SurgBoards Flashcards
Key steps of central line
If subclavian, check for hx of CKD or central stenosis.
US guidance, slight trendelenburg to prevent air embolus
Ensure appropriate monitoring, esp cardiac and SpO2
Prep & drape neck and chest, wear sterile gloves and gown
Timeout
Access vein in area above collar under US guidance
Thread wire while ensuring no ectopy on monitor
Make small skin incision, dilate tract and place catheter
Post procedure CXR
The central line appears to be going to the L side of the heart.
Central line may be in the artery –confirm by looking at it with an US, transduce catheter.
Next steps after confirming central line is in the carotid.
Disclose to the pt
Debrief with the team
Call vascular – consdier removing under fluoro (endovascular interventions)
In my hands, I would take the pt to the OR, ID the trajectory, and repair it primarily. Ensure also that the catheter did not pass through IJ into carotid.
At what point should pt with CKD be referred for permanent access?
Stage 4 CKD (GFR <3-0 mL/min)
At what point can you start using AVF?
About 6 months
t what point can you start using AVG?
3-6 weeks
Risks of AV access
Thrombosis, infection, central v stenois/occlusion
Key steps: dialysis catheter
Perform it using fluoro in the OR
Sedation at least
Micropuncture needle to get into IJ, insert wire and catheter sheath. Counter incision on anterior chest, tunnel catheter under SQ tissue and insert it into the sehath. Peel away sheath while advancing the dialysis catheter. Shoot completion x-ray and ensure appropriate venous blood. back from catheter
Pre-Op eval prior to dialysis access surgery – HISTORY
Age, expected time frame to start dialysis, dominant hand, access history.
re-Op before fistula creation – PHYSICAL EXAM
Examine arms, pulses. Allen’s test to determine forearm vsesel responsible for dominant arterial supply to the hand.
Pre Op before fistula creation – ANCILLARY STUDIES
Vein mapping
Arterial studies and oDoppler waveforms
Medically optimize with PCP – cardiac, pulmonary etc
Criteria for adequate vessels for AV fistula
Adequate diameter (vein 3 mm, artery 2 mm), no HD signfiicant arterial inflow stenoses, no venous outflow stenoses, peripheral vein segment of suitable length and diameter
Order of preference for AVF fistulas
Radiocephalic > radiobasilic > brachiocephalic > brachiobasilic
Key steps of AV access operation
Perform on non dialysis day under regional anesthesia using short acting agent to allow assessment of hand motor and sensory in early post op
Use US before starting the procedure to map out the trajectory of the vein
I would then make an incision to skeletonize both the artery and vein. Once I’ve defined the anatomy, I would clamp the vein and artery after administering systemic heparin. I would then ligate the distal vein, spatulate the end, perform an arteriotomy and construct an end-to-side anastomosis using 6-0 non-absorbable suture. I would listen for a bruit and feel for a thrill after finishing the anastomosis. I would also feel for distal pulses.
Extreme pain in hand after anesthesia wears off following AV fistula operation – PALPABLE PULSE/NORMAL WBI
I would be concerned with ischemic monomelic neuropathy 2/2 shunting of blood causing damage to distal nerve fibers. The patient would need to go back to the OR for ligation of fistula.
Extreme pain in hand after anesthesia wears off following AV fistula operation – POOR PULSE IMPROVES W/COMPRESSION and/or LOW WBI
DRIL procedure – bypass with autologous vein like GSV from above fistula to distal forearm with interval ligation of fistula
POD # 1 s/p AV fistula – concerns for occlusion
This is a technical failure until proven otherwise. I would take the patient back to the OR to explore and if needed take down the anastomosis and do it again.
Rule of 6’s for dialysis
6 weeks for fistula to mature
6 mm in diameter
<6 mm deep to skin
Able to achieve at least 600 mL/min of flow
8 weeks s/p AV fistula creation – 300 mL/min of flow. What are you concerned about?
I would be worried that there’s branches diverting blood away from the fistula. I would confirm this with an ultrasound, and if there is, I can fix that simply by ligating the branches.
S/p AV fistula and artery with pulsatile flow and vein not well defined? What are yu concerned about and what would you do?
I would be concerned about venous stenosis. I would evaluate that with a duplex or fistulogram and treat it with balloon angioplasty first followed by surgical revision if that fails.
1 year s/p AV fistula –> hard time dialyzing, machine says high pressure, prolonged bleeding
First get duplex of entire venous and arterial system.
Look for outflow stenosis in venous system –> If identified, do fistulagram and balloon angioplasty of stenosis
2 years s/p AV fistula creation – large 3 cm ulcer starts bleeding spontaneously from aneurysmal area of fistula.
This has a high rate of recurrence and can lead to exsanguination. I would ligate the fistula and resect ulcer. He needs established dialysis access at another site.
Bleeding pinhole from dialysis session
Treat with suture and fistulagram + balloon angioplasty of venous stenosis
Pt at 1 mo f/u after AV fistula with hand pain, worse throughout day, ulce rat tip of finger. What are you concerned abou t and how do you work it up?
Diogital PPG, duplex w and without compression –> will be monophasic without compression and normal with compression
Tx for chronic steal syndrome options
Banding outflow tract
Distal revascularization interval ligation
Advantages and disadvantages of peritoneal dialysis
You can do it yourself in your own home.
The disadvantages are potential infectious complications, kinking of the catheter requiring additional surgery and increased frequency in which you’ll need dialysis.
Tx of pertioneal dialysis catheter infection
Intraperitoneal vanco and gentamicin
Increased dwell time and intraperitoneal heparin may help
IV abx not as effective as intraperitoneal
Removal of catheter for peritonitis that lasts for 4-5 days
If fecal requires lap to find perforation
Some say need removal for ALL fungal, TB and pseudomonas infections
MC organisms in peritoneal dialysis catheter infection
Usually MONOmicrobial
S epi is #1 and S aureus and Pseudomonas
Key steps of peritoneal dialysis catheter placement
First, you want to make sure there’s no history of significant abdominal surgeries with adhesions or hx of IBD. Next, I would confirm the patient has the means to support daily dialysis in their home in a clean environment. If so, I would perform the procedure in the operating room under GA.
I would make a 5-cm incision slightly lateral to umbilicus and go through to the rectus muscle and insert the catheter which has two cuffs.
One cuff will be embedded in the SQ tissue, and the 2nd cuff will be embedded in the RECTUS muscle with the catheter exiting the peritoneal cavity directed towards the pelvis. I do this with laparoscopic guidance to visualize the catheter entering the pelvis. I would then introduce 1L of normal saline through the catheter into the peritoneal cavity, then place the bag on the ground and expect to see the majority of that fluid to go back into the bag and fill it up.
Focused history in patient with history of hepatitis
how long she’s been diagnosed with hepatitis, if she’s ever been treated for it, has she had any complications related to portal hypertension like ascites or upper GI bleeding from esophageal varices, has she ever had an EGD.
Evidence of portal HTN on exam
dilated umbilical vessels, ascites with a fluid shift, hernias, asterixis, or any evidence of fluid overload like peripheral edema.
MELD score components
(sodium) bilirubin INR creatinine
Child Pugh Score components
Total bili
INR
Albumin
Encephalopathy
Ascites
4 phases of liver protocol CT
The four phases would be non-contrast, contrast, delayed venous washout and portal vein washout
CT liver protocol shows arterial phase enhancement with early washout in delayed venous – consistent with?
HCC
Child Pugh A cirrhotic + HCC
Consider surgical resection.
Child Pugh B or C cirrhotic + HCC
Consider transplant if satisfies Milan Criteria
Milan Criteria
single tumor < 5 cm, or 3 separate tumors each less than 3 cm, and she satisfies that criteria
Desired FLR in cirrhotic pt
40-50%
Desired FLR in healthy patient
20-30%
Desired FLR in pt who has received chemotherapy
30-40%
Child Pugh A, tumor is 6 cm, and FLR is 20%
Puts her at risk for hepatic failure. One option would be to proceed with portal v embolization of disesased segment in effort to hypertrophy the remaining healthy liver and increase FLR
Child Pugh C with single liver tumor of 5 cm
Cannot get liver txp and worried about offering surgical resection ebcause her perioperative mortality risk would be so high. I would get the opinion of my colleagues at an MDC but I would recommend TACE or some sort of ablative therapy like RFA.
Child Pugh A with 2.5 cm mass –> operative approach including anesthesia
For any liver resection, its important to have a discussion with anesthesia before operating because I would really prefer to keep her CVP as low as possible so a central line and possibly a swan would be something to consider putting in before we start. I would make sure she’s TYPED AND CROSSED, has a foley, received VTE chemoprophylaxis and perioperative antibiotics. After a surgical time out, I would make a R subcostal incision and use some sort of instrument to facilitate exposure like a Bookwalter. Once I get in the abdomen, the first thing I would do is an IOUS which will allow me to accomplish three things. #1) I would identify the different segments of the liver depending on the portal, venous and arterial anatomy. #2) I would do a meticulous search of the liver to identify the mass, as well as any other lesions not identified on the pre-operative CT. And #3) I would figure out my resection margins by scoring the parenchyma. Once I know the resection margins, there’s a couple different methods of dissecting the parenchyma. I like having an argon beam in the room, and various staplers, but my primary method of dissecting the parenchyma is with ultrasonic shears. And for large structures I would place clips or suture ligate them. Before I start dissecting the liver, I would perform a pringle maneuver with a Rommel tourniquet but wouldn’t deploy it – I would like to have that readily available in case I run into bleeding during the surgery. At the end of the surgery, I would LEAVE A DRAIN, ensure meticulous hemostasis and check for bile leaks, as well as PERFORM COMPLETION IOUS to make sure I have preserved inflow and outflow, and that there’s no other lesions I may have missed.
How to perform Pringle Maneuver
I would open up the gastrohepatic ligament, put a finger in the foramen of Winslow, get umbilical tape around the portal triad and place a rommel tourniquet.
Post op liver resection pt with LFTs in 800-900 range
The number one thing I would be worried about is hepatic failure and I would have a high index of suspicion but elevated LFTs for even the first week after this surgery is not uncommon, and as long as they are trending down by the end of the first week, and there’s no other signs of organ dysfunction, I would just offer supportive care and observe it.
MC variant. of arterial blood supply R lobe of liver
additional or replaced R hepatic from SMA
MC variants of arterial blood supply L lobe of liver
Accessory or replaced L hepatic from L gastric
If history of liver disease, important to ask questions in history
Hepatitis
Cirrhosis
Alcohol use
Blood transfusion
tattoos
IVDA
Platelet count in a cirrhotic which is relative CI to major hepatic resection
<100 K
CTP A with evidence of portal HTN or thrombocytopenia and liver amss
SHould not undergo hepatic resection, may be considered for TXP
Peripheral enhancing lesion on liver CT
Adenocarcinoma or mixed cholangioCA
Signs of cirrhosis on liver CT
nodularity, portal HTN, recannulization of portal v, varices, splenomegaly
If bx proven metastatic liver lesion, next diagnostic steps?
cscope, mammogram, EGD, lung oimaging
Can also perform further staining –> TTF-1 (lung), ER/PR, CK-20 (colon), CK-7 (pancreatobiliary)
How to determine FLR
volumetric assessment (volume of liver segments preserved divided by total estimated liver volume)
Tx for metastatic or recurrent liver CA
Systemic chemo with sorafenib
After portal v embolization to improve FLR, next steps?
Repeat imaging 3-6 weeks s/p embolization with repeat volume estimates
Aim to operate 21-30 days following PVE
Intra op for liver resection you find additional lesions. What can you do?
I could consider resection but if I have any concern for leaving an inadequate remnant I’d abort the procedure and consider using RFA or microwave ablation
If absolutely cannot tell source of liver met, assume?
Liver (cholangiocarcinoma(
If biopsy proven metastatic liver lesion and CT and upper and lower scope don’t give an answer?
Small bowel or cholangioCA. Do capsule endoscopy and look for ulcer c/w CA
f metastatic colon or small bowel lesion in liver?
Chemo first, then resect if response
Margins for cholangiocarcinoma
1 cm
Post op liver resection mgmt
Low threshold for ICU
Volume status, hepatic and renal function closely monitored
IV opioids
PO intake fairly quickly
Drain, DC once on full diet
If bile present in drain but low volume, leave in lace. If high volume –> ERCP + sphincterotomy + endobiliary stent.
Unstable trauma pt – initial eval/plan
Yes – I would make sure all team members know their designated roles. In particular, I would like a pharmacist there, a bedside nurse to start two large bore IVs as soon as the patient arrives, a bedside procedural doctor in case I need an emergent procedure like a chest tube and a doctor at the head of the bed in charge of the airway. I would make sure that we have blood available, as well as a rapid infuser, and TXA, and I would notify the blood bank that based on what the patient looks like when he arrives, I may activate the massive transfusion protocol. I would make sure we have everything we need to potentially intubate the patient, as well as a thoracostomy kit and a thoracotomy kit.
Pelvis XR shows large open book pelvic fx. Foley is placed easily and returns gross hematuria. Next steps?
I would place a pelvic binder with either a commercially available product my hospital carries or I would use a large sheet, and I would place the binder at the greater trochanters to try to reduce the pelvic volume and tamponade any on-going bleeding.
After giving blood products, what should you check?
Repeat labs to assess for improvement
Replete lytes PRN (calcium!)
How to perform pelvic packing
I would place a pelvic binder with either a commercially available product my hospital carries or I would use a large sheet, and I would place the binder at the greater trochanters to try to reduce the pelvic volume and tamponade any on-going bleeding.
Concern for pelvic fx –> impt components of PE
DRE – gross blood, high riding prostate, rectal tone
NEUROVASC EXAM waist down
Irrigate and pack any large perineal wounds before applying binder
Intraoperative control of pelvic bleeding in trauma
ligation of hypogastric aa (difficult exposure) and venous pelvic bleeding is best controlled by tamponade
CT cystogram shows outlined loops of bowel – what is injured
intraperitoneal bladder
CT cystogram shows extrav into RP including space of retzius, lateral colic, into groin adn thigh –what is injured?
Extraperitoneal bladder rupture
Operative mgmt of bladder rupture
Extraperitoneal: lower midline or transverse Pfannensteil
Intraperitoneal: midline, slightly higher on abdominal wall
Visualize bladder neck, ureteral orifices
Repair in 2 layers with running slowly absorbable suture (2-0 polyglycolic acid)
1st layer = mucosa + muscularis
2nd layer = muscularis and overlying serosa
If bladder neck can do single layer
Repair neck injury before symphyseal plating
Smaller lacs can be repaired w/I bladder with single layer
Closed suction drains adjacent to bladder
Blood at urethral meatus –> imaging?
retrograde urethrogram
Liver mass (incidental during appendectomy)
I would be very cautious with doing anything to the liver without knowing what it is or talking to the patient about it because the risks of even a simple biopsy could be great like bleeding or a bile leak. For example, if that’s a hemangioma, I might cause a lot of bleeding if I poke into it to get a biopsy. I would take intraoperative pictures and plan for a multi-phase MRI post-operatively to better characterize the mass. An alternative would be to use intraoperative ultrasound right now to characterize the mass, but even that’s something I would want to talk to the patient about before performing.
Incidental finding: large mass in cecum presumed to be causing appendicitis.
A mass in the colon always makes me worried about a cancer. But there are benign etiologies as well like a colonic lipoma. If the base of the appendix appears healthy, not inflamed, and not involving the mass, I would complete the appendectomy but if it looks inflamed or if the mass is intimately involved, I would abort the operation and keep the patient on antibiotics. In any case, I would also take lots of intraoperative pictures, and schedule a postoperative colonoscopy as well as a CT scan of the chest, abdomen, and pelvis.
What if appendix appears completely normal during lap appy?
I would look for other causes of abdominal pain. I would run the bowel laparoscopically looking for a Meckle’s diverticulum and I would look in the pelvis for any obvious pathology.
28 yo woman with presumed appendicitis. You’re in the OR. The appendix appears fine and you find a R ovary with a 3 cm simple cyst.
It’s possible that the cyst is causing the pain, but I wouldn’t do anything about that. I would take intraoperative pictures and would expect a 3-centimeter simple cyst on the ovary to resolve on its own. I would finish the operation, get a post-operative pelvic ultrasound, and consult gynecology.
What if you’re doing a lap appy and you discover an ovarian abscess?
I would request an intraoperative gynecology consult. My thoughts would be that we have not yet tried a course of antibiotics, and I would hate to do anything to the ovary and potentially affect her fertility, especially if I haven’t talked to her about it so I wouldn’t feel comfortable doing anything other than taking pictures, getting a gynecology consult and keeping her on IV antibiotics. I would also get blood cultures and probably a CT of her abdomen in a few days to see if the abscess has gotten smaller or resolved.
Performing appy on 60 yo F and you note a 7 cm mass in the R ovary
A 7-centimeter solid mass in a post-menopausal woman is highly concerning for a malignancy. I think this mass needs to come out but the biggest barrier to that is the lack of consent because I didn’t know about the mass prior to the operating room. The way I would handle that is to find the patient’s next of kin, explain my intraoperative findings, and my recommendations which would be to get an intraoperative gynecology consult, and remove this mass, which may require open surgery since the mass is 7-centimeters. The patient would then need to be staged with a CT chest and abdomen/pelvis. I would also order tumor markers including CA-125, AFP and LDH.
Key steps of ovarian cystectomy
Expose and stabilize ovarian mass –> create a superficial incision in ovarian serosa over anterior surface of mass –> use blunt and sharp dissection to ID mass and separate it from its serosal and stromal attachments –> hemostasis within remaining ovarian cavity achieved with either ligation using fine absorbable suture or with cautery–> ovarian serosa either left open or reapproximated with absorbable suture
Salpingo-oopherectomy: Key Steps
I would expose the infundibulopelvic ligament by dissecting the peritoneum around it. I would then identify the ureter, the iliac arteries, and veins. I would then ligate the ovarian vessels. I would dissect the ovary and fallopian tubes from its peritoneal attachments and once I have the ovary and fallopian tube isolated from all its surrounding structures, I would ligate the fallopian tube at its base as it enters the uterus. I would then send it off for permanent pathology.
R adnexa significantly tender on exam. What labs would you send?
I would move on to sending blood work with a CBC, CMP, lipase, lactate, beta-hCG, CA 19-9, CA-125, AFP, LDH, coags and a STD screen. I would also order a pelvic ultrasound with doppler studies to assess ovarian flow.
What if on pelvic doppler US there showed no blood flow to the ovary?
That would be concerning for ovarian torsion. It’s possible that she has a cyst or a mass serving as a lead point which led to the torsion. I would consult the gynecology service for ovarian torsion.
Let’s say the doppler shows no flow to the R ovary and closest GYN is about 6 hours away.
I have never done this operation, but I would take the patient to the operating room for an exploratory laparotomy and detorsion. Before I do that, I would have a discussion with her about her wishes for fertility in the future. If I perform an oophorectomy, she doesn’t become infertile but her reproductive potential will decrease.
Pt with a 3 cm ovarian cyst with a twisted adnexa in the OR. Would like to preserve fertility if possible.
I would untwist it and see if the ovary pinks up. I would place warm towels around it and feel the ovarian ligament looking for a strong pulse.
While in OR for ovarian torsion, ovary pinks up after 15 min.
The ovarian cyst is probably due to her menstrual cycle, or it could be a benign cyst. In any case, if I had an intraoperative gynecology consult available, I would call one in but if not, I would take pictures and have her follow up with a gynecologist postoperatively. For the torsion, I would perform an oophoropexy and close the abdomen.
In OR for ovarian torsion, ovary continues to look dusky and necrotic.
I think the pendulum has swung towards ovarian conservation even in these cases. It’s been about 4 to 6 hours since the onset of symptoms and the patient wants me to maximize her reproductive potential. Leaving a necrotic appendage can induce an inflammatory response, but oftentimes these necrotic appearing ovaries regain function and cause no problems so I would untwist it, pexy the ovary, close the abdomen and watch her very closely over the next few days for signs of sepsis.
In OR for ovarian torsion, pale twisted ovary and 4 cm ovarian mass?
There’s several options and it primarily depends on the age and malignant potential of the mass. If it looks invasive and the patient had history concerning for cancer like recent unexpected vaginal bleeding or unexpected weight loss, or elevated tumor markers I would find her next of kin and discuss my findings intraoperatively and recommend performing an oophorectomy, ideally with a gynecology consult. If none of those risk factors are present, I would again request an intraoperative gynecology consult and if none were available to me, I would get a biopsy, take pictures, and have the patient follow up with gynecology post-operatively. I would address the torsion during that operation too.
In OR for ovarian torsion, pt was 55 yo post menopausal pt, and you found 4 cm solid mass intra op?
I would again request an intraoperative gynecology consult but if none were available to me, I would find her next of kin and discuss my findings. In a post-menopausal patient, a 4-centimeter solid mass is cancer until proven otherwise, so I would strongly recommend proceeding with a salpingo-oophorectomy.
Bedside reduction of inguinal hernia in pediatric patient
Well, he’s likely going to need to be sedated because he’s not going to like me putting lots of pressure on his groin. I would get an ice pack and place it on his right groin and place him in Trendelenburg position for 10 to 15 minutes. I would then ask the nurse to get 0.05 mg/kg of IV midazolam + 20 mcg of IV fentanyl. I would make sure he has NO ALLERGIES to these medications and I would monitor his HR, rhythm and oxygen saturation. Once the meds are administered, I would try reducing the hernia by applying firm constant pressure and elongation of herniated bowel to help it slip back in.
Pediatric inguinal hernia – able to reduce it at bedside. Next steps
I would admit him to the hospital, keep him NPO and on maintenance IV fluids with a dextrose source. I would check a CBC to make sure he doesn’t have an elevated WBC and lactate. I would observe him overnight and allow the edema in his groin to resolve, after which I would offer surgical repair.
Pediatric inguinal hernia repair (open)
I would place him supine. I would give him preoperative IV antibiotics and ask him to try to urinate before the case to decompress his bladder. I would make a curvilinear incision right above the inguinal ligament. After going through scarpas fascia I would visualize the EO APONEUROSIS. I would make a small incision along the fibers and open it with scissors making sure to protect the underlying ILIOINGUINAL N. I would separate the hernia sac from the spermatic cord, and then open up the sac to inspect its contents and perform a high ligation. I would then close the incision and start a diet later that day if he’s recovering well.
In OR for pediatric inguinal hernia repair – bowel appears viable but is stuck?
I would first ask anesthesia to make sure he’s RELAXED, and even PARALYZE him to help reduce the bowel. I would also insert an NG TUBE to decompress his GI tract in case that helps. If that doesn’t work, I would OPEN THE DEFECT FURTHER (ext inguinal ring) just a bit so that I can reduce the bowel – I would then close it after performing a high ligation.
In OR for pediatric inguinal hernia repair case – anestehsia administers paralytic. You were unable to visualize proximal and distal aspects of bowel but the bowel that you did see looked fine.
I would first check with anesthesia to make sure the patient is hemodynamically stable and without a fever. A midline laparotomy is not something I would do without a reasonably good indication, especially for a child. In this case I didn’t visualize any compromised bowel and it’s unlikely that the segments of bowel that weren’t incarcerated are compromised so I would perform a high ligation, close the incision, keep him NPO and monitor his abdomen and trend his white blood cell count and lactate. I would avoid any antibiotics so that I don’t mask any underlying bowel compromise. If there’s any concern for intra-abdominal sepsis, I would discuss the utility of performing CT imaging or a diagnostic laparoscopy with the parents.
hat if intra op for inguinal hernia repair and you divide vas deferens?
Consult urology – can be repaired
Anesthesia considerations in a child
Depending on post conception age at time of surgery may need overnight observation for concerns of post op apnea –discuss with anesthesia
What if the pt is a child with a story more consistent with inguinal lymphadenitis (not inguinal hernia)
Get US to r/o hernia, get more info
Tx azithromycin for catscratch
Which side hernia is more common in pediatrics?
Right because left processus vaginalis closes first.
qSOFA components
HoTN (SBP <100)
Tachypnea (RR > 22)
AMS (GCS <15)
62 yo M presents to OR for R IHR. Relatively healthy otherwise. Difficulty placing foley. Incision, through Scarpa’s fascia, pt is suddenly hypotensive and tachycardic.
Hypotension is not something I was expecting for this elective case. There are several things that could be causing this, some of which I can diagnose and treat at the same time. The simplest thing would be if the patient was intravascularly dry to begin with, and the general anesthesia removed some of his sympathetic drive leading to the hypotension, so I would treat him with a fluid bolus.
After admin fluid bolus for intra op hypotension – next steps
Check CBC, CMP and arterial blood gas. I would also review the medications that the patient received in the preoperative area and in the operating room.
Intra operative hypotension –things to rule out
Malignant hyperthermia
Anaphylaxis
Pneumothorax (tension)
Cardiac
Pulm embolus
Air embolus
How to rule out pulm embolus and air embolus intra op
I would ask anesthesia to get ready to perform a transesophageal echocardiogram to look for any evidence of right heart strain. And while they’re getting setup, I would place the patient in Trendelenburg position with the right side up and aspirate 60 cc of blood from the central line with the hope of aspirating an air embolus.
What to look for on TEE when dealing with intraoperative hypotension?
Wall motion abnormalities or global hypokinesis to suggest MI
Dilated right heart which would suggest PE.
After ruling out bleeding, air embolus, clinically significant PE, medication reaction, cardiac etiology, malignant hyperthermia, what is the only thing left on differential for intra operative hypotnesion?
Sepsis
Treatment for septic shock (and workup)
Fluid resuscitate
Send CBC, CMP, lactate, blood cx, sputum cx, UA with reflex cx, CXR, start broad spectrum IV abx, and start levophed for a MAP goal >65
Discuss a screening colonoscopy including risks, prep.
A colonoscopy is a camera inserted through the anus and into the rectum and colon. It will allow us to see if there are any concerning lesions that may be cancerous or pre-cancerous, in which case we would remove the lesion or take a biopsy. There’s a small chance of bleeding, <1% and an even smaller chance of causing a small hole in the rectum or colon which most often is treated without surgery. And depending on what we find, you may need an additional colonoscopy or possibly a referral to see a surgeon for an operation. You would also need to complete a bowel-prep to clean out your colon the day before the procedure.
Pt in room for cscope, prep?
Yes, I would like her to help with monitoring. I would like to monitor three things continuously during the procedure: HR, BP, O2 sat.
I would also like an assistant helping me do the colonoscopy, so that the nurse can focus on the patient’s vitals and to help administer the medications.
I would review the patient’s ALLERGIES but my general combination for a colonoscopy is midazolam and fentanyl. I typically like to give incremental doses as necessary during the course of the procedure starting with 2 mg of midazolam and 50 mcg of fentanyl.
Pt is in position for cscope. Key steps?
Ensure all equipment working properly
After medicating the patient, I would first insert a finger in the anus and feel for any obvious masses or lesions. I would then insert the colonoscope into the rectum and work my way up the sigmoid colon and towards the cecum.
How is cecum identified in cscope?
Appendiceal orifice, ileocecal valve, crows foot of cecum.
During cscope, you’re stuck at splenic flexure.
Reduce any loops.
Abd pressure from assistant.
Stiffen scope.
Switch to peds scope.
Increase sedation or put pt on back.
Did all maneuvers to try to move past splenic flexure on cscope. What next?
Call senior partner to see if he/she can make forward progress. If not, abort procedure and do CT colonography the same day.
Cold snare polypectomy – best for?
Larger polyp removal in one piece instead of piecemeal
Hot snare polypectomy – best for?
Larger polyp >1 cm, pedunculated
Close mucosal defect with clips
Hot/cold biopsy forceps on cscope – best for polyps of what size?
<5 mm
Sessile polyp >1 cm, mechanism to biopsy?
Endoscopic submucosal resection
Which side of the colon wall is thicker?
R colon
At what size polyp should you tattoo?
Adv polyp >1 cm
1-2 tubular adenomas on cscope
5 years
3-10 tubular adenomas on cscope
3 years
Single adenoma >10 mm tubulovillous or villous or HGD
3 years
> 10 adenomas
1 year
After performing snare polypectomy for pedunculated polyp, how would you remove it?
Extract it with forceps or suction through scope with trap door
How would you biopsy sessile polyp?
Raise the mucosa by injecting saline to give you a base to then perform polypectomy. If that doesn’t work, I would grab a piece of it with forceps and pull.
What if you’re doing a cscope and see a partially obstructing mass?
Biopsy central ulceration and tattoo just distal to it in all 4 quadrants with India ink
Try to better delineate location by looking for key landmarks and measuring how far in scope is after reducing all loops
Bleeding from polypectomy site – what can you do to control it
Inject epinephrine around the lesion.
Can try placing a clip.
Cautery – small pinpoint lesions that are bleeding. A lot can lead to full thickness perforation.
Dosage of naloxone in opioid naive
Start with 0.2 mg and redose with 0.5 mg in 2-3 minutes if no response.
Dosage of flumazenil
0.2 mg
Criteria to treat post-polypectomy syndrome non op
No peritonitis
No systemic signs of worsening sepsis
Triggers for OR: peritonitis, HoTN, fevers + tachycardia, uptrending WBC and/or lactate along with worsening abdominal pain
Radiologist questions use of IV contrast in pt with AKI
The AKI is likely a result of dehydration which I can treat with fluids. Although I would be a bit more worried about the theoretical toxicity of contrast in a patient with renal disease, in an otherwise healthy patient, an accurate dx is more important to me than the potential risk of contrast in a patient with healthy kidneys. I could administer another 500-cc bolus of LR before and after the scan to help washout the contrast and make my radiologist feel more comfortable. But I think it’s important she gets the contrast. In addition, the oral contrast will also potentially help treat the patient.
Things to look for on CT in pt with sBO
Transition point
Free fluid in between loops of bowel or in the pelvis
Hypoperfusion of the bowel wall or wall thickening
Partial vs complete SBO
Intussusception
Volvulus
Hernia
Description of GGC
After a minimum of 4 hr NGT decompression, 100 mL gastrograffin + 50 cc water via NG tube
Clamp for at least 8 hrs unless pt nauseas or vomiting
Get xray at 8 hrs and 24 hrs
OR for SBO
Run entire small bowel; multiple points of obstruction can be present → assess bowel blood supply. If there is uncertainty, consider a “second look” operation. Carefully inspect for potential enterotomy. Preserve as much bowel as possible.
Intact duodenum and colon – how much residual small bowel is sufficient to prevent sx of short gut?
200 cm (or 100 vs 180)
14 days s/p recent operation for SBO – tx?
High risk of enterotomy. Non op preferred with NG decomrpession, fluid resuscitation, serial exams, supportive care. Replace lytes and start TPN.
WAIT AT LEAST 4 WEEKS
Intraoperative sx of Crohn’s disease
creeping fat, thickening of bowel wall (esp TI), free perforation from full thickness ulceration, and fibrotic structure
To assess bowel viability
Place warm lap over bowel and wait several min to see if pinks up
Doppler US to eval mesentery
Admin ICG and use SPY technology
Fluorescein dye + wood’s lamp
Principles of mgmt in ECF
he principles of management now are to control intra-abdominal sepsis with source control, optimize nutrition, provide excellent wound care, and give this enterocutaneous fistula a chance to heal on its own. This is probably best done with a multidisciplinary effort with a dietitian, nutritionist, and wound-care nurse.
How to determine location of ECF
Fistulogram +/- SBFT – location of fistula and length of distal SB
Enteric feeding considerations in ECF
It depends on the amount of output from the fistula and whether or not I think the fistula is distal or proximal in the small bowel. Typically, a distal fistula produces less output and more likely to heal non-operatively. I would initially start the patient on TPN to help optimize nutrition, a PPI to help decrease fistula output, and depending on how much is coming out I may consider starting a somatostatin analogue which may decrease the fistula output. I would make sure the patient remains appropriately hydrated and without electrolyte derangements. If the output is low, <500 mL/day, and there’s no problems with electrolyte derangements or dehydration, I would trial enteric feeding, and if the output doesn’t increase and the patient continues to do well, I would stop the TPN and continue enteric feeding.
Impaired fistula healing causes
FRIENDS (Foreign body, Radiation enteritis, IBD, Epithelialization of fistula tract, Neoplasm, Distal obstruction, ongoing Sepsis)
OR for ECF
My primary goal would be to resect the segment of bowel that has fistulized to the anterior abdominal wall with a laparotomy. I would try to minimize my surgery as much as possible to accomplish that goal. A secondary goal would be to repair the abdominal wall. However, I think what better serves this patient is to have a staged procedure with the 1st surgery involving taking down the fistula and reconnecting the bowel. If the fascial defect comes together, great, but if not I would choose to bridge the defect with biologic mesh and close the skin loosely. I would also place OMENTUM between the bowel and the biologic mesh in an effort to prevent this complication from occurring again. I realize this is likely to result in a hernia weeks to months later but I rather stage his abdominal wall repair with a surgery at a later date instead of compromising this surgery with permanent mesh which may get infected.
Fistulas that will not close and require OR
Fistulas that HAVE NOT closed in 30-45 days despite maximal supportive measures
Fistulas that are NOT LIKELY to close due to eversion of mucosa or large size (>1/3 bowel circumference)
Fistulas that CANNOT close bc of assoc conditions precluding closure, such as distal obstruction, foreign body, neoplasm, IBD, radiation enteritis, local infection
Strategies for managing large wall defect @ time of fistula takedown
Retention sutures or dynamic fascial closure devices
Partial fascial bridging w/non permanent mesh
Local cutaneous flaps
Type of cells MTC derived from
Parafollicular C cells
Neuroendocrine tumor
MEN 2A
MTC
Pheo
Parathyroid
MEN 2B
MTC
Pheo
Mucosal neuromas, Marfans, MSK abnormalities
1 cause of death in MEN 2 pts
MTC
Sx of calcitonin
flushing, diarrhea
MC mets in MTC
lung, liver, bone, mediastinum
When to perform total thyroidectomy with bilateral CLND (level VI) for MTC
> or = 1 cm in diameter or bilateral thyroid disease
When can you possibly avoid CLND in MTC?
If <1.0 cm in diameter and unilateral thyroid disease
When to consider therapeutic EBRT for MTC
Grossly incomplete tumor resection and additional attempts at surgical resection ruled out
When to perform lateral modified neck dissection in MTC
Clinically or radiologically identifiable disease (levels II-V)
If high volume or gross disease in adjacent CENTRAL neck
If pt with MTC has RET protoconcogene oidentified (MEN2B) – next workup?
Basal serum calcitonin level
CEA
Pheo screening
Central and lateral neck compartments US
Consider neck CT if indicated
If pt with MTC has RET protooncogene identified (MEN2A or FMTC) – next workup?
Basal serum calcitonin
CEA
Pheo
Serum Ca and PTH
Central and lateral neck compartments US
Consider neck CT
When to perform thyroidectomy in MEN2B
First year of life (or at diagnosis of MEN)
Should consider prophylactic bilateral CND
Post op mgmt of MTC
Basal calcitonin and CEA annually
When to perform thyroidectomy in MEN2A
Age 5
If basal calcitonin or CEA elevated post op for MTC pt – next steps in workup?
Neck US
If >150, CT or MRI with contrast of neck, liver, chest
Consider bone scan and MRI of axial skeleton if v elevated calcitonin
Impt aspect of PE in neck masses/thyroid (esp if hoarseness)
CRANIAL N EXAM
If calcitonin <500 and N0 (MTC) – surgicaal tx?
Total thyroid + CND
If calcitonin >500 or N1 (MTC)
Chest CT, liver triple phase CT or MRI, bone scintigraphy
If MTC diagnosed after thyroid lobectomy, completion lobectomy should be performed for..
Presence of RET mutation
Radiologic evidence of residual MTC
Post op elevation of serum calcitonin
Pre op DL shows paralysis of RLN
I would make sure number one that the patient’s aware that he has paralysis of the right sided recurrent laryngeal nerve which may be related to the stab wound or the operation, and that’s resulted in hoarseness in his voice. If his contralateral recurrent laryngeal nerve is also injured, he may not be able to protect his airway, may need to remain intubated postoperatively and may even require a tracheostomy if the nerve injury’s permanent. That’s certainly a significant risk of the operation but his risk of dying is near 100% if we don’t do anything.
Key steps of total thyroidectomy
With all my thyroid surgeries I prefer to use a nerve stimulating monitor but especially in the case of a previous neck dissection and a confirmed recurrent laryngeal nerve injury. I would place a towel roll behind the patient’s shoulders to extend the neck. I would prep and drape the neck, perform a surgical time out and then mark the cricoid cartilage and sternal notch. I make my incision about two finger breaths above the sternal notch, transversely. I would then raise subplatysmal flaps, get through the sternohyoid and sternothyroid muscles, and then through the median raphea which will expose the thyroid gland. I would then peel the thyroid gland inferomedial starting with the superior pole and with the use of an energy-device. I would ligate the superior thyroid artery with a silk suture making sure not to injure the superior laryngeal nerve. As I continue peeling the thyroid, I would try to visualize the recurrent laryngeal nerve to protect it from harms away. And finally, I would dissect the thyroid gland off the ligament of berry and make sure I have hemostasis. During the surgery I would also visualize the parathyroid glands to protect them. fI would then close the incision in layers over a drain.
Key steps of central lymph node dissection
For the central lymph node dissection, I would remove all fibroadipose tissue medial to the two carotid sheaths going all the way superiorly to the hyoid bone and inferiorly to the brachiocephalic vessels.
Lateral neck dissection involves LN tissue from where?
LN tissue from anterior and posterior triangles, defined as submandibular gland superiorly, IJ v medially, trapezius muscle laterally, and clavicle inferiorly. CONSIDER DRAIN.
During your dissection of thyroid gland on R, significant amount of white milk like substance. What do you think that could be from and how would you handle that?
I would be worried about an injury to the thoracic duct or a branch of some lymphatic channel. I would suction out what I think is chyle, find the channel or duct and clip it.
If post op chyle leak suspected?
fat free diet, abx, application of pressure dressing. May need surgical exploration with ligation of thoracic duct or application of biologic sealant.
If blood supply to parathyroids cannot be preserved during surgery for MTC in pts with MEN2A
PTH should be grafted to muscular bed such as brachioradialis in which future resection would be feasible in case hyperPTH develops
Endovascular tx for chronic mesenteric ischemia – key steps
Choose approp access site → insert sheaths and catheters → perform AP and lateral abdominal aortogram → admin heparin → obtain wire access of mesenteric vessel → place long guiding catheter or long sheath into target vessel → choose appropriate type and sized stent (consider IVUS to assist selection) → treat additional mesenteric vessel as above if indicated → perform completion angio → surrender wire access and remove sheaths → consider use of closure devices → check distal pulses and monitor post op
Key steps of mesenteric bypass
I use a midline incision and start by surveying the abdomen. The first thing I would do is make sure all of the bowel looks healthy. I would then expose the supraceliac aorta by dissecting gastrohepatic ligament and R crus of diaphragm. While doing that, I need to be sure there is no replaced or aberrant L hepatic a along gastrohepatic ligament and if so, avoid injuring it. I would then expose the celiac and SMA at the base of the mesentery. If I’m unable to expose the vessels there I would perform a L sided medial visceral rotation. Once my targets are exposed, I’d heparinize the pt and use side-biting aortic clamp to sew my proximal anastomosis. I would then unclamp the aorta, clamp the graft, and then clamp the distal targets and perform my distal anastomosis. I would assess mesenteric perfusion at the conclusion of the case and assure hemostasis.
Mesenteric bypass (Retrograde) – inflow
infrarenal aorta or iliac artery
The pt’s supraceliac aorta is heavily calcified and you’re unable to get a sidebiting clamp. Any additional options for inflow?
I could perform a retrograde bypass from the iliac vessels
Post op surgical tx for chrfonic mesenteric ischemia – medications?
Anti platelet tx daily + statin
medications
I would use etomidate at 0.3 mg/kg, and rocuronium 1 mg/kg
Increasing pressor requirements despite source control– next step in workup?
Random cortisol
No set cutoff but if its <12 – treat with 3 days of hydrocortisone, 100 mg q8h
Workup for PEH/GERD/HH
1) EGD would help identify any tumors or masses, which she did not have.
2) Barium swallow to identify any obstructions or lesions in the esophagus like a zenker’s diverticulum or achalasia
3) Ambulatory pH to identify the local acidic environment of the esophagus
4) Impedance study which can measure the amount of reflux seen in the lower esophagus
5) Esophageal manometry to identify any esophageal dysmotility.
4 types of PEH
Type 1: sliding, MC, migration of GEJ through hiatus
Type II: GEJ normal and below diaphragm, portion of stomach herniates above GEJ
Type III: both GEJ and gastric fundus above diaphragm with portion of stomach above GEJ
Type IV: another intra-abdominal organ migrating into thorax
Key steps of PEH repair
Gentle reduction of herniated intra-abdominal contents.
Dissection of hernia sac along inner border of crura.
ID of anterior and posterior vagus nn.
Circumferential control of distal esophagus and vagus nn with Penrose drain.
Careful mediastinal dissection for complete hernia reduction including 3 cm of intra-abdominal esophagus.
Division of short gastric vessels if performing fundoplication.
Closure of the crural defect with nonabsorbable pledgeted sutures. Fundoplication (posterior 270)
In OR for PEH repair and unable to approximate R and L crus.
I would make a relaxing incision on the right side of the diaphragm. I would also reinofrce my repair with biologic mesh
ng repair of PEH the left diaphragm is billowing and anesthesia is having difficulty ventilating
This gives me concern for pleural injury and capnothorax. First I would lower my insufflation pressure. I would ID the tear and equalize the pressure between the chest and abdomen by placing a red rubber catheter open to the atmosphere and have anesthesia give breaths.
If foreshortened esophagus during PEH repair
Gastropexy (could use tube) but if truly unable to get GEJ into abdomen –> Collis gastroplasty
Post op PEH repair with 2 cm L apical PTX, large pneumomediastinum, SQ air
Evaluate pt and monitor respiratory status
Give high flow O2 to assist with resorption of capnothorax
Post op PEH repair with leak
IV abx and antifungal
OR for lap exploration with EGD
Source control by draining mediastinum
ID perforation and perform primary closure with 2 layers
Leave drain
Have advanced GI stent if needed
DISTAL FEEDING ACCESS
Concerning APGAR scores
<8
Immediate mgmt of omphalocele
Cover up baby with warm blankets
Make sure baby is breathing and calculate APGAR score now and 5 minutes from now
If omphalocele sac is ruptured
If it’s ruptured it completely exposes the abdominal viscera and increases the risk of injury, infection, and ileus, and it also predisposes him to severe dehydration so I would be more worried in the case of a ruptured sac, and I would be more aggressive in fluid resuscitation.
Fluid resuscitation in omphalocele
D10/0.25 NS @ 140-150mL/kg/day and then maintenance of 80-100 mL/kg/day.
Pre op mgmt of omphalocele
I would send a full set of labs including a CBC, CMP, coags, and lactate. I would also send blood cultures. I would resuscitate him with a 20 ccs per kilogram bolus of fluids and titrate his maintenance fluids to a urine output of 1 milliliter per kilogram per hour. I would also insert a nasogastric tube and a foley catheter for decompression. He should also have a karyotype sent to look for chromosomal abnormalities. I would consider establishing central venous access early as pt will require PN (DON’T USE UMBILICAL VESSELS)
What congenital abnormalities are you worried about with omphalocele? How to rule them out?
I would be worried about either pulmonary or cardiac abnormalities and I would start off with a chest x-ray and an echocardiogram.
Omphalocele with 7 cm defect – mgmt?
There are several approaches that have been described including using a bridging mesh but my training involved the use of silos and that’s what I’m most comfortable with. This would involve sewing a silastic silo to the fascial edges and suspending it from a bar overlying the neonate. The silo is then tightened every few days in an attempt to reduce the viscera and bring the edges together. Once they’re close enough, I would then take the patient to the operating room, remove the silo, and attempt to close the fascia primarily.
On HD# 8 for infant with omphalocele and silo, noticfe R sided inguinal hernia.
It’s not uncommon to have this because as the viscera is reduced back in the abdominal cavity, that definitely increases intra-abdominal pressure, and the neonate may have a patent processus vaginalis allowing abdominal contents to herniate into the inguinal canal and scrotum. I would observe it for signs of bowel compromise or strangulation, and go a little bit slower in tightening the silo.
Shortly after tightening silo on baby with omphalocele, hypoxia and hypotension
Tightened too much reducing preload and FRC –> hypotension and hypoxia. First thing I would do is loosen it.
Pentology of Cantrell
sternal cleft, omphalocele, anterior diaphragm hernia, and no pericardium
KEy steps of subclavian central line
I would first review his chart to make sure there’s no contraindication for a subclavian insertion like a history of chronic kidney disease or central stenosis. If not, I would get all my supplies readily available at bedside. I would prep and drape the right chest and neck area and complete a surgical time-out. I use external landmarks for a subclavian line so I would mark out the deltopectoral groove, sternal notch and medial third of the clavicle. I would insert an introducer needle 1 centimeter inferior to the medial third of the clavicle and angle it towards the sternal notch in a 45-degree angle. I would then walk the needle down the clavicle until it enters the subclavian vein.
What are some ways to confirm you’re in the subclavian vein when palcing a central line?
An ultrasound might demonstrate the needle entering the vein. Another option is to insert a wire, and then a small angiocatheter in the vein and connect it to clear tubing and hold it above the patient’s heart. If it’s an artery, blood will eventually come out of the other end of the tube. If it’s the vein, blood will eventually stagnate and how ever many centimeters it stops at above his heart is a good estimate of the central venous pressure. You can also send a blood gas to see if its arterial or venous. And lastly, you can connect it to a transducer and look for an arterial waveform.
e/control of R subclavian artery
I would get proximal control using a median sternotomy and distal control with an axillary dissection to control the axillary artery. Once I have proximal and distal control, I would gain access to the subclavian artery with a supraclavicular incision parallel to the clavicle. I would dissect down to the clavicular head of the sternocleidomastoid muscle and divide it. I would then free the clavicle from all its surrounding attachments and use a giggly saw to remove the middle third of the clavicle. This will then expose the phrenic nerve which I would identify and preserve. I should then see the anterior scalene muscle which I would divide to then find the subclavian artery behind it.
Injury to anterior surface of sublcavian artery –how to fix?
If the patient isn’t bleeding to death, I would heparinize and clamp proximal and distal to this. I would then debride all devitalized tissue and if it’s < 50% of the circumference of the vessel, I would perform a primary repair transversely in an effort not to stenose the artery. I would use permanent suture such as 5-0 prolene.
Proximal control of L subclavian artery
Left anterolateral thoracotomy
Tx for mild c diff
PO Vanco 125 mg q6h
OR
PO fidaxomicin 200 mg q12 x 10 days
Tx for severe c diff
IV flagyl 500 mg TID + PO Vancouvers 125 mg q6h
Fulminant c diff and tx
Assoc hypotension, ileus, ICU, septic shock, megacolon
PO Vancouvers 500 mg q6h + IV flagyl 500 mg q8h
CONSIDER RECTAL VANCO
Tx of recurrent c diff
If Vanco used for initial episode – prolonged tapered and pulsed PO Vanco or fidaxomicin 200 mg q12h x 10 days
Why isn’t rectum removed in surgical tx of c diff?
Given the amount of inflammation from his current c diff colitis, a pelvic dissection is more likely to cause problems than help. I would plan on instilling rectal vancomycin through a red rubber post-operatively to try to clear the rectum, but it wouldn’t be safe to go after it now.
Total abdominal colectomy
I would explore to make sure there’s nothing I’ve missed like a cancer or tumor. I would then perform a lateral to medial dissection of both the right and left colon making sure to identify the ureters and preserve them. I would also mobilize the hepatic and splenic flexures. I would then transect the ileum about 10 centimeters from the ileocecal valve with a GIA stapler. I would then use a ligasure device to ligate the mesentery all the way to the rectosigmoid junction, and I would resect the bowel there too. I would inspect the rectal stump to make sure it looks healthy at the staple line, and if there’s any concern I would oversew it. I would then wash out the abdomen and if the patient’s not acidotic, hypothermic or coagulopathic, I would bring up an end ileostomy, close the fascia and then mature the ostomy.
Tx of high ostomy output (after ruling out intra abdominal source)
I think I’ve reasonably ruled out an intra-abdominal source for the high ostomy output so I would start treating him with fiber supplements, a PPI, and an anti-diarrheal medication like loperamide. I would also make sure that he doesn’t get dehydrated or develops any electrolyte abnormalities.
Who should be screened for Barretts
Male pts with 5+ years of GERD and 2+ RF (age >50, white race, central obesity, hx of smoking, family hx of BE or EAC)
perform screening for BE
high resolution endoscopy w/liberal use of narrow band imaging and biopsy
If BE and bx are inconclusive for duysplasia
PPI x 3-6 months
Repeat EGD
If still inconclusive –> repeat EGD 12 months later
If BE with LGD
Endoscopic tx if no significant comorbidity
OR
Repeat EGD in 1 yr
BE with HGD
Endoscopic therapy unless life limiting comorbid conditions
Tx of early intramucosal (T1a) esophageal adenoCA
May consider endoscopic therapy
If nodular BE, tx is?
EMR – diagnostic and therapeutic.
Pre op achalasia
These patients have a very high risk of aspiration with general anesthesia and intubation so I would do a couple things. First, I would talk to the anesthesiologist about my concerns. I would prefer to place a NG tube preoperatively and suction out as much as I can from the stomach before heading to the operating room. I would also prefer performing a RSI to decrease the risk of aspiration.
Heller myotomy
I would start by dissecting the anterior esophagus and proximal stomach. I would expose GEJ and take care to avoid injury to the vagus nn. I would start my myotomy on the stomach extending 6-centimeters proximally on the esophagus, and 2-centimeters distally on the stomach. I would perform the myotomy across both the longitudinal and circular muscles until I saw the mucosa pop out. Once that’s completed, I would perform an EGD to look at the mucosa directly and perform a leak test. Once that’s done and I confirm no leak I would buttress the repair by performing an anterior or Dor fundoplication with the fundus of the stomach.
Microperforation after Heller Myotomy
There are two options. The extra-conservative option would be to close the myotomy and perform it elsewhere, but I think that’s very morbid. Instead, I would perform my Dorr fundoplication which is going to buttress the repair and close whatever microperforation there is. And post-operatively, I routinely get an upper GI study the following day but, in this case, I’ll get the upper GI study on hospital day 5 to give it more time to heal. I would keep the patient NPO during this time.
Macroperforation after Heller Myotomy
That’s not something I would leave up to chance to heal. I would convert to an open surgery, repair the mucosa with absorbable suture, close the anterior myotomy, buttress the repair, and perform a posterior myotomy.
Post op Heller Myotomy
POD#1 esophagram to r/o perforation
CLD started and pt discharged home
POD # 3 Mechanical soft diet x 3 weeks
Send home on PPI
Tx of peptic stricture
Dilation –> intraluminal steroid injections –> GI consult for fully covered metal stent –> distal esophagectomy and recon
History in rectal prolapse
I got most of the history I need but I have a few clarifying questions. Has she ever noticed blood in her stool, does she have any associated perianal pain, has she ever had a colonoscopy, has she had any obstructive symptoms like nausea, vomiting, abdominal distention, or constipation? And does she have any children, or has she been pregnant previously?
How to reporduce rectal prolapse in clinic
A patulous anus with the history provided makes me concerned about a rectal prolapse. Since it likely only occurs with straining, I would ask her to reproduce it in clinic with the help of an enema in the squatting position.
Difference between rectal prolapse and hemorrhoids
Prolapse – concentric folds of prolapsed tissue
Hemorrhoid – radial invaginations or folds
Work up for rectal prolapse
Cscope + MRI defecography
Treat for constipation
If rectal prolapse + constipation or fecal incontinence
Anorectal manometry to evaluate rectoanal inhibitory reflex + squeeze pressure, and see if potentially injury to pudendal n
Rectal prolapse + healthy pt
There are two options with the trans-abdominal approach, one is an anterior rectal dissection, and the other is a posterior rectal dissection. There’s no difference between the two – the one I feel most comfortable with is a posterior dissection all the way down to the pelvic floor. I would then pull some of the redundancy of the rectum out of the pelvis, put it on a bit of tension and perform a rectopexy of the peritoneal edge of the rectum to the pelvic floor using permanent suture. Since she’s had severe constipation unresponsive to medical therapy, I would also perform a sigmoid resection with a primary anastomosis.
Principles of Delorme procedure
It’s a mucosal sleeve reduction so you essentially take off the mucosa and submucosa off the muscularis propria through a perineal approach, resect the redundant portion of the mucosa, and perform a pseudoanastomosis of the distal mucosa to the proximal mucosa allowing the bridging muscle to accordian back into the pelvis.
Lymphoscintigraphy for melanoma
Pt reports to nuc med for intradermal injection of technetium sulfur colloid to biopsy/tumor site. LSG defines drainage pattenr. In OR, gamma probe used to confirm location of sentinel nodes. Isosulfan blue dye injected around biopsy/tumor site. Targeted dissection using gamma probe and visualization of blue dye. Nodal excision complete once only background signal detected by probe without residual visible blue or suspicious nodes.
Path comes back from melanoma excision with SLN bx showing + 1 positive node. Next steps?
This confirms stage-3 disease so I would order a PET-CT from head-to-toe to look for any evidence of distant metastasis. I would also bring his case up at a multidisciplinary committee, but my recommendation would be to proceed with serial ultrasound imaging every 3 months and not proceed with an axillary lymph node dissection. I also think he would benefit from getting started on ipilimumab for at least a year. His biopsy could also be stained for a BRAF mutation because that might indicate that he would be a candidate for one of the BRAF-inhibitors like vemurafenib.
Inguinal lymph node dissection for melanoma
I would frog-leg the patient in the operating room, make a curvilinear incision from just under the ASIS to the midline of the inguinal ligament and go beyond it several centimeters. I would retract the peritoneum cephalad and remove all the lymph nodes in this region. I would then find the most superficial lymph node to the iliac artery which would be Cloquet’s node. I would send this for a frozen biopsy, and if that’s positive I would proceed with a deep inguinal lymph node dissection which would include all the lymph nodes posterior to Cloquet’s node. If it’s negative, I would stop.
Deep ILND
Deep dissected can be performed by creating a separate incision in EO aponeurosis or by dividing inguinal ligament
Peritoneum and ureter are retracted medially to expose iliac fossa. Iliac nodes are dissected off common and external iliac vessels. Obturator nodes dissected off the posterior surface of the external iliac vein
After closure over a deep drain, sartorius mobilized and transposed to sit over exposed femoral vessels
Superficial drain placed and incision is closed
Surveillance for melanoma
Surveillance w/ exam every 3 mo-6mo for 2-3 years, groin US every 4 mo 2-3 years, annual PET yearly. After 5 years, nodal Us annually until 10 years postop from SLN Bx
When to consider post op XRT in melanoma
extracapsular extension, multiple involved LN (>2 cervical or axillary, or >3 inguinal) or large nodes (>3 cm in neck or axilla, >4 cm in groin) but risks must be carefully weighed
Work up of “in transit” mets for melanoma
Stage III – should get full staging workup
BRAF testing
Surgical tx of “in transit” mets for melanoma
Ideally WLE with ~1 cm margins
If not feasible systemic tx
Rigler’s triad
pneumobilia 2/2 fistula, evidence of bowel obstruction with dilated bowel loops and air fluid levels, ectopic gallstone –often absent as gallstones may not be radio-opaque
Surgery for gallstone ileus
I would perform an exploratory laparotomy and I would consent the patient for a possible bowel resection. If the bowel looks persistently ischemic, compromised or frankly perforated I would perform an ileocecectomy with a primary anastomosis. If the bowel looks healthy, I would make an enterotomy proximally, away from any inflammation, and milk the stone out through that enterotomy. I would then diligently check the rest of the bowel and colon to make sure I don’t miss any stones. Once I’m confident that there’s no stones left behind, I would close the enterotomy transversely so that I don’t narrow the bowel.
How to repair cholecystoduodenal fistula
Fistula tract resected back to fresh viable edge of duodenum which can usually be closed in Heineke-Mikulicz fashion followed by omental patch re-inforcement
Lap chole with IOC - critical steps
I would retract the body of the gallbladder up and over the liver. I would then retract the infundibulum laterally and begin dissecting the peritoneum off the lower third of the gallbladder starting laterally. I would dissect until I get a critical view which would include two and only two structures entering the gallbladder with the lower third of the gallbladder dissected free off the liver. And once I’m confident with the critical view, I would perform an intraoperative cholangiogram. If there’s no stones in the ducts, I would ligate the cystic duct and artery and dissect the gallbladder off the liver completely and place it in an endocatch bag and send it to pathology.
Cystgastrostomy
I would use an upper midline incision and facilitate exposure with a Bookwalter. I would make an anterior gastrotomy which would then allow me to enter the stomach and access the posterior wall. I would then try to find exactly where the pancreatic pseudocyst is by using a small needle to aspirate the pseudocyst. Once I find it, I would then remove a small portion of the posterior gastric wall and suture the posterior backwall to the pseudocyst so that the gastric lumen and the lumen of the pseudocyst are freely communicating. I would then place a post-pyloric feeding tube through the nose so that I can feed him for a few days until everything heals. I would also leave a nasogastric tube for the first few days, close the anterior gastrotomy and finish the operation.
roux en y cystjejunostomy
I would perform a roux-en-y cystojejunostomy by dissecting the gastrocolic ligament and entering the lesser sac. I would then find the pseudocyst and perform an anastomosis to a limb of the jejunum about 10 cm distal to the ligament of treitz.
Post-Op Pseudocyst
NG x 24-48 hrs
Liquid diet within 48 hrs
Consider NJ or J tube
Abx if necrotic specimen
A/w VTE – DVT PPX x 4 weeks
What to do if concurrent gastric varices with pseudocyst?
Concurrent splenectomy (may be due to SVT secondary to either pancreatitis or pseudocyst)
cyst – intervention and likely cause?
Emergent angio and embolization
Usually from splenic, GDA or pancreaticoduodenal aa
When to perform prophylactic operation on FAP?
Age 20
Prior to operating for FAP?
CT chest abdomen and pelvis
CBC, CMP, Coags, Lactate, CEA
Surgical options for FAP
There are two surgeries to consider. One is a total proctocolectomy with an end ileostomy and the other is a total proctocolectomy with an ileal-pouch anal anastomosis with or without a diverting ileostomy. My decision would depend on his sphincter tone and if he reports having any incontinence. If he does not have incontinence and has good sphincter tone, a total proctocolectomy with an IPAA is what I would recommend. I would make sure he’s aware of the risks related to a pelvic dissection including injury to the lumbar nerves and subsequent pelvic pain, as well as infertility. I would also make sure he knows that his new normal is going to be maybe 5 to 10 bowel movements during the day and possibly 1 or 2 bowel movements at night.
Surveillance for FAP following surgery
I would plan on seeing him back in my clinic every 6 months for a history and physical exam. He has no rectum or colon and so shouldn’t have a risk of cancer, but there’s some reports of cancer developing at the anal transition zone so I would screen for that with a DRE. He also needs to be scheduled for an EGD to look for duodenal adenomas. He should get screened for that every 1-6 years depending on what the EGD shows. In addition, he should also get an annual neck ultrasound as FAP patients have a higher risk of thyroid cancer.
Tx for desmoid tumors
Resection if feasible, able to get clear margins, not near any major structures
NSAIDs (sulindac), Tamoxifen
At waht age does FAP screening begin
12
Causes of white out on CXR
He either has a large mucous plug from coughing up a lot of secretions, or he’s developed a significant parapneumonic effusion that needs to be drained.
Pt is crumping – concern for septic shock. Next steps?
I would make sure he’s been resuscitated with at least 30 milliliters per kilogram of lactated ringers. I would get a serum lactate and another set of blood cultures. I would broaden his IV antibiotics by adding pip-tazo. I would get him a central line, arterial line and start norepinephrine with a MAP goal greater than 65. I would also get an echocardiogram along with a BNP, troponin and EKG to make sure his hearts not contributing to the hypotension. I’m also worried that he may not be able to protect his airway so I would intubate him. And since he’s clearly gotten sicker, this would be a good opportunity to clarify his code status with his next of kin since the patient’s incapacitated.
Approach to intubation
I have a mental checklist that I go through before I intubate a patient. Number one I make sure there’s a ventilator in the room, and I make sure there’s an ambu-bag available so that I can bag-mask ventilate the patient if needed. I want a working yankower suction at bedside. I would make sure I have all the appropriate monitors on and working. In this case, he already has an arterial line so I can monitor his hemodynamics during intubation with that. I would want a color capnography available to help confirm proper airway position immediately after intubation. I would make sure I have several different sized endotracheal tubes in the room in addition to several different adjuncts to help me intubate like a glidescope, a direct laryngoscopy, a LMA, and in the worse-case scenario, a surgical airway kit. I would confirm that the patient has at least two working IVs and lastly, I would get my medications ready. For this patient I would use 0.3 milligrams per kilogram of etomidate, and 1 milligram per kilogram of rocuronium. And after intubation, I would confirm with color capnography, I would listen to both lung fields and get a chest x-ray.
Prone positioning for ARDS
18 hrs on, 6 hrs off
Increasingly difficult to oxygenate pt with ARDs. Next steps?
I would maximize his sedation and titrate it to a RAAS goal of -5. I would also paralyze him.
-NM blockade (cisatracurium) – needs heavy sedation
REcruitment maneuvers + higher PEEP
Inhaled NO/prostacyclins
Prone positioning
Fluid conservative mgmt ocne no longer in shock
Last resort for pt with ARDS
The only other thing to consider is VV ECMO. He has no significant cardiac problem so there’s no need for VA ECMO. There are several considerations for ECMO including his age, baseline function, the reversibility of his condition, and if he can be anticoagulated. I would discuss all those things with the ECMO team, as well as the family to see if this is something the patient would have wanted.
Definition of ARDS
Presence of bilateral pulm infiltrates of acute onset within 1 week of known clinical insult
PaO2:FiO2 ratio of <300
Resp failure not fully explained by volume overload
ARDS goals (O2 sat, PaO2 and FiO2)
O2 sat >88%, PaO2 >55-60 mm Hg, get FiO2 <60-65%
Pt explanation for hemorrhoid banding
Banding is a procedure we can do in the office. I usually only do one hemorrhoid at a time but since you only have one hemorrhoid this won’t be a problem. The hemorrhoids are inside your anal canal where you don’t feel pain, so this is often a pain free procedure. It takes only a couple minutes but what I essentially do is use an anoscope similar to the one I used previously for my exam. That will allow me to see the hemorrhoid which I would grab and place a rubber band at the base of. This will constrict the blood supply to that hemorrhoid which is itself a dilated vein, and the hemorrhoid should slough off in 4 or 5 days and likely come out with a bowel movement.
What if pt calls you after hemorrhoid banding concerned about BRBPR?
I would tell him that’s not normal and he should go to the emergency department to get checked out. Some bleeding is expected 4 or 5 days after banding but any significant bleeding or even mild bleeding during the first 48 hours should be investigated. If he can’t void or if he has high fevers, chills, or heart palpitations he should also come to the emergency department. I would also call the ED and let them know I’m sending a patient.
Key steps of hemorrhoidectomy
If the hemorrhoid was anterior, I would place the patient in prone jack-knife positioning, and if the hemorrhoid was posterior I would do it supine with the legs in lithotomy. After performing a DRE, I would place an anoscope to identify the hemorrhoid, clamp it with a peon, and resect the hemorrhoid above the mucosa with electrocautery. I would then close the incision with a running absorbable suture.
RF for hemorrhoids
Constipation, pregnancy, COPD, hepatic dysfunction causing increased portal venous pressure
Grade I internal hemorrhoid
no prolapse
Grade II internal hemorrhoid
prolapse spontaneously reduces
Grade III internal hemorrhoid
manually reducible
IV internal hemorrhoid
Does not reduce
Tx for grade I and II internal hemorrhoid if fails medical mgmt
Rubber band ligation
Sclerotherapy
IR coagulation
External thrombosed hemorrhoid – tx (<48 hrs)
1% lido with epi into dermis overlying hemorrhoid
Ellipse of skin excised over the area of thrombosis
Extract thrombi individually with hemostat
Cover with slightly moistened gauze
Rubber band ligation – steps
Left lateral decubitus 🡪 examine perineum and anal verge 🡪 DRE prior to anoscopy and ensure no full thickness rectal prolapse 🡪 place rubber band 2 cm above dentate line after testing sensation using hemorrhoidal forceps (ensure hemorrhoidal pedicle is above dentate line)
Sclerotherapy of hemorrhoid – steps
2-3 mL hypertonic saline injected directly into hemorrhoid using a long 25 gauge needle just above dentate line into submucosa
Tx of hemorrhoids in pt with portal HTN
Sclerotherapy if conservative mgmt fails
Stapled hemorrhoidopexy is next line after optimal medical tx to reduce portal pressures and tips
Relationship of portal HTN + hemorrhoids
Collaterals between inferior hemorrhoid vein and systemic venous drainage system
Pt presents with neck mass – basic HPI?
I would start with a focused history and physical exam. I would like to know how long the neck mass has been there, if it’s evolved in any way, if she’s had increased pain, difficulty swallowing, difficulty breathing, if it’s grown, if she’s had any skin irritation or redness, or if she’s had any night sweats, fevers or chills. would then ask her about any hypo or hyperthyroidism symptoms like recent weight gain or weight loss, heat or cold intolerance, hair loss, fatigue, or palpitations. I would also like to know her medical and surgical history, particularly if she’s had any neck surgeries or neck or chest radiation, her smoking and drinking history, and lastly, her family history including any endocrine disorders or any family members with neck lesions or head and neck cancers.
Concern for Hashimoto’s – next step?
thyroperoxidase antibody test.
Concern for graves – next test?
TSH receptor antibody.
Tests + for TSH receptor antibody
I would order an EKG as well as an echocardiogram to make sure there’s no cardiac pathology. I would make sure she’s not pregnant by checking a beta-hCG, and if not, I would order a radionucleotide thyroid scan to be 100% sure of the diagnosis.
What if thyroid scan shows diffuse uptake?
Grave’s disease
Various options for mgmt of Graves
There are three options including radioactive iodine, antithyroid drugs, and a thyroidectomy. Radioactive ablation is the most common form of treatment and reasonable for most young adults with symptomatic disease unless she’s planning on getting pregnant in the 6 months following therapy. Antithyroid drugs are more often used for elderly patients, or those that have a high surgical risk or those that are mildly symptomatic or don’t want surgery or radioactive ablation. Pregnant patients or those wishing to get pregnant can’t be on these medications. A thyroidectomy can also be offered but that’s usually reserved for those with large symptomatic goiters that are causing mass effect or if cancer is suspected or if the patient is planning on getting pregnant in the next 6 months. The one major caveat to a thyroidectomy is that the patient will need to be on a daily thyroid hormone for the rest of her life.
Tx for thyroid storm
I would treat her with beta blockers, methimazole, steroids, inorganic iodide, Tylenol, cooling blankets and volume resuscitation. She’ll need ICU level of care and if she decompensates or can’t protect her airway, I would intubate her.
FNA of thyroid nodule –steps
10-millimeter syringe and a small fine needle, maybe a 22-guage. And with ultrasound guidance I would aspirate the mass several times and send that for pathology.
Risks of thyroid surgery
With all surgery there’s a risk of bleeding, infection, and injury of nearby structures. The bleeding can be particularly dangerous because if there’s a lot of bleeding in the neck it can compromise the airway, but we have various ways of making sure there’s not a lot of significant bleeding while doing this operation. There are several important nerves around the thyroid, namely the nerve that allows you to speak and that controls the pitch of your voice, so we’ll be careful not to injure those. That same nerve also controls your vocal cords which allow you to breath so there’s a risk of injuring that. And lastly, your parathyroid glands live around your thyroid gland, and the job of the parathyroid glands are to control the amount of calcium in your body so it’s possible that you may have low calcium after the surgery if the parathyroid glands are injured, but most of the time that’s only temporary. The surgery is done as an outpatient and most patients go home the same day.
Anatomic relation of parathyroid glands to RLN
Superiorly the glands are POSTERIOR and LATERAL to the nerve
Inferiorly the glands are ANTERIOR and MEDIAL
Pathology report shows 4.2 cm high grade follicular CA s/p hemithyroidectomy. Next steps?
Since the size is greater than 4-centimeters, I would offer a completion thyroidectomy. And since it’s high grade I would offer radioactive ablation. Both of those interventions would also help me follow her in the future for tumor recurrence with thyroglobulin levels. And if I take out her other thyroid gland, she will need daily thyroid hormone for the rest of her life.
Patchy or multifocal uptake on RAIU
toxic multinod goiter
Tx of toxic adenoma or toxic multinodular goiter
Radioiodine or lobectomy (TA) or near total thyroidectomy (TMNG)
Low TSH + normal FT4
Nonthyroidal illness
Subclinical hyperthyroidism
Thyroid hormone therapy
Dopamine
Glucocorticoids
T3 toxicosis
Low TSH + high FT4 + low RAIU
Acute thyroiditis
Subacute thyroiditis
Painless thyroiditis
Factitious thyrotoxicosis
Struma ovarii
Functioning mets
Amio-induced thyroiditis
Jod-Basedow
Anti-thyroid drugs of choice
MMI due to superior safety profile - except during first trimester of pregnancy
Contraindications to RAI in Graves
Pregnancy
Lactation
Coexisting thyroid CA
Moderate to severe active Graves’ eye disease
Inability to comply with radiation precautions
Near total thyroidectomy leaves how much thyroid?
1-2 g of tissue
BKA
I would first exsanguinate all the blood from the lower extremity up towards the thigh and then place a sterile tourniquet. I would mark out the borders of the incision making sure to leave more of a posterior flap so that I can close the incision with the suture line on the anterior surface. After removing the muscle and soft tissue off the bone using electrocautery and a periosteal elevator, I would use an oscillating saw to transect the tibia first. Following that I would transect the fibula about 2-centimeters proximal to where the tibia was transected. I would file down all the edges of the bone and use a big amputation knife to cut the remainder of the muscle and soft tissue off the posterior flap. I would tie off the greater saphenous vein and nerve, the anterior tibial artery and nerve, the posterior tibial artery and nerve, the peroneal nerve and artery, and the lesser saphenous vein with 2-0 silk ties. I would then take down the sterile tourniquet and look for any areas of bleeding. Once all that’s addressed, I would irrigate the wound and close the fascia first and then the skin using vertical mattress sutures.
Imaging in diabetic foot
Plain radiographs of the foot in every pt (FB, gas, osteolysis, joint effusion, delineate anatomy)
Complete vascular exam –doppler
ABIs (non compressible tibial vessels due to medial calcinosis –> FALSELY elevated ABIs
Toe pressures (if <30 mmHg, not compatible with healing)
Arterial duplex US
Intra-arterial digital subtraction arteriography is most accurate – must show approp inflow and outflow and incorporate infrapopliteal circulation
Lower Extremity Bypass - key steps
ID greater saphenous vein and harvest with full length leg incision → obtain control of proximal and distal anastomotic sites → create tunnels for bypass (subq or subfascial) → dilate vein with heparinized saline, check for any holes requiring repair → heparinize pt systemically → perform proximal anastomosis, tunnel vein, confirm pulsatile flow → perform distal anastomosis → confirm unobstructed Doppler signal in distal artery and at anastomosis → reverse heparin with protamine → close incisions and confirm pulses or signals in foot prior to leaving OR
Post Op Plan lower extremity bypass
Neurovasc checks q1-2 hrs
Can DC aline and foley after 1-2 days once BP stabilized
OOB to chair POD # 1
Consult PT early
Consider comorbidities –be vigilant of post op complications
Surveillance duplex q3 months x 1 year, then every 6 months for 1 year, then yearly
What if venous conduit not suitable quality or length during bypass procedure
consider splicing GSV with alternative conduits or using alternative conduit altogether (contralateral lesser saph vein, basilic or cephalic arm vv, prosthetic)
*Vein diameter >3 mm considered adequate
*Can also do hybrid endovascular procedure –shorter bypass with either inflow or outflow endovascular procedure
Open inguinal hernia repair
I would place him supine, intubate, administer IV antibiotics, clip any hair around the affected groin, place a foley catheter, and prep and drape the groin and scrotum. I would make a line between the ASIS and pubic symphysis which would indicate where his inguinal ligament would be. I would then make a curvilinear incision, about 5 cm or so, get through scarpas fascia, as well as the external oblique aponeurosis. I would then get around the cord contents and hernia sac, and begin dissecting the hernia sac away from the cord contents. Once the hernia sac is freed, I would open it making sure there’s no bowel and then ligate it with a stick tie. I would then reconstruct the floor with a polypropylene mesh. I would fix the mesh to the public symphysis, shelving edge of the inguinal ligament and conjoint tendon. I would then reconstruct the internal ring with two slits of the mesh making sure I can fit my pinky in between it so that it’s not too tight. I would then close the external oblique, scarpas fascia and skin. And at the end I would make sure the testicle is placed back in the scrotum.
What if while sewing on the shelving edge you encounter a large amt of dark blood?
I would be concerned that I had injured the femoral vein. I would remove the stitch and hold pressure. If it continues bleeding, I would then find the injury and repair it primarily, but I would expect it to stop with pressure.
1 week post op open IHR with bulge in R groin
That’s either going to be a hematoma or seroma – if the incision looks good, his vitals are normal and he’s got no complaints, I would simply observe it as it will resolve with time. Aspirating it to confirm what it is can potentially seed a sterile cavity and wouldn’t change my management. I would have him come back to my clinic in a week.
R for incarcerated hernia – you open up the sac and find a knuckle of bowel that appears ischemic
I would try to open up the fascial defect a bit so that I could examine the proximal and distal portions of that segment of bowel. I would be extra careful to not let the bowel reduce back in his abdominal cavity without fully evaluating it.
How would you perform a hernia repair without mesh?
I would perform a Basinni repair which involves sewing the shelving edge of the inguinal ligament directly to the conjoint tendon.
What if during inguinal hernia repair you find a femoral hernia,again finding a knuckle of bowel that appears ischemic?
In this case, I would need to perform a McVay repair which involves suturing the conjoined tendon to Cooper’s ligament from the pubic tubercle medially to the femoral vein as it crosses Cooper’s ligament laterally. At that point, a transition stitch is placed incorporating the conjoined tendon, Cooper’s ligament, the femoral sheath at the medial aspect of the femoral vein, and the inguinal ligament. The remainder of the inguinal floor is repaired by approximating the conjoined tendon to the inguinal ligament extending laterally to the area of the internal ring.
If tension while trying to repair using McVay repair (femoral hernia)
I would make a relaxing incision along the rectus abdominis and possibly the external oblique aponeurosis, if needed.
Triangle of doom
deep to cord structures; vas deferens medially, spermatic vessels laterally, ext iliac vessels inferiorly; contains ext iliac a and v and deep circumflex iliac v
OR - lap inguinal hernia repair
The patient would be type and crossed for 2 units, preoperative antibiotics and preoperative VTE chemoprophylaxis administered before going to the OR. I would place him supine and after he’s intubated, I would place a foley catheter. I would then prep the abdomen and both groins. I would place my camera port at the umbilicus and use two additional ports lateral to the rectus. After identifying the medial umbilical ligament, I would make an incision in the peritoneum lateral to the medial umbilical ligament and dissect all the way towards the ASIS. I would then use blunt dissection to create the pre-peritoneal space. Next, I would identify the hernia and reduce it completely into the peritoneum making sure not to injure the spermatic cord. Once that’s completed, I should hopefully have a good view of the myopectineal orifice and be able to identify the conjoint tendon, iliopubic tract, inferior epigastric artery as well as the pubic symphysis. I would then introduce an appropriate size of polypropylene mesh, lay it smoothly to cover the myopectineal orifice, and tack it to the pubic symphysis. I don’t use any other tacks to prevent injury to the nerves and vasculature. I would then close the peritoneum with a self-retaining suture. I would then perform the same thing on the contralateral side. At the end of the surgery, I would make sure both testicles are in the scrotum.
Critical view in inguinal hernia repair (lap)
identify myopectineal orifice with conjoint tendon, iliopubic tract, inferior epigastric artery, and pubic symphysis
Left POSTEROlateral thoracotomy – exposes?
Left hilum
Descending aorta
How to access supraceliac aorta
I would dissect the gastrohepatic ligament making sure not to injure an aberrant or replaced left hepatic artery, dissect off the right crus, find the aorta and put a clamp in the 2-o’clock position.
To access suprahepatic IVC
if subdiaphragmatic clamping isn’t possible, open diaphragm and access R chest clamp supradiaphragmatic IVC (may become VERY unstable due to decreased VR to heart) → may have chance to repair injured hepatic vv and retrohepatic IVC
Component Separation
I would start with a midline laparotomy incision and carefully take down all the adhesions to the bowel. I would remove all the previous mesh and all devitalized tissue. I would then incise the posterior rectus sheath about half a centimeter from its medial border. That will allow me to carry out a retrorectus dissection freeing the entire posterior rectus sheath from the rectus muscle. I would carry that dissection all the way up towards the ribs and all the way down towards the pubis, and laterally towards the linea semilunaris. I would then do the same thing on the contralateral side, and then check to see if I’m able to approximate both edges towards the midline.
Transversus abdominis release
About 0.5 cm MEDIAL to LINEA SEMILUNARIS I would incise the posterior rectus sheath to find the transversus abdominis muscles and divide those with electrocautery. That will allow me to then develop a large retromuscular plane. I would then check again if I can approximate the posterior rectus sheath now that I’ve released the transversus abdominis.
Petit hernia
Ext oblique
Lat dorsi
Iliac crest
Spigelian hernias
Lateral border of rectus, adjacent to linea semilunaris
almos always inferior to semicircularis
Occcurs between muscle fibers of IO and insertion of EO aponeurosis into the rectus sheath
TIPS
This is done in the procedure suite. The right internal jugular vein is cannulated, and a wire is inserted all the way down to the right hepatic vein under fluoroscopic guidance. A stent is then deployed across the hepatic vein towards the right portal vein to shunt the blood away from the liver. This can cause or worsen pre-existing encephalopathy, but he needs this right now to save his life.
It is a SIDE to SIDE portal canal shunt
Distal pancreatectomy
Camera at umbilicus
4 trocars trinagulating to LUQ
RO mets
Enter lesser sac via gastrocolic ligament
Retract stomach to expose pancreas
splenic a coursing along superior border of pancreas
Open along inf pancreas with energy device
May haeve to mobilize spleen by opening splenocolic ligament
Dissect splenic vessels away and clip branches
Once vessels mobilized out towards hilum, divide pancreas at neck using stapler
Remove specimen in bag
Intraop frozen to make sure no high grade dysplasia at margin
Key steps of sleeve gastrectomy
The first thing to do is to define the anatomy. I would start the operation by ligating the short gastrics and I would attempt to clear about 6-centimeters proximal to the pylorus which is right around where the angle-of-his would be. I would then insert a bougie so that I don’t narrow the stomach too much, and use a linear cutting stapler starting 6-centimeters proximal to the pylorus and removing the fundus of the stomach making sure not to narrow the angle-of-his too much. I would then perform an EGD and inspect the staple line, submerge it in saline and perform a leak test with insufflation. And once I’m happy with the staple line I would complete the operation.
Mesenteric defects in RYGB
As b below
Type I gastric ulcer and tx
Lesser curve
Wedge resection
Type II and III gastric ulcer and tx
II: gastric and duodenal
Type III: pyloric/prepyloric
Tx: Truncal vagotomy and antrectomy
Enlarged pancreatic head WITHOUT dilated duct
Beger procedure (duodenum sparing resection of most of head with division of neck over mesenteric vessels with side to side and side to end pancreaticojejunostomy to drain remaining head and tail of pancreas)
