Operative Steps Flashcards
Left Adrenalectomy (5 steps)
1) mobilize the splenic flexure of the colon, divide the splenocolic ligament
2) reflect the spleen medially and mobilize and retract the pancreatic tail medially
3) create a plane between adrenal gland and the aorta
4) dissect and divide the INFERIOR PHRENIC vessels and CENTRAL ADRENAL VEIN
5) mobilize the adrenal gland by diving the inferior and lateral attachments.
Right adrenalectomy (5 steps)
1) retract right love of the liver medially
2) open the peritoneum overlying the adrenal gland inferior to superior
3) create a plane between the adrenal gland and the vena cava
4) dissect and divide the adrenal vein
5) mobilize the adrenal gland by dividing the inferior and lateral attachments and take it out
How do you do a cricothyroidotomy (3-4 steps)
1) Find the thyroid cartilage and cricoid cartilage and make a 2-3 cm longitudinal incision
2) palpate the cricothyroid membrane. Puncture it with the knife. This is when it bleeds
3) put a bougie in and then sendinger the ET tube in
Describe a splenectomy
1) divide the gastrocolic ligament and enter the lesser sac
2) identify and retract the pancreas posteriorly and inferiorly to visualize the splenic artery superior to the pancreas
3) clip the artery
Or
1) divide the splenocolic ligament and mobilize the splenic flexure
2) divide the short gastrics all the way up
3) divide the lenorenal ligament
4) divide the hilar vessels
For AAA gain proximal control
1) take down left lobe of the liver
2) make sure they have an OG. Move the esophagus out of the way
3) find and divide the crus of the diaphragm
4) with the clamp, get all the way down to the spine and clamp
How do you do a puestow? (~6 steps)
1) enter lesser sac by dividing gastrocolic, expose the entire anterior surface of pancreas
2) do a wide Kocher maneuver, mobilize the right colon
3) identify the duct with needle aspiration of clear fluid (can use ultrasound)
4) filet the entire duct from head to tail
5) construct 50-60cm roux limb
6) create pancreaticojejunostomy, jejunojejunostomy
How do you do a whipple?
1) rule out Mets. Start kocherizing
2) dissect the infrapancreatic smv and start creating a plane between the smv and the neck of the pancreas up to splenic vein. Decide to proceed or not
3) do CCY
4) dissect the common hepatic duct and divide it
5) dissect the portal vein and create a plane between portal vein and the neck of the pancreas
6) divide the distal 1/3 of the stomach and divide the distal duodenum/proximal jejunum
7) lift the distal stomach/proximal duodenum and dissect out the GDA and ligate it
8) divide the neck of the pancreas and hand off the specimen
9) RNY reconstruction
How do you do a psoas hitch? 3 steps
Mobilize the bladder dome by dividing the umbilical artery remnants (medial umbilical ligament) bilaterally
Place three interrupted stitches through the detrusor muscle to anchor the bladder to the psoas muscle above the iliac vessels
Reimplant the ureter into the bladder
Open AAA Repair
1) prep and drape before induction
Proximal control
2) take down the left lobe of the liver. Make sure there’s an OGT in. That’s how you’ll move the esophagus out if the way.
3) Divide the crus of the diaphragm
4) get your fingers on either side of the aorta and get clamp all the way down until it hits the spine
Distal control
5) clamp the iliacs or open the sac and put a balloon down each iliac
6) heparinize
7) thrombectomize
3 key steps of the Cattell-Braasch maneuver
1) mobilize the right colon along the white one of Toldt
2) Kocher maneuver
Intrahepatic vena cava, right kidney & renal vasculature, right iliacs are accessed
3) incision of the avascular line of fusion of the small bowel mesentery to the posterior peritoneum. This is carried around the cecum and all the way up along the white line between the cecum and the ligament of Treitz
Describe RNYGB (5 steps)
1) divide the jejunum 35-40cm from ligament of trites
2) create the roux limb (the crotch of the Y) by measuring 130cm of the remaining distal small bowel up to the stomach.
3) do the ileoileostomy at 130cm from the divided end.
4) divide the stomach and create the gastric pouch
5) do the gastrojejunostomy
Expose the SMA
Do an embolectomy
1) lift the transverse colon up
2) incise the ligament of Treitz, working medially to the root of the mesentery
3) once the vessel is identify, isolate it with a vessel loop
4) make a transverse arteriotomy, retrieve the clot with a Fogarty balloon
5) close the arteriotomy
Describe a total gastrectomy
1) Examine the abdomen for mets
2) separate the omentum from the colon. Ligate the right gastroepiploic and short gastric arteries
3) divide the proximal duodenum. Ligate the right gastric artery
4) divide the left gastric artery at the origin
5) divide the esophagus
6) reconstruct
Describe distal panc with splenectomy
1) divide the short gastrics
2) divide the splenocolic ligament and dissect the spleen off of gerotas to medialize the spleen
3) ligate the splenic a. and v.
4) free the pancreas from its peritoneal attachments inferiorly, posteriorly and divide it
Describe the Blakemore tube
1) intubate the pt
2) insert the tube and verify on XR
3) inflate the gastric balloon first
4) only if that stops the bleeding inflate the esophageal balloon
5) periodically deflate the esophageal balloon every 45min-1hr
