & stomach bluntly from left pillar and mobilise posterior sac from the mediastinum
  • ensure complete circumferential oesophageal mobilization; identify and preserve the posterior vagus nerve and dissect the confluence of the right and left pillars away from the posterior oesophagus
    
    • place penrose drain around distal oesophagus for retraction
    • check at least 3cm of oesophagus resides within the abdomen when traction is released
• cruroplasty
  
  • use 3 interrupted, figure-of-8, 2-0 Ethibond sutures for the posterior cruroplasty
  • some use Bougie to size (58-60Fr?)
• wrap
  
  • identify the posterior gastric fundus and feed it from left to right through the retroesophageal space while maintaining anterior traction on oesophagus – ensure the posterior fundus is passed behind the oesophagus not behind the stomach itself
  • shoe-shine manoeuvre to ensure it slides easily and isn’t twisted
    
    • Toupet: 270 degree posterior fundoplication – take the fundus around the back and suture to the right crus and suture each side of the fundus to the oesophagus
    • Nissen: 360 degree wrap – place bites on either side of fundoplication and oesophageal bites to create a 2cm fundoplication
    • Dor: 180 degree anterior fundoplication – suture take the fundus anteriorly and suture to the right crus - use 3 interrupted nylon sutures to secure the wrap
• closure
  
  • note the placement of the NG tube at the end of the case
  • remove ports under vision and close skin
• post-op
  
  • clear fluids 6-24hrs
  • then sloppy diet 4wks
  • avoid fizzy drinks
• complications
  
  • immediate
    
    • bleeding
    • pneumothorax – typically manage conservatively
    • perforation <1%
    • conversion
    • visceral injury
  • early
    
    • perforation unrecognized
    • infection
    • bleeding
  • Late
    
    • Gas bloat/increased flatulence
    • Dysphagia
    • Gastric inertia – vagal injury
    • Failure/recurrence
    • Can’t vomit

Question 71

Feeding jejunostomy

Answer 71

• Open approach; small midline incision
• Identify DJ flexure; select jejunum 30cm distal w good mobility to abdo wall
• Use 8 Fr T tube and prepare this - cut at an angle on each side so that the anti-tube side is shorter than the tube side, and split longitudinally the anti-tube side - so that when you pull it out it can deform/collapse
• Make opening in abdominal wall as far lateral as possible so you don’t create a lateral recess for bowel to herniate into - so in front of colon
• Test pulling the T tube out through the fascia so you know you’ll be able to later
• Purse string with 3-0 PDS
• Enterotomy
• Put tube in
• Then do 4 interrupted sutures in 4 quadrants around with 3-0 PDS between bowel & abdominal wall around the purse string; do the posterior one first and anterior one last
• Then do another 2 interrupted sutures 10cm proximal and distal so you don’t create a pivot point for things to twist around
• Close

Question 72

Options for oesophageal anastomosis

Answer 72

• single layer 3-0 PDS sutures forming an interrupted oesophago-jejunal or oesophago-gastric end-to-side anastomosis; use three back wall sutures initially w long ends on clips then use interrupted sutures to close the back wall w the sutures tied on the inside of the lumen
  
  • close front wall w sutures on outside over an NG/NJ tube
• end-to-side stapled circular anastomosis using a 25mm EEA stapler; inset the anvil into the oesophagus and secure w 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 ≥2cm from any staple line then join the pin and anvil
  • close the gun and fire then slowly release and withdraw
  • check donuts
  • test join

Question 73

Technical considerations when operating on oesophagus

Answer 73

• oesophagus lacks a serosal coat except for its short intramuscular portion; serosa forms adhesions readily & is sometimes capable of sealing small leaks; oesophagus not privy to this
• outer longitudinal muscular coat doesn’t 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 v narrow; don’t anastomose under these conditions as gaps may be left, use stay-sutures or a Foley to improve spacing of anastomotic sutures
• want generous margins on oesophageal cancers bc they spread not only to regional LNs but also along the submucosal lymphatic channels of the oesophagus

Question 74

Ivor Lewis vs McKeown approach

Answer 74

• Require transthoracic access, through right posterolateral thoracotomy in 5^th ICS or thoracoscopy
  
  • ILO defined by an intrathoracic anastomosis
  • McKeown approach characterized by cervical anastomosis
• Order in which dissection performed also differs between techniques
  
  • IL approach starts w gastric mobilization, then proceeds with thoracic (or thoracoscopic) dissection and intrathoracic anastomosis
  • Modified McKeown starts with right thoracoscopy or thoracotomy to dissect mediastinal oesophagus from a left lateral decubitus position
    
    • Pt then placed supine for the abdominal dissection and gastric conduit creation
    • Gastric conduit created along greater curve then brought through left neck to perform the anastomosis

Question 75

Ivor Lewis Oesophagectomy

Answer 75

• Performed for distal oesophageal or GOJ tumours
• Combined upper abdominal approach then right posterolateral thoracotomy; requires double lumen ETT
• Access
  
  • Initially positioned supine, arms out, abdomen accessed through upper abdominal incision
  • Staging exam
  • Gray’s retractor, mobilise and retract left liver
• Abdominal component
  
  • Dissect GOJ
    
    • Expose the crura and mobilise the oesophagus at the hiatus circumferentially; place a penrose drain for retraction
    • Divide the vagi and dissect to the left to divide the short gastrics
  • Mobilise the stomach
    
    • Divide the gastrocolic omentum, staying 1-2cm outside the gastroepiploic arcade and preserving the right gastroepiploic - medially dissect past D2
    • Reflect stomach anteriorly, exposing the lesser sac to check for metastatic disease; divide any retrogastric adhesions to the pancreas
    • Anterior reflection of the stomach exposes the right gastric artery to allow dissection of station 8 lymph nodes
    • Can divide coronary vein and left gastric here or later
    • Lesser omentum is divided from the 2nd part of the duodenum up to the right crus
    • Preserve the right gastric artery and its perforators
    • The base of the left gastric artery is identified either from the right side of the stomach or from underneath the stomach; it is skeletonized and divided to provide access to the preaortic plane, which will be extended into the mediastinum
  • Create the conduit
    
    • Pinch up the fundus to select the highest point and resect along the line connecting the points where the vessels of the left gastric area enter the gastric wall (starting at the crows foot) - so that the pericardial nodes and the nodes in the left gastric basin are all removed; do this with 2 or 3 applications of a linear stapler
    • Don’t fire the final staple load to separate the fundus
  • Lymph node dissection
    
    • For distal oesophageal cancers and GOJ cancers, LN dissection includes skeletonizing left gastric pedicle and prox CHA as needed
    • Extensive lymphadenectomy of gastric cancer surgery not routinely performed unless there is lymphadenopathy on imaging
    • Nodal tissue is left en bloc w specimen
  • Some perform pyloromyotomy
  • Consider feeding jej
  • Re-check mobility of conduit then close abdomen w 2-0 PDS small bites
• Thoracic part - access
  
  • Reposition in left lateral decubitus position with table break and a gutter for the arm
  • Access via right 5^th intercostal posterolateral thoracotomy (incision from spine of scapula along 5^th ICS anteriorly and up towards midline as high as T4); 6^th rib can be taken at posterior margin to improve access
  • Right lung deflated and 2 Finochietto retractors are placed and slowly opened
• Thoracic part - mobilisation
  
  • Inferior pulmonary ligament divided
  • Mediastinal pleura divided, azygos vein dissected and tied in continuity prior to dividing
  • Oesophagus mobilized circumferentially down to hiatus to meet w previous dissection; encircled and retracted using a Penrose drain
  • Perioesophageal soft tissue and lymphatic tissue resected en bloc, skeletonising the pericardium and descending aorta
    
    • Thoracic duct is resected en bloc with the oesophagus
  • Oesophagus is divided above azygos vein
  • Identification and preservation of membranous airway vital, bc thermal injury can result in delayed airway perf, increasing risk of conduit-airway fistulae
  • Specimen attached to gastric conduit delivered into chest – care to maintain anatomic orientation
• Staple or hand-sewn oesophago-gastric anastomosis
  
  • Typically end-to-side functional end-to-end anastomosis performed between oesophagus and greater curve of stomach; as close as possible to end of right gastroepiploic artery to maximize conduit viability
  • 25mm anvil introduced into oesophagus and secured w 2-0 Prolene purse-string
  • Temporary gastrotomy made, gun introduced per gastrum and pin fired through neofundus 2cm away from staple line
  • EEA gun is stapled then fired and removed w a check of the donuts
  • Gastrotomy is closed and a leak test performed and an NG tube placed
  • Preserved omental pedicle then placed between gastric conduit and membranous airway and secured to conduit
  • Sometimes mediastinal pleura and azygous vein can be preserved to act as a tissue barrier between airway and anastomosis
• Closure
  
  • JP drain placed next to anastomosis and two 28Fr chest tubes placed on UWSD
  • Ribs are re-approximated w Z-sutures of 2-0 PDS avoiding intercostal nerve bundles
  • Muscular layers are closed continuously and skin closed w clips
• Post-op
  
  • A water-soluble contrast study is performed on POD5 and feeding slowly reintroduced if no leak

Question 76

Heller’s myotomy

Answer 76

• The key to a successful Heller’s myotomy is complete muscular division over the affected area of achalasia with confirmation of healthy epithelium intraoperatively
• Access:
  
  • Laparoscopic approach with patient supine; legs split and secured
  • Steep reverse Trendelenberg
  • 5 ports used; 10mm supra-umbo camera port with 4 ports spaced across both hypochondria with a bias to the patient’s left; the right central port is 10mm and the others are 5mm
• Exposure:
  
  • Retract liver with Nathanson via the right hypochondrial port
  • Divide lesser omentum, be aware of accessory left hepatic and hepatic branch of vagus; preserve both
  • Dissect out the hiatus, taking care to preserve the vagi
  • Mobilise the oesophagus and place a Penrose drain around it and have assistant retract
  • Free up the distal 6cm of the oesophagus
  • Mobilise the fundus of the stomach, starting from angle of His
    
    • I selectively divide the short gastrics - only if length is required
• Myotomy
  
  • 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
  • Enter submucosal plane, carry proximally 5-6cm from the GOJ and distally 2-3cm onto anterior gastric wall
  • Separate muscle edges for 50% of circumference
  • Stomach muscle is identified by a change to oblique muscle fibres
  • Check myotomy with an on-table endoscopy – rule out perforation and show obstruction is cleared (can pass a 54-58F bougie) to stretch mucosa and ensure all muscle fibres divided)
• Wrap/Fundoplication
  
  • perform 270 degree Toupet fundo
    
    • deliver stomach behind oesophagus
    • ensure it is tension free and the wrap is above teh z line (ie oesophageal not cardiac)
    • suture right side of wrap to right side of myotomy using 3-4 interrupted sutures (braided, non-absorbable - ethibond); for the first 1-2 sutures pick up the left crus
    • suture left side of wrap to left side of myotomy using 3-4 interrupted sutures; for the first 1-2 sutures pick up the left crus
  • if concerns about mucosal integrity then perform a Dor fundoplication to provide fundal cover
    
    • Suture an anterior 180 degree (Dor) wrap across the myotomy with interrupted 2-0 nylon
• Closure:
  
  • Remove the instruments and close the skin

Intraoperative complications & challenges

• Perforation – repair with lap interrupted 5-0 monofilament absorbable sutures and gentle knots

Post-operative complications

• 6% complications, increased if previous balloon dilatation or botox
• immediate
  
  • perforation
• early
  
  • perforation
  • inflammation and transient dysphagia, uncommon
  • pain
• late
  
  • stricture
  • chronic pain
  • recurrence

Post-op care

• slow progression from clear fluids through free fluids through light diet over 6wk period

NB: layers of oesophagus – mucosa, submucosa, circular muscle, longitudinal muscle, adventitia; layers of stomach – mucosa, submucosa, oblique muscular layer, circular muscle, longitudinal muscle, serosa

Question 77

Thoracotomy for perforated oesophagus

Answer 77

Key principles

• Resuscitate patient
• Source control, wide drainage
• Consider feeding jejunostomy
• Seek assistance from oesophagogastric colleague
• I perform a thoracotomy to assess the perforation, control it by either repair or exteriorization, drain the chest cavity widely and consider performing a concurrent feeding jejunostomy

Operative details

• A double lumen ET tube is used for these operations whenever possible
• Left posterolateral thoracotomy for lower oeosphagus (6^th, 7^th or 8^th intercostal space)
• Right posterolateral thoracotomy for mid oesophagus (5^th-7^th ICS depending on level of perforation)
• Pt is positioned & secured in lateral decubitus w arms in prayer position and table broken to maximize access
• Place a pillow under contralateral axilla and a pillow between the legs with the pt strapped to table
• Base incision on 5^th ICS, passing through a point 3cm below inf spine of scapula
  
  • This can be continued anteriorly and into upper midline laparotomy incision if needed
• Muscular layers are divided w diathermy and top of 6^th rib scored w diathermy
• Ask anaesthetist to exclusively ventilate contralateral lung then enter pleural cavity sharply and extend this incision for length of wound
• If space is tight, resect prox posterior 1cm segment of 6^th rib w rib cutters
• Finochietto retractors placed and opened in intervals
• Washout and identification of the injury is performed w warmed saline
• Oesophageal injury is explored, debrided and extended to ensure whole injury seen
• Repair injury in two layers with 3/0 PDS and cover repair w local tissue flap (pericardium, diaphragm, pleura if thickened, intercostal muscle; if wound edges can’t be brought together, repair injury over a wide bore T-tube and bring this out through chest wall
• Rarely if unstable and severe contamination staple off distal end and bring proximal end out as cervical oesophagostomy
• Other side is assessed via anterior mediastinum and washed out??
• Haemostasis secured
• Leave 2 x 28Fr chest tubes after washout is clear w a Blakes drain adjacent to anastomosis
• Close chest with figure of 8 1 PDS and use staples for skin
• ICU
• Consider feeding jejunostomy

If need to extend incision to upper abdomen for access to abdomen:

• Subcostal margin has to be divided to link the two incisions
• Diaphragm divided at its periphery where it attaches to chest wall until crus encountered; this is spared

Post-op

• ICU support
• Parenteral or enteral (jejunostomy) feeding
• Continue IVAB
• Serial CXR to assess for pneumothorax/effusion/empyema
• Contrast swallow day 5-7 to assess for leak
• Remove drains as volume decreases

Perforation of cervical oesophagus

• Oblique incision in left neck
• SCM retracted laterally and omohyoid and middle thyroid vein divided
• By retracting trachea medially, blunt dissection can be used to free the oeosphagus into the mediastinum

Perforation of abdominal oesophagus

• Upper midline laparotomy
• Mobilization and rightward retraction of left lateral segment of liver facilitates access to oesophageal hiatus

Question 78

Bleeding peptic ulcer

Answer 78

• Upper midline incision
• Ligate and divide ligamentum teres and incise falciform
• Assess
  
  • Never assume single cause
  • Look for PHT
  • Look for scarring of stomach or duo
  • If no cause identified, repeat endoscopy after a large bore gastric washout
• Bleeding duodenal ulcer
  
  • Kocherise the duodenum if known to be D1 on OGD
  • Use prepyloric vein as a landmark to identify pylorus
  • Traction sutures superior and inferior to pyloric ring
  • Longitudingal full-thickness incision made, starting on prepyloric antrum halfway between greater and lesser curve
  • Once distal stomach is entered, use a blunt haemostat to gently traverse the pylorus into the proximal duodenum to guide the full-thickness cut through the pylorus into the duo; 3cm longitudinal incision sufficient
  • Traction on sutures open the incision into form of a diamond, which allows adequate exposure
  • May need to extend the incision 1-2cm further into duo if slightly more distal
  • When actively bleeding duo ulcer is identified, direct pressure followed by suture ligation
    
    • Should transfix gastroduodenal complex at three points; ligate GDA proximal and distal, and with a third stitch make a U stitch to transfix the transverse pancreatic branch which is medial
    • Use 2-0 PDS (may need heavier round surgical needles if excessively thick scarring of posterior wall of duo from ulcer which is usually the case
    • Avoid going to deep and catching bile duct or with superficial ulcer getting ampulla of Vater
      
      • If ampulla of Vater involved with ulcer, may need to place biliary fogarty catheter into CBD via cystic duct and thread this into the duo to mark the ampulla and avoid injury
  • Closure of pyloromyotomy transversely
    
    • Close in transverse direction using a single layer of sutures; place all sutures first then tie
• Bleeding gastric ulcer
  
  • Gastrotomy
  • Biopsy
  • Suture
  • Ipsilinear closure

Intraoperative complications & challenges

• Can’t find source of bleeding
  
  • Consider gastrotomy or gastroduodenotomy
  • Consider biliary source
  • Don’t proceed if no source; rather consider other modalities
    
    • CTA
    • RC scan
    • Embolization
• Uncontrollable bleeding either stomach or duo
  
  • Subtotal or total gastrectomy w Roux-en-Y reconstruction
• Large ulceration

Post-op complications

• Immediate: bleeding
• Early: bleeding, GOO
• Late: stricture, recurrence

Question 79

Kocher’s duodenal mobilisation

Answer 79

• Appraise
  
  • This raises the head of the pancreas contained within the duodenal loop into its embryological midline position, restrained by the structures in the free edge of the lesser omentum above, the superior mesenteric vessels below and the body and tail of the pancreas to the left
  • The head and neck of the pancreas can be examined from behind and palpated between fingers and thumb
  • The lower end of the CBD can be palpated and sometimes seen though it is usu buried within the panc head
  • The duodenum & espec the ampullary region can be palpated
  • Duodenotomy allows inspection of the interior of the duodenum
    
    • If the incision is placed at the level of the ampulla this can be seen and palpated for tumours or stones
    • Biopsy, excision of ampullary neoplasms, sphincterotomy, sphincteroplasty and cannulation or instrumentation of the bile and pancreatic ducts can be carried out under vision
  • Mobilization is essential for excision of the pancreatic head and duodenal loop in a Whipple’s pancreaticoduodenectomy
  • Elevation of the duodenal loop and panc head reveals the IVC when performing portocaval anastomosis or major hepatic resections
  • The maneouvre is particularly valuable in gastroduodenal operations
    
    • Pyloroplasty can be performed easily and the extremities of the gastroduodenal incision can be brought together w/o tension
    • In gastrectomy, the proximal duodenum is easily dissected and can be closed or united to the stomach with ease
    • Full mobilization may be a useful step when the stomach is drawn up for gastro-oesophageal or gastropharyngeal anastomosis, however it is usu the porta hepatis & its connection to first part of duo that limits further mobilization
• Action
  
  • stand on patient’s left
  • midline laparotomy
  • take down hepatic flexure or retract inferiorly
  • divide peritoneum 1cm away from lateral margin of duodenal loop (D2) using diathermy
  • roll and retract duo to midline using a pack and my left hand
    
    • combination of medial retraction and lift in order to bring it off the IVC
  • ​careful dissection with a right angled forceps and diathermy or scissors
  • continue dissection up to epiploic foramen and down to D3
  • continue retracting duo medially, exposing
    
    • IVC
    • R&L renal veins
    • R gonadal vein
    • retropancreatic nodes
    • aorta where it is tethered by the SMA and its pancreatic branches
  • If incomplete mobilization is sufficient, as for palpating the lower end of the bile duct or the panc head or for the purpose of carrying out a pyloroplasty and gastrectomy by the Polya method, then it may be sufficient to elevate only the superior part of the duodenal loop and pancreatic head
    
    • Insinuate a finger into the opening of the lesser sac and divide the floor of the foramen downwards, to separate the upper duodenum and pancreas from the IVC
    • Extend the mobilisation by continuing the division with scissors or diathermy blade, downwards, just outside the convexity of the duodenal loop

Question 80

Open chole

Answer 80

• I stand on the patient’s right side with the first assistant and scrub nurse opposite; if there is a second assistant this is v useful and they stand to my left
• I use a sub-costal incision 3 fingerbreadths below the costal margin from mid-axillary line to xiphisternum
• 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 further 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 retracted towards the right shoulder by the second assistant
  • I grasp Hartmann’s pouch and use a right angle Lahey 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 for IOC
  • The gallbladder is then removed from the fundus down to the posterior window then delivered as a specimen
• After a washout and haemostasis check I close the fascia w a loop-0 PDS
• The skin is closed w staples

Question 81

Lap chole

Answer 81

• Review imaging and LFTs, consider risk factors for difficult lap chole eg post ERCP, gangrenous cholecystitis in a diabetic, obese with fatty liver
• GA, supine, right arm out, strapped to table, foot plate if obese
• I use a vertical transumbilical 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 GB with the fundal grasper and retract it over the liver to the right shoulder (10 o’clock position)
  
  • In order to achieve this retraction need to make sure lateral port is sited as far laterally as possible; if difficult to achieve this position bc of underlying GB neck obstruction, aspiration of the GB may be helpful; or in elective setting, pts w hepatic steatosis should be considered for a v low calorie diet preop
• I grasp Hartmann’s pouch and lift it up and across toward the origin of the segment IV pedicle
  
  • If this step is prevented by a large impacted stone, it may be possible to ‘milk’ the stone back into the GB or alternatively to open the GB and remove the stone
  • This combined with 10 o’clock fundal retraction maximizes the exposure of the posterior peritoneum of the hepatobiliary triangle
• I take a moment to check my orientation
  
  • (identify Rouviere’s sulcus, which marks the level of the right posterior portal pedicle; identifiable in at least 80% of pts and supposedly when viewing laparoscopically from umbilicus w normal upward retraction of GB, an imaginary line drawn along the sulcus and carried across to the base of segment IV shows the level ventral to which dissection is ‘safe’ and dorsal to which it is not)
• With my left instrument controlling Hartmann’s pouch and lifting it up towards the origin of the segment IV pedicle I use scissors to incise the posterior then anterior leaf of the peritoneum then hook dissection is used to extend this to the fundus
  
  • (Approaching the posterior wall first prevents the inadvertent encirclement of the CBD but Saxon Connor describes completing all of the posterior dissection up so that the posterior surface of the cystic artery is seen before moving to anterior dissection ie as the dissection proceeds layer by layer close to the GB, the grasper holding Hartmann’s pouch can be repositioned to hold the under-surface of the GB, thus tensioning the tissue within the hepatobiliary triangle such that further dissection will expose the posterior surface of cystic artery)
  • SC: keep dissection lateral to cystic node
• 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 artery and duct and divide these
• I then remove the gallbladder from the hepatocystic 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 w dissolvable sutures

Intra-op difficulties

• Obese patient
  
  • Consider optifast in elective setting
  • Setup – appropriate table, body strap, foot plate, arms strapped
  • Consider transumbilical entery or Palmers point visiport
  • Extra port for liver retraction or caudal omental/LB/SB retraction with fan retractor
  • Fundus grasper lower htan normal
• Unable to dissect Calot’s/obstain critical view of safety
  
  • Convert to open
  • Subtotal – opening GB, removing stones and remove majority of the GB at the level of Hartmann’s pouch
    
    • Ideally place an endoloop below Hartmann’s pouch
    • Outherwise usu leave remnant gallbladder open with a purse-string suture or place a drain into the GB fossa
    • If posterior wall of GB left behind ablate mucosa with diathermy
    • If bile leak post subtotal, wait 5 days; if ongoing perform ERCP and stent
• Bleeding
  
  • Apply pressure with swab or GB and wait; don’t blindly clip
  • Inform anaesthetist
  • If significant consider conversion to open procedure and enlisting help from colleage
  • If injury to hepatic artery or portal vein obtain proximal and distal control and close with 5-0 proglene
  • If bleeding from middle hepatic vein (which can lie superficially in GB fossa) inform anaesthetist as risk of air embolism and apply pressure
    
    • Figure of 8 suture either lap or open
  • If ooze from GB fossa consider surgical or haemostatic agents
  • Suspected bile duct injury
    
    • If suspected intraop, pause and obtain advice from HPB colleague; don’t attempt primary repair yourself
    • Obtain cholangiogram to clarify anatomy/injury
    • Typically repair by HPB surgeon; if non available, place large drains and transport patient – don’t continue cholecystectomy
  • CBD stone – see separate

Complications

• Bile injury 0.5%
• Other injury 0.2% - bowel 0.1% (usu duodenum)
• Bile leak 0.5% - ERCP + stent
• Convert to open 5-7%
• Wound infection 0.5%
• Hernia 0.4%
• Bleeding
• Spilled stone
• Respiratory, DVT
• Late: retained stone 1-3%, post cholecystectomy syndrome

Question 82

IOC

Answer 82

• I call for radiology then ensure theatre staff are adequately protected from ionizing 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 3-4Fr IOC catheter passed down its length; this is primed w 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 GB neck then make a small transverse incision in the cystic duct near the clip and expect to see bile
• I insert the Reddick-Olsen down the medial RUQ port and feed into the cystic duct w a Marylands grasper in the right hand about 10-15mm; I clamp the Reddick-Olsen and flush some saline down the biliary system to check for resistance and leak
• Patient flattened or even head and right side down, 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 with diluted contrast and proceed as required
• Saxon Connor IOC checklist:
  
  • Proximal filling of CBD
  • Confirm presence of 3 hepatic ducts (right anterior, right posterior, left main)
  • Filling of duodenum
  • Absence of filling defects
  • Presence of the cystic duct as indicated by the presence of spiral valves – if present the spiral valves may provide useful confirmation that correct duct has been cannulated
• If flow into duo doesn’t occur, 1mg glucagon IV to induce relaxation of biliary sphincter
• If spiral cystic duct valves not visualized, attempts to withdraw catheter slowly may encourage filling of cystic duct
• If flow into hepatic ducts not clear, position head down
• Ensure image not projected over spinal column to allow adequate visualisation

Question 83

CBD stones

Answer 83

• 2mm likely to pass spontaneously; >4mm less likely to do so
• assess size, number, location and size of duct
• flush with 50mL saline
• 1mg glucagon IV
• buscopan 20mg IV (wait for tachycardia)
• flush again
• may place additional clip or endoloop on the cystic duct, insert large adjacent drain and subsequent ERCP
• may place trans-cystic stent if trans-cystic CBD exploration unsuccessful or even without attempting that
• a trans-cystic or trans-ductal CBD exploration approach may be used
  
  • trans-cystic less likely to be successful when stone is >8mm, if there are proximal stones or when anatomy (valves, tortuous angulated duct) hinders the approach
• CBD exploration may be lap or open

Question 84

Lap transcystic exploration

Answer 84

• I remove the cholangiogram catheter form the cystic duct
• I milk the cystic duct to clear any stones from it
• Often I will dissect the cystic duct further proximally
• Under II guidance I use a Nathanson basket (5.5Fr catheter 70cm long with visual markers spaced 2cm apart)
• I have the tip withdrawn into the catheter which protects the bile duct from the hard basket
• I advance the tip of the catheter whilst screening past the most distal stone in the SBCD
• I open the basket and draw it back to retrieve the stone via the cystic duct
• or a 3-5Fr Fogarty balloon – deplay/inflate and gently pull back under guidance to remove stone via cystic duct dichotomy
• Repeat IOC
• Endoloop duct
• Can use 3mm choledochoscope if skilled/available
• Transcystic stent
  
  • Double pigtain 7Fr 7cm endobiliary stent
  • Place over a Bengsten Cerebral guide wire which is hydrophilic with a beveled end
  • Arrange post-op ERCP

Question 85

Lap CBD exploration

Answer 85

• Contraindicated if CBD <8mm
• Divide peritoneum over supraduodenal CBD to expose its anterior surface over 2cm (minimize mobilsation to avoid damage to blood supply at 3 and 9 o’clock
• Use scissors to to make a transverse dichotomy, 1/3 of diameter
• May need to dilate with a balloon before subsequent interventions to extract calculi
• Can clear with choledochoscopic or fluoroscopic stone removal using either Fogarty balloon or wire basket; start proximally if stones present
• ?if choledochoscopic requires additional 12mm working port in left rectus, lap tower over left shoulder and cystoscope tower over right shoulder; use special padded grasper
• Confirm clearance with choledochoscope
• Close choledochotomy with interrupted 5/0 PDS (don’t routinely stent or place T-tube)
• Place closed suction drain adjacent

Question 86

Open CBD exploration

Answer 86

1. Place fixed retractor with an omnitract
2. Stand on patient’s left side
3. Divide the peritoneum overlying the supraduodenal bile duct to expose its anterior surface over a length of around 2cm; the cystic duct can be followed down to its origin and confirm by aspirating bile (25G)
4. Don’t attempt on ducts <8-10mm or will stricture. Don’t dissect duct laterally or posteriorly as risk injury blood supply, resulting in possible stricture formation.
5. Place stay sutures with 4-0 PDS on either side of the proposed choledochotomy and tent the CBD up at the 3 o’clock and 9 o’clock position
6. Use an 11-blade to make a longitudinal choledochotomy and extend with Potts - about 1cm total
7. Suck out/pick out the stone if possible
8. Massage stone up if possible
9. Irrigate the stone and retrieve if possible
10. Pass a 3-4F Fogarty balloon catheter and retrieve after inflation of the balloon
11. Use a 5mm choledochoscope (or an 8.5F flexible ureteroscope w 3.6F working channel) and basket the stone out
12. If stones are impacted distally, may be possible to dislodge them by bimanual manipulation of the intra-pancreatic portion of the duct (dont squeeze pancreas too hard
13. if stone stuck fast, make a 3cm duodenotomy opposite ampulla and control with stay sutures; gently insert a catheter from the distal end of the duct in attempt to dislodge the stone; if this fails and stone is palpable above ampulla through posterior wall of duo, then rarely direct incision of duct and transduodenal sphincteroplasty can be performed (not by me). Close duodenotomy w interrupted 3-0 PDS
14. Close choledochotomy with interrupted 4/0 PDS (some close over a T tube (10-16Fr) which is left for minimum 3wks)
15. Place drain and close

Question 87

Escharotomies

Answer 87

• aim: to release rigid and inelastic burnt skin (eschar) to allow
  
  • circulation (in a limb)
  • breathing (when chest involved)
  • BEFORE problems arise or to treat an existing problem
• nb inelastic burn skin - doesn’t have to be full-thickness
• ideally done in theatre under GA with diathermy
  
  • can be done in ED/resus with LA
  • can be done with scalpel but will need diathermy to control bleeding
• procedure
  
  • ensure limb is in anatomical position (forearm supinated not pronated)
  • prep wound, drap
  • cut with either diathermy or scalpel along lines
    
    • limbs - release both medial and lateral sides; along line of fusion between anterior and posterior surfaces of the limbs
      
      • avoid key landmarks
        
        • arm: medially ulnar nerve, radial sensory branch; laterally radial nerve, cephalic vein
        • leg: medially GSV, posterior tibial vessels; laterally common peroneal nerve, SSV, sural nerve
    • chest - release entire breast plate
  • ensure incision is skin depth only - see fat not muscle at base of wound
  • run finger along wound to ensure no remaining tight bands
  • escharotomy extends above and below burn into unburnt skin where possible
  • monitor for return or preservation of circulation/breathing
  • dress with algisite (in escharotomy wound), bactigras over rest of burn wound but not circumferential, loose melonin & crepe as outer dressing
• Indicated when there are circumferential full thickness burns that are likely to cause compartment syndrome
• Use either scalpel or diathermy through insensate skin along lines of fusion between anterior and posterior surfaces of the limbs
• Avoid key landmarks:
  
  • Upper – ulnar nerve, radial nerve
  • Lower – GSV, PT pedicle, common saphenous

Question 88

AKA

Answer 88

• Supine, roll under thigh, ?tourniquet if sufficient length
• I mark out a fish-mouth incision with the corners of the flap at the level of the planned femoral amputation which is ideally at the junction between the middle and distal thirds or ~10cm/handsbreadth above the patella (but for clinical reasons may need to be higher). The length from the corners of the flap is ¼ the leg circumference and the anterior and posterior flaps are equal
• I divide the skin and fascia with diathermy
• I ligate the GSV which will be encountered superficially in an anteriomedial location
• I then divide the muscle in the line of the flaps using diathermy, starting with anterior and medial compartments and extend this all the way down to the femur; I do this by dissecting with Roberts then diathermying down onto the Roberts clamps
• As I’m doing this, anteromedially I identify the Sartorius then the femoral artery and vein/s in the adductor canal and suture ligate then proximally tie the vessels with 1-0 prolene
• I also identify the femoral nerve and ligate it with a fine suture then cleanly cut it while putting it on traction distally so that it will retract up into the tissues
• I then free muscle and periosteum off the femur circumferentially (with diathermy and a periosteal elevator) and place a large pack through the defect behind the femur
• I use an oscillating saw with water for irrigation to transect the femur
  
  • Smooth bone edges with a rasper, bone wax for haemostasis if needed
• Now retract distal femoral fragment and find small profunda femoris artery which will lie posterior to femur, between vastus and adductor magnus, close to the medial side of the femur; clamp and divide
• Posterior to the femur I also identify the sciatic nerve between the adductor magnus and biceps femoris muscles (can palpate between fingers but may have to open up the fatty tissue w scissors to find it)
  
  • Nerve placed on gentle traction, ligated proximally with PDS on 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, down to the posterior skin flap that I had marked out
• I irrigate the stump then check hemostasis
• I use a finger to sweep adjacent to 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
• I draw the quadriceps muscle down and fix it over the end of the bone with absorbable sutures, then suture the remaining muscles to the quadriceps, attempting to retain roughly equal tension in all the muscle groups
• I place a 15Fr suction drain beneath the muscular closure and bring it out laterally
• I close the skin with 3-0 Nylon vertical mattress sutures
• Use well-padded dressing on stump to make sure it is protected, being careful not to pull the stump into flexion with the dressing
• Post-op
  
  • Remove drain 48hrs
  • Regular physio
  • Remove sutures 10-14 days
  • Apply firm stump bandage at 2 weeks, temporary pylon (?) at 3-4 weeks and definitive limb at 6-12 weeks

Complications

• Bleeding
• Infection
• Stump breakdown/flap necrosis
• Phantom pain
• Neuromas
• Erosion

Question 89

BKA

Answer 89

• Mark level of tibial transection - a hands-breadth/10cm below the tibial tuberosity
• Mark skin flaps - measure the circumference of the leg at the planned site of tibial transection and divide this measurement into thirds
  
  • I mark the inferior edge of my anterior flap at a measurement below the planned tibial transection that is 1/3 of the leg circumference; I extend this medially and laterally so that I’ve marked out 2/3 of the circumference of the leg
  • I then mark the posterior flap, the inferior limit of which is a distance below my anterior flap corresponding with 1/3 of the circumference of the leg
  • From the edges of my anterior flap I draw an oblique line inferiorly towards the medial and lateral malleoli until I meet the line of my posterior flap and I round the edges
  • (Blood supply to posterior flaps is derived mainly from two sources: first, vessels accompanying the various cutaneous nerves, eg saphenous nerve, sural nerve, sural communicating nerve and lateral cutaneous nerve of the calf; second perforating vessels from gastrocnemius. Jamiesons says no blood supply comes from soleus which is therefore best excised from flap)
• I sharply divide the skin and fascia, identifying and ligating GSV which lies medially in the subcutaneous plane
• I divide the anterior compartment with diathermy, down to interosseous membrane, taking care to ligate the ant tib vessels and deep peroneal nerve which are on the interosseous membrane here (divide between clips and transfix with 2-0 vicryl)
• I also identify the superficial peroneal nerve between peroneal longus and brevis; I draw it down and transect it as proximal as possible
• I divide the fibula 1cm proximal to the planned tibial division after stripping it cranially with a periosteal elevator (bone cutters or a periosteal saw, perpendicular)
  
  • I’m mindful here that just behind the fibula are the peroneal vessels which run along the medial border of the fibula deep to tib post - of the three main vessels, peroneal artery is perhaps the most likely to be patent – can be damaged along w its accompanying veins during freeing up of the fibula prior to its transection
• I then elevate the periosteum off the tibia and dissect around it and pass a medium pack through the defect, and transect using an oscillating saw usually at a 45 degree angle anteriorly then move to a 90 degree angle to finish the division; use a bone rasper to smooth the edges
• I use a bone hook to distract the distal part of the tibia
• I then divide tibialis posterior and identify and ligate the posterior tibial and peroneal vessels, and cleanly divide the posterior tibial nerve, allowing it to retract
• I identify the plane between the soleus and gastroc and remove all of the soleus bulk off the flap from the level of the tibial division downwards
• SSV is found superficially in the posterior midline; when I remove the leg and am filleting off the skin I’ll identify it there and make sure I control it, and it will be accompanied by the sural nerve which I will draw down and divide
• Check no spots on bone that need to be rasped down
• Wash and check haemostasis
• Put a nerve catheter up to where the tibial nerve is
• Place a drain through the muscle laterally that will be sitting in the space underneath the flap
• Close two fascial layers
  
  • Bring gastroc fascia over the top of the tibia and secure this to the periosteum of the tibia with figure of 8 1-0 vicryl sutures
  • After that use the superficial fascia of the posterior flap and bring it over and sew it to the fascia of the anterior compartment muscles – closing fascia to fascia
• Might need to trim posterior flap and make sure its gently rounded so it meets the anterior skin incision
• Skin closed with 3-0 Nylon vertical mattress sutures
• Dress wound with gelonet, gauze, sofban, crepe, premade amputation elastic sock, then make plaster of paris cast that will help control post-op oedema and protect the stump; make sure postop the pts don’t flex the knee cos can get flexure contractures
• Usu won’t sew in the nerve catheter or drain so if these need to be removed before day 5 they can just be pulled out from under the dressings

Question 90

Brachial embolectomy

Answer 90

• 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 inflow; should be audible
• Start with proximal passage of 3Fr Fogarty balloon then flush with hep saline
• Move on to radial and ulnar arteries; flush with hep saline
• Close arteriotomy with continuous 5-0 Prolene avoiding raising the intima of the bottom flap
  
  • Consider small vein patch for brachial
• Release clamps and check pulses, close over drain in layers
• Consider fasciotomy

Complications

• Reocclusion
• Bleeding
• Infection

Specific post-op care

• Long-term anticoagulation
• Evaluate underlying disease
  
  • Medical optimisation

Question 91

Femoral embolectomy

Answer 91

* Key principles:

* Indicated for embolic occlusion
* Decide early between salvage and amputation
* Revascularization in a totally non-viable limb is invariably fatal w reperfusion injury * Preparation
* On table angiography
* Vascular set
* Clear drapes
* Heparin planning * Vertical longitudinal incision over artery; midpoint of incision corresponds roughly with groin crease (which is about 2-3cm below ing ligament) * Dissect down to sheath and incise longitudinally
* The femoral vein lies medially and must be protected
* The nerve lies laterally and is plane deeper; excessive retraction is avoided to minimize 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 and SFA; dissect and sling these, being careful to avoid the profunda vein - a main tributary of which passes anterior to profunda artery (can divide this) * Make a longitudinal arteriotomy directly over origin of profunda with an 11-blade, extend with Potts scissors * Pass a 4Fr embolectomy catheter proximally beyond the clot; inflate and withdraw (while adjusting pressure within the balloon to accommodate changes in diameter of vessel – avoid severe friction between balloon and arterial wall since this can cause intimal damage to the vessel)
* Control the anticipated bleeding with an assistant holding the sling * Repeat until no more thrombus retrieved and adequate forward arterial flow is obtained from the vessel * Instill hep-saline and clamp proximal vessel * Repeat procedure distally * Fill vessels with hep-saline and close arteriotomy directly with 5/0 prolene * Close wound in layers with interrupted skin sutures or clips after instituting suction drainage * Consider calf fasciotomies

Issues

• The catheter won’t pass proximally or forceful forward bleeding isn’t obtained
  
  • Can be due to pre-existing arterial disease or to the catheter having been introduced in a subintimal plane
  • Avoid direct aorto-iliac reconstruction under these circumstances if at all possible and perform either a femoro-femoral crossover or an axfem bypass
• The catheter won’t pass distally
  
  • Obtain on-table angiogram – may show embolus impacted at the popliteal bifurcation and in the tibial arteries, or evidence of atherosclerotic occlusion
  • Instil small amount of a thrombolytic agent (streptokinase, urokinase or tPA) locally through a small catheter advanced to site of occlusion
  • Then pass small Fogarty catheter 15mins later; more embolus may be retrieved
  • Alternatively, expose infrageniculate popliteal artery to enable Fogarty catheters to be introduced directly into the tibial vessels (requires GA)
  • If longstanding atherosclerotic occlusion of SFA, restoration of blood flow to profunda system alone is likely to be sufficient to save the limb, but if distal perfusion remains poor, proceed to fempop bypass
  • Where facilities for intra-op fluoroscopy exist, as an alternative to exposure of popliteal artery for retrieval of emboli from tibial arteries, pass the embolectomy catheter over a guide-wire negotiated into each vessel in turn; assess the result by angiography

Question 92

Embolectomy catheter sizes

Answer 92

3F for axilla, brachial and distal SMA, 4F for superficial and profunda femoral and proximzl SMA, 5F for aortic bifurcation

(Fogarty catheters go from 2 to 7; 7 is the largest)

Question 93

Ruptured AAA

Answer 93

• Permissive hypotension is advocated for patients with a clinical diagnosis of AAA to maintain an alert pt and sbp >70mmHg
• Immediate transfer to operating room for pts considered to be surgical candidates
• Supine crucifix position; skin prep onto pt while awake, scrub team ready prior to induction of anaesthesia
• Maximum access midline incision
• If actively bleeding, immediate supra-coelic control via lesser omentum;
  
  • retract down stomach
  • window through lesser omentum
  • retract oesophagus to left (NGT can help ID)
  • blunt dissection with fingers or scissor dissection is used to divide the crus and expose the aorta
  • blunt dissection to get down the sides of the aorta; this is then clamped
• if haematoma is mainly distal and patient stable, the aorta can be approached initially infrarenally for clamp placement
• alternatively entire abdominal aorta can be exposed from supracoeliac level to aortic bifurcation by performing a medial visceral rotation (incise left posterior peritoneal attachments latearl to left colon and solid abdominal viscera and reflect them medially)
• Infrarenal approach:
  
  • transverse colon retracated cephalad, SB packed into RLQ
  • ligament of Treitz incised allowing retraction of duo and exposure of retroperitoneal tissue overlying aorta
  • retract left renal vein superiorly (if necessary can divide as close to IVC as possible)
  • disect and clamp infrarenal neck of aorta (dissection limited to anteiror and lateral aortic walls)
  • if successful, communicate with anaesthetist and remove supracoeliac clamp (hypotension may occur from liver and intestinal reperfusion)
  • if anatomy too obscured/distorted by haematoma, may need to enter aortic sac, define neck and then place proximal clamp as distally as possible to perfuse renal and visceral outflow
• after placement of prox aortic clamp, dose of IV heparin
• Get distal control; expose and clamp iliacs (identify vein and ureter)
  
  • if anatomy difficult to define, can open aortic sac and place 14Fr Foley or large caliber Fogarty catheters into iliacs w balloon inflation for control; can irrigate catheters distally w hep saline
• Talk to anaesthetists; catch up on blood loss
• Identify IMA
  
  • if not patent (most often), ligate
  • if patent, bulldog clamp and assess bowel changes; if ok, ligate; if not, will need to reimplant at the end (excise button of AAA with IMA)
• Open aneurysm and T the top and bottom; evacuate contents
  
  • insert self retainer and oversew lumbar back bleeders and median sacral artery - figure of 8 3-0 Prolene
  • flush hep saline down either leg (5000iu in 250mL)
• Insert a dacron/PTFE tube graft soaked in antibiotic
  
  • inlay technique; try to use a tube graft bc faster and only use a bifurcated graft if absolutely necessary
  • proximal anastomosis with 3-0 prolene double armed round taper; paracute in top back wall; in to out aorta and out to in on graft; clamp graft and assess proximal suture line by release of proximal clamp
  • reapply proximal clamp ditsal to anastomosis
  • stretch & cut to length
  • distal anastomosis with 3-0 prolene
  • flush aorta from above and below prior to completion of anastomoses
    
    • if no back bleeding - embolectomy of iliacs
  • restore flow slowly to iliac arteries sequentially to limit declamping hypotension after warning anaesthesia
• assess iliac & femoral pulses
• reimplant IMA if necessary using Satinsky
• confirm haemostasis
• close aneurysm sac over graft
• appose peritoneum
• consider laparostomy closure to prevent ACS
• consider fasciotomies to lower limbs

Question 94

Open SFJ ligation and GSV stripping

Answer 94

• Preparation: ensure routine duplex to exclude deep venous insufficiency and mark site of SFJ, incompetent perforators and mark SPJ if SSV disconnection being performed
• Key principles
  
  • Identification of SFJ before ligation
  • Eversion stripping
  • +/-Stab avulsions
• Positioning
  
  • GA, supine, strapped for Trendelenberg tilt to 30 degrees, supine hip abducted & knee flexed, leg(s) & groin free draped with perineal exclusion (U drape), foot wrapped
• Oblique incision based on a point 2 fingerbreadths below and lateral to the pubic tubercle, check for femoral pulse laterally
  
  • Incise skin, subcut tissue, superficial fascia
  • From here I dissect carefully expecting to encounter the tributaries
  • I sweep away the fat from the tributaries draining into the GSV so that they are easily identifiable
  • I place a self-retainer
• Identification
  
  • Identify GSV or one of its tributaries and follow it through fossa ovalis towards the femoral vein
  • I don’t cut any veins until I am satisfied that I have identified the CFV, GSV and SFJ; things that help identify the GSV are:
    
    • GSV enters the CFV on its anteromedial border at an acute angle
    • GSV typically receives multiple tributaries and looks thin-walled compared to the CFV
    • I dissect the CFV 2cm proximal and distal to the SFJ to ensure the CFV continues down into the thigh
• Ligation
  
  • Once I’m happy I ligate the GSV tributaries in continuity using 2/0 vicryl ties
    
    • Anterolateral accessory branch
    • Posteromedial accessory branch
    • Superficial & deep external pudendal
    • Superficial epigastric
    • Superficial circumflex iliac
  • Watch for superficial external pudendal artery – runs across lower lip of cribriform fascia
  • I apply clips on the GSV with distal clip approx. 0.5cm from the SFJ and divide the vein
  • I tie the distal end with vicryl then lift the stump of the GSV to ensure I’ve identified and ligated all tributaries, then suture ligate the SFJ without narrowing the CFV using 0 vicryl
• Strip
  
  • I introduce a flexible plastic stripper with a blunt tip through a small venotomy distal to my tie on the divided end of the GSV and pass it to ~1 hands breadth below knee
  • Remove olive and tie a strong cuff around proximal bulb at GSV
  • Cut down onto vein, ligate distal GSV, deliver stripper through small venotomy
  • ?Tumescent local anaesthesia placed around GSV
  • Eversion strip
• Pressure
  
  • My assistant and I apply firm constant pressure over the course of the GSV for 2-3mins to minimize bruising
• Perforation
  
  • Ligation of incompetent perforators previously marked
  • Stab avulsions w a small blade nerve hook
  • Mosquito forceps
• Monocryl to skin
• Apply a pressure dressing then a compressive stocking and elevate leg post-op
• Bandages for 1 week, encourage mobilisation rather than standing or sitting w legs dependent
• Compression stockings following for 3wks

Intraop issues

• Can’t pass stripper down from groin
  
  • Withdraw it slightly and try again w a rotating action twisting the free end to help negotiate valves & other irregularities
• Can’t pass it beyond knee
  
  • Flex and extend the knee and place external pressure on the tip of the stripper
• Still can’t negotiate the stripper
  
  • Make an incision below the knee over the LSV and pass a second stripper from proximal to distal til the two meet
  • Then advance the first stripper from the groin whilst withdrawing the lower one
• Still can’t get either of these strippers to pass an obstruction
  
  • Cut down onto the tips of both and avulse it in both directions leaving the middle segment, which you can avulse if varicose

Complications

• Bleeding
• Nerve damage
  
  • Sural (SSV)
  • Saphenous (GSV)
  • Thrombophlebitis
  • DVT
  • Recurrence

Recurrent varicose veins frequently caused by (Jamiesons)

• Failure to flush ligate the SFJ
• Recanalization of SFJ
• Failure to strip or ablate above knee GSV
• Missed SPJ incompetence
• Unexpected deep venous incompetence
• Most surgeons image the venous system of the leg w duplex USS in both primary and recurrent varicose veins to reduce incidence of recurrence from missed sites of incompetence

Question 95

SPJ ligation

Answer 95

• Prone
• 20 degree head down and slightly abduct legs
• make a 4cm transverse incision in region of popliteal fossa over marked junction
• make a vertical incision in deep fascia and expose the termination of the vein by blunt dissection
• insert Langenbeck retractors to display confidently the T-junction between the popliteal and saphenous veins
• I look for the vein of Giacomini joining the SSV from above and ligate it with 2/0 Vicryl ties
• I am careful not to damage the sural nerve emerging laterally in popliteal fossa
• I divide the SSV with 2/0 vicryl ties and doubly ligate the stump flush on the popliteal vein

Question 96

Identification of GSV and SFJ

Answer 96

• placement of incision – groin crease medial to femoral artery pulse
• GSV enters CFV on anteromedial border at an acute angle
• GSV typically receives many branches & looks thin walled cf CFV
• Pre-op duplex USS can aid localization
• Dissection of CFV 2cm proximally and distally to SFJ ensures that the CFV continues down into thigh
• Deep external pudendal ARTERY travels lateral to medial over distal GSV superiorly; this can be ligated if need be

Question 97

Portacath insertion

Answer 97

• I insert a Cook Vital Port under GA
• Chest and neck are prepped and draped
• Head is turned away from right side
• Use an USS to identify IJV
• Skin is incised near clavicle and a space over IJV dissected
• I puncture the micropuncture needle into the IJV and thread in the wire
• 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 LA and adrenaline
• The skin is incised and then a subcut space developed
• Next I run a tunneling device w the attached catheter through the subcut 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 xray; 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’s no leak
• The port parachuted into the pocket with 3 interrupted 3-0 vicryl sutures
• The port and IVJ sites are closed and the position is checked again
• The port is locked with Heparin as per local protocol

Question 98

Open transabdomoinal adrenalectomy

Answer 98

• Supine ? +/- w ipsilateral side slightly elevated on a bolster
• Prepped from nipple line to pubis
• Subcostal or upper midline (with midline both glands can be more easily explored though can extend subcostal across midline)
• LEFT
  
  • Enter lesser sac through gastrocolic ligament & incise retroperitoneum inf to tail of pancreas which takes you down to left renal vein & left adrenal vein (more direct) OR expose by rotating spleen, panc tail & stomach anteromedially (similar to lap)
  • Mobilise splenic flexure inferiorly
  • Plane medial to adrenal developed
  • Adrenal vein isolated, tied in continuity & divided
  • Small adrenal arteries can be ligated or electrocoagulated
  • Complete circumferential dissection
• RIGHT
  
  • Complete mobilization of right lobe of liver incl lateral attachments & falciform
  • Retract liver superiorly using long padded retractors
  • Kocher’s maneuver to enter retroperitoneum & reflect duodenum medially to expose IVC
  • Plane between adrenal and IVC developed
  • Sequentially ligate vascular structures (which may be numerous in highly angiogenic tumours)
  • Isolate adrenal vein, securely tie it and divide
  • Loss of control of adrenal vein stump may be managed w application of a side-biting (Satinsky) vascular clamp
  • Locally invasive right-sided adrenal tumours can be challenging to mx bc frequently invade adjacent venous structures; may need to involve experienced vascular or liver surgeon
  • Resect locally invaded organs (most commonly kidney) en bloc w primary mass
  • Complete radical resection = critical determinant of survival in pts w malignant adrenal tumours; in some cases this can be achieved only if immediate venous recon performed

Question 99

Laparoscopic lateral transadominal left adrenalectomy

Answer 99

• Placed in the lateral decubitus position facing opposite to the side of the adrenal lesion for excision with table jack-knifed to open lumbar space between costal margin & iliac crest (also drops iliac crest away from plane of lap instruments)) – 10^th rib directly over break point in table
  
  • and appropriately cushioned and secured taking care to avoid tissue or nerve compression; beanbag rigidified in a position that supports buttocks & back while leaving umbo, an important surface landmark, exposed
  • wide cloth tape to secure pt at chest, hips and legs
• prep from nipple to pubis and from umbo to midline of back
• slightly head up to irrigation fluid, omentum & intra-abdominal contents will tend to fall away from site of dissection
• I operate from the abdominal side
• I use 3-4 ports on left in the subcostal position from the midaxillary line to the midline
  
  • 10-12mm trocar in left subcostal region (can do Veress technique or optical trocar at Palmer’s point – 2cm inf to costal margin in MCL); then 2 or 3 other subcostal ports so ports equally distributed 2cm below costal margin, w posterior port placed as far lateral-posterior as permitted by position of colon; aim for at least 5cm (4fingerbreadths) between each port (ports evenly placed between midaxillary and midabdominal lines)
    
    • Occasionally a 4^th port is used to retract the spleen and colon
• Steps
  
  • Divide lateral splenic attachments, splenocolic and posterior aspect of splenorenal ligament to allow spleen to fall medially (goal of rotating LUQ viscera anteromedially)
  • Continue splenic mobilization until greater curve of stomach becomes visible at its apex, at which pt the spleen & tail of panc are allowed to fall anteriorly w rightward tilting of table & gentle use of fan retractor, if necessary
  • In pts w large or inferiorly positioned tumours, splenic flexure of colon must be mobilized caudally by dividing splenocolic ligament
  • Identify tail of pancreas medially; renal and adrenal vein should lie lateral to this
  • Use open book technique which involves developing the cleft-like plane just medial to adrenal gland & lateral to aorta
    
    • Left-hand page of book = spleen, tail of panc & greater curve of stomach
    • Right-hand page of book = kidney and adrenal tumour
  • Left crus of diaphragm = useful landmark that leads me to left inf phrenic vein; this courses along medial aspect of left adrenal gland before joining w left adrenal vein; by developing the cleft of the open book, moving from sup to inf, adrenal vein is encountered at inferomedial aspect of adrenal gland
    
    • Small adrenal arteries that lie in this plane can be handled w ligasure or clipped and ligated
    • Left adrenal vein carefully dissected out, aggressively coagulated or clipped and divided (?vasc stapler)
    • Inferior tip of left adrenal gland may extend low, approaching renal hilum within mm; but bc left adrenal vein rather long (2cm), generally not necessary to expose renal vasculature during left adrenalectomy
  • Many pts have a superior pole renal artery branch that approaches inf aspect of left adrenal gland; keep dissection close to adrenal capsule while specimen is elevated away from medial aspect of sup pole of L kidney to avoid injury to this branch
  • Incise all remaining gland attachments circumferentially & posteriorly, taking specimen off superior pole of kidney & post abdo wall
    
    • These attachments deliberately divided last bc they aid in suspending adrenal gland on lat-sup wall of operative field, providing exposure of medial vasc plane during critical initial portion of procedure
  • adrenal removed in a bag
  • washout of surgical bed and meticulous check for haemostasis
    
    • beware that during lap surgery the pneumoperitoneum may prevent venous bleeding being immediately apparent
  • drains left in situ
  • closure of port sites in usual fashion

Question 100

Laparoscopic lateral transabdominal right adrenalectomy

Answer 100

• Placed in the lateral decubitus position facing opposite to the side of the adrenal lesion for excision with table jack-knifed to open lumbar space between costal margin & iliac crest (also drops iliac crest away from plane of lap instruments)) – 10^th rib directly over break point in table
  
  • and appropriately cushioned and secured taking care to avoid tissue or nerve compression; beanbag rigidified in a position that supports buttocks & back while leaving umbo, an important surface landmark, exposed
  • wide cloth tape to secure pt at chest, hips and legs
• prep from nipple to pubis and from umbo to midline of back
• slightly head up to irrigation fluid, omentum & intra-abdominal contents will tend to fall away from site of dissection
• I operate from the abdominal side
• I use 4 ports on right in the subcostal position from the midaxillary line to the midline
  
  • the 4th is to retract the liver
• Steps
  
  • ?left-hand page of open book is made up by kidney & adrenal tumour & right-hand page composed of bare area of liver
  • Retract right lobe of liver cephalad with Nathanson retractor
  • Mobilise inferior & lateral liver attachments (right triangular ligament)
  • Continue medially to identify the IVC & incise the peritoneum lateral to this along its length
  • (on right side, colon usu lies well inf to operative field)
  • Cautious dissection heading inferiorly between IVC & gland aiming to identify right adrenal vein
    
    • This is much shorter than left so care taken not to injury IVC
    • Be mindful of adrenal vein variants
    • R adrenal vein = potentially perilous structure to manage bc is short, wide, variable & confluent w thin-walled, large-capacitance vessels (IVC in >80% of cases, followed by renal vein & uncommonly R hepatic vein) that can bleed briskly if directly injured (eg by cautery), lacerated from undue traction on adjacent structures or sheared by clips
    • Significant 2^nd adrenal vein may be found in up to 10%
  • Dissect superior pole of adrenal first, so gland remains attached to kidney & doesn’t migrate further upwards
  • Dissect out vein & definitively ligate (2 clips on pt’s side) then divide
    
    • If lose control of adrenal vein stump have to convert to open
    • Nb junction of IVC & right renal vein often difficult to identify; in vivo transition is gradual curve cf 90degree takeoff depicted in anatomy texts
    • Therefore can’t be used as reliable anatomic landmark for ID of adrenal vein
  • After control of vein, remaining mobilization of R adrenal gland straightforward bc inferomedial limb generally doesn’t reach down as far toward renal hilum as on left side
    
    • Arteries can often be taken w harmonic scalpel, but particularly the inferior vessel may need individual dissection and ligation
    • Avoid inadvertent injury to superior pole renal vessels (which may subsequently manifest as renovascular hypertension) by gently retracting caudal aspect of gland away from renal hilum
  • adrenal removed in a bag
  • washout of surgical bed and meticulous check for haemostasis
    
    • beware that during lap surgery the pneumoperitoneum may prevent venous bleeding being immediately apparent
  • drains left in situ
  • closure of port sites in usual fashion

Question 101

Open retroperitoneal adrenalectomy*

Answer 101

Open lateral (retroperitoneal) approach

• Position in lateral decubitus position w table broken to open space between costal margin & iliac crest
• Incision along line of 11^th or 12^th rib, which is then excised
• Expose adrenal taking care not to injure pleura or peritoneum
• Gives more limited exposure than anterior approach but better exposure than posterior
• Jamieson’s describes as an extension of the posterior approach (below) but while providing good access to retroperitoneal structures on the side undergoing operation, it produces more morbidity & precludes bilateral approach w/o repositioning

Open posterior (retroperitoneal) approach

• Positioned prone & back flexed by jack-knifing table
• Near-vertical incision (moving slightly towards iliac crest) made & neck of 12^th rib divided (or completely excised to expose gland)
• Bilateral parallel incisions if bilateral excisions (but tumours >5cm difficult bc access limited)

Jamieson’s describes:

• Approach either through bed of 11^th or 12^th ribs (or occasionally through bed of 10^th rib) or just above the appropriate rib
  
  • In practice doesn’t matter v much, but removal of rib tends to provide slightly better exposure
  • Bc right adrenal gland lies higher than left, best to approach it w incision over 11^th rib, while for left gland an 11^th or 12^th rib approach can be used
• Lat dorsi divided in line of rib
  
  • Depending on degree of exposure required this incision can be extended into flank muscles – ext oblique, int oblique & transversus; these muscles take attachment from rib or its costal cartilage & have to be divided if a rib is removed
• Under lat dorsi, some fibres of serratus posterior inferior muscle are divided & incision extended medially til vertical fibres of sacrospinalis are seen
• Pleura is related to medial half of 12^th rib & to medial ¾ of 11^th rib; therefore care must be taken if pleural damage to be avoided
  
  • Bc blunt dissection or pushing of pleura away from rib & diaphragm often leads to a hole in pleura, some surgeons prefer deliberately to incise it then divide the diaphragm which lies directly beneath incision
• while is possible to remove adrenal glands w/o division of diaphragm, it facilitates exposure, particularly on right side & is best regarded as essential step
• during procedure should seek neurovasc bundle as it lies below 12^th rib & bundle is protected
• superior pole of kidney = only structure easily found by this incision then adrenal is sought in usual way

Question 102

Laparoscopic retroperitoneal adrenalectomy

Answer 102

Lateral (retroperitoneal) endoscopic approach

• through similar tissue plane to traditional open loin approach
• less widely used than transperitoneal approach
• same lateral decubitus position as for a lateral transperitoneal approach
• port placed under direct vision into retroperitoneal space through muscles below 12^th rib
• balloon passed down port & inflated to create a working space
• 2 further ports inserted to enable adrenal to be dissected out

Posterior (retroperitoneal) endoscopic approach

• same position as for open posterior approach (ie prone w table jack-knifed)
  
  • supports under lower chest & pelvic girdle so abdo allowed to hang anteriorly
  • flex bed 30 degrees at junction of upper and lower torso and 45 degrees at junction of lower torso and legs
  • in this position, boundaries of retroperitoneal space are paraspinal muscles medially, kidney/adrenals/peritoneum anteriorly (closer to operating table), and thorax/ribs posteriorly (closer to surgeon)
• 3 ports placed
  
  • initial 10mm port placed with direct cut-down halfway between paraspinal muscles and proposed lateral port; explore retroperitoneal space digitally then use index finger to guide insertion of 2 further ports into retroperitoneum
  • lateral port placed just inferior to costal margin, ideally as far lateral as possible
  • medial port placed just lateral to paraspinals
• relatively high insufflation pressures of 20-22mmHg used to create working space
• working space initially created by dissecting retroperitoneal contents anteriorly away from ports
• after opening Gerota’s fascia, superior pole of kidney is identified, mobilized & reflected inferiorly to expose adrenal gland
• mobilization of adrenal gland begins near paraspinous muscles, at inferomedial aspect of the gland
  
  • this is where the left adrenal vein is almost always encountered early in the procedure
  • on the right side, vein is encountered slightly later as dissection proceeds superiorly
• small adrenal arteries that run within medial vasc space are coagulated
• after superior apex of adrenal gland mobilized, dissection proceeds circumferentially to include periadrenal fat

Question 103

Bleeding from IVC during adrenalectomy

Answer 103

• immediate pressure to stop bleeding & avoid air embolism
• compression w swabs above and below defect
• primary suture closure
• low threshold for conversion to open
• call for help early

Question 104

Total thyroidectomy

Answer 104

Preoperative preparation

• Ensure euthyroid
• Vocal cord check
• Consider CT if large MNG
• NIMS tube and not paralysed if intraop neuromonitoring planned

Operative details

• Neck extended in midline with head on a head ring and shoulder bolster support (lengthwise between shoulders), arms tucked at side?bed in reverse trendelenberg
• Set up NIMS machine
• Inject local +/- cervical nerve block
• Transverse skin crease incision, 2 finger breadths above sternal notch in a skin crease (below cricoid cartilage
  
  • Length depends on size of thyroid/patient factors – roughly lateral extension to medial border of SCM
  • Divide subcutaneous tissue and platysma muscle
• Raise superior and inferior sub-platysmal flaps anterior to anterior jugular veins
  
  • Superior to level of thyroid prominence and inferior to sternal notch; laterally to SCM muscles
• 2x Jolls retractor
• Strap muscles separated in midline from thyroid cartilage to sternal notch
  
  • Median raphe = avascular, consists of the pretracheal or deep cervical fascia over the thyroid gland and trachea
• Sternothyroid and sternohyoid retracted laterally; use Allis clamps then Kelly’s retractors to free sternothyroid muscle from anterior surface of thyroid lobe by dividing intervening loose areolar tissue
  
  • Horizontal division of sternohyoid and sternothyroid may be necessary to fully expose v large gland – do this at level of cricoid to avoid injury to ansa cervicalis, which enters this muscle inferiorly
• If pyramidal lobe easily identified during this phase can be dissected free from its attachments and ligated to allow for greater mobility of gland – dissect it out as superiorly as the thyroid cartilage and completely resect to avoid recurrence in this area
• Anteromedial traction applied to lobe, and middle thyroid vein divided
• Separate areolar tissue between thyroid gland and CCA using a combo of blunt and sharp dissection, allowing for further anteromedial mobilization of thyroid gland
• Subcapsular dissections helps minimize risk of postop hypocalcaemia and nerve injury
• Apply caudal and lateral traction to thyroid parenchyma at superior pole to expose superior thyroid artery and veins
  
  • Open the avascular space between the medial surface of thyroid and underlying cricothyroid (space of Reeve) medial to superior pole
  • May identify EBSLN (some say routinely identify & others simply attempt to avoid it by ligating well skeletonized vessels close to their insertion into thyroid) – be aware of possibility of a Cernea type 2 nerve
  • Use a Dietrich right angle to dissect on the lobe and divide superior-pole vessels close to thyroid gland, staying lateral to muscles of pharynx and larynx to avoid injury to EBSLN
• Reflect the upper pole forward and start to look for superior parathyroid on the back of the lobe; preserve this and its blood supply
• Identify inferior thyroid artery, and then RLN
  
  • Trace RLN through its entire course and preserve; intraoperative nerve monitoring used to help confirm location and integrity of nerve
• Inferior pole of thyroid gland mobilized ideally only once RLN identified, by ligating branches of arteries and veins close to thyroid gland (some describe division of inferior pole before identifying RLN)
  
  • By ligating vessels close to gland, blood supply to parathyroid glands therefore preserved, and RLN protected
  • Be aware inferior parathyroid is more variable
• anterior surface of trachea then exposed, and simultaneous anteromedial retraction of superior and inferior poles of thyroid enhances exposure of RLN
  
  • few landmarks that might help identify RLN and parathyroid glands:
    
    • TZ, trachea, oesophagus and TOG
  • Technique of capsular dissection aims to preserve blood supply to PT glands and ‘encounter’ the RLN
  • Pretracheal fascia enveloping thyroid lobe is incised along posterior surface, in the craniocaudal direction, anterior to the PT glands; dissection continues on broad front towards TOG, in doing so safely dissecting the PT glands and their blood supply off the surface of thyroid gland
  • TZ then rotated anteromedially to reveal underlying RLN
    
    • But remember that on rare occasions, RLN may be lateral to tubercle
    • Important to trace RLN inferiorly for a couple of cms to ensure there is not a more anterior motor branch
• With RLN fully exposed, remaining branches of ITA and other attachments of the gland to the trachea can be divided
• once lobe of thyroid gland been separated from RLN, the remainder of the ligament of Berry can be divided, separating isthmus from trachea
• be alert to possibility of thyroidea ima artery present in 3%
• check nerve
• contralateral lobe resected identically, and after complete removal, integrity of RLN is confirmed, both by visual inspection and with nerve probe
• haemostasis checked and irrigation w normal saline – head down and Valsalva
• check all parathyroids
• sternohyoid muscles reapproximated using interrupted 3-0 pds (through only fascia not muscle)
  
  • inferior aspect left open over 1-2cm to allow blood to decompress into subcut space if bleeding develops
• platysmal muscle layer then reapproximated with interrupted 3-0 pds
• continuous 4-0 monocryl to skin

Post-operative care

• calcium and PTH 6hrs post and next morning
• clinical voice check
• thyroxine replacement

Complications

• RLN injury – permanent <1%, transient palsy 7%
• EBSLN injury
• Hypoparathyroidism – permanent 3%, transient 10%
• Recurrent hyperthyroidism
• Thyroid crisis/storm
• Haemorrhage/airway obstruction

Question 105

Consequences of nerve injury during thyroidectomy

Answer 105

• Damage to EBSLN leads to loss of function of cricothyroid muscle, and therefore loss of ability to tighten the cord on the side of the nerve; makes it difficult for the pt to make high-pitched sounds or to project the voice
• Damage to one RLN may produce some weakening of the voice but as the cricothyroid muscle is unaffected (assuming the external branch of the SLN has not also been damaged) the cord lies close to midline and opposite cord can cross midline to compensate for the injury
• Damage to both recurrent and external nerves on same side leads to cord assuming cadaveric position of mid adduction, so that there is hoarseness of the voice and an inability to cough
• Bilateral RLN paralysis leads to both cords initially being in the semi-adducted position, so there is not usually early resp difficulty; but with time the cords tend to move towards the midline so that the voice improves but resp difficulty develops and a trache is usually required
• Idiopathic unilateral cord paralysis (which is often asymptomatic) is said to occur in ~1% of normal individuals

Question 106

Minimally invasive parathyroidectomy

Answer 106

Preferred approach IF localized

Preparation

• Positioned supine, arms tucked, shoulder support, head ring, reverse Trendelenburg
• Prep neck and upper chest
• Stand ipsilateral side
• 1g Cephazolin

Incision and access

• 2-4cm incision placed according to location that targets site of pathology
• for upper adenomas, incision on anterior border of SCM & a posterolateral or ‘back-door’ approach is used to reach retrothyroid space
• for ant lower adenomas, incision made at suprasternal notch level
• skin and platysma divided
• space between SCM and strap muscles

Key steps

• once exposure gained, medial carotid sheath exposed, retracted laterally and TOG entered
• search for gland within, dissect out in capsular fashion and remove
• can gain additional access by dividing sternothyroid medially
• if unable to find gland look in locations outlined below
• close platysma and skin +/- drain

Question 107

Parathyroidectomy - 4 gland exploration

Answer 107

Preferred approach IF performing subtotal, non-localised or reoperative. Medial (traditional) or lateral approaches

• skin crease curvilinear incision 2 finger breadths above clavicular heads
• skin and platysmal divided and subplatysmal flaps created (to 2cm above cricoid & to sternal notch)
• strap muscles separated in midline taking care to avoid ant jugular veins
• retract gland medially and straps laterally (may need to divide middle thyroid vein)
• identify ITA and RLN as landmarks for identification of glands
• may require mobilization of inferior pole
• look first for superior gland
  
  • exposure of posterior aspect of thyroid by displacing gland medially & forwards and retracting jugulocarotid bundle outwards
  • in 85% of cases can find normal superior gland in its orthotopic site by doing this – floats in loose fatty setting immediately adjacent to inf cornu of thyroid cartilage, v close to RLN & most cranial branch of ITA – 3 basic landmarks in search for sup parathyroid
  • if abnormal, tends to migrate posteriorly & downwards – see locations below; these adenomas can be revealed by their vascular pedicles – origin found at middle or upper third of thyroid lobe & they emerge w simple traction on their pedicle
  • before mobilizing need to ID nerve bc can be adherent to capsule
  • if can’t find, stop and move to inf gland
• look for inferior gland
  
  • more variable; initially search from ITA to inf thyroid pole where it usually is, in front of recurrent nerve
  • check thyrothymic ligament and around inf pole of thyroid lobe – lat, ant, inf
  • become more anterior the lower they are – see other locations below
  • if can’t find, stop and move to contralateral side – don’t want to damage a normal inf PT with more aggressive dissection
• on other side, do same order as first – remember natural symmetry in 80%
• at end of initial bilateral exploration, decide whether to continue or not; can abandon if:
  
  • 4 glands been discovered & one or more abnormal – a continued search for a supernumerary gland justified only in cases of familial hyperparathyroidism
  • 1 gland is pathological, the other gland(s) identified are normal, but <4 glands discovered – except in cases of familial hyperparathyroidism the low risk of multiglandular disease that might go unnoticed doesn’t justify obstinate pursuit of an exploration that might be more risky than beneficial, and dx of solitary adenoma becomes more likely as number of normal glands found approaches 3
• should pursue exploration if:
  
  • no gland or <4glands discovered & none pathological
  • <4 glands been discovered & at least 2 enlarged – dealing w multiglandular disease – missing gland(s) must be found
  • all 4 glands have been discovered but all normal – remain convinced of diagnosis and consider probable ectopic supernumerary adenoma
• identify and remove abnormal glands or perform subtotal – either 3.5 gland excision and leaving of 30-50mg marked with clip or reimplantation; rarely perform total requiring lifelong replacement
  
  • if reimplantation consider brachioradialis – can be difficult localizing hyperactive tissue – autografts or supernumerary gland?
  • Identification and resection of autografts not always easy (seeding in muscle)
• pathological nature of glands essentially determined from gross appearance – av weight ~40mg so abnormal if >75mg – therefore surgical excision based on this macroscopic evaluation which is more valuable if all the glands have been identified & exposed
• care not to enter capsule of gland which can lead to recurrent HPT from soft tissue implantation of parathyroid cells (parathyromatosis)
• can use IOPTH as adjunct
  
  • >50% decline 10mins after excision of all hyperfunctioning parathyhroid tissue is indicative of cure; if not need further exploration
  • if solitary adenoma, mobilization of adenoma completed before taking the blood supply; take blood from IJV or peripheral vein for IOPTH
  • main blood supply to adenoma ligated and additional blood obtained 5 and 10mins after excision
  • >50% decline in IOPTH cf preexcisional or preop value = cure and no additional exploration necessary
• should routinely search for supernumerary glands if doing subtotal – occurs in 10-15%; most often found in thymus so routine transcervical thymectomy
• if unusually large, chocolate-brown glands
  
  • suggests water-clear-cell hyperplasia; when doing subtotal advisable to save larger fragment (100-150mg) bc PT tissue functions poorly
• if doing subtotal
  
  • can either leave smallest gland - reduced so as to leave a fragment 40-60mg
  • or might be preferable to leave the fragment from the gland furthest from the nerve
• close platysma and skin +/- drain

Post-op care

• repeat Ca and PTH at 4hrs then following am
  
  • PTH levels decrease and almost undetectable 4hrs postop then begin to return within normal range on day1
  • expect calcium to return to normal in 24-48hrs
• generally 1 night stay if primary
• follow up 6wks
  
  • 1mo after surgery elevated serum PTH levels = observed in up to 30% of pts despite normalization of serum calcium; pts operated on for primary hyperparathyroidism show decreased sens to PTH
• when open parathyroidectomy done by expert surgeon, 95-98% pts become normocalcaemic

Post-op complications

• immediate
  
  • recurrent laryngeal nerve – 1%
  • injury to EBSLN
  • failed localization 1-2%
• early
  
  • haematoma 0.3%
  • hypocalcaemia – transient 15%, permanent 0-3%
  • wound infection
• late
  
  • persistence or recurrence (occurs after >6/12 normocalcaemia)
    
    • repeat localization +/- venous sampling
  • parathyromatosis

What are the causes of persistent & recurrent secondary hyperparathyroidism

• initial parathyroidectomy incomplete
• remnant too large
• further hyperplasia of parathyroid tissue in remnant left in neck or in autograft in forearm
• up to 15% HD pts have supernumerary PT gland in neck of mediastinum – ie missed gland; during initial op usu small & often appear to be embryological rests of PT cells, mostly assoc w thymus either in mediastinum in neck; in healthy pts these have little physiological importance but can develop functional significance following chronic stimulation over many yrs in pts w renal failure
• parathormatosis (capsular rupture of pathological gland at time of op)
• all pts who need re-op should have localization studies

Question 108

Unable to find PT glands during 4 gland exploration

Answer 108

• review preop localization
• divide MTV & mobilise inf pole if not done so already; may need to mobilise superior pole
• compare left and right, look in ‘common locations’
  
  • superior tend to be posterior; inferior anterior
  • ectopic superior glands: TOG, retropharyngeal, retroesophageal, posterior mediastinal, intrathyroidal (only 0.2%)
    
    • also ensure not stuck to back of upper lobe – ligate superior thyroid pedicle and mobilise upper pole to carefully check
  • ectopic inferior glands: within thymus or thyrothymic ligament (30%), anterosuperior mediastinum, undescended in submandibular location, within thyroid gland
• important to know if missing gland is sup or inf; remember that
  
  • congenital ectopias, in neck or anterior mediastinum, respectively caused by defective or excessive embryological migration, are related to inf PTs
  • acquired ectopias in posterior mediastinum caused by migration affected by gravity, secondary to adenomatous pathology, essentially related to sup PTs
• to check for intrathyroid adenoma, digitally palpate for it
• consider abandoning and repeat localization looking for intrathoracic gland
• consider venous sampling if unable to localise
• if unable to find but can localise side perform hemithyroidectomy and excision of all ipsilateral tissue excluding RLN

Question 109

Superficial parotidectomy

Answer 109

• Pre-op preparation includes assessment of facial nerve function
• Aim to preserve facial nerve and its branches unless definite malignancy
• Most parotid tumours are in superficial lobe, so vast majority of operations are superficial parotidectomy only
• Pt positioned head up 30-45 degrees (or until EJV collapses) and head turned to contralateral side; pt lies near surgeon’s side of table
• Appropriate head draping with attention paid to eye care and transparent drape, protect auditory opening with Vaseline-gauze
• Discuss w anaesthesia team re avoidance of paralysis – for facial nerve monitoring
• Options for nerve monitoring: having an assistance observe pt’s face for movement intraop or more formal EMG monitoring
  
  • insert needle electrodes into the ipsilateral frontalis and mentalis muscles to record EMG signals from them, producing audible and visual signals when the facial nerves supplying them re stimulated; nerve monitor can also be used as an aid to identify a doubtful nerve or to confirm that the nerve is intact by demonstrating a signal on stimulating the nerve
• Pre-auricular Lazy S incision from level of zygomatic arch, to below ear-lobe then back to mastoid then soft curve anterior, at least 2.5cm behind ramus of mandible and at least 3cm below base of mandible
  
  • Make hatch mark before incision to assist w proper alignment of earlobe at closure
• Incise skin, fat and SMAS/platysma
• skin flaps elevated to anterior aspect of parotid gland (careful not to extend too far anteriorly (>1cm) over masseter where distal facial nerve branches become superficial)
  
  • in the neck the plane is immediately deep to platysma, and in parotid region it’s immediately deep to SMAS
  • anteriorly, SMAS is lifted off parotid fascia
• suture flap to drape with silk
• retract lobule of ear posteriorly and dissect in posterior aspect of wound to identify greater auricular nerve; try to preserve the posterior branches to the lobule and divide the anterior branch as it enters the gland
• try to preserve the ext jugular vein, but ligate it if required
• deepen incision in 3 stages, starting inferiorly (to avoid blood tracking into wound)
  
  • neck portion
    
    • identify anterior border of SCM and deepen this incision to locate and dissect out the posterior belly of digastric and stylohyoid muscle
    • follow these as proximal as comfortable and dissect overlying parotid parenchyma off them
  • mastoid portion
    
    • deepen dissection along the anterior border of SCM down towards mastoid process with assistant providing anterior retraction of the gland; expose more of the posterior belly of digastric and stylohyoid
  • facial portion
    
    • open up tissue anterior to tragus on the cartilaginous portion of the EAM using an artery clip, and deepen this towards the tympanomastoid suture line/tragal pointer
• identify facial nerve
  
  • wound is well opened up except at central portion over mastoid process; work on this tissue piecemeal w right angle dissection
  • identify main trunk of facial nerve as it exits stylomastoid foramen; clues:
    
    • 1cm inferomedial to tragal pointer
    • 0.5-1cm deep to tympanomastoid suture line
    • 1cm medial and superior to posterior belly of digastric
• nerve is followed carefully into gland w dissection proceeding over and parallel to the direction of the nerve, with division of overlying parotid parenchyma
  
  • watch for the retromandibular vein tributaries which have a variable relationship within the gland
  • create plane with artery forceps or McCabe facial nerve dissector lifting tissue off the nerve and its branches, and use bipolar to divide tissue between/for haemostasis
  • once pes anserinus is encountered, dissection then proceeds in stepwise fashion along branches of facial nerve so that superficial lobe and tumour are removed en bloc (gland reflected forward in this manner, maintaining a broad front)
  • closely monitor patient’s face for movement to avoid injury to facial nerve
  • branches of facial nerve should never be sacrificed unless there was a loss of function preop or the nerve is encased in malignant tumour; preserve nerves adherent to tumours even in case of malignancy
  • consider nerve graft in cases where facial nerve sacrifice expected
  • anteriorly, nerve dives away over masseter and superficial layer may be divided with impunity from anterior border, always checking back edge of gland for plane of dissection
• branches of parotid duct are divided as lobe is excised
• haemostasis obtained w BP normalised
• wound bed irrigated
• 12Fr closed suction drain is placed parallel to PBD and wound closed in layers

Complications

• Haematoma most common
• Infection <5%
• Unintentional facial nerve injury 3-5%
• Sialoceles rare when suction drain used (managed with repeat aspiration and compression dressings, and rarely with oral anticholinergics and Botox
• Gustatory sweating (Frey syndrome) from aberrant regrowth of parasympathetic fibres into skin, possibly facilitated by excessively thin skin flaps
  
  • Only small % symptomatic & can be managed with antiperspirants or topical anticholinergic agents; Botox if severe

Question 110

Submandbular gland excision

Answer 110

• Benign disease:
  
  • Indications include submandibular gland stones, sialadenitis
  • To remove the superficial and deep lobes of the SMN gland, the structures that need to be protected are:
    
    • The marginal mandibular branch of the facial nerve (supplies depressor anguli oris, depressor labii inferioris, risorius and part of orbicularis oris – injury causes facial asymmetry and drooling)
    • The cervical branch of the facial nerve
    • The hypoglossal nerve (motor to all intrinsic muscles of the tongue except palatoglossus)
    • The lingual nerve (sensation and taste to ant 2/3 of tongue
• 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)
• GA, supine with neck extended and head turned away on a head ring, DVT prophylaxis
• Steps:
  
  • Incision and access
  • Dissection of superficial lobe
  • Dissection of deep lobe
  • Ligation of duct and excision of gland
  • closure
• Mark out the palpable lesion
• Locate incision to avoid the marginal mandibular and cervical branches of the facial nerve; skin crease 4cm below inferior border of mandible
• Develop flaps; for benign disease lift SMG fascia with the platysma by suturing together
  
  • This ensures protection of the thread-like marginal mandibular
• The inferior border of the SMN gland is bluntly dissected free and the facial vein is ligated as it is encountered on its superficial surface
• The posterior aspect of the SMN gland is dissected free; the facial vein and artery are ligated and divided when encountered
• The superior border of SMN gland is dissected; the facial artery is again ligated on the superior border as it loops around the inferior border of the mandible
• The superficial lobe is dissected off the mylohyoid muscle
• I retract the SMN gland laterally while my assistant retracts the posterior border of mylohyoid medially and I bluntly dissect the deep lobe of the gland free
  
  • The deep lobe lies between mylohyoid and hyoglossus
  • The hypoglossal nerve lies on hyoglossus inferiorly and is protected; it is deep to the tendon of the digastric
• The SMN duct extends from the deep lobe and is closely related to the lingual nerve; the lingual nerve is superior to the duct and is retracted inferiorly with the gland
  
  • SMN ganglion fibres attaching the nerve to the duct are divided, freeing the lingual nerve, which is retracted superiorly
  • The SMN duct is ligated with vicryl ties and divided; the gland and the duct are excised and checked for stones
• The wound is washed and a 10 bellovac drain inserted
• Closure in layers using vicryl and monocryl

Malignant disease

• In the case of malignancy, the aim of the operation is to remove both the submandibular gland and the associated lymphoid tissue in the submandibular triangle
• So the initial dissection is carried only through platysma and subplatysmal flaps are created
  
  • Important to stay on platysma while creating the superior flap; the marginal mandibular nerve is then formally identified in the fascia deep to platysma and retracted superiorly
• Dissection then proceeds to remove all the tissue below the mandible and between the posterior and anterior bellies of digastric
  
  • Care is again taken to preserve the lingual and hypoglossal nerves, but the preservation of the above structures may not be possible depending on the extent of the malignancy being treated

Question 111

Sistrunk procedure

Answer 111

• Pre-op USS to ensure the pt has a normal thyroid gland
• Incision and access
• Treatment requires en bloc excision of the cyst and the duct remnants from the foramen caecum to the pyramidal lobe and includes resection of a central portion of the hyoid bone – Sistrunk procedure
• Simple cystectomy w/o resection of the duct is associated with high rates (up to 80%) of recurrence
• 1% risk of thyroglossal duct carcinoma
• GA, supine with neck extended and shoulder roll between the shoulder blades
• A transverse skin crease incision is made over the location of the cyst
• Skin and platysmal flaps are created
• Median raphe between the strap muscles of the anterior neck is identified and opened – the cyst is located beneath the median raphe
• 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 skeletonized out to the lesser cornu
• The hyoid is then transected with bone-cutters medial to the lesser cornu, excising about 6-7mm of the hyoid
• 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
  
  • It is difficult to isolate the duct above the hyoid bone as it is often small and fractures easily; dissection proceeds at a 45 degree angle created by a horizontal plane through the anterior hyoid and a plane perpendicular to this towards the foramen caecum
  • A central core of tissue is resected ~3-4mm on each side
• Placing finger transoral to palpate the tongue base and push the foramen caecum toward the operative field can facilitate the dissection
• This dissection passes though the central portions of the mylohyoid and geniohyoid muscles and the foramen caecum is resected
  
  • This last part is not an 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 reapproximated with absorbable sutures and the skin is closed with an absorbable subcuticular suture
• If there is ectopic thyroid tissue and pt doesn’t have a normal thyroid gland will need permanent thyroid hormone replacement

Question 112

Leg fasciotomy

Answer 112

• 2 incisions used to release 4 compartments
• mark tibial tubercle, tibial crest, medial malleolus, posterior border of tibia, fibular head, fibular shaft, lateral malleolus
• anterolateral incision
  
  • longitudinal incision 1 fingerbreadth in front of the fibula, extending from about 2-3cm below patella to 2-3cm above lateral malleolus
  • dissect down to fascia overlying anterior and lateral compartment and identify the superficial peroneal nerve where it pierces the fascia of the lateral compartment about 10cm above lateral malleolus and courses into anterior compartment, and identify the anterior intermuscular septum (marked by perforators in the swollen limb)
  • fascia opened in an H-shaped incision; make the transverse incision with a scalpel at the midpoint of the anterior intermuscular septum
  • use scissors to make a longitudinal incision in the fascia on either side of the septum, curving the scissors away from the septum to avoid damage to the superficial peroneal nerve
  • distally in the anterior compartment avoid straying too medially so as to avoid injury to dorsalis pedis
  • after opening both compartments, identification of the septum and deep peroneal nerve ensures that both compartments have been entered
  • inspect the skin and extend skin incision if needed; skin itself can cause residual constriction if not adequately released
• medial incision
  
  • longitudinal incision one thumb posterior to the posterior medial palpable edge of the tibia
  • identify and preserve GSV and saphenous nerve where possible; ligate tributaries of GSV as needed
  • incise fascia just posterior to the medial tibial shelf to enter the superficial posteiror compartment, extending proximally to level of tibial tuberosity and distally to a point 2-3cm proximal to the medial malleolus
  • dissect soleal arch off the back of the tibia (better to start at the inferior aspect of the soleal arch rather than starting from above and doing it blindly which puts posterior tibial neurovascular bundle at risk) and retract soleus to expose the deep fascia covering FDL & tibialis posterior; release this fascia to decompress the compartment
  • identification of the posterior tibial neurovascular bundle ensures the deep posterior compartment has been entered
  • once this has been confirmed, the fascia of the deep posterior compartment is separated further and opened the length of the leg
• alternatively, in an emergency, removing the middle half of the fibular releases all 4 compartments
• check haemostasis
• in acute compartment syndrome, leave wounds open and plan to suture the skin 3-5 days later when swelling has subsided, or if necessary use a SSG

Question 113

Ray amputation of forefoot

Answer 113

• eg if plantar ulcer under MTPJ with OM of adjacent MT and prox phalynx
• consider tourniquet
• mark out a dorsal and ventral wedge to include the affected rays
• in diabetic ulcers, approach through the sole and remove all infected tissue - this includes the chronic infected fibrous cavity and the dead bone of the MT and/or proximal phalynx
• excise the wedge of the forefoot, disarticulating the MT at the tarsometatarsal joint or dividing the MT at its base
• leave the wound open; apply a VAC or dress til wound has closed by secondary intention
• if not infected: close the wedge, approximating the remaining adjacent MTs with strong Vicryl, and close the skin

Question 114

Toe amputation

Answer 114

• may require ray resection for gangrene or diabetes
• if need to amputate the great toe, try to preserve the attachments of the short flexor and extensor tendons on the proximal phalanx
• consider tourniquet
• mark out a racquet incision for amputation of individual toes
  
  • for amputation of all toes use a transverse incision, passing across the root of the toes on the plantar aspect (overlying the proximal phalanx) and across the MTPJs on the dorsum; the eventual scar should lie dorsally
• take the flaps straight down to bone and dissect off the proximal phalanx
• preserve the base of the proximal phalanx if possible, dividing the bone just distal to the insertion of the capsule - this creates a small wound cavity, which heals quickly, and the amputation doesn’t damage the transverse MT ligaments; alternatively, perform a careful disarticulation
• secure haemostasis
• leave open or close skin with interrupted nylon and ROS 10/7

Question 115

Carpal tunnel release

Answer 115

• confirm diagnosis with nerve conduction studies
• indicated if conservative treatment with night splint, steroid injections and ?diuretics fails to relieve symptoms, or if abnormal neurological signs are present espec wasting of thenar muscles, loss of sensation and dexterity (look for wasting and weakness of thenar muscles and dryness of skin over radial 2/3 of hand)
• if under LA, combo of1% lignocaine and 0.5% marcaine with adrenaline - at site of proposed incision and 1-2cm proximal to distal palmar crease
• armboard with arm in supinated position, tourniquet
• identify landmarks for incision
• incision made in line with radial border of ring finger extending from distal wrist skin crease for approx 3cm
  
  • position aims to avoid palmar cutaneous branch of median nerve which runs superficial to the ligament - lies between PL and FCR tendons
  • if too far to ulnar side, risk hitting ulnar nerve as it runs in Guyon’s canal
• dissect down through the longitudinal fibres of the palmar aponeurosis to identify transverse fibres of the flexor retinaculum (often partly obscured by origins of thenar and hypothenar muscles) - use bipolar for haemostasis
• place West’s retractor
• identify proximal and distal extents of FR, careful blunt dissection under proximal aspect to release underlying structures
• incise flexor retinaculum longitudinally with a scalpel to expose the median nerve & pass a McDonald dissector deep to the retinaculum to protect the nerve while the remaining transverse fibres are divided
  
  • take care not to injure recurrent motor branch of median nerve that supplies thenar muscles (if division kept close to ulnar border of median nerve will avoid this)
  • take care not to injure superficial palmar arch which usu lies 5-10mm distal to FR
• check carefully w blunt probe that ligament has been completely released at the proximal part where it disappears under the skin at the proximal end of the wound, by passing the probe along the surface of the nerve
• release the tourniquet, bipolar for haemostasis, close skin with interrupted 4-0 nylon
• firm compression dressing then replace with adhesive dressing after 24hrs, tell pt to move fingers, ROS 10/7

Question 116

Thoracosocpic sympathectomy

Answer 116

• indications: localised palm and axillary hyperhydrosis and facial blushing
• other possible indications rarer and not clearly defined:
  
  • consider for digital artery vasospastic disorders producing pre-gangrenous skin changes but only as adjunctive measure
• although there is a sympathetic innervation to the arteries of the skin and muscle of the limbs, and following sympathetic blockade skin blood flow increases, there is a modest rise only in muscle flow
  
  • therefore no role for sympathectomy in managing PAD
• sympathetic nervous system = 2 neuron system
  
  • cell body of pre-ganglionic neuron is in spinal cord; its fibres pass through the ventral roots of the spinal nerves, travel in the sympathetic chain and synapse in the ganglia
  • the sympathetic ganglia lie in a chain running over the heads of the ribs - postganglionic fibres from the cell bodies in the ganglia pass to the corresponding spinal nerves to enter the limb in one or other of the majro nerve trunks
  • the sympathetic fibres to the arm synapse in ganglia T2-3 (T2 for hand, T2+3 for axilla)
  • the upper (T1) ganglion fuses with the inf cervical ganglion to form the stellate ganglion; damage to sympathetic stellate ganglion = Horner’s syndrome - ptosis, myosis, anhydrosis
• several approaches to upper thoracic chain: transaxillary and anterior (supraclavicular)
• risks: compensatory sweating, Horner’s syndrome, post-op pain, possibility of chest drain, possibility of conversion to open and 10% failure rate
• pre-op CXR to exclude pulmonary disease
• undertake surgery 1 side at a time to guard against small risk of bilateral pneumothorax
  
  • occasionally unilateral surgery has a bilateral effect
  • also if compensatory sweating follows unilateral operation, pt can decline surgery on other side
• GA, usually normal ET tube, supine with small sandbag under operation side; bring this side to edge of table and place pt’s arm over face, held in place with wool and crepe bandaging onto a right angle bar
• through mid-ax line at base of axillary hairline, make a small 1cm incision between ribs 3 and 4
• establish articficial pneumothorax using a Verress needle inserted through the wound after fully informing the anaesthetist
• showly insufflate 1cm of CO2 into pleural space
• through same incision 1cm introduce 1 10mm lap port between the ribs with optiport
• insert thoracoscope, usu 0 degrees deflection with a central channel
• confirm orientation, place scope looking in top corner, which is a safe area
  
  • make sure the ribs run horizontally
  • follows rib medially until you see the sympathetic chain and ganglia lying on the necks of ribs; highest rib you see on either side is the second, though in the tall, thin pt, first rib may be visible
• ensure lung is collapsed; if not, slightly raise the insufflation pressure
  
  • carefully divide occasionally encountered pleural adhesions, exerting minimal traction
  • identify first rib; ask anaesthetist to palpate it in supraclavicular plane you can see it (and avoid dissecting to that level to avoid Horner’s syndrome)
• with a blunt (non-diathermy) probe, identify the third rib by tapping it
  
  • identify the ganglia by pushing against them gently w the probe to confirm their soft consistencey and glistening surface
  • if adhesions obsure view over 3rd rib, you can easily identify the chain by visualising the fourth or fifth rib and following chain superiorly
  • in right chest, azygos vein may lie close to sympathetic ganglia & can be quite large
• identify lowest and most effective diathermy setting and get under the pleura - lift pleura up and carefully dissect third thoracic ganglion free over the rib, using sharp dissection
  
  • having cleanly dissected it over the third rib, divide under vision
• Clipping of the sympathetic chain is possible and reported to achieve same results in hyperhidrosis and flushing; theoretical advantage is that clips can be rmeoved later if complicating side effects are intolerable
• if any of small veins around chest start to bleed, apply direct pressure with nondiathermy probe to pleura over vessel and wait; bleeding will stomp - now wash pleural cavity w saline
• 40mL 0.25% marcaine to pleural cavity
• withraw port and thoracoscope to chest wall; turn off insufflation and open gast inlets while watching lung inflating w assistance of anaesthetis
• confirm the fluid in the pleural cavity is a clear small amount of LA and not bloodstained
• smose small wounds w stitch or plastic adhesive strip
• don’t routinely place chest drains
• CXR in recovery to check for residual pneumothorax
• forbidden from flying or driving for 1mo

Complications

• immediate complications: damage to intrathoracic structures requiring thoracotomy, pneumothorax,
• failure to resolve and compensatory sweating - may develop many years after surgery
  
  • compensatory hyperhidrosis = usu chest and back, occurs in 50% pts
• especially if chain was divided at high level: Horner’s syndrome
  
  • nasal congestion and eyelid drooping
  • but thoracoscopic syndrome has virtually abolished this
  • highest rib that can be directly viewed intrapleurally in thoracoscope is second rib
  • if you need to go to a high-placed ganglion, as for facial sweating, avoid using diathermy and employ sharp dissection alone to isolate ganglion over neck of highest, most easily viewed rib - should avoid Horner’s syndrome
    
    • transient Horner’s syndrome may occur if use too high-powered diathermy or if you cause damage above level of 2nd rib
• haemorrhage from intercostal vessel trauma or damage to azygos vein

Question 117

Supracoeliac aortic clamp

Answer 117

• initially can compress with hand against spine - pull stomach down, bluntly enter lesser omentum in its avascualr portion, feel aorta pulsing immediately below and to the right of the oesophagus, and compress it against the spine
• if you have time, mobilise left lateral lobe of liver by incising left triangular ligament which improves workspace but isn’t essential to get to aorta
• bluntly open lesser omentum immediately to right of lesser curve of stomach and insert Deaver retractor into hole
• retract stomach and duo to left to expose posterior peritoneum of lesser sac and, underneath it, right crus of diaphragm
• palpate pulsating aorta above superior border of pancreas to orient yourself
• bluntly make hole in posteiror peritoneum, then using either your finger or blunt-tipped Mayo scissors, separate the two limbs of the right crus of diaphragm to expose anterior wall of lowermost thoracic aorta
• using fingers of your left hand, create just enough space on both sides of aorta to accomodate your clamp
• take an aortic clamp and guide it to the correct position using the fingers of your left hand as a guide
• clamp and check distal aorta for pulsation
• encircle the aortic clamp with an umbilical tape and secure the tape to the drape over the pt’s lower chest to immobilise the clamp

Question 118

Right-sided medial visceral rotation

Answer 118

1. Classic Kocher maneuver - mobilise duodenal loop and HOP
   
   • identify duo and incise posterior peritoneum immediately lateral to it
   • insinuate your hand behind duo and HOP to begin lifting them up, and continue mobilising the duo loop from CBD superiorly to the SMV inferiorly
   • hepatic flexure lies over lower part of duo loop & you may need to mobilise it too
   • now can reflect duo loop and HOP medially to see IVC and right renal hilum
     
     • beware of injury to right gonadal vein as it enters IVC at this level
2. Extended Kocher maneuver - gives wider exposure of retroperitoneum
   
   • carry the incision in the posterior peritoneum in a caudal direction towards the white line of Toldt, immediately lateral to the right colon
   • fully mobilise the right colon and reflect it medially
   • gives access to entire infrahepatic IVC, right kidney and renal hilum + right iliac vessels
3. Super-extended Kocher maneuver - Cattell-Braash maneuver
   
   • carry the incision in the posterior peritoneum around the caecum
   • now gather SB to the right and cranially and incise the line of fusion of the SB mesentery to the posterior peritoneum from the medial side of the caecum to the ligament of Treitz
   • now should be able to bring SB and right colon out of abdomen and swing them upward onto anteiror chest
   • ie this maneuver begins at CBD and ends at ligament of Treitz; when complete, gives view of entire inframesocolic retroperitoneum with access to the infrarenal aorta and IVC, as well as both renal arteries and veins and the iliac vessels on both sides; also provides access to third and fourth parts of duo and the superior mesenteric vessels
   • pitfall = injury to SMV at root of mesentery; once you detach the right colon from its peritoneal attachment it is hanging by its mesentery alone - an inadvertent pull will avulse the right colic vein off the SMV ie bleeding from root of mesnetery

Question 119

Axillary dissection

Answer 119

• Supine, arm abducted to 80 degrees 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
• Raise a superior flap superficial to the clavipectoral fascia and find pec major and lat dorsi
• Incise the clavipectoral fascia 1cm below the lateral edge of pec major (ensures the medial pectoral nerve isn’t injured)
• Dissect pec major (+/- inter-pectoral packet - Rotter’s nodes) then pec minor up towards the axillary vein; preserve medial pectoral pedicle just lateral to pec minor and divide any vascular branches heading into the axilla from this pedicle to allow pec minor to be released and dissected off the chest wall to maximize the exposure of axillary vein and levels II and III
  
  • Lateral limit of level II = lateral thoracic vessels (may be preserved or ligated)
  • Medial limit of level III = Halstead/costo-clavicular ligament
• Incise the clavipectoral fascia medial to LD and continue superiorly towards axillary vein
  
  • (clues that I am close to the axillary vein are: superior to medial pectoral pedicle, superior to the intercostobrachial nerve, palpation of the pulsation of axillary artery which can be a sign dissection is too high)
• Incise the intervening clavipectoral fascia between medial and lateral margins then identify the axillary vein running transversely; use peanut dissection to dissect vein and tributaries
  
  • All fatty tissue and lymph nodes under the vein are dissected and swept downwards
• Find thoracodorsal/subscapular vessels
  
  • Nerve originates from posterior cord medial to thoracodorsal artery and vein, heads inferolaterally towards lat dorsi
  • There is often an unnamed superficial vein which runs anterior to the thoracodorsal leash; prior to dividing this I identify the thoracodorsal branch and the deeper plane it runs in
• Take down the superolateral corner of the dissection where these vessels meet the axillary vein
  
  • Lateral limit of level I = thoracodorsal pedicle and lat dorsi tendon
• Trace thoracodorsal bundle inferiorly until (the artery branches into two)/ the level of the angular veins draining into the thoracodorsal vein
• Find subscapularis and trace it medially, tunneling bluntly in the avascular plane anterior to subscapularis, to reach the chest wall
• Retract axillary contents inferolaterally and head back up to find the long thoracic nerve medially, follow it down while sweeping it towards the chest wall, and meet up with plane in front of subscapularis
• Encircle the axilla and excise it (ensure neuromuscular blockade has worn off)
• Inferior limit = at level of angular vein
  
  • Angular vein drains the chest wall and joins the thoracodorsal vein to form the subscapular vein
• Haemostasis, 14Fr drain(s), two-layered closure with monocryl

For a level 3 dissection: division of pec minor no longer routinely practiced; adduction of the arm relaxes pec major and allows retraction of pec minor laterally to facilitate level III axillary dissection. The medial limit of the axillary dissection is the Halstead’s ligament/costo-clavicular ligament; superiorly the entire fibrolymphatic tissue right up to the axillary vein needs to be dissected exposing but not denuding the axillary vein of its sheath

Issues

• Can’t find long thoracic
  
  • Trace tendon of LD up to point where it crosses ax vein
  • Trace pectoral pedicle upwards towards axillary vein
• Can’t find axillary vein
  
  • transverse skin crease incision which is deepened into subcut tissue
  • outer border of pec major and then pec minor are in turn identified and fascia overlying is divided
  • fascia of lateral border of pec minor (suspensory ligament of the axilla) is divided & this allows entry into axilla proper
  • ax artery identified by palpation and hence, medial to this, will be possible to find the axillary vein behind pec minor muscle
  • fascia over inf and medial border of ax vein gently divided; allows correct and safe identification of ax vein & allows ax dissection to proceed

Question 120

Breast core biopsy

Answer 120

• Verbal consent
• Prepare lab form and pot w formalin
• Use USS guidance & IR when feasible
• Check anticoagulant status
• Mark out lump, LA w 5mL 11% lignocaine w adrenaline
• Prepare are and trolley with sterile gloves etc
• Demonstrate to pt the sound the gun makes
• 11 blade scalpel to make skin incision
• introduce core-biopsy needle into 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 (skin to bottom) are taken from different directions
• pressure for 5mins

Question 121

HW WLE

Answer 121

• Wire placed day of surgery by radiology, traversing as little breast as possible and aiming for lesion or just past (within 1cm); diagrams from interventionalist 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 during procedure
• Complete pathology forms and notify radiology when specimen ready
• Principles
  
  • mobilise skin flaps
  • locate and deliver the wire
  • complete procedure - WLE or excision biopsy
• Supine, remove padding round wire
• Prep and drape, care not to dislodge
• Mark curvilinear incision over area (dynamic lines of Kraissl) or periareolar if feasible
  
  • Only need to excise skin directly overlying a cancer if v superficial and/or skin tethered
• Incise, raise flaps with diathermy
• Identify & control wire on underside of flap
• Deliver wire back through skin
• Littlewoods to grasp wire & tissue
• WLE using wire as guidance
• Aim for 1cm macroscopic margin margins; sharp dissection with scissors, down to chest wall
  
  • Not necessary to excise pec fasci unless it is tethered to tumour
• I usually dissect around three sides of the cancer, then deliver it from the wound and grasp it gently with my finger and thumb or a littlewoods to complete the excision
• Specimen should be oriented and marked
  
  • Long lateral (3 clips), medium medial (2 clips), short superior (1 clip), loop anterior
• Specimen for xray
• Check haemostasis
• Mammoplasty if required with 2-0 vicryl on large taper needle
  
  • (small defects <5% usually don’t need mobilization of surrounding breast tissue; if large, mobilise from chest wall and skin/subcut tissue – extent to which the breast tissue can be mobilized depends on the density; larger defects can be filled with local flaps or more major breast reshaping w a unilateral or bilateral therapeutic mammoplasty)
• Local anaesthetic if no block
• Close with 3-0 monocryl
• Wake patient when xray confirmed

WLE in general: 35% chance of reexcision

1cm macroscopic margin

Question 122

Mastectomy

Answer 122

• key steps
  
  • raising skin flaps
  • removing the breast
  • haemostasis and closure
• Patient supine, arm free draped and abducted to 80 degrees
• Elliptical skin incision marked incorporating the nipple-areolar complex, skin overlying the breast cancer en bloc with skin margins that lie 1-2cm from the cephalad and caudad extents of the cancer, as well as the core biopsy site – can orient ellipse obliquely as required
• Skin sharply incised and (covered) diathermy used to develop plane and flaps, which are taken down to chest wall
  
  • Flap thickness should vary with pt body habitus but ideally 7-8mm thick
  • Flap tension should be perpendicular to chest wall w flap elevation deep to the cutaneous vasculature, which is accentuated by flap reconstruction
  • Elevate skin flap w consistent thickness to void creation of devascularised subcut tissues, which can contribute to wound seroma, skin necrosis and flap retraction
• Retraction/elevation of flaps with littlewoods on dermis – retraction key
• Upper limit usu 2-3cm below clavicle (Fischers says subclavius muscle); place dry pack
• Lower limit is to IMF which should be preserved if recon planned (Fishcers sys 3-4cm inferior to IMF); place dry pack
• Lift breast (and pec major fascia) off the pec major muscle
  
  • Perforating vessels from the lateral thoracic or anterior intercostal arteries are end-arteries that supply pec major and minor and breast parenchyma; regularly encountered during elevation of breast of the breast parenchyma and pec major fascia; clipped or suture ligated with 2-0 or 3-0 prolene
  • Continue elevation of breast parenchyma and pec major fascia laterally until lateral edge of pec major muscle and underlying pec minor exposed
  • Be aware of location of the lateral neurovascular bundle in which the medial pectoral nerve (laterally placed with origin from the medial cord) courses to innervate the pec major and minor muscles if possible this nerve is routinely preserved to prevent atrophy of lateral head of pec major (signif cosmetic and functional deficit)
  • Lateral limit is anterior margin of lat dorsi
• Mark the superior aspect of the breast
• Obtain haemostasis
• Perform axillary surgery if planned
• Two-layer closure over 1-2 closed suction drains (12Fr Blakes) using interrupted 3-0 monocryl at dermal layer and 3-0 monocryl subcuticular continuous for skin

Question 123

SNB

Answer 123

• principles: to identify and remove only the sentinel nodes, preserving the non-sentinel tissue
• indications:
  
  • staging N0 breast cancer (unifocal <4cm)
  • for DCIS if >4cm, high grade, mass or patient having mastectomy
  • contraindicated if locally advanced/clinically involved nodes, previous axillary surgery
• key steps
  
  • find nodes
  • remove only the sentinel nodes with little additional tissue
  • confirm low background count and intra-operative results
• Pre-op localization with both technetium-99 and 3mL of 1% isosulfan blue dye for intra-operative localisation; after warning anaesthetist inject blue dye into sub-lateral areolar complex/sub-dermis after positioning and massage for 5mins
• Chlorhexidine skin prep and U/square drape arm
• Mark max signal intensity detected by Gamma probe
• Incise skin accordingly or1cm inferior to hair-bearing area of axilla
• Develop skin flaps
• Incise clavipectoral fascia and open axilla
• Find blue lymphatic; trace it to find the lymph node(s) and dissect them free; if direction of dissection unclear then use the Gamma probe
• Use a Babcock’s to deliver the lymph node packet
• Check the counts; both of node and background which must be <10% of SLN count
• Haemostasis
• 3-layer closure with 3-0 then 4-0 monocryl

Question 124

Elective pilonidal disease

Answer 124

• prone jack-knife position
• the aim of my operation is to excise the disease, close off the midline and flatten the natal cleft
• I draw lines of safety with the buttocks pushed together then splay the buttocks with tape
• I draw out a scimitar shape, with the lateral margin just within the line of safety and extending to a point adjacent to or just below the anus, curving round the anus before drawing the medial margin outside any perianal disease
• I use the diathermy on cut to incise the medial skin edge then undermine the flap; I make it about the same width as a mastectomy flap, leaving the apex near the anus a little thicker and being 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
• debride underlying granulomatous tissue and score to release any scars
• draw flap across and secure with 2 layers of interrupted 2-0 vicryl sutures
• close skin with monocryl or interrupted nylon

Question 125

Deep spaces of hand and where incision should be made to drain pus within

Answer 125

• pulp spaces
  
  • on palmar side of tips of fingers and thumb
  • contain fatty tissue that is divided into numerous compartments by fibrous septa that pass between distal phalanx and skin
  • terminal branches of digital vessels course through the spaces & some of them supply the end of distal phalanx (but not the epiphysis which is supplied by proximal branches); infection of pulp spaces may occlude these vessels & cause necrosis of end of the bone
  • pulp space limited proximally by the firm adherence of the skin of the distal flexion crease to the underlying fibrous flexor sheath; this prevents pulp infection from spreading proximally along finger
• flexor tendon space
  
  • synovial sheaths of index, middle and ring fingers commence at distal transverse palmar crease to distal phalanges
  • make 2 incisions; one at the base of the pulp and one at the base of the proximal phalynx and irrigate
  • NB in carpal tunnel the flexor tendons are invested w synovial sheaths that extend proximally for ~2.5cm into lower part of forearm & proceed distally to varying extent
    
    • On tendon of FPL the sheath extends from above the flexor retinaculum to the insertion of the tendon into the terminal phalanx of the thumb
    • Tendons of superficial and deep flexors are together invested with a common synovial sheath that is incomplete on the radial side; this common sheath extends into the palm and on the little finger it is continued along whole extent of flexor tendons to terminal phalanx
    • Common flexor sheath ends over remaining 3 sets of tendons just distal to flexor retinaculum
    • The common flexor sheath communicates at the level of the wrist w the sheath of FPL in ~50% of individuals
    • In index, middle and ring fingers, where common sheath ends beyond flexor retinaculum, a separate synovial sheath lines fibrous flexor sheath over the phalanges
    • Proximal limit of these sheaths is at level of distal transverse crease of palm
    • Thus there is short distance of bare tendon for index, middle and ring fingers in middle of palm; is from this situation that the lumbrical muscles arise
    • Fourth lumbrical obliterates the synovial sheath at its origin from the tendon to the little finger
    • All the synovial sheaths have a parietal layer related to the environs through which the tendons pass & a visceral layer on the surface of the tendons
    • The two layers are continuous at the proximal & distal ends of the sheaths
• palmar spaces
  
  • palmar aponeurosis, fanning out from distal border of flexor retinaculum, is triangular in shape; from each of its two sides a septum dips deeply into palm
    
    • septum from ulnar border is attached to palmar border of fifth metacarpal bone
    • septum from radial border attached to palmar surface of middle metacarpal bone
  • hypothenar space = medial to medial septum, contains hypothenar muscles ?? is this a space infection gets into – not in Netters
  • midpalmar space = below palmar aponeurosis, deep/dorsal to flexor tendons and lumbrical muscles, superficial/volar to middle and ring finger metacarpals
    
    • incise at level of distal palmar crease. Pass artery clips into lumbrical sheaths to ensure drainage
  • thenar space = lateral to lateral septum
    
    • deep to index flexor tendons, superficial to adductor pollicis
    • lateral septum usually passes deeply between flexor tendons of index & middle fingers, ie flexor tendons of index finger overlie thenar space
    • incise in webspace between thumb and index finger
  • (these are potential spaces & their margins are difficult to define by dissection; pus may accumulate in them in infections of the hand and be initially confined within the boundaries described)
  • in thenar and midpalmar spaces, infection easily breaks through into the lumbrical canals (connective tissue sheths of the lumbrical muscles)
  • remember that in web spaces, between the palmar & dorsal layers of the skin lie the superficial and deep transverse ligaments of the palm, the digital vessels & nerves and the tendons of the interossei and lumbricals on their way to the extensor expansions
    
    • superficial transverse metacarpal ligament lies just deep to palmar skin adjacent to the free margins of the webs; digital vessels and nerves lie immediately deep to the ligament, with nerves on the palmar side of the arteries, and the digital slips of the palmar aponeurosis and lumbrical tendons lie posterior to the vessels
    • web of thumb lacks both superficial and deep transverse ligaments; transverse head of adductor pollicis and first dorsal interosseous muscle lie here and between them emerge the radialis indicis and princeps pollicis arteries; each hugs its own digit and the central part of the web can be incised w/o risk to either vessel
• space of Parona
  
  • space between pronator quadratus and flexor digitorum profundus
  • limited proximally by oblique origin of flexor digitorum superficialis
  • becomes involved in proximal extensions of synovial sheath infections
  • can be drained through radial and ulnar incisions to the side of the flexor tendons
  • longitudinal incision radial side of ulnar pulse

Question 126

Hadfield’s procedure

Answer 126

• principle: removal of all the mammary ducts for symptom control and/or identification of a discrete pathology
• indications include:
  
  • persistent troublesome multiduct discharge
  • persistent periareolar infection
  • single duct discharge in those beyond child bearing years (who may have already had an unsuccessful single duct excision)
• key steps:
  
  • isolate ducts
  • excise a disc of tissue
  • appose tissue to fill defect
• patient positioned supine with arm out at 80 degrees
• chlorhex skin prep and square draping
• periareolar incision 2-3/5 of circumference of areola
• raise flaps
• nipple complex is dissected free of surrounding fat using blunt dissection with artery clip
• once circumferentially dissected an artery clamp is placed across the distal nipple 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 at least 3cm deep conical segment of the ductal system is excised
• to prevent nipple retraction, a purse-string suture is placed to close the conical defect; alternatively, the nipple can be resited after depithelialisation superiorly
• layered closure is performed

Question 127

Microdochectomy / Single duct excision for nipple discharge/papilloma

Answer 127

• principle: removal of pathological duct whilst preserving the remaining normal ducts
• indications:
  
  • persistent, identifiable single duct discharge in those of child bearing age
  • mammary duct fistula
• key steps
  
  • identify and cannulate pathological duct
  • excise the duct
  • confirm lesion in duct and/or no further discharge
• identify candidate duct preoperatively
• supine
• chlorhex 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 proximally as far as possible (at least 2-3cm) - dissect around probe and send for histo
• ligate duct proximally and distally
• open duct to ensure a cause for discharge is present and distal remnant inspected to ensure entire dilated duct has been excised
• obtain haemostasis and close with 4-0 monocryl
• complications
  
  • immediate: bleeding, missed lesion
  • early: infection, nipple necrosis, malignant diagnosis
  • late: persistent discharge, change in nipple sensation, nipple inversion

Question 128

Lap gastric sleeve

Answer 128

• essentially a partial gastrectomy of the greater curvature along the vertical axis of the stomach; so the remaining stomach is made mainly of the lesser curvature with a volume of 100-200mL
  
  • a functional pylorus and variable portion of the antrum are left in place
• optical entry supraumbilical just to left of midline
  
  • 2x 5mm ports - subxiphi for liver retractor and along nt ax line just below 12th rib for assistant
  • retract liver cephlad w fan-type retrctor
  • other ports…
• divide short gastrics 2-6cm from pylorus using ligasure, allowing access to lesser sac (can argue at this point you are actually dividing branches of right gastroepiploic rather than short gastrics)
  
  • then divide rest of short gastrics heading along greater curvture of stomach
  • assistant retracts upper body of stomach medially and inferiorly to expose uppermost short gastrics and left crus of diaphragm
• if hitus hernia identified, hiatl dissection and posterior cruroplasty repaired at end of procedure
• additionl posterior gastric adhesions removed to assure proper visualistion of lesser curvature of stomach
• insert bougie 32-36Fr, advance to ntrum under direct visual guidance
• 60mm linear stapler to sequentially divide the stomach
  
  • assistant laterally retracting greater curve symmetrically
  • first fire starts 2-6cm from pylorus, oriented horizontally ish towards left shoulder
  • avoid excessive narrowing at incisura angularis, avoid spiral twisting of spleen from asymmetrical lateral traction
  • at GOJ avoid abutting stapler to bougie and preserve oesophagogastric fat pad - decreases chance of potential ischaemia of superior corner of sleeve
• haemolock greater omentum to sleeve
• extract specimen out right lateral port
• close ports (right lateral port fascia with endoclose)
• clear liquids day 1 then bariatric fluids after 1L
• mechanisms: restrictive; removal of fundus -> decreased ghrelin therefore decreased hunger and increased satiety; accelerated gastric/duo emptying
• 40-50% excess weight loss
• reflux not uncommon

Question 129

RYGB

Answer 129

• key points:
  
  • gastric pouch <30mL, roux limb 100-150cm length, BP limb 50-150cm length
  • BP: many use 80-100, in superobese can do 150
  • roux: at least 100, in superobese can do 150
• can do pouch first or roux first
• 34Fr orogastric tube
• make pouch
• divide SB 100-150cm distal to ligament of Treitz (proximal to this will be BP limb that transports secretions from gastric remnant, liver and pancreas)
• Roux limb anastomosed to new gastric pouch
• Distal end of BP limb (cut) and Roux limb are anastomosed 100-150cm distal to gastrojejunostomy
• Closure of potential hernia sites (3)
  
  • Peterson defect = between Roux limb mesentery & transverse mesocolon - close w pursestring sutures (if running/interrupted can open after weight loss)
  • mesentery of JJ anastomosis - close w pursestring sutures (if running/interrupted can open after weight loss)
  • opening in transverse mesocolon (if retrocolic) - mesocolon sutured to Roux limb in several areas
• mechanisms: altered GI hormones, restriction/malabsorption, altered gastric emptying
• 50-65% excess weight loss

Question 130

One-anastomosis gastric bypass

Answer 130

• includes division of stomach between antrum & body on lesser curve; stomach further divided in cephalad direction to angle of His & this subsequent pouch is anastomosed to a loop of jejunum as an antecolic & antegastric loop
  
  • 150-180cm distal to ligament of Treitz
• comparable weight loss to RYGB and superior/comparable to sleeve
• easier than RYGB and only one anastomosis
• similar to RYGB in induction of remission of T2DM
• higher rates of alkaline bile reflux

Question 131

Deflation of gastric band

Answer 131

• Huber point needle
• Position pt lying with rolled towel behind back, lift head off bed which makes band more palpable
• Find the port – feel below largest scar, ask patient
• Puncture port – stabilize port with fingers, go straight down, needle should support itself if inserted correctly
• Draw back all fluid
• If still can’t get in – set-up/positioning is the key - ?longer needle, phone a friend, ED ultrasound can be helpful, can ask radiology to puncture and deflate band if needed

indicated for:

• obstructed band eg band been overfilled, poor eating habits
• gastric prolapse

Question 132

Removal of gastric band

Answer 132

• if buckle visible in lumen in case of erosion, endoscopic removal possible
  
  • divide tubing and remove port either before or during procedure
  • endoscopic division and removal of band which can be removed via mouth
  • post-procedure contrast swallow
  • less likely to leak than lap removal bc not disrupting the tunnel which kind of works as a flap valve - but partly why you do a contrast swallow
• buckle not visible in lumen in case of erosion, or for slipped band: has to be removed surgically
  
  • lap +/- open
    
    • nathansen retractor optional
    • don’t forget to take port out - start by dissecting it out, then put first port in same area
    • unbuckle if you can, but often easiest to just cut through it with sharp (disposable) scissors
    • hook diathermy to burn through the scar tissue/’capsule’ - burning against the band is safe
    • some say you also need to remove the eschar - in an emergency just need to take the band out
    • even if you cant remove the band, it may be enough to just unbuckle the band and release the constriction
  • can be difficult, may involve anterior gastrotomy
  • closure of defect - suture closure, omental patch
  • if buckle not seen in lumen and pt well, can wait for significant erosion then remove endoscopically

Question 133

Carotid endarterectomy

Answer 133

• main indication = TIA or proven infarct with int carotid artery stenosis >70%; should be done within 14days of acute event
• do it on DAPT
• GA or regional
• supine, head of table raised to reduce pressure in neck veins, head ring, turned to opposite side w neck extended
• prepped area includes pinna (to allow access for SCM to be raised from mastoid process if exposure of artery needed at a high level)
• oblique skin incision along ant border SCM from mastoid process to SCJ
• divide all subcut tissue and platysma in same line
• sacrifice cutaneous nerves crossing line of incision but preserve greater auricular nerve
• mobilise ant border of SCM and retract posteriorly
• identify facial vein and divide between ligatures - allows IJV to be displaced posteriorly
• avoid damage to hypoglossal nerve which sometimes loops surprisingly low into neck & may be quite superficial; can sling it
  
  • find ansa cervicalis on surface of carotid sheath and trace it up to locate hypoglossal nerve; can cut ansa hypoglossi which supplies strap muscles
• dissect in a plane posterior to parotid to avoid bleeding
  
  • digastric deep to parotid but doesn’t impede access to artery
• open carotid sheath initially towards lower end of incision to expose common carotid artery; vagus nerve lies posteriorly and deep to artery and is not usually at risk, but its position should be noted so can be protected
  
  • sling common carotid artery
• expose carotid bifurcation and trace ICA (which is post to ECA) superiorly
  
  • be gentle when handling to avoid dislodging atheromatous material
  • clear as much of it as possible distal to bifurcation & carefully sling it
• dissect origin of ECA and its superior thyroid branch; sling each of these
• before clamping, plan what you will do to protect brain from ischaemia during this
  
  • temporary plastic shunts can be used routinely or selectively
  • if selectively, need to identify who needs them - with int carotid artery stump pressure measurement which checks collateral circulation through circle of Willis; or transcranial doppler; or operate under LA and ask pt to intermittently squeeze squeaky toy with contralateral hand - if cant do so or cant speak, shunt inserted
• IV heparin 1000IU for each 10kg body weight, wait 3mins
• clamp ICA, CCA, ECA in that order
• longitudinal arteriotomy on CCA extending into ICA beyond distal limit of plaque
• apply Spencer Wells clamp to centre of shunt
• insert Javid shunt into CCA and retain it with ring clamp
  
  • relese Spencer Wells allow a little bleeding from end of shunt to ensure it is completely filled and that all air ejected
• insert other end into distal ICA, apply ring clamp and after checking no air in shunt, release Spencer Wells clamp
• perform endarterectomy with Watson-Cheyne dissector
• flush with hep saline
• close arteriotomy with a patch - prosthetic preferred to vein bc of risk of rupture - 6-0 prolene
• clamp shunt and remove it
• re-apply clamps to carotid vessels and complete closure of arteriotomy
• flush all vessels before tightening last stitches
• to declamp: remove clamp from ICA first, allowing blood to fill back into the bifurcation, displacing air through suture line, then reapply clamp to ICA more proximal than previously placed at level of bifiurcation to maximise flow into ECA and minimise emboli to ICA
  
  • remove ECA clamp then CCA, then ICA
  • to ensure any bubbles/fragments pass into ext carotid and not into brain
• difficulties:
  
  • can expose more of ICA superiorly by extending incision behind ear onto mastoid and raise SCM from attachment and divide digastric muscle +/- excise tip of styloid process

Question 134

Oncologic gastrectomy

Answer 134

• consider subtotal only if 5-10cm margins can be achieved for intestinal type
• steps:
  
  • mobilise greater curve with omentectomy and division of left gastroepiploic and short gastric vessels
  • infrapyloric mobilisation with ligation of right gastroepiploic vessels
  • suprapyloric mobilisation w ligation of right gastric vessels
  • duodenal transection
  • D2 lymphadenectomy
  • Gastric (or oesophageal) transection
  • reconstruction by loop or Roux-en-Y gastrojejunostomy (or Roux-en-Y oesophagojejunostomy)
• greater curve mobilisation
  
  • mobilise entire greater omentum off transverse colon and mesocolon; lift stomach up and anteriorly (omentum is resected with specimen)
  • enter lesser sac and assess for spread of disease/posterior invasion of retroperitoneal structures
  • with greater omentum reflected up also dissect it off splenic flexure & inf pole of spleen, exposing body & tail of panc
  • divide left gastroepiploic vessels near origin from splenic vessels
  • divide short gastrics close to spleen (for total, all of them; for subtotal, need to preserve at least a few bc all 4 main arteries are divided so taking all can put anastomosis at risk of ischaemia)
• infrapyloric mobilisation
  
  • dissect omentum off hepatic flexure & divide it up to duo
  • divide gastroepiploic vein at its junction w gastrocolic trunk and inf pancreaticoduodenal arcade (v fragile veins)
  • divide right gastroepiploic
  • dissect station 6 LNs away from HOP
  • develop plane just ant to HOP and post to pylorus, sweeping all nodal and soft tissue off panc w specimen
• suprapyloric mobilisation
  
  • divide gastrohepatic ligament, being cognizant of a possible accessory or replaced left hepatic artery coursing through this layer (if discovered put bulldog clip on for several mins and if liver remains well perfused, divide)
  • open hepatoduodenal ligament vertically in direction of proper hepatic artery, completely exposing right gastric and gastroduodenal arteries
  • divide right gastric at its origin, divide right gastric vein close to its junction w portal vein & dissect station 5 up w specimen
  • ligate any residual fatty attachments/small vessels - duo now fully mobilised
• duodenal transection
  
  • divide D1 w GIA stapler (green) - just distal to pylorus unless invasion of duo suspected in which case divide more distally
  • invert staple line w Lembert sutures
• D2 lymphadenectomy
  
  • D1 = perigastric LN stations along lesser curve (1,3,5,7) and greater curve (2,4,6)
  • D1+ = +CHA (8a) + celiac (9) + 11p
  • D2 = + splenic artery (10), hilar nodes (11d), ?12a
  • D3 = portahepatic and para-aortic
  • during this ligate left gastric at its origin
• Gastric or oesophageal transection
  
  • for subtotal, divide along line connecting a point 2cm distal to GOJ on lesser curve and a point at least 5cm prox to upper border of tumour on greater curve
  • for total, divide phrenoesophageal ligament w diathermy and reflect paracardial nodal tissue in stations 1 and 2 off the right and left crura and toward the specimen
    
    • both vagus nerves divided and intra-abdo oesophagus circumferentially dissected free for at least 5cm
    • if handsewn anastomosis, Satinsky clamp on oesophagus prior to its division to prevent its retraction up into mediastinum
• Reconstruction
  
  • after subtotal Billroth II loop gastrojej or Roux-en-Y
  • for ReY, jejunum divided 20cm distal to lig of Treitz + side to side gastroej; then side-to side jej-jej 45-50cm distal to gastrojej
  • for total: end to side oesophago-jejunal anastomosis performed after stay sutures are placed in the distal oesophagus with a ???21mm EEA (50cm from DJ and 50cm from anastomosis)
• Closure
  
  • drains placed adjacent to anastomosis
  • washout and closure

nb if splenic injury occurs during distal gastrectomy and splenectomy is required, a total gastrectomy will need to be done bc gastric remnant will no longer have supply from short gastrics

Question 135

Ingrown toenail

Answer 135

Wedge excision

• supine, ring block with mixture of 1% lignocaine and 0.5% marcaine with no adrenaline
• prep foot, drape forefoot, tourniquet
• use a blade to excise a wedge of tissue that includes the lateral edge of the nail and skin by making two incisions
  
  • starting ~5mm proximal to the proximal nail fold, carried deep until distal phalanx is felt, then carried distally through nail plate
  • then another incision is made along outside the lateral nail fold and carried distally, with all the overlapping soft tissue/hypergranulation tissue excised
  • ensure blade is kept perpendicular to skin
  • remove this soft tissue, nail plate and lateral portion of the nail matrix en mass
• check there is no white shiny nail matrix left and use a curette to scrape the tissue that makes up the germinal matrix
• if any doubt, apply phenol - protect skin with paraffin jelly from jelonet and apply phenol (80-90%) with cotton tip applicator, twice for a minute each
  
  • irrigate with alcohol
  • +/- cautery
• close wound with 3-0 nylon
• non-stick gelonet, gauze and crepe, remove tourniquet
• 24hrs leg elevation
• dressing change in 7 days with ROS at 14 days

Zadek’s

• make diagonal incision from each corner of nail and use elevator under nail and under proximal nail fold to free the nail
• excise whole nail with matrix attached
• use curette and phenol
• close skin flaps with 3-0 nylon

Question 136

Forearm fasciotomy

Answer 136

• two compartments plus carpal tunnel and cubital fossa
• flexor compartment
  
  • single curved incision with a lazy S from medial to reach the lateral border of the forearm; distally cross wrist with a lazy S around medial aspect of thenar eminence to finish on thenar eminence
  • divide the deep fascia of forearm
  • proximally divide the bicipital aponeurosis and distally decompress the carpal tunnel by dividing the flexor retinaculum distal to the wrist crease +/- Guyon’s canal
• extensor compartment (DSTC video says unnecessary)
  
  • longitudinal incision down the length of the dorsal forearm
    
    • identify fascia
    • longitudinal fascia incision
  • wounds left open and dressed with saline soaked gauze
• may need to do interosseous incisions on dorsum if v tight hand
• if wanted to do finger decompressions always stay behind the finger creases where the neurovascular bundles are

Question 137

Arm fasciotomy

Answer 137

• two compartments
  
  • longitudinal incision laterally from deltoid insertion to lateral epicondyle
    
    • identify fascia and intermuscular septum
  • transverse incision through intermuscular septum
  • longitudinal incision either side of septum to divide fascia of anterior and posterior compartments
    
    • radial nerve crosses septum from posterior to anterior halfway down arm
  • wounds left open and dressed with saline soaked gauze

Question 138

Split skin graft

Answer 138

• LA if small or sedation/GA if large area
• principle is to take a shaving of epidermis from the donor site, preserving the deeper levels of epidermis which will regenerate
• choose area; usually a convex area chosen for ease of harvesting e.g. anterolateral thigh; shave and mark and tumescent infiltration with LA and/or adrenaline mixed with saline
• ensure wound bed prepared - gently curette and freshen wound edges
• measure the size of the defect and mark out at the donor site the size of graft required
• can do free-hand with a knife or a handheld dermatome (electrical or compressed air-powered)
• set up the dermatome
  
  • graded in multiples of 1/1000 of an inch and 5/100 of a mm; most grafts harvested are between 8/1000 and 12/1000 of an inch; harvesting thicker grafts requires longer time for donor sites to heal & may preclude that site from repeat harvesting, particularly important in burns (adjust to thinner for elderly or those on steroids - 8/1000; for younger use 10/1000)
• take the graft
  
  • prepare donor site with paraffin
  • together with my assistant use two boards to place tension on the skin
  • take the graft applying the dermatome at a 45 degree angle (gently push forward while exerting modest pressure on dermatome) - angle up and away at the end and divide with scalpel/scissors if the graft doesn’t come away
  • carefully place the graft onto the tray for fenestration
• apply adrenaline soaked swabs to donor bed
• mesh the graft
  
  • (done to increase the area the graft will cover, to allow fluid to drain freely which improves graft take, more contact points for diffusion of nutrients and blood supply, and because meshed graft conforms better to curved surfaces)
  • most common ratio is 1:1.5
  • larger mesh ratios reserved for pts w limited donor sites eg severe burns
  • meshed grafts heal with more scarring so less aesthetically appealing cf sheet (unmeshed) grafts, which are used in cosmetically sensitive areas e.g. face & hands
  • (FTSG make small incisions with blade)
• graft placement and fixation
  
  • wound bed debrided & prepared already
  • SSG transferred dermis-side-down
  • Generally use a few vicryl sutures to tack it in place, trim the skin and use glue around the circumference
  • (FTSG put suture in place with also some quilting sutures (can also use tissue adhesives))
• dress recipient site
  
  • nonadherent and want to immobilise graft to recipient bed to prevent shearing of graft and/or accumulation of fluid under graft which would prevent neovascularisation and therefore graft failure
  • two layers of foam or NPWT or PICO (pressure at 80mmHg for up to 7 days)
  • if area subjected to shear bc of motion e.g. antecubital fossa, stabilise with splint, and should elevate extremities
• hypafix at donor site

Question 139

Groin dissection

Answer 139

• Principles
  
  • To remove all the lymphatic tissue from the femoral region, preserving the femoral artery, vein and nerve
  • NB boundary of a groin dissection doesn’t correspond exactly w the boundary of the femoral triangle; laterally go to the lateral border of sartorius (whereas femoral triangle is medial), and superiorly go well above the inguinal ligament
    
    • Some also take the medial border further than the medial border of AL and go to anterior border of gracilis
• Patient supine with thigh slightly abducted and externally rotated with a pillow under knee
• Prep from above umbilicus and iliac crest all the way down to junction of middle and lower thirds of thigh
• U-drape/shutoff leg
• ‘Lazy S’ incision extending relatively high as want to take 6-8cm of tissue above inguinal ligament
• Cut down to scarpa’s fascia and raise skin flaps to expose the limits of the dissection
  
  • Superiorly 6-8cm above the inguinal ligament
  • Medially to pubic tubercle and medial border of adductor longus; I dissect through the fascia on the medial aspect of adductor longus to score the medial edge of my dissection
  • Inferiorly to the apex of the femoral triangle where sartorious crosses adductor longus
  • Laterally to lateral aspect of sartorius – I score the fascia here preserving the lateral femoral cutaneous nerve which courses obliquely over Sartorius near its origin
• I use a scalpel to mobilise any subcutaneous fat and lymph nodes from the external oblique down towards the inguinal ligament
• I then work from the medial aspect and dissect the fascia lata off the adductor longus and pectineus until the medial side of the femoral vein and sheath is entered; distally at the medial aspect I will encounter the GSV which I ligate and divide (some preserve it if no major disease near it as they believe less lymphoedema if you leave it)
• Next mobilise fascia over sartorius from lateral to medial; on reaching an area of loose areolar tissue I will encounter branches of the femoral nerve, most of which are sensory to the anteromedial thigh (head towards skin) which I divide
• As the femoral arery is approached, dissection within the sheath covering this vessel is continued on the lateral aspect of the artery, and thus the sheath is dissected off the surface of the artery, ligating and dividing small branches of the superficial femoral artery
• From distal to proximal, remove all the tissue superficial to the vessels (nerve will be deep)
• Ligate GSV proximally if taking it; or ligate its tributaries if not
  
  • Suture ligate as well as tie
• Dissected tissue is then mobilised towards the femoral canal area
  
  • If only a superficial groin dissection is planned, the lymph nodes in the femoral canal are mobilised and the specimen is amputated at the femoral ring, including Cloquet’s node which is situated at the femoral ring
• See separate card for iliac dissection
• Remove specimen and mark
• Haemostasis and LA
• Two drains
• Close with 3/0 vicryl and 3/0 monocryl

Question 140

Iliac lymph node dissection

Answer 140

• Indications
  
  • Cloquet’s node involved?
  • Extensive superficial nodal disease (esp if extra-capsular disease)
  • Involvement of iliac nodes on CT/PET
  • Julie Howle – slightly controversial; if activity in pelvic nodes on PET then do it; if not then just inguinal – previously some did routinely but better systemic therapy now
• Leave the specimen of the superficial groin dissection attached to the femoral canal so that it can be removed in continuity with the deep nodes
• Incision through external oblique from 6-8cm superomedial to ASIS proceeding obliquely towards the inguinal ligament ~2cm lateral to femoral artery; transect the inguinal ligament
• Then divide internal oblique and transversus abdominis superior to the level of the inguinal ligament (?transversely), to enter the retroperitoneal space
• Peritoneum displaced superomedially using blunt dissection
• Careful of deep iliac circumflex vessels which arise from lateral aspect of ext iliac vessels and course in a fold of the iliac fascia posterior to inguinal ligament – can divide these
• As medial portion of ing ligament is lifted, encounter inferior epigastrics originating from terminal part of EIA – doubly ligate and divde; medial and adjacent to artery is inf epigastric vein – also doubly ligated and divided
• Dissection continues on top of ext iliac artery to bifurcation of CIA, mobilising the lymph nodes by entering the sheath of the EIA and the EIV
  
  • Lymph nodes are separated superiorly from ext iliac vessels, and anteriorly must be separated from peritoneum and transversalis fascia
  • Over bifurcation of CIA, ureter is visualised and displaced superiorly
  • Any lymph nodes over internal iliac artery are dissected
• Urinary bladder is separated from obturator nodes
• Behind EIV, obturator fascia is exposed; dissection then continues between the fascia and the lateral aspect of the obturator nodes
• Then reach the posterior aspect of these obturoator nodes and separate them from obturator nerve, ideally preserving this
• Can continue up common iliac artery/vein if ext iliac and obturator nodes are involved
• Remove specimen, irrigate and haemostasis
• Close incision by approximating transversus abdominis and int oblique with running 0 absorbable suture and ext oblique aponeurosis is closed with running nylon
• Interrupted 0 absorbable sutures between ing ligament and pectineal ligament on side medial to vessels and between the lateral portion of the inguinal ligament (careful of femoral nerve)
• Sartorius can be divided off its origin form ASIS and dissected free and pulled under the lateral femoral cutaneous nerve, and shifted to cover the femoral vessels
• 2 suction drains exiting through lower ends of medial and lateral flaps
• Trim ~0.5cm from flaps then close w interrupted 3-0 monocryl to dermis and staples to skin

Question 141

Portacath placement (S)

Answer 141

• principles:
  
  • percutaneous placement of an implantable device into the SVC
• preparation
  
  • consider previous access +/- venous USS if concerns
  • arrange USS and II
• USS neck before scrubbing
• prep and drape
• head down
• check device; flush tubing and port iwth hep saline
• puncture right IJV under USS
• insert guidewire into SVC under II (landmark is 2nd-3rd rib)
• dilate tract
• insert peel away sheath
• insert catheter - confirm tip position (in SVC) under II
• create pocket in chest wall
• tunnel catheter retrograde into pocket
  
  • ensure there is no acute angle in neck
• trim catheter, assemble port and aspirate/flush
• secure port to fascia - 2-0 nylon
• close in layers
• access port, confirm aspiration and flush

Question 142

Nasal packing (S)

Answer 142

• 90% bleeding is anterior from Little’s area on the nasal septum
  
  • supplied by anterior and posterior ethmoid arteries and sphenopaletine artery
• conservative measures first
  
  • ABC
  • direct pressure over cartilaginous portion of nasal septum
  • cotton balls soaked in LA and adrenaline
  • nasal speculum examination and direct cauterisation (either diathermy or silver nitrate stick)
  • if all this fails, or bleeding is rapid, proceed with packing
• pack bleeding side first
  
  • apply LA topically - either spray or with cototn balls
  • evacuate old blood and clot - blow nose or suction
  • either use a commercial kit or ribbon gauze
  • commercial kit
    
    • Rapid Rhino by Smith and Nephew
      
      • Balloon nasal tampon
    • soak in saline for 30secs (softens and activates self lubricant)
    • insert horizontally along floor of nasal cavity
    • inflate with air using a syringe - use pilot cuff to judge pressure
  • ribbon gauze
    
    • use petroleum impregnated ribbon gauze (Jelonet)
    • introduce with long pair of forceps - all the way back adn layer it from the floor up
• if packing fails
  
  • bilateral packing
  • posterior bleed - posterior packing
• risks
  
  • immediate: bleeding
  • early: infection, nasal septum perforation

Question 143

PD catheter (S)

Answer 143

• principles: placement of a PD catheter into colovaginal/colovesical pouch
• indications: dialysis - limited abdominal adhesions and closed peritoneal cavity
• pre-op marking by dialysis nurse
• consider pre-op dialysis if on HD already
• key steps
  
  • tunnel 5mm port
  • place catheter tunnel skin exit
• prep and drape
• 10mm port at umbilicus
• abdominal inspection - can pouch be reached
  
  • if yes, proceed
  • avoid too much dissection - causes bleeding which blocks catheter
• 5mm port suprapubic area slightly to opposite side of final catheter - beware of bladder
• 5mm port tunneled through rectus sheath - done by feel
  
  • skin incision 3-4cm medial to final catheter skin exit
  • breach peritoneum in midline, just above pelvis
• rail-road a grasper from suprapubic port up the tunneled port
• open up catheter; I use Argyle Swan Neck Curl Cath Peritoneal Dialyssi Catheter by Coviden
  
  • ensure correct side is opened (L vs R)
• introduce catheter down the port by pulling with the grasper
  
  • ensure correct orientation - marker line up
• pull catheter through enough for length and also so cuffs are in correct location
  
  • distal cuff just above peritoneum, proximal cuff just below skin
• place pigtail in colovaginal/colovesical pouch
  
  • ensure correct orientation
• remove tunneled port
• create skin tunnel
  
  • use the kit introducer with catheter attached
  • gentle upward curve from current skin exit (port site incision) to intended skin exit
  • final catheter exits downward facing
  • pull catheter through and ensure no kinks
• check that it flushes and drains
• confirm pigtail still in correct location
• remove ports
• close fascia with 1/0 vicryl, Monocryl to skin
• dressing (glue so watertight)
• delay catheter use for a week then begin w low volumes
• risks
  
  • bleeding, infection, blockage
  • late - adhesions, blockage, infection, repeat procedures

Question 144

Lap chole in pregnancy

Answer 144

• Pts need to be slightly head-up and tilted to their left, allowing uterus to fall away from vena cava
• Entry into peritoneum can be via Veress needle in LUQ (angle 15degrees caudad to minimize risk of splenic injury), or supraumbilical port 6cm above fundus w a Hasson technique
• Trocars generally placed in usual locations but as uterus enlarges, can be advantageous to move epigastric port into LUQ to provide greater perspective – determine this after pneumoperitoneum been established
• Maintain pressures ≤12mmHg
• ?give steroids (for foetal lung maturity) in case of preterm delivery

Question 145

Elective distal pancreatectomy

Answer 145

• indications include: chronic inflammation, trauma, tumour in body and tail of gland, or as part of radical gastrectomy for stomach cancer
• conventional distal pancreatectomy includes splenectomy - indicated for the limited number of ductal carcinomas that are resectable and for most cases of chronic pancreatitis, espec when associated w severe inflammation, pseudocyst and/or splenic vein thrombosis
• conservative distal pancreatectomy involves separating distal panc from splenic vessels and preservingn spleen - may be indicated for less severe cases of chronic panc & for endocrine tumours in body and tail; useful to preserve immunological function of spleen
• pre-op vaccines 2-4wks before op
• upper midline or transverse subcostal incision
• can do either a prograde fashion, starting with tail, or retrograde, dividing neck of pancreas early and securing splenic vessels before elevating pancreatic tail and body
  
  • prograde espec useful in chronic pancreatitis, in which extensive retropancreatic fibrosis has obscured anatomical landmarks of superior mesenteric and portal veins
  • prograde described below

Elective conventional distal pancreatectomy

• free neck of pancreas from underlying portal vein
  
  • trace middle colic vein downwards to root of transverse mesocolon & incise peritoneum along inferior border of neck and prox body of pancreas to display middle colic’s junction with SMV
  • then gently develop plane between SMV and pancreas; pass finger upwards through this tunnel and expose tip of finger by dividing peritoneum along superior border of neck of panc
  • now that superior mesenteric and portal veins have been freed, safe to proceed to mobilise tail and body of panc towards midline
    
    • (alternatively, continue dissection to left to identify, ligate and divide the splenic artery and vein before mobilising tail of pancreas - ligating splenic artery prior to vein reduces bleeding and venous congestion within spleen)
• in chronic pancreatitis, espec if pseudocyst, posteiror surface of stomach and transverse mesocolon and splenic flexure can become adherent to distal panc and need to be dissected free
• mobilise spleen upwards by dividing posterior layer of the lienorenal ligament
• greater omentum will have been partly divided already in entering the lesser sac; now complete the division
• ligate and divide the short gastric vessels
• if spleen has been torn during dissection can ligate its vasc pedicle and complete the splenectomy at this stage
• pancreatic tail lies at splenic hilum and has already been partly mobilised; divide peritoneum along upper and lower borders of distal pancreas
  
  • several small vessels need to be ligated or coagulated by diathermy
  • continue dissection towards midline, lifting the body and tial of pancreas forwards and to right
• as the prograde pancreatic dissection approaches the midline, identify the splenic artery as it reaches the posterior surface of the gland near its upper border - encircle w right-angled Lahey and tie it with 2-0 vicryl, doubly ligating on the proximal side
• ligate and divide splenic vein ideally before entry of IMV
• lift pancreas gently off portal vein
• decide where to transect pancreas (in hemipancreatectomy usu in front of portal vein bu surely in trauma distal to this?)
• insert 2/0 PDS stay sutures at the upper and lower border of the pancreas at this point and either
  
  • place a soft intestinal clamp across the neck
    
    • divide pancreas to the left of the clamp and stay sutures and remove the specimen
    • remove the clamp and secure haemostasis
    • look for the amputated main panc duct (usu 2-3mm) - under-run it with 4/0 PDS and close the pancreatic stump using interrupted 3/0 PDS sutures
  • ​or use reinforced black load endo GIA - or 60mm vascular load endo GIA
• check splenic bed and pancreas are dry
• insert 1-2 tube drains and close abdomen
• leave drain for minimum 5 days then shorten and remove them over a period of 2-3 days
• watch out for endocrine or exocrine insufficiency
• in spleen-preserving, free neck and prox body from underlying great veins, divide pancreas and oversew duct/stump at this stage
• then head towards tail and gradually free pancreas from splenic vessels, ligating and dividing the branches that connect them

Question 146

Emergency burr hole/craniectomy/craniotomy for EDH

Question 147

Craniotomy for EDH*