Procedures

Question 1

Ileal Pouch Anal Anastomosis

Answer 1

1. Patient is placed in the modified lithotomy position with access to the anus.
2. Perform total proctocolectomy or completion proctectomy, dividing the mesentery near the bowel, unless cancer is a concern.
3. Staple and divide the terminal ileum, initially preserving the ileocolic artery.
4. For double-stapled technique, use a TA-30 or other suitable stapler to staple the anorectal junction at the level of the levator muscles. Watch out for anterior structures (vagina, urethra).
5. Mobilize the small bowel and its mesentery, including full LOA and separation of the SMA pedicle from the third portion of the duodenum.
6. If reach is insufficient, perform lengthening procedures including dividing the peritoneum, selective vascular ligation, and/or consideration of an alternate pouch shape.
7. Create a 15-20cm long J-pouch by stapling the distal two limbs of ileum together with a GIA stapler and inserting anvil of EEA stapler if double-staple technique is planned.
8. Perform stapled or hand-sewn anastomosis.
9. Diverting loop ileostomy.

Question 2

Oversewing a Bleeding Duodenal Ulcer

Answer 2

1. Longitudinal pyloroduodenotomy allows for inspection of the duodenal bulb and gastric antrum if the exact site of bleeding is not known.
2. The bleeding vessel at the base of the ulcer can be oversewn superiorly and inferiorly. Be aware of the CBD posterior to the duodenum.
3. GDA may be ligated superior to the duodenum if bleeding persists.
4. Approximate ulcer crater edges if possible after achieving hemostasis.
5. Close pyloroduodenotomy transversely.
6. Vagotomy if indicated.

Question 3

Component Separation

Answer 3

1. Remove all prosthetic material and address any bowel issues as necessary.
2. Perform complete adhesiolysis of the entire anterior abdominal wall to the paracolic gutters to allow muscular components to slide to the midline during reconstruction.
3. Elevate lipocutaneous flaps 2cm lateral to the edge of the rectus muscle.
4. Incise the external oblique fascia and separate the external and internal oblique muscles in their avascular plane.
5. Continue the dissection 3-4cm above the costal margin and inferiorly to the inguinal ligament.
6. Release the posterior rectus sheath, 2cm lateral to the linea semilunaris.
7. Place an appropriately-sized biologic graft as an underlay, redistributing tension across the graft to help medialize the rectus complex. Place drains over mesh.
8. Reapproximate midline with sutures.
9. Remove excess devascularized skin, and close over multiple drains.

Question 4

Laparoscopic Splenectomy

Answer 4

1. Position patient in modified right lateral decubitus position.
2. Access abdomen with 12mm Hasson in L midclavicular line 3-4cm below costal margin. Two additional 5mm ports in the midline between the existing trocar and the xiphoid process. Additional (stapler-sized) trocar in L anterior axillary line below the costal margin.
3. Inspect abdomen carefully for accessory splenic tissue.
4. Mobilize splenic flexure caudad by dividing the splenocolic ligament.
5. Divide short gastrics up to the level of the superior pole of the spleen.
6. Mobilize inferior pole of the spleen by dividing splenorenal ligament.
7. Mobilize superior pole of the spleen to isolate splenic hilum.
8. Divide splenic hilar vessels with a stapler.
9. Morcellate spleen in endocatch bag and remove through initial trocar site. Inspect abdomen again for accessory splenic tissue.

Question 5

Open Lichtenstein Tension-Free Hernioplasty

Answer 5

1. Skin incision over the inguinal canal for exposure of the pubic tubercle
2. Cord structures dissected from the cremasteric muscle and transversalis fascia fibers and retracted off the inguinal canal.
3. Cord explored for an indirect hernia sac or cord lipoma.
4. Polypropylene mesh is secured medially to the pubic tubercle, inferiorly to the shelving edge of the inguinal ligament and superiorly to the rectus sheath and internal oblique muscle.
5. The internal ring is reconstructed by suturing two leaves of the mesh together.
6. The spermatic cord is returned to the original position and the aponeurosis of the external oblique is reapproximated.
7. Check that the testicles are still in the proper anatomical place in the scrotum.

Question 6

Hand-Assisted Laparoscopic Left Hemicolectomy

Answer 6

1. Place ports: Gelport at extraction site (Pfannenstiel suggested), umbilical camera port, working ports in RUQ and RLQ.
2. Transect IMV at the level of the ligament of Treitz.
3. Transect the left colic artery at the level of its origin from the IMA.
4. Complete the medial to lateral mobilization of the splenic flexure of the colon. Avoid the ureter.
5. Transect the white line of Toldt, the splenocolic and the gastrocolic ligaments.
6. Transect the colon proximally and distally.
7. Intracorporeal (if extraction site is Pfannenstiel) or extracorporeal (if extraction site is midline) colocolonic anastomosis.

Question 7

Lap Chole in Pregnancy

Answer 7

1. Appropriate port placement based on fundal height of the uterus, preferably via an open Hasson technique
2. Position the patient in the supine position. Use a left lateral recumbent position for for third-trimester patients.
3. Insufflate abdomen 10 10-15mmHg. Limit 12mmHg in patients with restrictive lung physiology.
4. Retract gallbladder toward abdominal wall.
5. Dissect peritoneum from the gallbladder and the triangle of Calot to obtain the critical view of safety.
6. Identify the cystic artery as it courses from the R hepatic artery to the gallbladder.
7. Divide and ligate both the cystic artery and the cystic duct.
8. Use electrocautery or Harmonic scalpel to dissect the gallbladder from the liver fossa.
9. Remove ports under direct visualization and close port sites.

Question 8

Laparoscopic Nissen Fundoplication

Answer 8

1. Incision of the gastrohepatic ligament through the avascular space to expose the right crus. Avoid accessory or replaced L hepatic artery.
2. Blunt dissection to develop a plane between the esophagus and the crus until the crural decussation is visualized.
3. Completely mobilize the fundus.
4. Extensive mediastinal dissection to deliver at least 2.5-3cm of esophagus into the abdomen. Watch out for the posterior vagus in particular.
5. Closure of the crural defect with nonabsorbable pledgeted sutures.
6. Creation of a 2cm long, 360º posterior fundoplication using nonabsorbable suture over a 60Fr bougie.

Question 9

Gallstone Ileus

Answer 9

1. Full abdominal exploration with manual palpation for gallstones.
2. Localization of point of obstruction.
3. Proximal longitudinal enterotomy on antimesenteric surface of intestine.
4. Retrograde extraction of gallstones. Don’t try to push them forward, they’ve already gotten stuck. Bowel resection as necessary.
5. Check the rest of the small bowel again. Check the gallbladder/RUQ for additional stones.
6. Transverse closure of enterotomy to prevent stricture.

Question 10

Open Adrenalectomy

Answer 10

1. Obtain adequate central venous access and arterial blood pressure monitoring given potential need for large-volume resuscitation.
2. Subcostal or midline laparotomy with full exploration for metastatic disease.
3. Divide triangular ligament to mobilize liver medially for right adrenalectomy. Mobilize spleen and tail of pancreas medially for left adrenalectomy.
4. Open posterior peritoneum to enter retroperitoneal space.
5. Dissect and ligate central adrenal vein, which originates from IVC for the right adrenal and left renal vein for the left adrenal. Additional venous supply comes superiorly from the inferior phrenic vascular pedicle (especially prominent on the left).
6. Arterial supply to the adrenal is via multiple small vessel entering posteromedially, originating from the aorta and renal arteries.
7. Include wide margins of retroperitoneal tissue.
8. En bloc resection of kidney, IVC, diaphragm, adjacent organs, or venous tumor thrombectomy is sometimes required for locally invasive tumors.

Question 11

Total Mesorectal Excision

Answer 11

1. Modified lithotomy with Foley, DRE and rectal washout.
2. Exploratory lower midline laparotomy with abdominal exploration for metastatic disease. Pack the small bowel into the upper abdomen.
3. Mobilize sigmoid starting with the white line of Toldt, then identify the left ureter and gonadal vessels. Score the peritoneum along the superior rectal artery up to the IMA.
4. Ligate the IMA just distal to the takeoff of the L colic artery. Divide the mesentery of the L colon and divide the colon with a stapler.
5. Score peritoneum bilaterally into the pelvis and around the anterior peritoneal reflection. Lift the rectum anteriorly to develop the avascular plane.
6. Sharply divide Waldeyer’s fascia down to the pelvic floor (for mid-low cancers). Complete the lateral dissection, avoiding the autonomic nerves.
7. Develop the anterior dissection. In male patients, continue through or anterior to the Denovillier’s fascia, removing it from the seminal vesicles and the prostate in anterior lesions.
8. Transect the mesorectum and rectum (at least 1cm distal to the tumor).
9. Reconstruct with the L colon or sigmoid (splenic flexure mobilization often required) and a circular EEA stapler. Perform proctoscopy to check for leak.
10. Diverting ileostomy as indicated.

Question 12

Laparoscopic Distal Pancreatectomy

Answer 12

1. Place one suprumbilical camera port and four additional working ports, two in each hemiabdomen.
2. Explore the liver and peritoneal surfaces for evidence of metastases.
3. Enter lesser sac through gastrocolic ligament; retract posterior stomach cephalad.
4. Establish plane inferior to pancreas; identify and preserve splenic vessels.
5. Dissect the pancreas free from splenic vessels out to splenic hilum. If performing splenectomy, transect and ligate vessels with a stapler.
6. Transect pancreatic parenchyma with a buttressed linear cutting stapler or energy device, oversewing main pancreatic duct and parenchyma as necessary.
7. Retrieve specimen with Silastic bag, morcellation of the spleen if necessary, and enlargement of supraumbilical port to accommodate removal.

Question 13

(Axillary) Sentinel Lymph Node Biopsy

Answer 13

1. Dual agent mapping.
2. Meticulous dissection once clavipectoral fascia is scored to identify the blue channel.
3. Trace the blue channel to SLN, or use gamma probe if blue channel not visible.
4. Be deliberate with the gamma probe to avoid unnecessary dissection.
5. Remove all “hot,” blue or suspicious lymph nodes (max 5).

Question 14

Ovarian Cystectomy

Answer 14

1. Expose and stabilize the ovarian mass.
2. Create a superficial incision in the ovarian serosa over the anterior surface of the mass.
3. Use blunt and sharp dissection to identify the mass and to separate it from its serosal and stromal attachments.
4. Hemostasis within the remaining ovarian cavity is achieved with either ligation using fine absorbable sutures or with cautery. Most significant bleeding occurs at the base of the tumor where the ovarian vessel enter the hilum.
5. The ovarian serosa can either be left open or reapproximated with absorbable suture.

Question 15

EVAR

Answer 15

1. Choose appropriate endograft based on 3D reconstruction of CT scan.
2. Expose the CFAs.
3. Insert sheaths and catheters and perform abdominal and pelvic aortogram.
4. Administer heparin.
5. Insert main body of endograft just below renal arteries.
6. Obtain wire access of contralateral side gate of endograft and place contralateral iliac limb.
7. Balloon angioplasty sealing zones and joints.
8. Perform completion angiogram to determine presence of endoleaks.
9. Administer protamine.
10. Close arteriotomies and groin wounds. Check distal pulses.

Question 16

VATS Bleb Resection and Pleurodesis

Answer 16

1. Prepare the patient with general anesthesia and a double-lumen endotracheal tube.
2. Thorough bronchoscopy of the tracheobronchial tree.
3. Lateral decubitus position with single-lung ventilation.
4. Place the camera in the 5th intercostal space.
5. Depending on the location of the pathology, additional ports may be placed in the 4th intercostal space or the 7th intercostal space.
6. Similar to a wedge resection, grasp the affected tissue and apply the endoscopic stapler across the base of the bullae/bleb. Use a reinforced, linear GIA stapler.
7. After resection, abrade the parietal pleura through the VATS ports. This can be accomplished using the electrocautery scratch pad, the electrocautery or the argon beam coagulator.
8. Chemical pleurodesis can be accomplished by evenly distributing 1-5mg of aerosolized talc to the pleural space.
9. Upon completion of the procedure, remove the ports and insert a single chest tube into the inferior VATS port.

Question 17

Open Distal Gastrectomy (for bleeding)

Answer 17

1. Upper midline incision.
2. Mobilize the stomach and duodenum: Kocher maneuver (don’t hit the cava or the porta), divide gastrocolic ligament to access lesser sac (avoid middle colic artery).
3. Locate the ulcer to determine extent of resection.
4. Divide the greater omentum along the greater curve from the duodenum halfway to the GEJ.
5. Ligate the R gastroepiploic vessels near the GDA.
6. Incise the gastrohepatic ligament and divide the R gastric artery proximally.
7. Staple the stomach and duodenum and oversew staple lines, leaving a portion of the gastric staple line for reconstruction.
8. Bilroth I (avoid if under tension or if duodenum is inflamed) or II reconstruction as is anatomically possible. Place a “crown stitch” at the angle of sorrow of either gastroduodenal or jastrojejunal anastomosis.

Question 18

Redo Parathyroidectomy

Answer 18

1. Two concurrent preoperative localization studies reviewed by the surgeon and at least one showing anatomic detail.
2. Consider intraoperative recurrent laryngeal nerve monitoring.
3. Baseline PTH levels drawn preoperatively.
4. Cervical collar incision with subplatysmal flaps.
5. Midline vs lateral (separating medial border of SCM from the lateral border of strap muscles) approach to central neck based on pre-op imaging.
6. Identification of adenoma and ligation of arterial blood supply.
7. Repeat PTH levels at 10min postexcision and use institution-specific criteria for cure.
8. Be prepared for an extended exploration of central neck as dictated by PTH levels.
9. Autotransplantation/cryopreservation of parathyroid tissue as indicated.

Question 19

Transhiatal Esophagectomy

(Do Ivor-Lewis or three-hole for any fixed tumors or with dense periesophageal fibrosis!)

Answer 19

1. Upper midline laparotomy and abdominal exploration; assess suitability of stomach as esophageal replacement.
2. Divide triangular ligament, retract liver to the right with table-mounted upper hand retractor.
3. Mobilize stomach by dividing and ligating high short gastric, left gastroepeploic and left gastric vessels while preserving the right gastric and right gastroepiploic vessels.
4. Perform generous Kocher maneuver and extramucosal pyloromyotomy.
5. Insert 14Fr red rubber jejunostomy tube.
6. Open peritoneum overlying the hiatus and mobilize the distal 10cm of the esophagus under direct vision, clamping and ligating lateral attachments with long right angle clamps and dissecting with electrocautery.
7. Through oblique left cervical incision anterior to the SCM, mobilize and encircle cervical esophagus while avoiding the direct placement of metal retractors/instruments directly against the tracheoesophageal groove.
8. Mobilize the thoracic esophagus from the posterior mediastinum with posterior, anterior and finally lateral dissections.
9. Retract 3-4in of esophagus into the cervical wound, divide with a surgical stapler, and deliver the mobilized stomach and attached esophagus out of the posterior mediastinum into the abdomen.
10. Through the diaphragmatic hiatus, inspect the posterior mediastinum for bleeding and assess the integrity of the mediastinal pleura and the need for chest tubes (place now if needed); place gauze packs into the posterior mediastinum from above and below to encourage hemostasis.
11. Divide stomach 4-6cm distal to the esophagogastric junction from lesser curve, progressively straightening the stomach by traction of the gastric tip. Remove specimen from the field and assess need for frozen section on gastric margin.
12. Oversew gastric staple line and and transpose stomach through the posterior mediastinum until 3-5in of gastric tip is visible in the cervical wound. Make sure gastric staple line is on the patient’s right!
13. Loosely narrow diaphragmatic hiatus and suture stomach to edge of diaphragm and L lobe of liver against hiatus.
14. Bring out jejunostomy tube and close abdomen.
15. Perform side-to-side CEGA (cervical esophagogastric anastomosis) and place drain. Close neck.
16. Post-op CXR in the room to evaluate for occult hemo- or pneumothorax.

Question 20

Excisional Breast Biopsy/Partial Mastectomy

Answer 20

1. Incision placed along Langer’s lines, periareolar if possible, radial in lower half of the breast.
2. Biopsy - wide margins are unnecessary.
3. In partial mastectomy, rim of normal tissue should be excised. (I’m putting this in because it’s in the book, although I’m not sure it’s still correct.)

Question 21

Roux-en-Y Hepaticojejunostomy

Answer 21

1. Right subcostal incision
2. Careful portal dissection - mobilizing duodenum, omentum, hepatic flexure away from the porta.
3. “Anterior-only” dissection of the hepatic duct. Circumferential dissection can interrupt blood supply.
4. Lower the portal plate to allow exposure of the anterior aspect of the hepatic duct bifurcation.
5. Starting along the long extrahepatic portion of the L hepatic duct may facilitate exposure of the bifurcation.
6. Create tension-free Roux-en-Y limb, brought up to RUQ via defect of the transverse mesocolon to the right of the middle colic vessels.
7. Broad biliary-enteric anastomosis using absorbable monofilament suture.
8. Closed suction drainage.

Question 22

Laparoscopic Ventral Hernia Repair

Answer 22

1. Place ports laterally enough for 4cm overlap of mesh to fascia.
2. Sharp adhesiolysis as needed, leave hernia sac in place.
3. Reapproximate the fascia if possible/desired.
4. Select a non-adherent mesh, if prior infection avoid ePTFE. Size should be 4-5cm larger on each side than the defect. Place sutures in each quadrant of the mesh.
5. Insert mesh into abdomen through 10-12mm port. Pull sutures through 1mm skin incisions through abdominal wall.
6. Tack mesh in place circumferentially.

Question 23

Laparoscopic Appendectomy

Answer 23

1. Inspect abdominal cavity to verify diagnosis.
2. Dissect open a “window” in the mesoappendix adjacent to the base of the appendix.
3. Divide the base of the appendix.
4. Divide the mesoappendix.
5. Remove appendix, irrigate and close.

Question 24

Laparoscopic Right Adrenalectomy

Answer 24

1. General anesthesia induced with patient in supine position, then place patient in lateral decubitus position, ipsilateral side up.
2. Obtain laparoscopic access with camera port just superior and right of the umbilicus.
3. Retract right lobe of the liver medially and open peritoneum overlying adrenal gland inferior to superior.
4. Bluntly create a plane medial to the adrenal gland and lateral to the vena cava.
5. Dissect and divide the central adrenal vein (clip or linear stapler).
6. Mobilize the adrenal gland by dividing the inferior and lateral attachments.
7. Remove adrenal gland from abdomen and inspect suprarenal site for hemostasis.

Question 25

Total Thyroidectomy

Answer 25

1. Position the patient with the neck extended.
2. Place your incision to enable access to both the upper and lower poles.
3. Elevate subplatysmal flaps and separate the strap muscles.
4. Take the upper pole vessels first.
5. Mobilize the lobe anteriorly and medially to facilitate identification of the RLN.
6. Carry all dissection as close as possible to the thyroid gland.
7. Always identify the parathyroid glands and preserve their blood supply. Autotransplant any inadvertently-removed or -devascularized parathyroid glands.

Question 26

Laparoscopic TAP Repair of Inguinal Hernia

Answer 26

1. Incise the peritoneum and develop the preperitoneal space.
2. Reduce direct and/or femoral hernias medially.
3. Dissect indirect hernia sac off of the cord structures and then reduce indirect hernia sac and cord lipoma from within the deep inguinal ring.
4. Extensively dissect the peritoneum with parietalization of the cord.
5. Place a nonabsorbable mesh to cover the entire myopectineal orifice.
6. Close the peritoneum.

Question 27

Mastectomy

Answer 27

1. Breast tissue, nipple areolar complex and pectoralis fascia removed.
2. Borders of the breast: clavicle, sternum, latissimus dorsi, inframammary fold.
3. +/- reconstruction.

Question 28

Open (elective) AAA Repair

Answer 28

1. Midline abdominal incision.
2. Reflect small bowel to the right and transverse colon superiorly; place self-retaining retractor.
3. Dissect duodenum off aorta and define proximal clamp site.
4. Dissect distal aorta and proximal iliac arteries, taking care to avoid sympathetic nerves.
5. Choose appropriate graft size; administer heparin, Lasix and mannitol.
6. Clamp iliac arteries, followed by proximal aorta.
7. Open aneurysm sac above IMA, remove thrombus, and oversew back-bleeding lumbar arteries.
8. Sew in graft starting proximally, followed by distally, with monofilament suture.
9. Reestablish blood flow through graft, administer protamine, and obtain hemostasis.
10. Close aneurysm sac and retroperitoneum over graft. Close abdomen and check distal pulses.

Question 29

Total (open) Gastrectomy

Answer 29

1. Midline laparotomy and full abdominal exploration.
2. Mobilize GE junction and esophagus, taking a margin of diaphragmatic crura and pericardial lymph node packet. Watch out for accessory or replaced L hepatic in gastrohepatic ligament.
3. Separate the omentum and lesser sac lining en bloc from the transverse colon.
4. Divide the short gastric vessels close to the spleen and skeletonize the celiac, splenic and common hepatic arteries, taking their lymph nodes with the L gastric artery. (This is D2. Need 15.)
5. Ligate left and right gastroepiploic arteries at their bases.
6. Divide esophagus, stomach and jejunum. Inspect duodenal stump, if it appears ischemic then oversew.
7. Reconstruction with Roux-en-Y esophagojejunostomy and jejunojejunostomy.

Question 30

Infrainguinal Bypass with Nonreversed Saphenous Vein

Answer 30

1. Expose inflow artery for proximal anastomosis and evaluate suitability for proximal anastomosis.
2. Expose target artery for distal anastomosis and evaluate suitability for distal anastomosis.
3. Expose saphenous vein of adequate legth through skip incisions Ligate and divide side branches. Ligate divide vein distally and at saphenofemoral junction.
4. Prepare vein for bypass with gentle distention with heparinized saline and repair any leaks.
5. Create bypass graft tunnel between donor and target arteries with blunt clamp or tunneler.Place umbilical tape through tunnel.
6. Systemically heparinize.
7. Perform proximal anastomosis.
8. Lyse valves in vein under arterial pressure with valvulotome. Confirm pulsatile flow.
9. Bring graft through tunnel under arterial pressure. Confirm pulsatile flow.
10. Perform distal anastomosis.
11. Confirm flow through graft and outflow arteries. Post-op obtain completion angiogram and/or duplex arteriography.

Question 31

Laparoscopic Paraesophageal Hernia Repair

Answer 31

1. Position patient split-legged or in lithotomy, surgeon stands between patient’s legs.
2. Port placement: Camera port: Supraumbilical, ~15-17cm below xiphoid process; Working ports: Left and right costal margins, ~10cm from xiphoid; Liver retractor; Assistant port: RUQ
3. Reduce hernia with gentle traction. Dissect hernia sac from left crus to right crus. Dissect into mediastinum taking care to reflect the pleural edges laterally.
4. Divide reduced sac from gastric attachments and take down short gastrics. Reduce posterior esophageal fat pad.
5. Place Penrose around GEJ and dissect esophagus into the mediastinum to get adequate (3-4cm) intra-abdominal length.
6. Perform fundoplication (partial or full) over 60Fr bougie.
7. Close hiatus hernia. Reinforce with mesh if necessary. Take care on the right in large, chronic hernias as the IVC may be pulled in quite close.

Question 32

Puestow

(Lateral Pancreaticojejunostomy)

Answer 32

1. Enter lesser sac through gastrocolic ligament.
2. Kocher maneuver to expose pancreatic head.
3. Identify, expose and unroof main pancreatic duct. 18g needle for aspirating clear, pancreatic fluid and palpation are usually effective in locating duct. Open distally to within 2cm of tip of tail, proximally to within 1-2cm of the duodenum.
4. Remove any impacted proximal stones within the duct.
5. Create retrocolic, Roux-en-Y conduit for drainage and suture to unroofed pancreatic duct.

Question 33

Parathyroidectomy

Answer 33

1. Position in semi-Fowler with neck in extension.
2. Kocher incision with development of subplatysmal flaps.
3. Early identification of the recurrent larygeal nerves.
4. Identification of the abnormal parathyroid gland(s); careful excision without breaching capsule of parathyroid.
5. Intraoperative rapid PTH if available.
6. Meticulous hemostasis within operative field and closure of the neck.

Question 34

Laparoscopic Ileocecectomy

(for Crohn’s)

Answer 34

1. Visual evaluation of entire small bowel.
2. Lateral-to-medial OR medial-to-lateral mobilization of the ascending colon and its mesentery.
3. Identification of the duodenum.
4. Ligation and division of the ileocolic vessels.
5. Division of the bowel proximal and distal to grossly-diseased intestines. Be wary of thick mesentery and mesenteric hematoma necessitating more small bowel resection.
6. Anastomosis of the ileum to the ascending colon.

Question 35

Open Right Hemicolectomy for Obstructing Transverse Colon Cancer

Answer 35

1. Lithotomy positioning
2. Midiline incision, explore for metastases.
3. Decompressive right colotomy if necessary.
4. Mobilize right colon from lateral to medial. Avoid the ureter!
5. Enter lesser sac at hepatic flexure.
6. Remove greater omentum from the stomach.
7. Mobilize splenic flexure.
8. Divide mesentery: ligate ileocolic vascular pedicle, middle colic pedicle, ligate ascending branch of left colic artery.
9. Construct ileocolic anastomosis and close mesenteric defect.
10. Irrigate and close abdomen.

Question 36

Laparoscopic Gastric Bypass

Answer 36

1. Pneumoperitoneum, trocal placement and exploration
2. Identify ligament of Treitz and divide jejunum 20cm distal to LoT.
3. Split mesentery and run a 75-150cm Roux limb.
4. Construct jejunojejunostomy and close potential internal hernia sites (Petersen’s defect: space between Roux limb and transverse mesocolon; space between biliopancreatic and Roux limbs at jejunojejunostomy; and within the mesocolon if a retrocolic approach is used).
5. Place liver retractor and construct 15-30ml, lesser curve-based gastric pouch.
6. Create gastrojejunostomy.

Question 37

Open Cystogastrostomy for Pancreatic Pseudocyst

Answer 37

1. Upper midline laparotomy
2. Cholecystectomy (if present).
3. Anterior gastrotomy (at least 5cm) to expose posterior gastric wall.
4. Aspiration of pseudocyst to ensure location if no apparent bulge, send fluid for culture.
5. Electrocautery to open the posterior gastric and anterior pseudocyst walls.
6. Biopsy pseudocyst (frozen and permanent) to exclude epithelial-lined cyst.
7. Explore pseudocyst cavity and debride necrosis.
8. Anastomosis (at least 5cm) completed with locking PDS or Vicryl suture.

Question 38

Salpingo-Oophorectomy

Answer 38

1. Expose the pelvic sidewall and identify the infundibulopelvic and round ligaments.
2. Incise the peritoneum approximately 1cm lateral to the infundibulopelvic ligament and develop the pararectal space.
3. Identify important retroperitoneal structures including the ureter, external and internal iliac arteries, and the external iliac vein.
4. Create a window through the peritoneum isolating the ovarian vessels from the ureter.
5. Ligate and divide the ovarian vessels.
6. Place the ovary and Fallopian tube on anterior traction while transecting the inferior peritoneal attachments toward the utero-ovarian ligament.
7. Ligate the Fallopian tube and the utero-ovarian ligaments close to the uterine cornua.

Question 39

Laparoscopic Heller Myotomy

Answer 39

1. Place an NGT prior to induction to prevent aspiration.
2. Five laparoscopic port sites.
3. Dissect the anterior aspect of the distal esophagus bluntly from the hiatus.
4. Expose the gastroesophageal junction by removing the gastroesophageal fat pad, taking care to preserve the anterior vagus nerve.
5. Divide the longitudinal and the circular muscle fibers for at least 6cm onto the esophagus and 2cm onto the stomach.
6. Separate the edges of the myotomy from the underlying mucosa for hald the esophageal circumference.
7. Insufflate the esophagus under water to test for a leak from the myotomy site. If esophageal perforation is recognized, repair with 4-0 absorbable suture, close myotomy and perform new myotomy on contralateral aspect of the esophagus.
8. Perform and anterior (dor) or posterior (Toupet) fundoplication.

Question 40

Open Appendectomy

Answer 40

1. Incise skin and subcutaneous tissues in a transverse (Rocke-Davis) or oblique (McBurney) orientation over McBurney’s point.
2. Divide the external oblique aponeurosis, internal oblique muscle and transversus abdominis muscle in the direction of their fibers.
3. Elevate and sharply divide the peritoneum.
4. Digitally explore the abdomen and deliver the appendix into the wound.
5. Divide the mesoappendix.
6. Ligate and divide the appendix at its base.
7. Invaginate the appendiceal stump using a purse-string suture or Z-stitch.
8. Irrigate and close in layers.

Question 41

Open Biliary Decompression

Answer 41

1. Upper midline or right subcostal laparotomy. Avoid smaller ducts (<5mm), ERCP or PTC preferred.
2. Self-retaining retractor used to lift liver cephalad, and retract colon caudally.
3. If present, gallbladder dissected “dome-down” until Calot’s triangle and the cystic artery are identified. Ligate cystic artery.
4. Cystic duct is followed antegrade to the common bile duct, which is dissected anteriorly. Avoid portal vein and hepatic artery.
5. Complete cholecystectomy.
6. A longitudinal choledochotomy is made 1-2cm distal to the confluence of the cystic duct and CBD.
7. The common bile duct is cleared with irrigation or a Fogarty catheter.
8. The choledochotomy is closed using absorbable suture over a T-tube and a closed suction drain is left in the area of the choledochotomy.

Question 42

Truncal Vagotomy

Answer 42

1. Retract the L hepatic lobe laterally, dividing the triangular ligament as needed to expose the esophageal hiatus.
2. Dissect the esophagus circumferentially.
3. Identify and dissect the anterior and posterior trunks of the vagus nerve.
4. Place proximal and distal clips ~2cm apart on each trunk and resect the intervening nerve segments. Send to pathology.
5. Inspect the esophagus to confirm no residual nerve remains.
6. Perform cruroplasty as necessary.
7. Pyloroplasty if no distal gastrectomy (ie for perforation or duodenal bleeding).

Question 43

Laparoscopic TEP Repair of Inguinal Hernia

Answer 43

1. Enter rectus sheath through infraumbilical skin incision.
2. Bluntly-dissecting balloon is placed in the space between the rectus muscle anteriorly and the posterior fascia, directed down to the pubis.
3. Two 5mm trocars placed in the lower midline between the rectus muscles.
4. Identify inferior epigastrics, Cooper’s ligament and ileopubic tract.
5. Reduce hernia sac and separate it from the cord structures.
6. Position a polyester mesh medial-to-lateral, covering internal ring laterally and superiorly and below the Cooper’s ligament.
7. Mesh fixation optional.

Question 44

Operative Management of Anastomotic Leak

Answer 44

1. Adequate resuscitation and stoma marking. Have a plan.
2. Careful blunt dissection.
3. Gentle exposure of the anastomosis.
4. Ask anesthesia how the patient is doing.
5. Resect and redo on the right if patient is stable.
6. End/loop stoma on the right if unstable.
7. Repair/redo and proximal diversion on the left if stable.
8. Resect and stoma on the left if unstable.

Question 45

Primary Repair of Perforated Esophagus

Answer 45

1. Thoracotomy:
   a. Proximal perforation: L neck exploration and drainage, left open and packed
   b. Midesophageal perforation: R thoracotomy in the 4-6th intercostal space
   c. Distal esophageal perforation: L thoracotomy in the 7th intercostal space.
2. Harvest intercostal muscle flap - not required; decision must be made prior to thoracotomy.
3. Debride pleura and mediastinum.
4. Mobilize esophagus.
5. Debride esophagus.
6. Perform myotomy to expose entire mucosal injury - very important!
7. Two-layer closure, with or without buttressing of repair.
8. Enteral access (if deemed necessary).

Consider resection instead in megaesophagus from achalasia, esophageal carcinoma or caustic ingestion. Perforation in the setting of achalasia without megaesophagus requires a myotomy along with primary repair.

Question 46

Central and Modified Lateral Neck Dissection

(for medullary thyroid cancer)

Answer 46

1. Make a transverse incision just below the cricoid cartilage and extend laterally or make a hockey-stick incision to facilitate lateral neck dissection.
2. Perform total thyroidectomy.
3. Central neck dissection is performed by dissecting out the recurrent laryngeal nerves and removing all fibroadipose tissue between the two carotid sheaths from the hyoid bone superiorly to the brachiocephalic vessels inferiorly. Don’t bag the paras!
4. Lymph node tissue from the anterior and posterior triangles, defined by the submandibular gland superiorly, the internal jugular vein medially, trapezius muscle laterally, and clavicle inferiorly is removed. Watch out for the phrenic and CNXI.
5. The medial aspect of the sternocleidomastoid is reapproximated to the sternothyroid muscle, followed by the platysma, and then the skin.

Question 47

Axillary Dissection

Answer 47

1. En bloc resection of level I and II lymph nodes.
2. Borders of axilla: subscapularis and latissimus dorsi, chest wall and serratus anterior, axillary vein, underarm skin and subcutaneous tissue.
3. Avoid injuring axillary vein, long thoracic nerve and thoracodorsal nerve.

Question 48

Open Cholecystectomy in a Pregnant Patient

Answer 48

1. Make a right subcostal incision.
2. Pack viscera and uterus from the operative field.
3. Grasp galbladder and dissect from a top-down approach.
4. Identify the cystic artery and duct just beyond the gallbladder neck.
5. Ligate and divide the cystic artery.
6. Use electrocautery to dissect the gallbladder from the liver fossa.
7. Close the abdomen in two layers.

Question 49

Laparoscopic Left Adrenalectomy

Answer 49

1. General anesthesia induced with patient in supine position, then place patient in lateral decubitus position, ipsilateral side up.
2. Obtain laparoscopic access with camera port just superior and left of the umbilicus.
3. Mobilize splenic flexure of colon and divide lateral peritoneal attachments of spleen and lienophrenic ligament.
4. Reflect spleen medially and mobilize pancreatic tail.
5. Bluntly create a plane medial to the adrenal gland and lateral to the aorta.
6. Dissect and divide the inferior phrenic vessels and central adrenal vein.
7. Mobilize the adrenal gland by dividing the inferior and lateral attachments.
8. Remove adrenal gland from abdomen and inspect suprarenal site for hemostasis.

Question 50

Open Liver Resection

Answer 50

1. Right subcostal incision with midline extension.
2. Thorough laparotomy for metastatic disease.
3. Limited mobilization of the liver to allow for ultrasound.
4. Intra-operative ultrasound: define segments, scan entire liver for lesions, plan resection with marking of capsule along line of transection.
5. Portal dissection - encircle porta with tape to allow Prinlge maneuver.
6. Extrahepatic ligation of segmental portal structures when indicated.
7. Parenchymal transection.
8. Obtain meticulous hemostasis and observe for biliary leaks.
9. Completion intra-operative ultrasound to document adequate inflow and outflow to liver remnant.

Question 51

Laparoscopic Liver Resection

Answer 51

1. Laparoscopic evaluation of abdomen and liver.
2. Mobilize liver as necessary.
3. Intra-operative ultrasound to determine extent of tumor. Mark edges of resection with cautery.
4. Resect liver mass/segment/lobe. Penrose or Rumel for Pringle. Use clips to divide small-medium-sized vascular structures and vascular stapler for larger vascular structures.
5. Ensure adequate hemostasis, can use argon as necessary,
6. Evaluate liver remnant for adequate perfusion and look for potential bile leaks. Oversew anything suspicious.
7. Place drain as indicated.

Question 52

Total Abdominal Colectomy

Answer 52

1. Lithotomy position, or supine with split-leg position.
2. Mobilize ascending colon and hepatic flexure (watch out for the duodenum and the ureter!), ligate ileocolic vascular pedicle, and divide ileum.
3. If preserving omentum, separate from transverse colon; if resecting omentum, divide and ligate outside the gastroepiploic arcade.
4. Mobilize sigmoid and descending colon (watch out for the ureter!), take down splenic flexure (don’t break the spleen), and ligate inferior mesenteric and middle colic vascular pedicles.
5. Mobilize and ligate upper mesorectum, and divide across upper rectum
6. Construct ileorectal anastomosis or ileostomy.

Question 53

Whipple

Answer 53

1. Midline laparotomy and inspection to rule out occult metastatic disease.
2. Mobilize hepatic flexure and perform complete Kocher maneuver.
3. Identify the origin and course of the SMA.
4. Identify the SMV at the inferior border of the pancreas and develop the plane posterior to pancreatic neck.
5. Portal dissection with definitive identification and safe division of the GDA. Don’t ligate a hepatic artery. Divide the stomach/first portion of the duodenum for a pylorus-preserving procedure.
6. Perform cholecystectomy. Divide the pancreatic neck with immediate evaluation of the distal margin. Divide the CBD above the level of the pancreatic head. Don’t ligate a replaced right hepatic.
7. Divide the small bowel at the duodenojejunal junction.
8. Dissect the uncinate process and head of the pancreas off of the SMA.
9. Reconstruction: pancreaticojejunostomy, choledochojejunostomy, antecolic gastro/duodenojejunostomy.
10. Place drains.

Question 54

VATS Pulmonary Wedge Resection

Answer 54

1. After positioning the patient in the lateral decubitus position, ask anesthesia to begin single-ventilation prior to prepping the patient so as to allow adequate collapse of the operative lung at time of entering the pleural space.
2. If the solitary pulmonary nodule cannot be visualized after adequate deflation of the lung, attempt to deflate the lung directly with a finger or indirectly using a grasper to localize the lesion that cannot be seen.
3. If the specimen is too large to remove through the port site, use an endoscopic specimen bagto avoid the seeding of malignant cells.
4. If the lesion cannot be identified, convert to a thoracotomy for open palpation and SPN excision.
5. Perform an intercostal nerve block under direct visualization upon completion of the surgery in order to diminish postoperative pain.

Question 55

Carotid Endarterectomy with Patch Angioplasty

Answer 55

1. Establish arterial pressure and neurological monitoring and position the patient.
2. Incise skin and platysma, retract the SCM laterally, and ligate the facial vein.
3. Expose the CCA, ECA and ICA with sharp dissection and minimal manipulation, identifying and preserving the hypoglossal and vagus nerves.
4. Administer heparin; clamp the ICA, CCA and ECA and insert shunt if needed.
5. Make arteriotomy starting on CCA and extending to ICA; perform the endarterectomy.
6. Flush with heparinized saline, assess the endpoints of the endarterectomy, and place tacking sutures if needed.
7. Sew in prosthetic patch, backbleed ICA and ECA, and forward bleed CCA prior to completion of patch placement.
8. Unclamp ECA, CCA and ICA.
9. Assure hemostasis and check for flow.
10. Close neck +/- drain. Check neuro status prior to taking patient to recovery.

Question 56

SMA Revascularization

Answer 56

1. Liberal midline incision and full abdominal exploration.
2. Exposure of SMA by cephalad retraction of the transverse mesocolon, retraction of the small bowel to the right and division of the ligament of Treitz.
3. Obtain proximal and distal control of the SMA and administer systemic heparin.
4. Perform an embolectomy via transverse arteriotomy and passage of a Fogarty catheter.
5. If inflow is re-established, close the SMA using a patch angioplasty if narrowing of the vessel is anticipated.
6. If inflow fails to be re-established, then the etiology is likely SMA thrombosis and a retrograde SMA bypass is necessary.
7. Create the distal anastomosis on the SMA first, ideally with saphenous vein graft.
8. Proximal anastomosis can be performed either on the infrarenal aorta or the iliac vessels.
9. Assess bowel viability after 30min using visual inspection, Doppler probe and/or fluoroscein.

Question 57

Iliofemoral Lymph Node Dissection

Answer 57

1. Patient is poitioned supine with the leg flexed and externally rotated in the frog-leg position.
2. An oblique, slightly S-shaped incision is created starting medial to the ASIS and coursing to a point 1-2cm below the femoral triangle. An ellipse of skin over a palpable mass may be included in the resection.
3. Progressively thicker skin flaps are raised laterally to the sartorius and medially to the adductor longus and superiorly to the inguinal ligament.
4. Lymph node-bearing tissue is excised from over the femoral nerve, artery and vein and off the external iliac aponeurosis.
5. A deep dissection can be performed by creating a separate incision in the external iliac aponeurosis or by dividing the inguinal ligament (consider detaching it from the ASIS to aid in wound healing as opposed to dividing it over the femoral vessels).
6. Retract peritoneum medially to expose the iliac fossa and disect nodes off of the common and external iliac vessels. The obturator nodes are dissected off the posterior surface of the external iliac vein.
7. After closure over a deep drain, the sartorius is mobilized and transposed to sit over the exposed femoral vessels.
8. A superficial drain is placed and the incision is closed.