Operative to sort

Question 2

Primary tissue repair for inguinal hernia*

Answer 2

Bassini repair

• Performed by suturing the conjoined tendon – distal ends of transversus abdominis and internal oblique muscles – to inguinal ligament, from the pubic tubercle to the deep ring

McVay/Cooper’s ligament repair

• Instead of suturing musculoaponeurotic structures to inguinal ligament, suture them to Cooper’s ligament (pectineal)
  
  • Lucy: so conjoint tendon and IO is sutured to Coopers ligament, pectineal fascia and anterior wall of femoral canal from pubic spine to end of ligament
• Uses a relaxing incision through anterior rectus sheath to limit tension on suture line
• Interrupted nonabsorbable suture is used to approximate transversus abdominis to Cooper’s ligament – continued down pubic spine to end of ligament
• Transition stitch placed to approximate Cooper’s ligament and the iliopubic tract
• Completed by approximating edge of transversus abdominis to iliopubic tract

Shouldice repair

• Four-layered tissue repair that has lowest recurrence rate of primary tissue repairs
• Is a double breasted posterior wall plication
• 1^st layer: transversus abdominis aponeurosis secured to iliopubic tract in continuous fashion from medial to lateral
• 2^nd layer: same suture then run from lateral to medial and approximates the transversalis fascia to the shelving edge of the inguinal ligament
• 3^rd layer: begins at medial portion of new internal inguinal ring, securing conjoint tendon or internal oblique aponeurosis to shelving edge of inguinal ligament, and is taken to the pubic tubercle
• 4^th layer: same suture then run medial to lateral and again approximates the internal oblique muscle to inguinal ligament as a more superficial 4^th layer, ending at the internal inguinal ring

Question 3

Approach to pain post inguinal hernia repair*

Question 4

Laparostomy*

Question 5

Plan for closing open abdomen*

Question 6

Colonoscopic polypectomy*

Question 7

Forefoot amputation*

Question 8

SPC insertion

Answer 8

• Indications
  
  • Acutely to drain a bladder in urinary retention when urethral catheterization not possible, eg in presence of a urethra stricture
  • Acutely to divert urine following injury to lower urinary tract eg from a pelvic fracture
  • To divert urine following complex reconstructive urological surgery
  • Preferred option for long-term catheterization – by bringing out catheter through a clean part of the anatomy is easier to maintain hygiene around catheter site, easier to clean, risk of infection reduced, leaves genitals free for sexual activity
• Anatomy
  
  • Bladder lies in anterior part of pelvic cavity behind fat-filled retropubic space; as it fills, it rises above the pubic crests and comes into contact w lower part of ant abdo wall
  • The distended bladder intervenes between the parietal peritoneum and the abdo wall, and access can be gained w/o breaching the peritoneum
  • Layers of abdo wall in midline: skin, subcut fat, Scarpa’s, rectus sheath, transversalis fascia, extraperitoneal fat
• Procedure
  
  • 3 types of suprapubic catheter
    
    • one where catheter is introduced over its own needle (Bonanno catheter)
    • another which relies on a Seldinger technique of placing a guidewire, dilating the track and then introducing the catheter
    • third type = introduced via a trocar and cannula placed blindly
  • Bonanno catheter = fine-bore catheter tube that can be used as a temporary method of draining the bladder; due to the narrow calibre of the catheter it is prone to blocking and not suitable for medium or long-term use
  • Foley balloon catheters are preferred for suprapubic drainage and generally available in kits for insertion
  • Prep abdomen supine; ensure midline of abdomen is identifiable
  • Locate site for insertion – 2 finger-widths above the pubic symphysis in the midline
  • Use USS to localise the bladder, if available
  • Infuse local anaesthetic into the skin and subut tissue
  • Continue to advance needle through all the layers of the anterior abdominal wall until urine is aspirated; can only safely introduce suprapubic catheter if aspirate urine
  • Place 1cm incision at site of injection using a blade and deepen through subcut fat
  • Insert SPC using Seldinger method safest
    
    • Attach a long 18-gauge needle to a syringe for deep LA infiltration and aspiration of urine from bladder
    • Once aspiration confirmed, detach syringe leaving needle in place with its tip still in bladder
    • Insert floppy tip of a guidewire through the long needle into the bladder; remove the needle over the guidewire and feed the stiff end of the guidewire through the aperture in the tip of the trocar and advance the trocar along the guide-wire into the bladder
    • Remove the trocar leaving the sheath in situ
    • Introduce a Foley catheter through the sheath and inflate the balloon
  • Where suprapubic catheter is required electively for long-term catheterization, perform this under direct vision by filling the bladder with a flexible or rigid cystoscope; cystoscope is used to watch the safe placement of the instruments from within the bladder
• NB
  
  • Blind placement of SPC can only be performed safely when bladder if full (I wouldn’t do this)
  • If bladder not palpable, placement may be possible with USS guidance
  • If pt has had previous abdominal surgery, this increases the risk of bowel injury – open insertion may be required

Question 9

Describe a modified Hanley procedure

Answer 9

• a sphincter-preserving procedure for the treatment of horsehoe abscesses and fistulas
• performed in difficult cases of anorectal fistulas, including pts with:
  
  • horseshoe fistulas
  • ischiorectal fistulas
  • deep postanal abscesses with fistulas
  • recurrent fistulas
• key components = to identify and drain all fistulous tracts
  
  • a probe is inserted through the internal opening into the deep space abscess cavity
  • an incision is made in the posterior midline, initially avoiding the superficial external sphincter
  • midline incision then deepened parallel to and through the fibres of the superficial external sphincter, thereby unroofing the deep space for drainage
  • a probe is then guided through the internal opening to exit through the midline surgical incision
  • the walls of the deep space are inspected to identify limbs of the horseshoe abscess fistula
  • if a deep postanal abscess or extension into the ischiorectal fossa is identified, use a modified Hanley technique for definitive mx w draining lateral setons & a snug seton in teh posterior midline
  • a counterincision is made over the appropriate site with the subsequent incision, drainage & curettage of all the fistulous tracts
  • next the seton is attached to the midline probe & retrieved through the internal opening and secured to itself with a 0 silk suture
  • the underlying perianal skin & anoderm between the primary midline opening and the secondary midline surgical incision are removed to allow subsequent tightening of the seton
  • Penrose drain is placed in the tract and removed 24-48hrs after surgery
• 91% of 23pts with high transsphincteric horseshoe fistulas treated w a modified Hanley procedure using snug setons, in a small retrospective study, had complete healing within 8mo & no incontinence reported