Operative

Question 1

In what situations does a Pringle not alter bleeding

Answer 1

Venous bleeding from hepatic veins or IVC
Aberrant hepatic artery anatomy (eg branch from left gastric

Question 2

Key steps - laparoscopic right adrenal

Answer 2

Lateral positioning
4 ports - subcostal from midaxillary line to midline
Mobilisation of the right triangular ligament
Open peritoneum
Dissect adrenal off IVC
Isolate right adrenal vein and clip then divide
Dissect circumferentially around adrenal, look for any vessels
Remove adrenal in a bag; may need to enlarge for large tumour

Pitfalls:
Short adrenal vein, risk of bleeding from IVC with traction injury
If vein wide consider vascular stapler

Close relations: liver, right kidney, IVC

Question 3

Key steps: lap left adrenal

Answer 3

Lateral positioning
4 ports - midaxillary line to midline
Mobilise spleen flexure (colon down) and spleen (medially) by dividing spleno-colic and spleno-renal ligaments and lateral splenic attachments
Sight pancreatic tail and retract medially
Open peritoneum
Dissect borders of adrenal
Clip left adrenal vein (drains into left renal)
Mobilise adrenal circumferentially, take vessels with energy device
Remove adrenal in bag
Haemostasis and drain

Pitfalls:
Pancreatic injury
Bleeding from branches of phrenic vein and artery supplying adrenal

Relations: left kidney and renal vein and artery, pancreas, spleen, splenic flexure

Question 4

Laparoscopic high anterior resection:
Steps medial to lateral mobilisation of splenic flexure

Answer 4

Reverse trendelenburg, right side tilt, hold transverse colon up
Small bowel to right, free up Trentz ligament
Identify IMV, enter mesentry under this
Find the embryological plane between mesentry and retroperitoneum
Sub-mesocolic dissection, laterally until you see the colon
Identify the pancreas, make opening to lesser sac
Take down IMV (at lower edge of pancreas)
Mobilise the mesentry off the pancreas and down line of toldt
Supracolic mobilisation (omentum off colon, entry lesser sac

Question 5

Steps of parotidectomy

Answer 5

Positioning and facial nerve monitor
Incision - preauricular to below mandible
Lift SMAS flap
Identify tragal pointer
Identify and dissect out facial nerve
Identify PES
Dissect out lesion/superficial parotid
Drain
2 layer closure

Question 6

Risks/complications of parotidectomy

Answer 6

Facial nerve injury
Frey’s syndrome
Salactocele
Fistula
Great auricular nerve division (numb ear)

Question 7

Ways to find the facial nerve

Answer 7

Anterograde:
At depth of the posterior belly of digastirc
Tragal pointer - 1cm medial, inferior and deep
Tympano-mastoid suture
Stylomastoid foramen

Retrograde

Question 8

Aims/principles of pilonidal surgery

Answer 8

Excision of all disease and midline pits
Off midline closure
Flattening of the natal cleft

Question 9

Hartmann’s: procedural steps

Answer 9

Entry/laparotomy
Mobilisation of the left colon
Ligation and division of blood vessels
Resection of disease segment (to control contamination and treat sepsis)
Decontamination of peritoneal cavity
Closure with formation of end colostomy

Question 10

Steps in feeding jejunostomy

Answer 10

Identify first mobile jejunal limb able to reach abdominal wall
Jejustomy tube through abdo wall
Purse string in jejunum, insert tube
Whizet stitch to tunnel tube
Anti-volvulus/plexy stitch
Secure and close

Question 11

Steps in SPC

Answer 11

Palpate/USS to check full bladder
LA
Spinal needle to check depth/direction of tract
Incise skin
Saldinger vs trocher entry
Insert IDC via trocher and remove trocher
Suture in place