SurgBoards Flashcards

Question

Tx for chronic steal syndrome options

Answer 1

Banding outflow tract Distal revascularization interval ligation

Answer 2

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.

Answer 3

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

Answer 4

Usually MONOmicrobial S epi is #1 and S aureus and Pseudomonas

Answer 5

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.

Answer 6

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.

Answer 7

dilated umbilical vessels, ascites with a fluid shift, hernias, asterixis, or any evidence of fluid overload like peripheral edema.

Answer 8

(sodium) bilirubin INR creatinine

Answer 9

Total bili INR Albumin Encephalopathy Ascites

Answer 10

The four phases would be non-contrast, contrast, delayed venous washout and portal vein washout

Answer 11

Consider surgical resection.

Answer 12

Consider transplant if satisfies Milan Criteria

Answer 13

single tumor < 5 cm, or 3 separate tumors each less than 3 cm, and she satisfies that criteria

Answer 14

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

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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.

Answer 19

additional or replaced R hepatic from SMA

Answer 20

Accessory or replaced L hepatic from L gastric

Answer 21

Hepatitis Cirrhosis Alcohol use Blood transfusion tattoos IVDA

Answer 22

SHould not undergo hepatic resection, may be considered for TXP

Answer 23

Adenocarcinoma or mixed cholangioCA

Answer 24

nodularity, portal HTN, recannulization of portal v, varices, splenomegaly

Answer 25

cscope, mammogram, EGD, lung oimaging Can also perform further staining --> TTF-1 (lung), ER/PR, CK-20 (colon), CK-7 (pancreatobiliary)

Answer 26

volumetric assessment (volume of liver segments preserved divided by total estimated liver volume)

Answer 27

Systemic chemo with sorafenib

Answer 28

Repeat imaging 3-6 weeks s/p embolization with repeat volume estimates Aim to operate 21-30 days following PVE

Answer 29

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

Answer 30

Liver (cholangiocarcinoma(

Answer 31

Small bowel or cholangioCA. Do capsule endoscopy and look for ulcer c/w CA

Answer 32

Chemo first, then resect if response

Answer 33

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.

Answer 34

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.

Answer 35

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.

Answer 36

Repeat labs to assess for improvement Replete lytes PRN (calcium!)

Answer 37

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.

Answer 38

DRE -- gross blood, high riding prostate, rectal tone NEUROVASC EXAM waist down Irrigate and pack any large perineal wounds before applying binder

Answer 39

ligation of hypogastric aa (difficult exposure) and venous pelvic bleeding is best controlled by tamponade

Answer 40

intraperitoneal bladder

Answer 41

Extraperitoneal bladder rupture

Answer 42

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

Answer 43

retrograde urethrogram

Answer 44

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.

Answer 45

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.

Answer 46

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.

Answer 47

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.

Answer 48

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.

Answer 49

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.

Answer 50

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

Answer 51

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.

Answer 52

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.

Answer 53

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.

Answer 54

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.

Answer 55

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.

Answer 56

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.

Answer 57

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.

Answer 58

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.

Answer 59

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.

Answer 60

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.

Answer 61

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.

Answer 62

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.

Answer 63

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.

Answer 64

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.

Answer 65

Consult urology -- can be repaired

Answer 66

Depending on post conception age at time of surgery may need overnight observation for concerns of post op apnea --discuss with anesthesia

Answer 67

Get US to r/o hernia, get more info Tx azithromycin for catscratch

Answer 68

Right because left processus vaginalis closes first.

Answer 69

HoTN (SBP <100) Tachypnea (RR > 22) AMS (GCS <15)

Answer 70

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.

Answer 71

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.

Answer 72

Malignant hyperthermia Anaphylaxis Pneumothorax (tension) Cardiac Pulm embolus Air embolus

Answer 73

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.

Answer 74

Wall motion abnormalities or global hypokinesis to suggest MI Dilated right heart which would suggest PE.

Answer 75

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

Answer 76

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.

Answer 77

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.

Answer 78

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.

Answer 79

Appendiceal orifice, ileocecal valve, crows foot of cecum.

Answer 80

Reduce any loops. Abd pressure from assistant. Stiffen scope. Switch to peds scope. Increase sedation or put pt on back.

Answer 81

Call senior partner to see if he/she can make forward progress. If not, abort procedure and do CT colonography the same day.

Answer 82

Larger polyp removal in one piece instead of piecemeal

Answer 83

Larger polyp >1 cm, pedunculated Close mucosal defect with clips

Answer 84

Endoscopic submucosal resection

Answer 85

Adv polyp >1 cm

Answer 86

Extract it with forceps or suction through scope with trap door

Answer 87

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.

Answer 88

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

Answer 89

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.

Answer 90

Start with 0.2 mg and redose with 0.5 mg in 2-3 minutes if no response.

Answer 91

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

Answer 92

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.

Answer 93

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

Answer 94

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

Answer 95

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.

Answer 96

200 cm (or 100 vs 180)

Answer 97

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

Answer 98

creeping fat, thickening of bowel wall (esp TI), free perforation from full thickness ulceration, and fibrotic structure

Answer 99

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

Answer 100

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.

Answer 101

Fistulogram +/- SBFT -- location of fistula and length of distal SB

Answer 102

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.

Answer 103

FRIENDS (Foreign body, Radiation enteritis, IBD, Epithelialization of fistula tract, Neoplasm, Distal obstruction, ongoing Sepsis)

Answer 104

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.

Answer 105

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

Answer 106

Retention sutures or dynamic fascial closure devices Partial fascial bridging w/non permanent mesh Local cutaneous flaps

Answer 107

Parafollicular C cells Neuroendocrine tumor

Answer 108

MTC Pheo Parathyroid

Answer 109

MTC Pheo Mucosal neuromas, Marfans, MSK abnormalities

Answer 110

flushing, diarrhea

Answer 111

lung, liver, bone, mediastinum

Answer 112

> or = 1 cm in diameter or bilateral thyroid disease

Answer 113

If <1.0 cm in diameter and unilateral thyroid disease

Answer 114

Grossly incomplete tumor resection and additional attempts at surgical resection ruled out

Answer 115

Clinically or radiologically identifiable disease (levels II-V) If high volume or gross disease in adjacent CENTRAL neck

Answer 116

Basal serum calcitonin level CEA Pheo screening Central and lateral neck compartments US Consider neck CT if indicated

Answer 117

Basal serum calcitonin CEA Pheo Serum Ca and PTH Central and lateral neck compartments US Consider neck CT

Answer 118

First year of life (or at diagnosis of MEN) Should consider prophylactic bilateral CND

Answer 119

Basal calcitonin and CEA annually

Answer 120

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

Answer 121

CRANIAL N EXAM

Answer 122

Total thyroid + CND

Answer 123

Chest CT, liver triple phase CT or MRI, bone scintigraphy

Answer 124

Presence of RET mutation Radiologic evidence of residual MTC Post op elevation of serum calcitonin

Answer 125

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.

Answer 126

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.

Answer 127

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.

Answer 128

LN tissue from anterior and posterior triangles, defined as submandibular gland superiorly, IJ v medially, trapezius muscle laterally, and clavicle inferiorly. CONSIDER DRAIN.

Answer 129

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.

Answer 130

fat free diet, abx, application of pressure dressing. May need surgical exploration with ligation of thoracic duct or application of biologic sealant.

Answer 131

PTH should be grafted to muscular bed such as brachioradialis in which future resection would be feasible in case hyperPTH develops

Answer 132

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

Answer 133

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.

Answer 134

infrarenal aorta or iliac artery

Answer 135

I could perform a retrograde bypass from the iliac vessels

Answer 136

Anti platelet tx daily + statin

Answer 137

I would use etomidate at 0.3 mg/kg, and rocuronium 1 mg/kg

Answer 138

Random cortisol No set cutoff but if its <12 -- treat with 3 days of hydrocortisone, 100 mg q8h

Answer 139

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.

Answer 140

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

Answer 141

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)

Answer 142

I would make a relaxing incision on the right side of the diaphragm. I would also reinofrce my repair with biologic mesh

Answer 143

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.

Answer 144

Gastropexy (could use tube) but if truly unable to get GEJ into abdomen --> Collis gastroplasty

Answer 145

Evaluate pt and monitor respiratory status Give high flow O2 to assist with resorption of capnothorax

Answer 146

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

Answer 147

Cover up baby with warm blankets Make sure baby is breathing and calculate APGAR score now and 5 minutes from now

Answer 148

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.

Answer 149

D10/0.25 NS @ 140-150mL/kg/day and then maintenance of 80-100 mL/kg/day.

Answer 150

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)

Answer 151

I would be worried about either pulmonary or cardiac abnormalities and I would start off with a chest x-ray and an echocardiogram.

Answer 152

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.

Answer 153

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.

Answer 154

Tightened too much reducing preload and FRC --> hypotension and hypoxia. First thing I would do is loosen it.

Answer 155

sternal cleft, omphalocele, anterior diaphragm hernia, and no pericardium

Answer 156

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.

Answer 157

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.

Answer 158

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.

Answer 159

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.

Answer 160

Left anterolateral thoracotomy

Answer 161

PO Vanco 125 mg q6h OR PO fidaxomicin 200 mg q12 x 10 days

Answer 162

IV flagyl 500 mg TID + PO Vancouvers 125 mg q6h

Answer 163

Assoc hypotension, ileus, ICU, septic shock, megacolon PO Vancouvers 500 mg q6h + IV flagyl 500 mg q8h CONSIDER RECTAL VANCO

Answer 164

If Vanco used for initial episode -- prolonged tapered and pulsed PO Vanco or fidaxomicin 200 mg q12h x 10 days

Answer 165

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.

Answer 166

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.

Answer 167

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.

Answer 168

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)

Answer 169

high resolution endoscopy w/liberal use of narrow band imaging and biopsy

Answer 170

PPI x 3-6 months Repeat EGD If still inconclusive --> repeat EGD 12 months later

Answer 171

Endoscopic tx if no significant comorbidity OR Repeat EGD in 1 yr

Answer 172

Endoscopic therapy unless life limiting comorbid conditions

Answer 173

May consider endoscopic therapy

Answer 174

EMR -- diagnostic and therapeutic.

Answer 175

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.

Answer 176

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.

Answer 177

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.

Answer 178

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.

Answer 179

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

Answer 180

Dilation --> intraluminal steroid injections --> GI consult for fully covered metal stent --> distal esophagectomy and recon

Answer 181

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?

Answer 182

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.

Answer 183

Prolapse -- concentric folds of prolapsed tissue Hemorrhoid -- radial invaginations or folds

Answer 184

Cscope + MRI defecography Treat for constipation

Answer 185

Anorectal manometry to evaluate rectoanal inhibitory reflex + squeeze pressure, and see if potentially injury to pudendal n

Answer 186

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.

Answer 187

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.

Answer 188

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.

Answer 189

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.

Answer 190

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.

Answer 191

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

Answer 192

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

Answer 193

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

Answer 194

Stage III -- should get full staging workup BRAF testing

Answer 195

Ideally WLE with ~1 cm margins If not feasible systemic tx

Answer 196

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

Answer 197

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.

Answer 198

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

Answer 199

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.

Answer 200

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.

Answer 201

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.

Answer 202

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

Answer 203

Concurrent splenectomy (may be due to SVT secondary to either pancreatitis or pseudocyst)

Answer 204

Emergent angio and embolization Usually from splenic, GDA or pancreaticoduodenal aa

Answer 205

CT chest abdomen and pelvis CBC, CMP, Coags, Lactate, CEA

Answer 206

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.

Answer 207

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.

Answer 208

Resection if feasible, able to get clear margins, not near any major structures NSAIDs (sulindac), Tamoxifen

Answer 209

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.

Answer 210

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.

Answer 211

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.

Answer 212

18 hrs on, 6 hrs off

Answer 213

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

Answer 214

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.

Answer 215

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

Answer 216

O2 sat >88%, PaO2 >55-60 mm Hg, get FiO2 <60-65%

Answer 217

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.

Answer 218

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.

Answer 219

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.

Answer 220

Constipation, pregnancy, COPD, hepatic dysfunction causing increased portal venous pressure

Answer 221

no prolapse

Answer 222

prolapse spontaneously reduces

Answer 223

manually reducible

Answer 224

Does not reduce

Answer 225

Rubber band ligation Sclerotherapy IR coagulation

Answer 226

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

Answer 227

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)

Answer 228

2-3 mL hypertonic saline injected directly into hemorrhoid using a long 25 gauge needle just above dentate line into submucosa

Answer 229

Sclerotherapy if conservative mgmt fails Stapled hemorrhoidopexy is next line after optimal medical tx to reduce portal pressures and tips

Answer 230

Collaterals between inferior hemorrhoid vein and systemic venous drainage system

Answer 231

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.

Answer 232

thyroperoxidase antibody test.

Answer 233

TSH receptor antibody.

Answer 234

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.

Answer 235

Grave's disease

Answer 236

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.

Answer 237

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.

Answer 238

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.

Answer 239

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.

Answer 240

Superiorly the glands are POSTERIOR and LATERAL to the nerve Inferiorly the glands are ANTERIOR and MEDIAL

Answer 241

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.

Answer 242

toxic multinod goiter

Answer 243

Radioiodine or lobectomy (TA) or near total thyroidectomy (TMNG)

Answer 244

Nonthyroidal illness Subclinical hyperthyroidism Thyroid hormone therapy Dopamine Glucocorticoids T3 toxicosis

Answer 245

Acute thyroiditis Subacute thyroiditis Painless thyroiditis Factitious thyrotoxicosis Struma ovarii Functioning mets Amio-induced thyroiditis Jod-Basedow

Answer 246

MMI due to superior safety profile - except during first trimester of pregnancy

Answer 247

Pregnancy Lactation Coexisting thyroid CA Moderate to severe active Graves' eye disease Inability to comply with radiation precautions

Answer 248

1-2 g of tissue

Answer 249

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.

Answer 250

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

Answer 251

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

Answer 252

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

Answer 253

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

Answer 254

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.

Answer 255

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.

Answer 256

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.

Answer 257

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.

Answer 258

I would perform a Basinni repair which involves sewing the shelving edge of the inguinal ligament directly to the conjoint tendon.

Answer 259

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.

Answer 260

I would make a relaxing incision along the rectus abdominis and possibly the external oblique aponeurosis, if needed.

Answer 261

This is highly concerning for a bladder injury during the hernia repair. I would send the fluid for creatinine and if elevated, I would consult urology for a cystoscopy or CT cystogram and if this is an extraperitoneal bladder injury, which is more likely to be the case, I would leave the foley in for two weeks and get a CT cystogram.q

Answer 262

Genital branch of genitofemoral nerve runs posterior to cord

Answer 263

First port at umbilicus and 2 addn ports placed on either side lateral to rectus sheath 🡪 peritoneum incised from ipsilateral medial umbilical fold to level of ASIS 🡪 preperitoneal space is bluntly dissected from ant iliac spine laterally, medial umbilical fold medially, and below cooper’s ligament inferiorly 🡪 hernia sac dissected from cord structures and returned to peritoneal cavity 🡪 mesh introduced and positioned to cover entire myopectineal orifice 🡪 peritoneal defect closed using sutures

Answer 264

ligate and excised proximally to allow retraction

Answer 265

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

Answer 266

medial to cord structures; spermatic vessels medially, iliopubic tract laterally, inferiorly the inferior edge of skin incision; contains lateral femoral cutaneous n and anterior femoral cutaneous n

Answer 267

medial to cord structures; spermatic vessels medially, iliopubic tract laterally, inferiorly the inferior edge of skin incision; contains lateral femoral cutaneous n and anterior femoral cutaneous

Answer 268

The next step now is to stage the patient with a PET-CT head to toe, as well as an endoscopic ultrasound which will tell me the T stage, and the presence of any enlarged periesophageal lymph nodes. I would also want to know nutrition markers like prealbumin and albumin to try to figure out if I need to get enteric access for him to keep up with his nutrition. I would also perforrm cardiopulmonary assessmenmost important prognostic determinant of outcome for locally resected early-staget and refer to smoking cessation if necessary.

Answer 269

lymphovascular invasion

Answer 270

muscularis mucosa

Answer 271

well differentiated, smaller than 2 cm, within sm1 and without LVI.

Answer 272

esophagectomy preferred

Answer 273

esophagectomy preferred

Answer 274

esophagectomy preferredIf R1 resection for esophageal SCC and pt did NOT receive neoadjuvant

Answer 275

Adjuvant nivolumab

Answer 276

cT1b–cT2,N0 (low-risk lesions: <3 cm, well o differentiated)

Answer 277

Perform microsatellite, PD-L1, and HER2 testing (if not done previously) if metastatic cancer is suspected

Answer 278

a superficial parotidectomy with facial nerve preservation and appropriate neck dissection of the draining nodal basins is recommended

Answer 279

paclitaxel and carboplatin

Answer 280

T1a is when the tumor’s limited to the lamina propria or muscularis mucosa. This is the one time in esophageal cancer where I think it would be reasonable to proceed with endoscopic mucosal therapy with either endoscopic mucosal resection or endoscopic radiofrequency ablation. I would discuss this with my GI colleagues and at a multidisciplinary committee.

Answer 281

I would start off with a laparotomy, dissect through the hepatogastric ligament making sure not to injure an aberrant left hepatic artery, if one existed. I would then dissect the phrenoesophageal ligament and try to mobilize the esophagus and stomach. I would ligate the left gastric and gastroepiploic arteries, as well as the short gastrics to help mobilize the stomach up into the chest. I would make sure the right gastric and gastroepiploic arteries are preserved as these would serve as the blood supply for my conduit. I would then staple off 4-6 cm below the gastroesophageal junction on the proximal stomach and send the gastric margin for a frozen biopsy to make sure there’s no cancer. I would finish off with a pyloroplasty before proceeding to a right sided thoracotomy. I would place the patient in the left lateral decubitus position and make an incision in the 5th intercostal space to gain access to the thoracic cavity and mobilize the esophagus making sure to ligate the azygous vein, if needed, to allow for enough mobility. I would then place the patient supine, make a left sided neck incision, gain access to the esophagus, resect it and send the esophageal margin for a frozen biopsy. I would then deliver the gastric conduit through the chest and into the neck to make a side-to-side stapled anastomosis. I would then insert a nasogastric tube to perform a leak test, if negative I would leave the NG tube distal to my anastomosis. I would also leave a penrose drain in the neck. And since I did a thoracotomy I would also leave a chest tube before closing all incisions.

Answer 282

I would watch him in the hospital and trend his labs. If he’s doing well on post-op day-1 I would start tube feeds since the feeds would be distal to the anastomosis. On post-op day-7 I would get a contrast swallow study to look for a leak, and if there’s no leak, I would take out the NG tube and let him eat, starting with full liquids, small portions several times a day. I would slowly advance his diet with the help of a nutritionist, and if he’s tolerating oral intake well for about a month, I'll remove the jejunostomy-tube.

Answer 283

There are several possibilities to explain this - one is an anastomotic stricture leading to proximal dilation and/or a leak, another is a gastric tip necrosis, and this may also be a surgical site or deep space infection. I would start fluid resuscitation, collect blood cultures, start IV antibiotics and plan to explore this in the operating room along with an EGD.

Answer 284

This is a very unfortunate situation. I would have to take down my anastomosis, resect the dead part of the stomach and place the healthy part back into the peritoneal cavity, leave a gastrostomy tube for decompression, and create an esophageal stoma. If he recovers well, in 6 months we can consider reconstructing him, but for now he’ll have the spit-fistula, g-tube for decompression and J-tube for feeding.

Answer 285

I’d get another cscope in 1 year, then 3 years later, then every 5 years. For the first 2 years after surgery I’d send a CEA and perform physical exam every 3-6 months and I would get a CT scan of the abdomen and pelvis every 6-12 months every 5 years.

Answer 286

If no gas distal to obstruction and/or rectum is decompressed, the mass is fully obstructing If small bowel decompressed, pt has competent ileocecal valve

Answer 287

Screen for rectal cancer q1-2 yrs, EGD q3-5 yrs, annual UA, annual H&P to r/o CNS tumor, annual CT torso and CEA, dermatology, and screening for siblings/children

Answer 288

Refer for genetic confirmation (MSH2)

Answer 289

TAH + BSO for risk of endometrial CA

Answer 290

Retrograde contrast study showing some extent of luminal patency required Severity of obstruction (impending perforation strongly favors definitive operative approach) Per CS: best option for palliation or bridge to surgery in pts with complete LBO due to splenic flexure colon CA with competent ileocecal valve

Answer 291

Ligate L colic, L branches of middle colic vessels, and IMV

Answer 292

Lithotomy positioning Midline incision, ex lap (examine peritoneal surfaces, liver) PRN decompressive enterotomy in R colon Mobilize R colon lateral to medial Enter lesser sac at hepatic flexure Remove greater omentum from stomach Mobilize splenic flexure Divide mesentery, ligating ileocolic vascular pedicle, middle colic pedicle, and ascending branch of L colic Construct ileocolic anastomosis Close mesenteric defect Irrigate and close abdomen

Answer 293

Confirm exact location of mass—looking for mass at hepatic flexure – confirm w/ laparoscopy Medial to lateral dissection of right colon High ligation of ileocolic pedicle and right colic pedicle (if present) after clearly identifying duodenum Mobilize ascending colon – protect duodenum, kidney, ureter in the retroperitoneal plane Incise white line of toldt laterally and take down gastrocolic ligament to get into lesser sac Extended right hemicolectomy (hepatic flexure lesion) – dissection and division of middle colics Divide ileum 5cm prox to cecum and distal to splenic flexure leaving left colonic vessels intact Tension free stapled side to side ileocolic anastomosis

Answer 294

All zone-1 penetrating hematomas need to be explored regardless of if they’re expanding or not. I would make sure that anesthesia has blood in the room, and they’re aware that I might encounter significant bleeding when I explore it, but I have to rule out an aortic, IVC or retroperitoneal duodenal injury.

Answer 295

I would explore it to look for an injury to the renal hilum or the kidney itself.

Answer 296

For penetrating trauma, I would explore it to rule out an obvious vascular or genitourinary injury that would need to be repaired.

Answer 297

I think all zone-1 retroperitoneal hematomas need to be explored, regardless of mechanism with the only exception being a stable retrohepatic hematoma – that might open up pandoras box and release tamponade of a retrohepatic caval injury which is incredibly challenging to surgically control, and so if the patient’s doing well, I would leave that alone. For blunt zone-2 hematomas, I would explore them only if they’re expanding. If a zone-3 hematoma is stable after blunt trauma, I would leave it alone. If it’s expanding, I would pack the pelvis and get a post-operative angiogram to see if there’s something to embolize.

Answer 298

ABGs Lactate PT, PTT Fibrinogen TEG

Answer 299

Observe if contralateral kidney intact Revascularize vs heparin if absent/small contralateral kidney If early lap for other reasons, consider revascularization

Answer 300

Heparin, serial CTAs or arteriograms OR Endovascular stent, heparin

Answer 301

Left medial visceral rotation involving L colon, spleen, tail of pancreas, fundus of stomach

Answer 302

Ipsilateral iliofemoral bypass using 8 mm PTFE graft Consider fasciotomy

Answer 303

Digital compression or lap pad Proximal and distal control (sponge sticks) OR Insertion of fogarty or foley into defect

Answer 304

Bleeding: cross clamp aorta at diaphragm Hematoma: L sided medial visceral rotation

Answer 305

Hemorrhage or hematoma --> base of mesocolon

Answer 306

Bleeding --> direct or medial mobilization Hematoma --> central control below L renal v

Answer 307

Bleeding --> eviscerate midgut, digitially control the artery Hematoma -->eviscerate midgut, proximal control at aortic bifurcation, distal control above inguinal ligament

Answer 308

Retract liver cephalad Right medial visceral rotation and Kocher maneuver Cross clamp infrarenal IVC Cross clamp renal vv Apply satinsky on IVC at ege of liver Cross-clamp infrarenal aorta with Crafoord-Debakey to preserve BP if IVC completely clamped

Answer 309

Right medial visceral rotation and Kocher maneuver Apply Satinsky to occlude injury to IVC Cross clamp aorta

Answer 310

Transect neck of pancreas if needed Otherwise incise retroperitoneum at base of mesocolon

Answer 311

Base of mesocolon

Answer 312

R medial visceral rotation and Kocher maneuver

Answer 313

Injury to proximal R common iliac vein --> retract artery with Cushing vein retractors. May require division of overlying R common iliac artery for exposure

Answer 314

Proximal Pringle Distal with forceps ID common and hepatic bile ducts before repair

Answer 315

Direct lateral approach by transecting hepatic parenchyma through laceration or by transection through Cantlie's line Rarely Schrock atriocaval shunt consisting of 36 Fr thoracostomy tube or #8 straightened endotracheal tube may need to be inserted after media nsternot

Answer 316

Direct lateral approach by transecting hepatic parenchyma through laceration or by transection through Cantlie's line Rarely Schrock atriocaval shunt consisting of 36 Fr thoracostomy tube or #8 straightened endotracheal tube may need to be inserted after median sternotomy

Answer 317

I would move all the small bowel out of the way towards the left upper quadrant. I would take down the hepatic flexure and begin to kocherize the duodenum by dissecting off the lateral peritoneal attachments. I would continue mobilizing this until I can see the IVC behind it. That exposure should provide me with a good look at D1, D2, and at least the anterior portion of D3.

Answer 318

I would mobilize the rest of the duodenum by completing a right medial visceral rotation. I would fully mobilize the right colon off the white line of Toldt. I would then incise the base of the mesentery off the retroperitoneum starting at the ileocolic pedicle and moving towards the ligament of Trietz. Once that’s completed, the entire small bowel should be free and I should be able to evaluate the entirety of the duodenum, and the remainder of the bowel.

Answer 319

The kocher maneuver should allow me to evaluate the head of the pancreas. For the body, I would get into the lesser sac by dividing the gastrocolic ligament. That would let me evaluate the posterior stomach, as well as the body and tail of the pancreas.

Answer 320

That makes it infinitely more complicated. The first step would be to confirm that the patient does actually have a pancreatic duct injury. I can do that intraoperatively by performing a cholangiogram through the gallbladder, but it wouldn’t change my management because I wouldn’t perform a pancreaticoduodenectomy during the index operation. Instead, I would widely drain the area, and get a post-op MRCP followed by possibly an ERCP. I would temporarily close the abdomen with a planned second look operation.

Answer 321

I would clean off the edges until there’s only healthy and viable tissue. I would make sure there’s no injury to the backwall or the posterior duo. And if < 50% of the circumference is involved, I would perform a primary repair transversely so that I don’t narrow the lumen. And if it’s >50% or it’s gonna be too stenotic after my repair, I would resect that segment and reconstruct with a hand-sewn primary anastomosis. I would leave a nasojejunal tube past the repair for enteral feeding, and a nasogastric tube to decompress the stomach, as well as external drains.

Answer 322

D2 is more challenging because it shares its blood supply with the pancreas and houses the ampulla. So, the first thing I would do is make sure the ampullas not involved. I would then see if less than 50% of the circumference is involved, and if so, I would repair it primarily. I would again leave both a nasojejunal tube past the repair, and a nasogastric tube, as well as external drains.

Answer 323

Again, I think a trauma Whipple during the index operation is the absolute last resort so I wouldn’t do that. There are several options and in the last 10 years I think we’ve shifted more towards a less is more approach. I would likely perform a primary repair to temporarily close or at least decrease the leak, widely drain the area, and come back with a more experienced partner or a hepatobiliary surgeon. My plan then would be to perform a pyloric exclusion with a gastrojejunostomy.

Answer 324

Biliary reconstruction in addition to duodenal repair CBD <50% -- repair over T tube Larger defect -- hepaticojejunostomy

Answer 325

I would try to manage that non-operatively with serial labs and serial abdominal exams to make sure he has no underlying perforation. The large hematoma can cause an obstruction so I would decompress his stomach with a nasogastric tube and start him on TPN. I would evaluate him for enteric feeding everyday based on his exam, NG tube output and a follow up upper GI contrast study.

Answer 326

If NOT expanding and <50% obstruction -- leave alone If >50% or expanding, open with care taken not to violate mucosa. Close defect primarily.

Answer 327

First, I would ask for shorter trocars and shorter instruments anytime I operate laparoscopically on a pediatric patient. Their bladders are also way more intraperitoneal compared to adults so it’s important that their bladders are decompressed so I would always place a foley before operating. In an adult, I think a veress needle at Palmer’s point is as reasonable and safe as a Veress through the umbilicus or a Hasson but in pediatric cases the liver is quite large and a Veress at Palmer’s point risks injuring the liver. I would routinely do a Hasson for pediatric laparoscopic cases. And lastly, I would use lower insufflation pressures, maybe around 8 or 10 and I would slowly insufflate since children can be more sensitive to the insufflation.

Answer 328

I use three ports, one periumbilical for my camera, one suprapubic and one in the left lower quadrant. I would position the patient right side up and Trendelenburg. I would then follow the tenia of the colon down to the cecum to help identify the appendix. I would then create a window between the base of the appendix and mesoappendix. I would use a vascular-load stapler to ligate the mesoappendix, and I would then use a bowel-load stapler to ligate the appendix. I would then place the specimen in an endocatch bag and send it off to pathology. I would close the port sites and skin.

Answer 329

I would take a good look around to find anything else that could be explaining the patient’s abdominal pain. In female patients, I would look at the uterus and ovaries. And in all patients, I would look for a Meckle’s diverticulum, or any suggestion of Crohn’s disease like large lymph nodes along the mesentery or creeping fat on the bowel. I would also look at the gallbladder to make sure that’s not obviously inflamed. I'd also consider cecal diverticulitis. And if I don’t find anything, I would still take out the appendix to avoid the diagnostic confusion in the future and definitively rule out early appendicitis by sending the specimen to pathology.

Answer 330

I would first make sure they got the correct specimen and are reporting on the correct patient. If they are, there’s a high possibility that I mistakenly either left the specimen in her body or only resected the mesoappendix and accidentally thought it was the appendix. I would inform the patient immediately and tell her about these two possibilities and tell her that I would like to order a CT scan to see if she still has an appendix. I would also tell her that if she does, she’s at risk for having another episode of appendicitis. I would also recommend that she gets a colonoscopy if she hasn’t had one recently (pt was older).

Answer 331

Pre op abx + OG + GA → Incise skin and SQ tissues in oblique orientation over McBurneys point → divide EO aponeurosis, internal oblique muscle, and transversus abdominis muscle in direction of fibers → elevate and sharply divide peritoneum → digitally explore abdomen and deliver appendix into wound → divide mesoappendix → ligate and divide appendix at its base → close the abdominal wall layers

Answer 332

Pre op abx + OG + GA → Incise skin and SQ tissues in oblique orientation over McBurneys point → divide EO aponeurosis, internal oblique muscle, and transversus abdominis muscle in direction of fibers → elevate and sharply divide peritoneum → digitally explore abdomen and deliver appendix into wound → divide mesoappendix → ligate and divide appendix at its base → close the abdominal wall layers

Answer 333

Hassons for access Minimal insufflation pressures Dependent positioning

Answer 334

Examine pt. Heart and lung exam. Abd exam. Review vitals. I&Os. Flush foley cath and perform bladder US. Send basic labs and assess hemodynamics. Assess AKI, worsening sepsis or bleeding. Look for signs of systemic congestion on exam (heart or liver failure) -- ECHO PRN CBC, CMP, UA, urine lytes Remove nephrotoxic medications and redose meds cleared renally, check chart to see if hx of cardiac or renal disease, address lytes, hyperkalemia If present, check drain for Cr

Answer 335

Examine pt. ID any pre-existing renal disease. Heart and lung exam. Abd exam. Neuro function. Perfusion status, signs of volume overload. Review vitals. I&Os. Flush foley cath and perform bladder US. Send basic labs and assess hemodynamics. CBC, CMP, UA, urine lytes, RENAL US Assess AKI, worsening sepsis or bleeding. ECHO PRN, consider EKG cardiac enzymes, CXR Remove nephrotoxic medications and redose meds cleared renally, check chart to see if hx of cardiac or renal disease, address lytes, hyperkalemia If present, check drain for Cr

Answer 336

AFterload reduction (vasodilators or diuretics) and/or imporvement of cardiac function (i.e., inotropes)

Answer 337

Fluid overload refractory to diuretics Hyperkalemia Metabolic acidosis Uremia (pericarditis, neuropathy, or encephalopathy) Toxins AEIOU: acidosis refractory to medical tx, severe acute electrolyte

Answer 338

I would divide the mesentery before detorsing the bowel to prevent circulation of inflammatory cytokines, followed by a sigmoid colectomy and if she’s not on any vasopressors, I would perform a primary anastomosis.

Answer 339

perform procedure with propofol sedation w/anesthesia after obtaining consent → perform surgical time out and then introduce scope through anus and rectum under direct visualization → advance with minimal insufflation until reach area of narrowing and twisting of sigmoid colon → traverse volvulus and enter dilated colon proximally → suction out as much gas and stool as possible and leave decompressive rectal tube

Answer 340

Midline lap and full exploration, examining for viability of bowel → place warm saline soaked lap sponges on any dusky appearing bowel and recheck periodically for improving perfusion → ID areas of torsed mesentery and redundant bowel and prepare to resect, including areas of nonresolving ischemia --> ID appropriate proximal and distal anastomotic site and divide sigmoid vessels and intervening mesentery without detorsing (to avoid exposing circulation to accumulating cytokines or bacteria) --> divide bowel proximally and distally, passing off the specimen --> perform anastomosis if clinical parameters are suitable (CV function, nutritional status, absence of bowel necrosis ,gross contamination) and remaining bowel appears healthy and without tension -if clinical parameters for anastomosis are not suitable, perform end ostomy and mucus fistula -if anastomosis performed, examine closely for evidence of adequate perfusion, anastomotic patency, and absence of leaks if possible

Answer 341

For a Whipple surgery, I think of a couple things that get divided, and a couple things that get reconstructed. The duodenum or stomach get divided depending on if you’re doing a pylorus preserving surgery, the common bile duct gets divided, the jejunum gets divided, as well as the pancreatic neck. I always start with a diagnostic laparoscopy first to look for any lesions. If there’s no lesions, I would proceed with a vertical midline incision, place a bookwalter to facilitate exposure, takedown the hepatic flexure, kocherize the duodenum all the way to the IVC, at which point I would divide the stomach. I would then perform a portal dissection by starting with a dome-down approach for a cholecystectomy, down towards the triad and ducts. I would then ligate the gastroduodenal artery, make a tunnel behind the pancreatic neck making sure not to injure the SMA or SMV, and divide the pancreatic neck with a stapler. I would then perform a proximal division of the jejunum, remove the specimen and make the first anastomosis which is a pancreaticojejunostomy, which I would do over a stent. I would then perform a choledochojejunostomy, followed by a gastrojejunostomy. I would leave drains by the anastomoses and finish the operation.

Answer 342

It may possibly be a replaced right hepatic artery coming off the SMA. I would review the preoperative CT to look for it. It can occur in up to 20% of the population as it’s a normal anatomic variant – and its typically posterolateral to the portal vein.

Answer 343

I would place a clamp around it and make sure the distal common hepatic artery is still pulsating.

Answer 344

**<180 degrees of SMA or celiac a is in direct contact with tumor **Short segment common hepatic artery encasement amenable to resection and reconstruction **Involvement of SMV or portal vein that’s amenable to resection and/or reconstruction

Answer 345

extrinsic compression of the mass obstructs both CBD as well as pancreatic duct

Answer 346

chronic pancreatitis

Answer 347

CBC, CMP, coag studies; CA 19-9 (unless bili >2) and assessment of diabetic control, nutritional status, performance status

Answer 348

pancreatic transection, resection of pancreatic head/uncinate process from SMV-PV and SMa margin dissection

Answer 349

I would want to know if the patient has any obvious symptoms concerning for carcinoid syndrome like flushing, nausea, diarrhea, cramping or abdominal pain. I would also want to get a CT scan of the chest, abdomen and pelvis to look for distant metastases. He would also need a colonoscopy but if all those studies are negative then the appendectomy itself is all he would need. However, I would still present him to a multidisciplinary committee and get a consensus regarding management.

Answer 350

Goblet cells suggest a more aggressive cancer and possibly even adenocarcinoma so after staging him with a CT chest, abdomen, pelvis, and completing a colonoscopy, I would present him at a multidisciplinary committee and if he has no evidence of distant metastasis, my recommendation would be to offer a right hemicolectomy.

Answer 351

Plasma chromogranin A (levels >5000 correlate with poor outcomes)

Answer 352

18F-FDOPA PET/CT 11C-5-HTP PET/CT In-labeled octreotide scintigraphy

Answer 353

Tumors >2 cm Incomplete res=ection Evidence of mets Goblet cell tumors

Answer 354

Determination of plasma Chromogranin A 24 hr urinary levels of 5-HIAA 18F-FDOPA PET/CT 11C-5-HTP PET/CT In-labeled octreotide sctinigraphy Cscope +/- EGD

Answer 355

Consider operative risk and tumor biology Elevated mitotic activity>2 cells or high Ki67

Answer 356

Withi n 3 months

Answer 357

Serial plasma chromogranin A CT chest/abd/pelvis

Answer 358

<2 cm Doesn't involve base No LVI

Answer 359

R hemicolectomy w/ileocolic lymphadenectomy

Answer 360

Stage with CT scan, CEA, complete colonoscopy Then R hemicolectomy w/ileocolonic lymphadenectomy

Answer 361

His presentation makes me very worried about a STEMI. The most important thing for this patient would be to get him to the cath lab to look for a coronary artery occlusion that we may be able to intervene on. I would give him an aspirin and sublingual nitrate, and activate the cardiology team to possibly take him to the cath-lab. I would also like to start a heparin drip, which might increase the risk of bleeding since he just had surgery. I would explain the risks and benefits to the patient and his family and tell them my recommendation which would be to start the heparin drip because we can stop bleeding but we can’t reverse the damage from a MI. This is also a good opportunity to discuss his code status

Answer 362

Systemic or cath directed tPA Other options: catheter directed thrombectomy, thrombectomy/ambolectomy, and ECMO

Answer 363

Determination of cannulation sites Eval of cannula size Anticoagulation Seldinger's technique insertion of cannulae with securing Connection to circuit Evaluation of LV function Adjustment to maintenance mechanical ventilation Consideration of reduction of total body salt and water

Answer 364

Well I’d first survey the abdomen, to be sure that there is no evidence of metastasis. I’d perform a high ligation at the superior rectal or IMA, depending on where my proximal transection point will be. I would similarly perform a high ligation of the inferior mesenteric vein so that I can get a tension-free anastomosis. I’d perform a lateral to medial mobilization of the left colon by dissecting off the white line of Toldt, being sure to check the underlying ureter. I would divide the mesocolon at the proximal site and then perform a total mesorectal excision by entering the plane between the visceral and parietal layers. I’d then divide my distal segment, making sure the entire tumor is in the specimen. I’d send a frozen section of both ends to be sure they are free of cancer and then I’d make a primary anastomosis, perform my leak test and visualize the anastomosis with flexible sigmoidoscopy.

Answer 365

For most of these patients I use the ERAS protocol –avoid excessive fluids unless pt needs it, start a multi modal pain regimen, minimize narcotics, and start a soft diet on the day of surgery if not nauseated from anesthesia. The foley is removed as soon as possible and I always encourage early ambulation. I would have also started the patient on VTE prophylaxis pre-operatively and continue that post-operatively.

Answer 366

T1 or T2 Node negative

Answer 367

induction chemo (oxaliplatin based) for 2-3 months prior to chemoXRT

Answer 368

More likely to receive planned chemo, higher rates of complete pathologic response, more likely to have early reversal of temporary ileostomy

Answer 369

FAVORABLE (<3cm, well differentiated, w/o angiolymphatic invasion, within 8cm of anal verge) - can consider full-thickness local excision assuming able to get 3mm margin OR

Answer 370

There are 3 options. Number 1 would be to use a synthetic mesh to bridge the hernia. Number 2 would be to use a biologic mesh to bridge the hernia. And number 3 would be to simply close the skin. I wouldn’t use permanent mesh because I would be worried about a chronic mesh infection. I think both the synthetic and biologic meshes have a high risk of recurrence and so I think the most simple and effective way to approach this is to just close the skin, tell the patient he has a known hernia, and one that we can fix 6 months from now when he’s fully recovered from this episode, is nutritionally optimized, medically optimized and has quit smoking.

Answer 371

I would make a longitudinal elliptical incision making sure the previous biopsy site is within my incision. The goal is a R0 resection so I would remove the mass in its entirety with a 1-centimeter gross margin, ideally in one piece, and I would send the margins for frozen section intraoperatively. If anything is positive, I would perform re-excisions of that site. Once everything is negative, I would place metal clips on the surgical bed in case the patient needs future radiation, and I would then close the defect.

Answer 372

if the final pathology is consistent with a high-grade sarcoma or if the tumor is 5 centimeters or larger

Answer 373

I would offer surgery and counsel the patient that I may need to reconstruct the femoral vessels, and for that I would use an autologous vein likely the greater saphenous from the contralateral leg. Since it’s above the knee, I feel comfortable doing this myself without a vascular surgeon.

Answer 374

I would be more worried that this is a high-grade cancer. I would resect the primary mass, as well as perform a wedge resection of that lung metastasis. If that lung lesions is confirmed to be a metastasis, the patient will likely need adjuvant chemotherapy and possibly radiation.

Answer 375

synovial sarcoma, clear-cell sarcoma, angiosarcoma, rhabdosarcoma, and epithelial sarcoma.

Answer 376

I would see the patient back in my clinic every 3 months for a history and exam, and at the 6 month mark I would get a MRI of the left leg and a CT chest and abdomen to look for local or distant metastasis. After that I would see the patient annually for a history and exam for 10 years.

Answer 377

I would ask for the patient’s temperature and heart rate. And review all the medications the patient received. -Could be MI (any cardiac hx) -PE

Answer 378

I would give 100 micrograms of 1:10,000 epinephrine. Can f/u with 200 mcg if persistent hypotension Adjunct: I would also give her 50 milligrams of IV diphenhydramine and start her on 5 milligram per kilogram of hydrocortisone to prevent a secondary phase reaction. If systolic drops again I would start a continuous infusion of epinephrine.

Answer 379

2.5 milligrams per kilogram q5min unti lresolution of sx.

Answer 380

Mobilize colon medially to visualize it, assisted by IV injection of methylene blue by anesthesia Can also do on table IVP or calling urology to perform retrograde cystourethrogram

Answer 381

Direct visualization, retrograde injectio nof emthylene blue through Foley, as well as retrograde cystourethrogram

Answer 382

Debride and closure in two layers, first PDS on mucosa, followed by silk. Ensure injury did not involve entrance of ureters

Answer 383

Perform diverting colostomy and rectal exam under anesthesia, irrigating any stool and necrotic debris from rectum. Monitor pt closely post op for signs of sepsis with low threshold to perform a CT scan to dx pelvic abscess since most amenable to IR drainage

Answer 384

Tie off transected ureter and post operative perc nephrostomy tube or intubating ureter with a thin catheter and exteriorizing drain followed by urology ocnsult for definitive repair

Answer 385

In the pre-op area, I would give the patient VTE chemoprophylaxis with heparin, pre-operative antibiotics, and I would type and screen him 2 units. In the OR, I would place a foley, lay him supine and after performing a surgical time-out I would place my ports. I use 5, first one would be my camera port. I would measure the xiphoid to the umbilicus and about 2/3 of the way down, just lateral to the rectus on the left side I would put the camera port. The second port would be on the subcostal anterior axillary line which would be my assistant’s port. I would then place a port in the mirror opposite on the contralateral side which would be my liver retractor. And where the falciform ligament enters the abdominal wall would be where I would place my right hand, and about one hand breath medial to that is where I would place my left hand. All the ports would be 5 millimeters except for my right-hand port which would be 12 millimeters.

Answer 386

I would identify the anatomy making sure there there’s nothing unusual. I would then start with a hiatal hernia reduction and repair. I would dissect the gastrohepatic ligament making sure not to injure a possible aberrant or accessory left hepatic artery. Once I’m through the ligament, I would attempt to identify the right and left crus, dissect circumferentially around the esophagus making sure not to injure the anterior and posterior vagal nerves. I would then reduce the hernia and its contents back into the abdomen making sure an appropriate length of esophagus is in the abdomen, which would be about 2-centimeters. I would approximate the crus with pledgeted non-absorbable sutures and reinforce this with biologic mesh. I would then move on to the fundoplication portion of the surgery. I would ligate the short gastrics, grab the fundus and bring it around the esophagus, and take seromuscular bites of one part of the stomach, the esophagus, and the contralateral stomach, and use pledgeted sutures to bring those together. I would perform the fundoplication over a bougie to make sure it’s not too narrow and finish the surgery.

Answer 387

I would need 2-centimeters of the esophagus in the abdomen so I would continue my dissection up into the mediastinum and try to get more of the esophagus down.

Answer 388

I would call a senior partner to come assist me in performing a collis gastroplasty in which I would tubularize the stomach with stapled resections to function as the distal esophagus.

Answer 389

Resuscitate with 20 mL/kg bous R Blood cutures Broad spectrum IV antibiotics covering for gram negatives and anaerobes Palce NG tube Order abdom x ray to r/o free air (pneumatosis intestinalis and/or portal venous gas)

Answer 390

peritonitis, pneumoperitoneum, or uncontrolled sepsis

Answer 391

I would consider trialing a diet at around day 12 or 14. My criteria would be normalized labs, a reassuring abdominal exam, reassuring x-rays, and normal vitals.

Answer 392

There’s no way to get to that endoscopically so my only option is a surgery which I would offer if the patient’s unable to tolerate a diet. I would offer a resection and a primary anastomosis if he’s doing well in the operating room. This is something a pediatric surgeon should perform, if one is available.

Answer 393

At that point he would have multiple reasons to go to the operating room. I would first resuscitate him with another 20 milliliter per kilogram bolus of lactated ringers, and start vasopressors if he doesn’t respond. I would have a frank conversation with the NICU intensivist and parents to let them know that this deterioration suggests intestinal necrosis and he’s at very high risk for death, and although the operating room will give him the best chance of survival, it might be too late, and he may die in the OR. I would also clarify the code status with the parents.

Answer 394

I would place the patient in supine position, and I would stand above their head. I would ask the circulating nurse to jaw-thrust the patient to help me intubate the esophagus by getting around the groove of the tongue. I would then slowly advance the scope in the esophagus under direct vision.

Answer 395

There’s two ways to approach a food bolus. One is the push technique, and the other is the pull or extraction technique. Historically, the push technique was discouraged because it was thought to lead to a higher risk of perforation but that doesn’t seem to be true as long as you can get around the bolus, intubate the stomach and make sure there’s no distal obstruction. If there’s no distal obstruction, I would gently try pushing the bolus into the stomach but if there’s lot of resistance I would stop and try the pull technique. Also, if I saw a bolus with sharp edges like a chicken or fish bone, or if it was really hard, I would use the pull technique instead.

Answer 396

Ideally, I would take it out in one piece but if it’s too big I can always do it piecemeal. The other option would be to use the suction port at the end of my scope to suck on the bolus and pull it out along with the scope.

Answer 397

There’s several different ways to manage a cholecystostomy tube. In some cases, it can be a definitive intervention which means they will need it life-long, and that’s used more for older patients that are poor surgical candidates. In other cases, the tube can be temporary, which is the case for this patient. I would discharge her with the drain with appropriate drain-care teaching, and plan for a cholangiogram using the drain in about a week or two. This will allow me to determine if the cystic duct is patent and that there’s no obstruction in the biliary tree, and if that’s the case I would clamp the tube for 24-hrs. If the patient tolerates a 24-hour clamp trial, I would then remove the tube.

Answer 398

The most common complication is a bile leak, which occurs in about 3% of patients. However, many of these cases are self-limited with no need for any invasive procedures or surgery. There’s also a risk of recurrence which may necessitate another intervention. And there’s also a chance of infection and/or bleeding when pulling the tube out.

Answer 399

Tenants: beta blocker, analgesia, nitrates, ASA, and oxygen (only if sat <92%) as it can induce vasospasm)

Answer 400

beta blocker, statin, ECHO, consider ACE-i If cardiac stent placed, start dual anti-platelet tx

Answer 401

I would want to know a little more about her medical history and if there’s anything to suggest that this incidentaloma is functional. Has she had any recent weight gain or weight loss, any virilization, new hair growth, decreased libido, irregular menses, mood changes, and new onset hypertension or hypokalemia requiring new medications? I would also like to know her surgical history, allergies, social history, and if there’s any relevant family history, in particular, I would like to know if anyone has had a history of endocrine disorders or head and neck cancers.

Answer 402

My standard panel for an incidentaloma would be a serum cortisol, sodium, potassium, 24-hour urine collection with aldosterone, renin, DHEAS, plasma metanephrines and normetanephrines. In addition, I would review the CT imaging myself and see if it was an appropriately phased study with an adrenal mass protocol.

Answer 403

I would get an adrenal protocol CT with a non-contrast, contrast phase and delayed washout. I would check the patient’s serum creatinine before ordering it.

Answer 404

The size, the attenuation or the Hounsfield units and the % of washout on the delayed phase.

Answer 405

I would place the patient in right lateral decubitus position, place my camera periumbilical and then put 3 additional subcostal ports. I would mobilize the splenic flexure and retract it caudally, retract the spleen medially to get access to the kidney, open up gerotas fascia, find the phrenic artery to ligate, and then find the adrenal vein which would be draining into the left renal vein, ligate the adrenal vein, then dissect the adrenal gland with a rim of fat around it off the kidney, place it in an endocatch bag and finish the operation.

Answer 406

I would place the patient in left lateral decubitus position. My ports would be on the right side. I would mobilize the hepatic flexure if it was in the way to get access to the kidney. Sometimes you need to mobilize the liver medially by dissecting the right triangular ligament of the liver. I would then open up gerotas fascia, find the adrenal vein which would be draining into the IVC, dissect around it, ligate it and then dissect the adrenal gland with a rim of fat around it off the kidney and send it to pathology.

Answer 407

I would be worried about an IVC injury, and I would immediately convert to an open surgery, place a sponge stick on the IVC, start a massive transfusion protocol and wait until anesthesia has had time to catch up. Meanwhile I would call one of my senior partners to help me dissect proximally and distally so that I can identify the injury on the IVC and repair it with a prolene suture.

Answer 408

I would be surprised that I didn’t pick that up on the preoperative imaging. Since I didn’t talk to the patient about removing her kidney, I would quickly call her next of kin to let them know about my findings and to discuss removing the kidney, I would also convert to an open surgery at that point.

Answer 409

I would first make sure that this isn’t part of an endocrine syndrome like MEN2 so I would make sure she doesn’t have occult hyperparathyroidism and I would ask her primary care physician or a genetics counselor to screen her for any familial disorders as well as optimize her for surgery. I would like an alpha blocker on for her hypertension, and only after the alpha-blocker has had time to work, and if she still has significant hypertension, I would then add a beta blocker. I would also like her hydrated appropriately for the couple weeks leading up to surgery. Once her blood pressure is controlled and she’s at the point where she has orthostatic hypotension, that’s when she would be ready for surgery.

Answer 410

size >6 cm, HU >20, delayed washout <60%

Answer 411

weight gain, central obesity, easy bruising, severe HTN, DM, virilization, fatigue, prox muscle weakness

Answer 412

1 mg night before blood draw – serum cortisol levels checked between 8-9 AM and normal should suppress to <1.5 microg/dL >5 is diagnostic Confirmatory: ACTH + 24 hr urinary cortisol Elv urinary cortisol + low/supp ACTH further support

Answer 413

confirm test with aldosterone suppression testing (saline infusion test or 24 hr urinary aldosterone while pt maintains high Na diet)

Answer 414

bilateral adrenal nodules, unilateral nodule <1 cm, normal-appearing glands, age >45 yo

Answer 415

Postop can DC phenoxybenzamine and monitor for HoTN and hypoglycemia; other anti-HTN resumed only if appears underlying essential HTN except if pt on long standing beta bkocker

Answer 416

optimizing comorbidities assoc with disease, VTE ppx, prophylactic abx and postop stress ulcer ppx; supp glucocorticoids postop

Answer 417

mineralocorticoid receptor antagonist (spironolactone) and may need K supp; post op can stop meds and closely monitor BP; may not be able to DC all anti-HTN; check serum K and aldosterone the AM after surgery

Answer 418

Repeat cross-sectional imaging with CT at 3-6 months then annually for next 1-2 yeasr Biochemical screening annually for up to 5 years

Answer 419

MEN2A, MEN 2B, NF, VHL

Answer 420

Li-Fraumeni syndrome (p53)

Answer 421

esmolol or sodium nitroprusside

Answer 422

Epi/norepi

Answer 423

Yes – I would check labs, and I would expect his cholesterol to be high considering his poor diet and claudication. But even if he doesn’t have hyperlipidemia, I would still want him on aspirin and a statin for the pleiotropic effects including the stabilization of an impending plaque rupture. Additional labs that I would get would include a chemistry panel to see what his baseline kidney function is, as well as a serum glucose to make sure he doesn’t have diabetes. He would also need a carotid ultrasound to rule out carotid artery disease, as well as an echocardiogram to rule out heart disease. I would also start him on cilastazol if his echocardiogram was normal. And lastly, I would refer him to an exercise program to help increase his exercise tolerance.

Answer 424

I would get access in the contralateral groin. Get a wire to the bifurcation under fluoroscopy and shoot an aortogram. I would then get the wire up and over onto the affected side and perform a selected arteriogram of the left lower extremity, place a stent over the diseased segment, and perform a completion angiogram. If it looks ok, I would see if the patient has a palpable pulse distally or at least a doppler signal. I would keep him on the aspirin and the statin postoperatively.

Answer 425

I would be worried about either a plaque embolization, a stent fracture, or an intimal defect. I would start him on a heparin drip and probably take him back to the operating room to shoot an angiogram. But I would first examine him myself to confirm that he doesn’t have a distal pulse, and I would check his femoral and popliteal pulses too.

Answer 426

I would perform this procedure steriley. I would make a small incision in the 4th or 5th intercostal space and use a blunt instrument to enter the chest. I would then dilate the tract and place a 24-French tube aimed posteriorly in the dependent region. I would then tie this in place at around the 10-centimeter mark if he’s an average sized adult male, and get a post-procedure chest x-ray.

Answer 427

Generally >1500 mL immediately or >250 mL/hr on average for 3 hours. In that case, I would take the patient to the operating room for a thoracotomy. I would also try to use a pleuravac capable of autotransfusion if I’m anticipating a large amount of bleeding.

Answer 428

I would continue chest tube drainage, and get another chest x-ray the following morning as long as he remains hemodynamically stable and asymptomatic. If the following morning, he has a persistent retained hemothorax I would take him to the operating room for a video-assisted thoracoscopic surgery to clean out the blood and reposition or replace the chest tube.

Answer 429

I would interrogate the tube to make sure there’s no obvious leaks in the system and review the imaging to make sure the sentinel hole is in the chest. I would also look at the pleuravac for evidence of an air leak.

Answer 430

As long as he’s hemodynamically stable, I would perform a bronchoscopy to rule out an injury to the larger airways.

Answer 431

These intercostals can be quite challenging to ligate in the operating room. I would try inserting a foley balloon through the bullet wound, inflate the balloon and pull it back to tamponade the artery between the balloon and the rib. I would also resuscitate with a balanced transfusion. If my efforts to tamponade the bleeding don’t work, I wouldn’t hesitate to take him to the operating room for a thoracotomy. At that point I can ID the area, place a circumferential suture around the rib with an absorbable suture and large needle from within the chest cavity. Both ends of the artery must be ligated.

Answer 432

I would perform a stapled wedge resection of the injured segment. WOULD NOT SUTURE CLOSED BECAUSE It’s a bad idea because it can result in continued hemorrhage which can bleed into the airway, and maybe even go to the contralateral and unaffected side. Suturing it closed also creates a potential for an air embolus because you create a closed cavity and if there’s an injured bronchus and vein, the air will travel down the path of least resistance which means it can enter the vein.

Answer 433

I would perform a stapled tractotomy to open the lung towards the area that I think is bleeding. Once I identify the injured vessel, I would directly suture ligate it.

Answer 434

I would clamp the pulmonary hilum, and if that doesn’t work, I would ligate the inferior pulmonary vein and perform a hilar twist.

Answer 435

performing suture repair will ligate LAD and cause fatal MI If lac is next to coronary, perform horizontal mattress suture underneath vessel

Answer 436

use Duval clamp on apex of heart to life heart or sequentially place lap pads behind heart If lift too quickly, pt will go into cardiac arrest due to kinking of great vessel

Answer 437

use FINGER to stop bleeding (not foley) Can primarily repair with large tapered needle – 2-0 nonabsorbable suture in figure of eight fashion

Answer 438

Supine position with neck extended and head toward nonop side EGD - pack with gauze to easier ID Place 36 Fr Maloney dilator Transverse incision at level of cricoid Develop subplatysmal flaps and open along anterior border of SCM (plane is between carotid sheath and central compartment fascia) Dissect adjacent to anterior edge of carotid a as retropharyngeal space approached (TO AVOID RLN INJURY) Mobilize diverticular sac ID back wall of pharyngoesophageal segment and make myotomy 1-2 cm to left of posterior midline - use a hemostat to define the muscle, separate it from the underlying mucosa and divide muscle sharply over hemostat extending downward onto cervical esophageal segment Resect diverticular sac using stapler Suction drains after thorough irrigation Close wound in layers

Answer 439

I would make sure the neck is extended to identify the anatomic landmarks which include the sternal notch, the thyroid, the cricoid and the cricothyroid membrane. I would make a vertical incision on the skin directly above the cricothyroid membrane. I would then make a transverse incision on the membrane, use the tracheal hook to lift the cricoid cartilage and insert either a tracheostomy tube or an endotracheal tube. I would again confirm placement with a color capnography and auscultation for bilateral breath sounds.

Answer 440

I would ask anesthesia to place a double lumen tube for single lung ventilation. After they intubate, I would perform a bronchoscopy to confirm placement of the tube and to look for any lesions or masses in the tracheobronchial tree that could be contributing to the pneumothorax. If I don’t find any, I would place the patient in a slight left lateral decubitus position, prep and drape, administer antibiotics, and proceed with my port placements. I would put the camera port at the 5th intercostal space at the anterior axillary line with two working ports in the 7th and 8th intercostal spaces. I would use ring forceps to grab the diseased apical bleb and perform a wedge resection with a stapler. I would then ask anesthesia to reinflate the lung to make sure there’s no obvious leaks and to make sure the lung fully expands.

Answer 441

There are two options – one would be to use some fibrin glue to see if that would seal it up, the other would be to perform an additional smaller wedge resection of that corner. I would try the fibrin glue first and do the wedge resection if I’m not happy with the glue.

Answer 442

I would get 500 mg of powdered doxycycline, mix it with 50 mL of normal saline and spread that evenly throughout the pleural space.

Answer 443

I would make sure he’s typed and crossed, I would give preoperative antibiotics and heparin for VTE prophylaxis, I would get a foley in and I would ask anesthesia to intubate with a double lumen tube to collapse the right lung. After he’s intubated, I would perform a bronchoscopy to make sure there’s no obvious intrabronchial lesions and to confirm proper placement of the tube. If it all looks good, I would place the patient in left lateral decubitus position making sure to pad all pressure points appropriately with a bean bag. I would then place a camera port in the 8th intercostal space and insufflate. I would then place two additional working ports in the 6th intercostal space and perform a wedge resection with a stapler. I would send this off for a frozen biopsy and talk to the pathologist myself.

Answer 444

I would debride them using a Watson blade for larger areas and a Weck blade for smaller areas. Once I get to the healthy bleeding tissue, I would place epinephrine-soaked gauze on top of it with some pressure for hemostasis. And if I have enough donor skin, which for him may involve his posterior legs, flanks, abdomen and left arm, I would harvest skin, mesh 1:1 and place the skin-grafts on healthy wound beds. I like to staple my grafts in place and use negative pressure wound therapy to buttress the repair and help keep it immobile. I usually take down the dressing on post-operative day 5 to see if the graft took.

Answer 445

There are several reasons. Either the wound bed wasn’t appropriately debrided, or the skin graft was too thin. He may have developed a hematoma preventing the skin graft from adhering to the wound bed, or may have had some sort of shearing of the graft after the procedure.

Answer 446

Distal gastrectomy w/bilroth or roux en y, make sure ulcer in specimen Other options: angioembolization...?

Answer 447

1a --spurting hemorrhage 1b -- oozing hemorrhage 2a--visible vessels 2b--adherent clot 2c --hematin at base 3--clean base

Answer 448

I would make sure that the OB team co-manages the patient with me and they check fetal heart tones before and after surgery. In pregnant patients, I always enter using the Hasson technique and I keep my insufflation pressures lower, around 12 instead of the usual 15. For the IOC portion, I would shield the lower abdomen to protect the fetus from radiation. The rest of the operation would be similar to any other patient.

Answer 449

Lower insufflation Desufflate + bolus 1 L IVF Uterus compressing IVC so turn her LEFT side DOWN, RIGHT side UP

Answer 450

I would immediately ask for the OB doctors to come in. My initial thoughts would be to open her lower abdomen and evaluate the injury and repair it primarily. I would also disclose this to the patient as soon as she wakes up.

Answer 451

I would grab the fundus of the gallbladder and retract that laterally. I would then dissect the peritoneum off the gallbladder neck. I would continue the dissection until I achieve the critical view of safety which includes two and only two structures entering the gallbladder, the cystic duct and cystic artery, along with a third of the gallbladder dissected off the liver fossa. I would then perform the intraoperative cholangiogram before clipping the duct and artery.

Answer 452

Place pt in head up, right side up If the colon, duodenum or omentum are in my way, I would place another 5 mm port and have an assistant hold the viscera down Convert to open

Answer 453

How far along are they? Complications? Regularly follow-up with OB? Fetus viability: 23-24 weeks

Answer 454

I would get labs to calculate a LRNEC score including a CBC, CRP and a CMP. LRNEC: WBC, sodium, CRP, Cr, glu, Hgb

Answer 455

I think covering for gram positives including MRSA, gram-negatives and anaerobes would be indicated so vancomycin and pip-tazo would be appropriate. I would also start clindamycin to neutralize any toxins from a clostridium or strep infection.

Answer 456

6 or greater but my clinical exam and history are more important.

Answer 457

I would place the patient supine with a towel roll behind his shoulders and turn his neck towards his right side as I would make my incision on the left along the anterior border of the sternocleidomastoid muscle. I would dissect down ventral to the carotid sheath and identify the diverticulum between the esophagus and cervical spine. I would perform a stapled resection of the diverticulum. I would then perform a myotomy of the cricopharyngeal muscle, leave a drain, and then close the skin.

Answer 458

Yes – 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 rapid sequence intubation to decrease the risk of aspiration.

Answer 459

There are two options. One is to surgically resect it and close the esophagus, and the other is to leave it. After a myotomy, a diverticulum that small is likely to heal on its own. To be conservative, I would likely perform a resection using a bougie, and repair the esophagus in two layers. I would then buttress the repair with strap muscles and leave a drain before I close. In that case I would also perform a swallow study to make sure my repair’s intact before I feed him.

Answer 460

I think he likely has a chyle leak. I would send the fluid off for a triglyceride level and if elevated that would confirm my suspicion. With nearly a liter out in 12-hours he likely has a big lymph channel leaking and since this is in his neck, I would be worried about airway compromise if his drain stops working for some reason so I would take him back to the operating room for a re-exploration

Answer 461

Transhiatal (cervical anastomosis)

Answer 462

I would make a subcostal incision, use a book-walter to facilitate exposure, perform LOA and get to the portal triad. Ideally, once I get to the common bile duct, I would keep my dissection anterior in an effort to not devascularize the duct. I would lower the hepatic plate to see the confluence of the left and right hepatic ducts bifurcating to the common hepatic duct because that’s where I would like to make the anastomosis. I would then find the ligament of treitz and about 15 cm distal to that is where I would bring the roux limb up. I would then ligate the common bile duct just distal to the perforation after removing the stent. I would debride all devitalized tissue and perform an end-to-side hepaticojejunostomy over a stent in two layers, followed by a jejunojejunostomy. I would then leave drains and finish the case.

Answer 463

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.

Answer 464

identify myopectineal orifice with conjoint tendon, iliopubic tract, inferior epigastric artery, and pubic symphysis

Answer 465

It would depend on if there’s high-risk features. For example, if it was larger than 3-centimter or there were mural nodules or it was symptomatic, I would recommend resection but if it didn’t have any of those, I would recommend observation with serial imaging and a CT scan in 6 months.

Answer 466

I would be most worried about bleeding, and with a sudden deterioration like that I would be worried about a GDA blowout. I would resuscitate with blood products by activating a massive transfusion protocol, and I would send a point of care hemoglobin. I would also send coags to make sure there’s no coagulopathy I can reverse. If this isn’t due to bleeding, I would look for other causes including a MI or PE which is less likely because of the EKG report and the normal oxygen saturation.

Answer 467

I would make an incision in the 4th intercostal space from his sternum down to the bed curving around the ribs. I would use scissors to cut the intercostal muscles and then use a finochietto retractor to spread the ribs. I would grab the pericardium and open it sharply anterior to the phrenic nerve in a parallel plane. I would then deliver the heart.

Answer 468

I would make sure the patient continues to get a balanced resuscitation and I would perform direct cardiac massage. If he still doesn’t have a pulse I would find the aorta by palpating around the diaphragm on top of the spine, finger dissect bluntly around the aorta and place a clamp in an effort to promote filling of the brain and heart. I would also give IV epinephrine but what he really needs is blood.

Answer 469

I need to get temporary control of that bleeding. I would remove the needle thoracostomy and close the laceration with a 2-0 prolene suture on a large, tapered needle in a figure-of-eight fashion. Once I do that, I would then continue cardiac massage.

Answer 470

Finger compression Foley catheter Vascular clamp (esp if atrial) Figure of eight horizontal mattress sutures or running suture using 2-0 polypropylene suture Skin staples

Answer 471

I would perform direct cardiac defibrillation using 50 joules

Answer 472

I would take out the suture and repair the laceration with the same type of needle but in a horizontal mattress fashion, underneath the LAD so that the cardiac parenchyma or muscle is approximated but the LAD remains open.

Answer 473

Her being relatively asymptomatic with a hemoglobin of 5 suggests this is a chronic process. The platelets are severely low and highly concerning. I would repeat it to make sure those numbers are accurate but if both the hemoglobin and platelets are that low, I would admit her to the hospital and get her a transfusion with packed red blood cells, as well as platelets. I would also be worried about internal bleeding so I would get a CT of her chest and abdomen with contrast, as well as a non-contrast CT of her head to rule out a spontaneous intracranial bleed. And lastly, I would get a hematology consult for the thrombocytopenia – in particular, I would ask for a bone marrow aspirate.

Answer 474

My triggers to admit a patient to the hospital are if they’re symptomatic, have a hemoglobin of 7 or lower, or platelets of 20,000 and lower.

Answer 475

Immune thrombocytopenic purpura or ITP, primarily because of the thrombocytopenia, splenomegaly and the absence of any other causes that can explain her thrombocytopenia. However, I think the bone marrow aspirate is important to look for normal cellularity so that I can be sure this isn’t cancer. The other possibility is TTP which I would expect to have more of a neurologic manifestation. Both can also cause renal impairment, but her creatinine is normal.

Answer 476

I would explain to her that although patients with ITP usually have a great response to steroids, it unfortunately doesn’t last long. There are second-line agents we can try and as a last resort we can talk about surgery but before I offer her surgery, I would like to try one of the thrombopoeiten receptor agonists like eltromopag. Since I don’t routinely prescribe this medication, I would talk to hematology about it and ask that they manage it.

Answer 477

I would kindly ask to hold off on any platelet transfusion until I ligate the splenic hilum, particularly the splenic artery because the platelets may go to waste if we give it before then. Plus, she’s not bleeding significantly and she’s hemodynamically stable.

Answer 478

Since she’s tachycardic I would give her packed red blood cells, and platelets knowing I might need to give her more platelets after I ligate the splenic artery.

Answer 479

<10K (consider if under 20K) to prevent spontaneous intracranial hemorrhage

Answer 480

intraop gamma probe scanning

Answer 481

Consioder ASA 81 mg if platelets >750K

Answer 482

Both hands compressing from apex to base Epi 1 mg boluses into LV using 18 gauge needle Sodium bicarb in 50 mEq boluses 50J internal cardiac defibrillation Warm IV fluids poured directly onto heart

Answer 483

Locate 2nd ICS and midclavicular line Prepare site with chlorhexidine Make puncture with angiocatheter or 14 G catheter Advance until rush of air encountered and remove needle while stabilizing catheter Place a one way valve if available Perform formal tube thoracotomy

Answer 484

Descending thoracic aorta Many cardiac and LEFT lung injuries

Answer 485

Left hilum Descending aorta

Answer 486

RIGHT hilum Thoracic esophagus

Answer 487

Requires pt to be repositioned in lateral position May exacerbate hemodynamic instability in hypovolemic patients WEll suited for approaching posterior lunch parenchymal injuries and intercostal vessel injuries

Answer 488

To improve exposure and access to heart (esp R sided structures) following left anterolateral thoracotomy performed for profound hypotneison or traumatic arrest To provide access to R chest in transmediastinal injuries or multiple penetrating injury to both the left and the right chest To allow cardiac massage following R sided thoracotomy

Answer 489

Obtain femoral artery access and insert 5 Fr sheath over a wire via US guidance Insert large compliant balloon through sheath and position in aortic zone 1 (L subclavian to celiac artery) for suspected abdominal ted abdominal and/or pelvic hemorrhagic source. Position balloon in aortic zone 3 (lowest renal artery to aortic bifurcation) for suspected pelvic hemrorhagic source. Inflate balloon with 1/2 mixture of sterile saline and contrast under fluoro. Secure balloon in place and have an assistant continuously monitor the wire, balloon, and sheath. Deflate the balloon slowly when aortic occlusion is no longer needed. Remove the sheath and close the arteriotomy with either a cut down technique or percutaneous closure device.

Answer 490

thiazide diuretics, lithium, calcium, biotin or vitamin D supplements.

Answer 491

If she’s symptomatic, if she’s younger than 50, if she has a history of pathologic fractures, if her serum calcium is 1 above the upper limit of normal, or if she has a T-score less than -2.5 on a DEXA scan.

Answer 492

I would get a full set of labs to make sure she has no other electrolyte imbalances so I would get a CBC, CMP and a GFR level, magnesium level, phosphate level, and a repeat serum PTH. I would also get a 24-hour urine collection to measure the amount of calcium so that I can rule out familial hypERcalcemic hypOcalciuria. I would also get a DEXA scan of the distal third of her radius (Bone resorption is more severe in distal radius (high cortical bone)). I would also get bilateral renal US to check for nephrolithiasis.

Answer 493

I would make sure she received her preoperative antibiotics. I would perform a complete cranial nerve exam before and after surgery. I would lay her supine on the operating room table. I always do my thyroid or parathyroid surgeries with a nerve-stimulating monitor so I would watch the patient get intubated and make sure the endotracheal tube is in contact with the vocal cords so that I know the nerve-monitor works appropriately. I I would make sure anesthesia does not paralyze the patient. would place a towel-roll behind the patient’s neck, extend the neck to visualize the sternal notch, cricothyroid membrane, and thyroid cartilage. I would prep and drape the neck, perform a surgical time out, and make a transverse incision two finger-breaths above the sternal notch. I would go through the platysma, raise subplatysmal flaps, dissect the median raphe, get through the sternohyoid and sternothyroid strap muscles, find the left thyroid gland, peel it inferomedially and find the superior parathyroid gland by the superior thyroid pole.

Answer 494

Somewhere between 12 and 75.

Answer 495

I would first review my pre-operative imaging to make sure that I’m not making a mistake and if not, I would have to move on to a 4-gland exploration.

Answer 496

I would get a small sample of it, send it off for a frozen biopsy to confirm that it is a parathyroid gland, and if it is and it looks enlarged, I would reHomove it and check PTH levels again afterwards.

Answer 497

I would be worried about parathyroid hyperplasia so I would take a small piece from one or two parathyroid glands and send it off for permanent pathology. I would also be worried about an ectopic parathyroid gland so I would look around for one. Can also consider bilateral thymectomy. (Otherwise close and do 4D SPECT CCT)

Answer 498

On the superior side, I would look in the tracheoesophageal groove and carotid sheath. On the inferior side, I would pull up the cervical thymus in my surgical field and look in there. I would also get an intraoperative ultrasound and look in the thyroid itself.

Answer 499

I wouldn’t go after it if I couldn’t safely get to it from my cervical incision. I would need to be very convinced that there’s an abnormal gland in the mediastinum for me to go after it, and that would need to be a 2nd planned operation with either a median sternotomy possibly with a thoracic surgeon or a mediastinal thoracoscopy. Doing that now during the index operation would be too morbid without more information so I would abort the surgery.

Answer 500

Replace vitamin D recheck labs

Answer 501

PTH activation of 1 alpha hydroxylase

Answer 502

genetic testing to rule out MEN

Answer 503

Ideally, the landing zone of the aorta should be about 15 millimeters with a diameter of 15-30 millimeters. The iliac artery landing zone should be about 20 millimeters in length and the diameter should be 5-20 millimeters and without heavy calcifications. The aorta should also not be heavily angled so anything up to 60 degrees would be tolerable.

Answer 504

I would get intravascular access in one of the femoral vessels, shoot an aortogram, and then place a sheath with a wire. Once I get up to the aneurysmal sac, I would deploy the stent infrarenal. I would then cannulate the contralateral side and deploy another graft in the iliac artery, and then shoot a completion angiogram, check for distal pulses and close with a percutaneous device.

Answer 505

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.

Answer 506

I would place a foley and a 7 French femoral sheath in case I need to perform an endovascular balloon occlusion if this becomes a free rupture. I would start antibiotics in case he has translocation with bowel ischemia and take him to the operating room for a midline incision. Your hospital does not have a REBOA. As you are prepping, his SBP drops to 60/30. I’m worried that this is now a free rupture. I would activate the massive transfusion protocol and I would get in the abdomen as quickly as possible. I would make a midline incision, put a sponge stick right at the diaphragmatic hiatus, and try to get supraceliac control. After your sponge stick, how would you access the 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. When you open the abdomen, lots of bleeding. You’re able to get supraceliac control but it is still pretty brisk. That’s because I still don’t have distal control so I would perform a right medial visceral rotation and get distal control at both iliacs. Ok, the bleeding slows down considerably. His BP improves with blood products. I would retract the colon cephalad, move all the small bowel out of the way and open the retroperitoneum looking for the proximal and distal ends of the aneurysmal sac. I would ligate all the branches going into the aneurysmal sac to prevent an endoleak. I would get a dacron graft and sew it proximally first and then unclamp the supraceliac aorta and clamp the graft distally to perfuse the bowel and get ready to perform a distal anastomosis. Once I sew the distal end, I would let anesthesia know because once I perfuse the legs his blood pressure might dip again. I would then close the aneurysmal sac over the graft to prevent an aortoenteric fistula. Is there anything else you would do before leaving the operating room? I would check for distal pulses and to see if his leg compartments are tense because I would be worried about compartment syndrome. I prefer to do selective fasciotomies and to watch this patient closely with serial compartment checks and to trend the CK. But if his compartments are tense in the operating room, I would perform a bilateral 4-compartment fasciotomy before leaving the operating room.

Answer 507

Firstly, an EVAR wouldn’t be appropriate for a juxtarenal triple A – those should be repaired with an open repair. I would first get supraceliac control, then iliac control, suture the graft and reimplant the renals directly into the graft. I would also ask my anesthesia colleagues to help with all the adjuncts for renal preservation including administering mannitol, furosemide and keeping the patient’s temperature a little lower than normal.

Answer 508

stent-stent interface; repair with addn endograft

Answer 509

directly through the graft (porosity) and usually heal spontaneously

Answer 510

occur @ attachment sites –needs to be intervened on before leaving operating room (prox 1a and distal 1b)

Answer 511

most common **collateral flow that causes increase in aneurysm sac size endovascular embolization if symptomatic

Answer 512

Ideally, I wouldn’t leave the portal triad clamped for more than 30 minutes.

Answer 513

That would suggest that the patient either has aberrant anatomy with a replaced right or left hepatic artery, or there’s bleeding from the hepatic veins and/or retrohepatic inferior vena cava.

Answer 514

ATRIOCAVAL SHUNT I would need to perform a median sternotomy first to get access to the heart, and more specifically, the right atrium. I would then get a large endotracheal tube, make a 2-centimeter hole on the side near the top of the tube, make an incision in the right atrium, insert the tube all the way down through the heart and into the retrohepatic IVC, blow up the balloon to then shunt blood from below the injury, through the tube, and into the right atrium.

Answer 515

My next option would be to place hemostatic agents in the wound, and try to tamponade it with some sort of balloon like a Blakemore tube. If that doesn’t work, I would attempt a hepatectomy. If I get control of the bleeding, I would then immediately take the patient to the IR suite for angioembolization.

Answer 516

The next maneuver would be to try suture ligation or clipping of any major bleeders. I would do this with a large blunt-tip liver needle using 0-chromic in a figure-of-eight fashion. If there’s omentum nearby and available, I would also try packing the parenchymal injury with omentum. If that doesn’t work, then my next step would be a tractotomy with a linear cutting stapler in an effort to identify exactly what’s bleeding and directly suture ligate it.

Answer 517

MC after high grade liver injuries. Routine post trauma scan of liver to assess for AVF –do 72 h after injury, tx with embolziation

Answer 518

present like GIB. Dx with CTA or EGD (blood from CBD)

Answer 519

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

Answer 520

If distal If proximal (mid trachea) continue breathing spontanoeusly bc don't want it to turn into a complete obstruction

Answer 521

I would make sure I have all my necessary equipment in the room and that everything is working properly including a rigid bronchoscope, lighting, several different types of forceps and suction. I would also have a surgical airway kit available in case I need it. I would pre-oxygenate the patient with a Fi02 of 100% and get his sp02 up to 100% before going after the foreign body.

Answer 522

I would use the rigid bronchoscope with a telescope attached to it. I would visualize the foreign body and once I do, I would take out the bronchoscope, advance optical forceps, grasp the foreign body and pull it out.

Answer 523

I would go back in and take a look at all the airways to make sure there’s no additional foreign body. I would then extubate him if he meets criteria and put him in the ICU for the night for airway watch. I would also give him scheduled nebulizers and albuterol because I anticipate airway edema and bronchospasms from the trauma.

Answer 524

burns, open globe injuries, NM disorders, hyper K+, pseudocholinesterase deficiency, crush injuries, chronic paralysis

Answer 525

14-gauge needle attached to 5 mL syringe punctures skin over cricothyroid membrane Angle 45 degree caudally for insertion through lower ½ of cricothyroid Aspirate air, DC syringe and connect with jet ventilation Convert to formal trach by 24-48 hours

Answer 526

I would prep pt from chin to knees Midline incision Open fascia Pack all quadrants Systematically look at all hollow organs from treitz to rectum, all solid organs including liver and kidneys as well as all retroperitoneal compartments

Answer 527

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.

Answer 528

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.

Answer 529

rectus muscle inferior inguinal ligament inferior epigastric

Answer 530

Ligate round ligament (found in inguinal canal) Return ovary to peritoneum Perform biopsy if looks abnormal

Answer 531

Ext oblique Lat dorsi Iliac crest

Answer 532

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

Answer 533

Howship Romberg sign (inner thigh pain with internal rotation) BOWEL GAS BELOW SUPERIOR PUBIC RAMUS Tx: operative reduction, may need mesh, check other side for similar defect

Answer 534

MAP PA pressure HR SVR CVP MAP PIP CO2

Answer 535

pH Venous return (IVC compression) CO FRC Renal flow secondary to decreased CO

Answer 536

Possibly due to peritoneal stretch receptor mediation via vagus nerve during insufflation Also believed to be proarrhythmic because it can irritate cardiac muscle and alter conduction pathways

Answer 537

Ilioinguinal Genital branch of genitofemoral Iliohypogastric

Answer 538

Cremasteric muscles Testicular artery Vas deferens Pampiniform plexus Ilioinguinal nerve Genital branch of genitofemoral nerve

Answer 539

Transversalis + internal oblique

Answer 540

Below inguinal ligament medial to femoral vein

Answer 541

externa loblique

Answer 542

Posterior rectus sheath/transversus abdominis

Answer 543

I would be worried about either under-resuscitation, a PE or MI. I would listen for breath sounds. I would ask for the UOP, lactate, arterial blood gas, EKG, troponins, and a TEE. For now, I would ask that they bolus him fluids, increase his Fi02 and possibly PEEP. If the hypotension continues, I would start vasopressors.

Answer 544

Spigalian - intramuscular hernia

Answer 545

5-7 mm bites with absorbable suture

Answer 546

Corona mortis (branch between obturator and external iliac artery)

Answer 547

If advanced IR services available at my institution, I would consult IR to perform percutaneous transhepatic biliary drain which would likely allow for GI to subsequently perform ERCP via a guidewire. If unstable, I would recommend surgical common bile duct exploration.

Answer 548

Right subcostal incision After standard cholecystectomy and IOC to confirm and locate filling defect, I would then perform a Kocher. aneuver and attempt to palpate stone I would make a longitudinal incision in CBD and use combination of warm saline irrigation, glucagon administration, biliary fogarty catgheters, and choledochoscope with wire basket if available to attempt stone extraction. Once I had removed the stones, I would perform a completion cholangiogram and close choledochotomy over a T tube. I would also leave a JP drain in this location.

Answer 549

After performing chole, trace the course of cystic duct down to CBD which should be anterior and lateral in porta hepatis. If unclear, I would use 18g needle and syringe to aspirate bile and confirm CBD kocation. I would maek my incision on CBD 1-2 cm distal to cystic duct branch.

Answer 550

If pt UNSTABLE, consider leaving a T tube, closing abdomen, transferring to ICU with further planned IR procedures through T tube when more stable. Otherwise I would perform a transduodenal sphincterotomy by making a transverse incision on lateral aspect of 2nd portion of duodenum. I would then eprform a sphincterotomy on the anterior aspect of the ampulla at the 10:00 position down to the stone or a dilator inserted from above.

Answer 551

Cystic fusiform saccular extrahepatic biliary dilatation MC

Answer 552

If pt UNSTABLE, consider leaving a T tube, closing abdomen, transferring to ICU with further planned IR procedures through T tube when more stable. Otherwise I would perform a transduodenal sphincterotomy by making a transverse incision on lateral aspect of 2nd portion of duo. I would then perform a sphincterotomy on the anterior aspect of the ampulla at the 10:00 position down to the stone or a dilator inserted from above.

Answer 553

Cystic, fusiform saccular extrahepatic biliary dilatation MC Cyst excision or hepaticoj **GB dissected out and clipped at cystic artery. The hepatic duct is identified and divided above the cyst. The cyst is dissected off and removed en bloc with the gallbladder. A standard 40 cm retrocolic Roux limb created and anastomosed to the hepatic duct in an end to side fashion using absorbable monofilament suture.

Answer 554

Extrahepatic biliary diverticulum Excision and primary closure over a T tube, likely roux en y biliary enteric reconstruction

Answer 555

Dilation of EXTRAhepatic INTRAduodenal biliary tree Approach transduo --> transduodenal excision or sphincteroplasty

Answer 556

IVA: intrahepatic and extrahepatic -- hepatic resection, biliary reconstruction IVB: multiple extra hepatic Excision and hepaticojejunostomy

Answer 557

Intrahepatic biliary cyst Actigall to reduce biliary sludge and reduce stasis Can do lobectomy for localized disease in one lobe or transplant for diffuse disease in bilateral lobes

Answer 558

Intrahepatic biliary cyst Actigall to reduce biliary sludge and reduce stasis Can do lobectomy for localized disease in one lobe or transplant for diffuse disease in bilateral lobes

Answer 559

Pull catheter back and try flushing again Trendelenburg to see if chane in imaging (back filling using gravity) Convert to open to investigate injury to hepatic duct

Answer 560

Open duo longitudinally, open medial wall of ampulla directly onto stone itself, ID pancreatic duct orifice (may need to give IV glucagon) and suture ductal mucosa to duodenal mucosa with fine absorbable suture

Answer 561

Preop bx not necessary if radiographic and clinical suggestioned of malignancy Dx lap to r/o disseminated disease (LN mets past porta hepatis and distant mets contraindicate resection as well as multifocal liver disease) Hepatic resection with negative margin is goal

Answer 562

Contralateral hemi-liver must have intact arterial/portal flow and biliary drainage uninvolved with tumor Reconstruction generally with Roux en Y hepaticojejunostomy

Answer 563

MC caused by splenic vein thrombosis secondary to pancreatitis Tx: SPLENECTOMY

Answer 564

2-4 +/- caudate

Answer 565

2-4 + 5 + 8

Answer 566

I would send her home with the T-tube, and I would teach her or her family how to care for it and record the daily output. I would see her back in clinic in 2 weeks. Perform cholangiogram through T tube prior to removal If no filling defects --> cap. F/u in 2 weeks and remove

Answer 567

Paralytic 0.15 mg/kg Safe in cirrhotics

Answer 568

Resuscitation Vasoactive drugs (IV octreotide 25 microg/hr, + IV vasopressin 0.4 U/min) IV ceftriaxone x 7 days Endoscopy, pref within 12 hrs

Answer 569

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

Answer 570

I would call IR and ask them if they would be willing to get a wire across it and either balloon dilate it or place a new stent.

Answer 571

I would insert the tube into his stomach, confirm placement by injecting air and listening with a stethoscope for a rush of air. I would then inject contrast diluted with saline into the gastric port balloon and then retract the tube back until I feel resistance. I would then get a KUB to ensure the gastric portion is pressed up against the gastroesophageal junction. And once that’s confirmed, I would inject contrast diluted with saline into the esophageal port to tamponade the esophagus and again shoot another x-ray to confirm placement. I would then keep the tube on traction using a helmet.

Answer 572

The only surgical intervention I can offer would be to devascularize his gastroesophageal junction by taking him to the operating room, dissecting his GE junction and deploying a TA stapler across it without cutting anything. I would also leave a jejunostomy tube for enteric access before finishing. Alternatively, he may benefit from a shunting procedure so I would talk to one of my hepatobiliary surgery colleagues regarding that because I don’t do that surgery.

Answer 573

Mesocaval -8 mm PTFE shunt between SMV and IVC Identify middle colic v, follow to SMv (to the RIGHt of SMA). ID IVC through R colonic mesentery adjacent to duodenum. anastomose to IVC first then to the side of SMV Does not dissecti n the porta hepatis so it does not compromise potential for future liver txp

Answer 574

Mural nodule >5 mm Obstructive jaundice MPD >10 mm

Answer 575

Cyst >3 cm Mural nodules <5 mm Thickened, enhancing walls MPD 5-9 mm Abrupt change in duct with distal atrophy Lymphadenopathy Cyst growth rate >5 mm over 2 years High CA serum High Ca 19-9

Answer 576

# mutations may predict malignant potential Predicts mucinous Incr # of mutations incr malignant potential

Answer 577

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

Answer 578

After obtaining access into abdomen, I would tak down the gastrocolic ligament all the way to the spleen, ligating the short gastric vessels along the way. I would then enter the lesser sac, and confirm with IOUS the location of the pancreatic mass. I would dissect along the inferior border of the pancreas proximal to the mass, and encircle the pancreas with a vessel lloop. I would then clip and ligate tehe pslenic artery at teh superior aspect of the pancreas followed by stapled transection of the pancreatic body and splenic vein. Finally I would free the pancreas from any retroperitoneal attachments using an energy device and take down remaining attachments to the spleen to remove the speicmen. I would leave a JP drain at the pancreatic stump before closing.

Answer 579

Distal to proximal dsisection En bloc resection to include cholecystectomy REsect to healthy right and left ducts Resect the caudate lobe if needed Perform RYHJ

Answer 580

REsect the GB and CBD to intra pancreatic portion adn hepatic ducts Create RYHJ

Answer 581

Methylnaletrexone

Answer 582

Acetylcholinesterase inhibitor

Answer 583

Mechanical bowel obstruction, distal obstruction Suspected ischemia or perforation Cardiac arrhythmias, recent MI Bronchospasm Hypotension, bradycardia Pregnancy Renal failure Cr >3

Answer 584

Transfer pt to monitored unit, place on telemetry Atropine and glycopyrrolate drawn and available as lethal side effects include BRADYCARDIA and BRONCHOSPASM After disucissing side effects with pt administer 2 mg of neostigmine IV over 5 minutes. Monitor for bowel function and continue cardiac monitoring for 30 min post procedure If there is partia lresponse, repeat in 24 hrs. I successful I would admin oral PEG for 7 days to prevent recurrence

Answer 585

Endoscopic decompression (colonoscope advanced as far as possible iwth minimal insufflation. Palce decompressive tube under direct visual guidance. Placed to LIS for 73 hrs then discontinued. Can repeat cscope PRN. If still unsuccessful, can consider cecostomy. If colon appears compromised, subtotal colectomy and end ileostomy.

Answer 586

My camera port would be placed 2/3rd of the way down from the xiphoid to the umbilicus, a little bit to the left of the midline. I would place an assistant port at the subcostal left anterior axillary line, and a mirror opposite port on the contralateral side for my liver retractor. I would place my right hand, which would be a 12 mm port where the falciform ligament enters the abdominal wall, and one hand-breath width away to the patient’s right would be where I place a port for my left hand.

Answer 587

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.

Answer 588

4 sutures in diamond formation along antimesenteric portion → enterotomy in middle of 4 sutures and 12-14 Fr silastic tube advanced into bowel directed distally along jejunum → 4 sutures anchored to abdominal wall using Carter-Thomason passer with tails tied extracorporeally → suture drain to skin with 3-0 nylon suture

Answer 589

As b below

Answer 590

Lesser curve Wedge resection

Answer 591

II: gastric and duodenal Type III: pyloric/prepyloric Tx: Truncal vagotomy and antrectomy

Answer 592

R hemi (ligation of ileocolic, R colic, R branch of middle colic, removal of 5-8 cm of ileum to proximal transverse colon)

Answer 593

Perfomr extended right hemicolectomy (ligation of ileocolic vessels to middle colic artery, removal of TI to splenic flexure, anastomosis between ileum and descending colon)

Answer 594

perform sigmoid colectomy (ligation of IMA distal to takeoff of left colic, anastomosis between descending colon and upper rectum)

Answer 595

Perform LEFt hemicolectomy (ligation of L colic with removal of descending colon and splenic flexure with anastomosis of transverse to upper sigmoid)

Answer 596

I would evaluate the entire bowel and then mobilize the right colon from medial to lateral. I would divide the ileocolic vessel and find a proximal transection point in the terminal ileum at a place that doesn’t appear grossly inflamed just proximal to the strictured segment. I would divide the bowel there, as well as the right colon using an EndoGIA stapler. I would then perform a primary anastomosis and finish the operation.

Answer 597

TSH/T3/T4 B-hCG LH Estradiol Testosterone LFTs

Answer 598

H2 blockers antipsychotics? marijuana steroids

Answer 599

That’s a great question – the lifetime risk of breast cancer in males with BRCA-2 is about 8% which is less than the lifetime risk of cancer in the average female, so a prophylactic mastectomy is not recommended. I would recommend yearly PSA testing because males with BRCA mutations do have a higher risk of prostate cancer. I would also recommend that his siblings and his children, if he has any, get tested.

Answer 600

If it’s in the esophagus, it needs to be removed. Since he’s only 4 and likely wouldn’t tolerate an awake EGD, I would recommend he gets intubated prior to the scope using rapid-sequence intubation since he’s high risk for aspiration.

Answer 601

The concern with a battery in the stomach is that it has the potential to cause a corrosive injury. Since it’s 3-centimeters in diameter, and the child is only 4 years old, I highly doubt that the battery would traverse the pylorus and make it around the duodenum so I would recommend the same thing, intubation with RSI and endoscopic removal.

Answer 602

It would be reasonable to watch him in the hospital overnight. I would also get a swallow study to make sure there’s no lesions and I would get an x-ray of the abdomen to make sure the battery made it into the small bowel. If it remains in the stomach for more than 2 days, it should get removed endoscopically.

Answer 603

I would discharge the patient and see him back in clinic every 2-3 days with another x-ray. I would also ask his parents to check his stool after every bowel movement to confirm it came out. I would also give them return precautions and tell them to come back to the ED if he develops any significant abdominal pain, nausea, vomiting or fevers.

Answer 604

I would attempt to take it out at bedside. I would place the patient in lithotomy and Trendelenburg position and perform a perianal block with local anesthetic. I would also perform conscious sedation using ketamine and make sure the patient’s on a cardiac monitor with an oxygen sensor on at all times. I would then use lubricant and try to grab the object to remove it. If that doesn’t work, I would ask an assistant to help apply suprapubic pressure. If my fingers can’t get to it, I would use some sort of instrument like ring forceps or Kocher clamps. NEXT I would get a Foley catheter balloon – try to maneuver it above the can, inflate the balloon and pull to try to remove it that way. NEXT I would take him to the operating room to perform an exam under anesthesia, flexible sigmoidoscopy, as well as a laparotomy and possible resection. But before I do that, I could be more aggressive in trying to remove it when he’s under general anesthesia. I would try some of the same maneuvers I did before but more aggressively since he would now be asleep.

Answer 605

I would try to milk the object from above and out the anus. If that doesn’t work, and the rectum appears healthy, I would make an incision on the rectum, remove the object trans-rectally, and then perform a primary repair.

Answer 606

With all cancer patients, ideally, I would like a tissue diagnosis. So, I would ask my IR colleagues if they would be willing to perform a CT guided core-needle biopsy. I would also review the CT with a radiologist to see how involved the left kidney is but it’s involvement now explains the gross hematuria. His DVT also needs to be treated with therapeutic anticoagulation, but I would like his anticoagulation held for the tumor biopsy to avoid bleeding. And I would also keep a close eye on the hematuria to make sure that doesn’t significantly worsen with anticoagulation.

Answer 607

The next step is to stage the patient with a CT head and chest looking for evidence of distant metastases. I would also present the patient at a multidisciplinary committee, and in the absence of distant metastasis my recommendation would be to proceed with complete surgical resection including a left nephrectomy. However, I would first get a renal scan to make sure the right kidney is functioning well. I would also get a urology consultation to help me remove the kidney in the operating room.

Answer 608

I would first survey the abdomen to make sure there’s no obvious evidence of distant metastasis to the peritoneum or liver. The key with all retroperitoneal mass resections is to keep the tumor capsule intact as a break in the capsule can seed the tumor and increase the risk of local recurrence. Aside from that my goal would be to remove the tumor in its entirety. Leaving any tumor behind increases the risk of local recurrence and so for this patient, I would perform a left sided nephrectomy as well, ideally with a urologist. I would then close the fascia and observe the patient in the hospital until he meets discharge milestones.

Answer 609

I would present the patient at a multidisciplinary committee. I don’t think there’s any great chemotherapy agents to treat this but if there’s a clinical trial that one of my medical oncology colleagues is aware of that’s something we can pursue. Similarly, there’s no role for radiation because the background radiation would be too toxic to the bowel. If there’s no clinical trials or new chemotherapeutic agents available, my plan would be to follow the patient with a CT scan in 6 months and I would let him know that there’s a high chance of this recurring, and if and when it does, we can discuss surgical resection at that time.

Answer 610

evaluate excessive endocrine hormone production, elevated germ cell tumor markers such as AFP, b-hCG, and LDH

Answer 611

critical vasc involvement, peritoneal implants, involvement at root of mesentery, or SC involvement

Answer 612

injury to splenic flexure of the colon, maybe an injury to the spleen or splenic vasculature with an area that’s infarcted, similarly, a kidney infarction, a pancreatic tail injury with a pancreatic leak or a postoperative abscess in the left upper quadrant

Answer 613

bilateral adrenal nodules, unilateral nodule <1 cm, normal-appearing glands, age >35 yo

Answer 614

PO sodium loading (6 d/day of sodium for 3 days) --> 24 hr urine collection for urinary sodium and aldosterone levels

Answer 615

What if both sides enlarged, both appeared to be functional and secreting aldosterone?

Answer 616

IVF w/o K K supps discontinued Monitor for hyperkalemia Titrate anti-HTN

Answer 617

50 mg IV hydrocortisone q6h and symptoms resolve. Plan for steroids –transition to oral dosage and do very slow taper as outpatient. Over many months. 3-12 months.

Answer 618

ACTH independent (adrenal mass)

Answer 619

I would first survey the abdomen to make sure there’s no obvious evidence of distant metastasis, and if I find anything concerning I would biopsy it and send it as a frozen for pathology intraoperatively. If there’s no evidence of distant metastasis, I would perform a total gastrectomy with an esophagojejunostomy. I would send the margins as a frozen biopsy to confirm they’re negative before I perform a reconstruction. I would perform a D1 lymphadenectomy where I remove all the perigastric lymph nodes. In addition, the NCCN guidelines now advocate for a modified D2 lymphadenectomy where you remove all the lymph nodes along the named vessels including the splenic, common hepatic and celiac. I would only remove the spleen if the hilum or the spleen were involved. The patient already has a jejunostomy tube so there’s no need to do that but if he didn’t have one, I would put one in before leaving the operating room. I would also leave two drains, one by the duodenal stump, and one around the pancreas and spleen where I performed the lymphadenectomy.

Answer 620

I would keep the patient NPO for two weeks with a plan to study my reconstruction with a swallow study at that time. I would start feeding through the jejunostomy tube on post-operative day one. I would plan on checking bilirubin and amylase levels from the drains on day three, and if negative, I would pull them out. If the swallow study does not demonstrate a leak at the two-week mark, I would start a bariatric clear liquid diet. I would make sure he has follow-up with oncology because he’ll also need adjuvant chemotherapy following the surgery. In terms of follow up with me, I would plan to see him for a history and physical exam in 2 weeks and to review his swallow study. After that he needs follow up every 6 months for two years. At the 1-year mark, I would plan on getting a CT scan to make sure there’s no obvious lesions. He also needs lifelong supplementation of a multivitamin along with iron and B-12.

Answer 621

Vit B12 Iron

Answer 622

Encourage frequent meals scheduled throughout day Consume a diet high in protein and fiber, and low in simple carbohydrates or concentrated sweets Avoid fluid consumption with meals

Answer 623

Consider treatment with antibiotics (rifaximin 550 mg TID x 7–10 days preferred) Consume a diet high in protein and low in carbohydrates

Answer 624

transhiatal/transthoracic esophagectomy with proximal gastrectomy and gastric pull-up with cervical/thoracic esophagogastrostomy

Answer 625

subtotal gastrectomy with BII or Roux en Y

Answer 626

Midline lap, full exploration → Mobilize GEJ and esophagus, taking margin of diaphragmatic crura → separate omentum and lesser sac lining en bloc from transverse colon → divide short gastric vessels and skeletonize celiac, splenic, and common hepatic aa., taking LN → ligate L and R gastric and gastroepiploic aa at bases → divide esophagus, stomach, and jejunum (send margins for frozen)→ reconstruction with EJ and JJ → place J tube if not present → drains at duodenal stump and EJ anastomosis

Answer 627

accessory L hepatic artery

Answer 628

The next step is to treat him because he has chronic pain. The first step is to advise him to quit drinking, because this is unlikely to get better if he keeps drinking. I would refer him to an alcohol cessation program and make sure he understands that his drinking is related to his epigastric pain, and quitting drinking will infinitely improve his overall health. Since he’s malnourished, I would also ask him to start drinking nutritional shakes as those are packed with calories – and I would also start him on pancreatic enzyme supplementation to help him digest his meals. And lastly, I would start him on a daily multivitamin including vitamin K for the elevated INR.

Answer 629

The next step would be to try to augment drainage with a pancreatic stent. I would refer the patient to GI to perform an ERCP and place a pancreatic stent.

Answer 630

It’s possible that the stent has migrated or been occluded. I would check his blood work, get a KUB to see if the stent has migrated and if so ask to reconsider repositioning or replacing the stent.

Answer 631

The next step is to pursue a celiac-axis block. I would refer the patient to a pain specialist for that. If the pain specialist wants to use any narcotics as an adjunct to that, it would be reasonable, but I would ask that they manage the narcotics.

Answer 632

I would use a midline incision and first survey the abdomen. I would then divide the short gastrics to get access to the pancreatic body. I would kocherize the duo to help identify the pancreatic head as well. Once the head and body are exposed, I would identify the pancreatic duct using a 25-guage needle. If I can’t find it, I would use an intraoperative ultrasound and mark it out. I would then dissect through the pancreatic parenchyma towards the duct using electrocautery, first towards the tail and then the head. I would then find the LoT and about 15 cm distal to this is where I would bring the roux limb up. I would then perform a side-to-side pancreticojejunostomy over a stent followed by a jejunojejunostomy. I would then leave drains and finish the case.

Answer 633

Lateral pancreaticojejunostomy/Puestow

Answer 634

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)

Answer 635

Frey procedure (coring out pancreatic head and essentially lateral pancreaticojejunostomy but going all the way to the pancreatic head)

Answer 636

I would send an EKG and troponin level in addition to a full set of labs including CBC, CMP, amylase, lactate and coags. I would also give him with a 1-liter bolus of fluids for the tachycardia. I would also get a chest x-ray making sure the neck is also in the film to look for free air, as well as an abdominal ultrasound to look for evidence of cirrhosis.

Answer 637

I would have tried a CT esophagram. If that was negative, and my suspicion was high, I would do an EGD next, but I would be very careful in advancing the scope only under direct vision and using minimal to no insufflation. Another option would be to place a chest tube in that pleural effusion, and if you see gastric contents – that would confirm the diagnosis.

Answer 638

NPO, IVF, IV abx + anti fungals Chest tube D/w GI re: stent (knowing prox and distal esophageal perforations stent is less likely to be effective)

Answer 639

Since this is a distal esophageal leak, I would perform a left sided posterolateral thoracotomy. I would ask anesthesia to use a double-lumen endotracheal tube so the lung won’t be in my way. The principle of this operation is source control. I would find the esophageal perforation, extend the myotomy so I can visualize the full extent of the injury and make sure there’s not an injury to the contralateral side. I would then debride any devitalized tissue and decide on a primary repair or a diversion depending on how much of the esophagus is injured.

Answer 640

There are three options – one is to place a T-tube with the short arm in the proximal esophagus, long arm in the stomach, and the T portion coming out from a separate skin incision. That would divert flow away from the perforation, allow for resuscitation in the ICU and I can come back another day. Another option, and the one that I would do would be to transect just distal to the perforation with a TA stapler. And then make a left sided neck incision to perform a cervical esophagostomy for diversion. He would also need a jejunostomy tube for feeding. I would then leave drains around the transected esophagus or a left sided chest tube and leave the OR. I would then perform a reconstruction many months later once he’s healthy and all the pathology’s back. And the last option, If the patients in extremis, I would widely drain the area and leave the OR.

Answer 641

pneumomediastinum left pleural effusion

Answer 642

I prefer selective shunting so I would look at both the back pressure and continuous intraoperative EEG monitoring so I would make sure that’s all set up for me. I would place a towel-roll behind his shoulders and turn his head towards his left. I would prep and drape the neck and after a surgical time-out I would make an incision on the anterior border of the sternocleidomastoid muscle. I would retract the muscle laterally, find the carotid sheath, open it and ligate the facial vein. I should then be able to find the IJ, common carotid bifurcation, internal carotid, and external carotid arteries. I would give the patient systemic heparin, 100 units per kilogram, and then clamp the ICA first, common carotid second, and external carotid third. I would then open up the common carotid at the bifurcation and extend it up to the ICA as far distally as I can to perform the endarterectomy between the intima and media. I would of course be careful not to injure the vagus nerve which would be posterior to the artery and vein, or the hypoglossal nerve which would be near the angle of the mandible. Once the plaque is removed, I would clean out any debris with heparnized saline and reconstruct with a patch angioplasty using bovine pericardium. Before I finish the patch angioplasty I would allow for back and forward bleeding, finish the repair, and then remove the clamps by taking off the external carotid first, and then common carotid so any debris gets flushed into the face instead of the brain. Before I leave the operating room, I would perform a completion ultrasound to make sure there’s no stenosis, residual debris, or obstructive lesions. I would then close the neck in layers and leave a subplatysmal drain. After he wakes up, I would perform a complete cranial nerve exam.

Answer 643

There are three things I would try. One would be a mandibular subluxation, another option would be dividing the digastric muscles and the third option would be fracturing the styloid process. If none of those work, he may need a stent.

Answer 644

I would take down the patch angioplasty, tack up the intimal flap, and redo the patch angioplasty with new bovine pericardium. I would again do a completion ultrasound before I leave the operating room.

Answer 645

I would take down the patch angioplasty, tack up the intimal flap, and redo the patch angioplasty with new bovine pericardium. I would again do a completion ultrasound before I leave the operating room.

Answer 646

Asymptomatic and >60% stenosis of ICA or CCA —> OR Symptomatic and >50% stenosis of ICA or CCA —> OR

Answer 647

It’s chemoradiation with 5-FU and mitomycin-C and 45-grays of radiation delivered in 25 fractions over 5 weeks.

Answer 648

I would first survey the abdomen to make sure there’s no evidence of metastasis. I would mobilize the left colon and sigmoid down to the peritoneal reflection and choose a proximal transection site which I would perform using a stapler. I would perform high ligations of the IMA and superior rectal artery and start a total mesorectal excision until I get to the pelvic floor. I would then approach it from the perineal slide continuing cephalad to meet the intra-abdominal portion of the dissection. Once the specimen is freed from the surrounding structures, I would remove it and close the defect. Since the field had previously been radiated, I would close the defect using a myocutaneous flap, and then close the soft tissue and skin in several layers. I would leave a drain in the pelvis, bring up the ostomy, close the fascia and then mature the ostomy.

Answer 649

Local excision with 1 cm margin

Answer 650

I remember the acronym VACTERL which would be vertebral, anorectal, cardiac, tracheal, esophageal, renal and limb anomalies. I would get x-ray studies to rule out vertebral anomalies. Any anorectal malformations can be ruled out with a complete physical exam which I would perform. Similarly, a cardiac anomaly can be suggested by the exam with a murmur, but I would order an echocardiogram regardless. I would also order a renal ultrasound looking for any lesions to the kidneys. And limb anomalies can be ruled out with a physical exam, but I would get x-rays to rule out occult skeletal anomalies. I would also send a karyotype.

Answer 651

Look for # of vert bodies on X-ray to determine if you can perform primary anastomosis <3 —> primary anastomosis >3 —> re-evaluate month 3-4 of life

Answer 652

Left sided aortic arch —> R posterolateral thoracotomy R sided aortic arch —> L posterolateral thoracotomy

Answer 653

I wouldn’t be able to bring it together during the index operation so my goals would be to provide him with a spit fistula for sham feedings, as well as a gastrostomy tube for real feedings, and re-evaluate him when he’s 3 or 4 months old to see if it’s amenable to a primary anastomosis then. What if it’s still not amenable? I would then consider letting him get a bit older and maybe using his stomach or colon as a conduit to connect the two ends.

Answer 654

It’s a type of treatment involving a probe inserted in the anus while the patient squeezes and views the muscle activity on a computer screen. A nurse therapist is also there guiding the patient with the goal of coordinating the rectoanal reflex to increase pushing effort as reflected back to the patient by a computer display to help synchronize relaxation of the anal sphincter.

Answer 655

I would move on to my secondary survey paying close attention to his neck wound, palpate for crepitus which would make me concerned for a tracheal injury, and for a thrill which would suggest an AV fistula. I would also look to see if the platysma was violated, although that can be difficult to tell with a small wound. I would get a good baseline neurologic exam and see if there’s any obvious cranial nerve injury. I would also ask the patient if he’s able to swallow or if it’s painful to swallow or if he’s spitting up a lot of blood as all those would be concerning for an esophageal injury to me. I would also want the patient to phonate loudly and see if his voice is hoarse or if he has trouble projecting his voice which would indicate a recurrent laryngeal nerve or superior laryngeal nerve injury, respectively.

Answer 656

I would manage that with antiplatelet therapy, close initial observation with neurovascular checks and repeat imaging in a week.

Answer 657

I would intubate in the ED and take the patient immediately to the OR to explore his neck.

Answer 658

I would make sure the OR has a vascular tray open in the field. I would prep the patient from his chin to his knees. I would make sure both groins are exposed, and hair is clipped. I would place a towel roll behind the shoulders and turn the neck slightly away from the injury. I would start by getting proximal control with an incision just caudad to the hematoma, and anterior to the sternocleidomastoid muscle. I would retract the muscle laterally, access the carotid sheath, and then control the common carotid with a Rummel torniquet. I would then try to get distal control cephalad to the hematoma if possible. I would then expose the remainder of the common, internal, and external carotid arteries, ligating the facial vein to expose the bifurcation. I would also expose the internal jugular vein, and make sure to identify and protect the vagus nerve which sits between the artery and vein.

Answer 659

I would not ligate the internal carotid artery – that is something that needs to be repaired. I would harvest greater saphenous vein and perform an interposition graft.

Answer 660

I would use a Fogarty balloon to get control. The mandible can be divided or subluxed to get distal control. I would also see if my ENT or vascular surgery colleagues can come help.

Answer 661

I would resect any obvious injured artery, then try to mobilize the common carotid and perform a primary end to end anastomosis, provided it’s less than 2 centimeters.

Answer 662

Swallow study and EGD

Answer 663

It’s a metric to grade the severity of the carcinomatosis. The peritoneum is divided into 13 regions and 0-3 points are assigned to each region depending on the size of the largest tumor, and a total score is calculated. Generally, the higher the score, the worse the prognosis is, and less likely that a HIPEC would benefit them.

Answer 664

I would first survey the abdomen to look for anything obviously necrotic or perforated and temporarily control it. I would then detorse the bowel in a counterclockwise fashion until it’s completely detorsed, which may take 3 or 4 full turns. I would then divide the lads bands which are the peritoneal attachments of the colon to the paracolic gutter. I would then straighten the duodenum and place the small bowel in the patients right upper quadrant, and place the colon in the patients left lower quadrant. I would then widen the base of the mesentery and perform an appendectomy. I would wash out the abdomen and if it all looks good, and the patient is doing well, I would close the fascia and skin.

Answer 665

I would make a lateral incision about 2 fingerbreadths in front of the fibula, and about 2 fingerbreadths below the knee and 2 fingerbreadths above the ankle. I would make a H-shaped incision in the intramuscular septum and open it cephalad and caudad. That would expose the lateral and anterior compartments. I would then make the medial incision 2 fingerbreadths posterior to the tibia, and about 2 fingerbreadths below the knee and 2 fingerbreadths above the ankle. I would then open the fascia and remove the soleus fibers from the underlying tibia until I identify the neurovascular bundle. That should get me access to the superficial and deep posterior compartments.

Answer 666

I would keep the patient on a heparin drip since this was a clot secondary to likely atrial fibrillation. I would get an echocardiogram looking for a thrombus in the left heart. I would put him in the ICU for hourly neurovascular checks, and I would trend his CKs. If there’s any concerning change in his clinical exam or elevation in his CK I would check compartment pressures.

Answer 667

I would be worried that I didn’t adequately release one of his compartments. I would take down his dressing at bedside and look at the muscles. If I’m unable to get a good exam at bedside, I would take him back to the operating room to explore. I would also check his other extremities, his back, and buttocks to make sure there’s no other potential source for the elevated CK. MAY be a result of rhabdo -- aggressive fluid resuscitation with goal uop 1 cc/kg/hr

Answer 668

Are they able to intubate the ileocecal valve to see if there’s bleeding in the small bowel?

Answer 669

He’s now had three episodes of life-threatening bleeding; I think it’s critical we identify a source and address it because he’s at high risk of going home and bleeding to death. Ideally my hospital would have a hybrid suite, and if it does, I would talk to my IR colleagues about doing a provocative angiography study to try to identify the bleeding source – we can use vasodilators or even intravascular heparin. If we do it in the hybrid suite, and the patient develops uncontrolled life-threatening bleeding, we would be ready for a surgical intervention. And if I don’t have a hybrid suite available, I would secure an operating room and an anesthesiologist so we can get the patient to the operating room immediately from the IR suite if he starts bleeding profusely and they can’t stop it.

Answer 670

I would take him to the operating room. This is a challenging situation because I’ve not yet identified a bleeding source. However, he’s 68 and most of the time it’s from the colon. However, it’s not implausible that he’s bleeding from his small bowel so if he’s semi-stable, I would ask GI to join me in the OR to perform a double-push enteroscopy to help me evaluate the remainder of the small bowel. If they aren’t able to, I would stick a scope through an enterotomy in the jejunum and evaluate both proximally and distally – if there’s no bleeding in the small bowel, I would go ahead with the total abdominal colectomy.

Answer 671

I would say that it depends on your risk factors. If he has no risk factors meaning no family history of colorectal cancer than I would recommend he starts screening at age 45, and if there’s no abnormalities, he should continue screening every 10 years. If he has any first degree-relative diagnosed with colorectal cancer before age 60, I recommend he starts screening at age 40 or 10 years earlier than the age that his first-degree relative was diagnosed with colorectal cancer. And finally, if he has any two first degree relatives diagnosed with colorectal cancer at any age, I recommend he starts screening at age 40.

Answer 672

Yes – there are alternatives. He can get an annual fecal occult blood test plus a flexible sigmoidoscopy every 5 years. However, if he has any abnormalities on either of those studies, he would need a full colonoscopy.

Answer 673

Sure – there’s 4 levels depending on where the foci of adenocarcinoma is localized and it only applies to pedunculated polyps. Level 1 is localized in the head, level 2 is at the neck, level 3 is anywhere along the stalk and level 4 is below the stalk. Level 1 to 3 is considered low-risk and level 4 is considered high risk.

Answer 674

I would score the peritoneum on the mesentery to get additional length. If that doesn’t work, I would find individual vessels in the mesentery, clamp them, check the integrity of the bowel with fluroesence and if the bowel’s not ischemic and ligating the vessel affords me additional length, I would ligate it.

Answer 675

No – there’s two classification systems for sessile polyps. One is the SM level, which there are three, SM1 is the top third, SM2 is the middle third and SM3 is the bottom third. The better and simpler classification system is by looking at the depth, if its less than 1 millimeter deep, its low-risk and if its greater than 1 millimeter deep, its high risk.

Answer 676

Yes – I would stop PPI therapy before this test. I would draw a baseline gastrin level and then administer 2 units per kilogram of secretin to the patient and check another serum gastrin level every 5 minutes for half an hour. If the patient has an increase in serum gastrin by>200 above baseline, that confirms the diagnosis of gastrinoma. In the absence of gastrinoma, secretin would cause serum gastrin levels to decrease.

Answer 677

I think I’ve ruled out the obvious things at this point. In an effort to be 100% sure that this isn’t an underlying infection, I would send blood cultures and a urine culture. I would also order a metabolic encephalopathy panel including HIV, syphilis, B12, folate, thiamine, and cortisol levels. But I suspect this to be a result of delirium which is a diagnosis of exclusion. There are several things to support a diagnosis of delirium including his older age, significant initial clinical presentation, a prolonged ICU stay, an emergency surgery and the waxing-and-waning nature of his confusion.

Answer 678

Most of the management is really prevention. If the patient has hearing aids or wears glasses, I would ask his family to bring those in. I would also ask his family members to visit often and to leave familiar objects in his room. I would promote proper sleep hygiene - stay awake during the day with a lot of sunlight in the room, and sleep at night. I would prescribe melatonin which can help regulate his sleep/wake cycle. I would minimize IV lines, and any tubes going inside the patient’s body so remove the NG tube and foley as soon as possible. I would ask physical therapy to work with the patient daily and promote early ambulation. I would limit deleriogenic medications and limit blood draws and vital checks at night so that he can sleep uninterrupted.

Answer 679

There are two surgeries to consider. One is a total proctocolectomy with an end ileostomy and the other is a total proctocolectomy with an ilial-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.

Answer 680

In this case, yes, because the rectum is also involved. In cases where the rectum doesn’t have any polyps, it’s reasonable to consider a total colectomy instead of a proctocolectomy but then the patient will need to continue to get screening of his rectum every 2-years.

Answer 681

Hemobilia after liver trauma is caused by a fistula from the biliary tree and vasculature. I would start blood transfusion and perform an emergent EGD in case this is related to a stress ulcer or something that can be treated endoscopically with a clip. If I find blood emenating from the ampulla that would be highly suggestive of hemobilia and I would ask IR for an emergent angioembolization.

Answer 682

I would start the patient on RIPE therapy with rifampin, INH, pyrazinimide, and ethambutol. He would need to have his LFTs monitored during treatment which would be for a total of 6 months.

Answer 683

One of the most important things I can do right now is to prevent any secondary insults to the brain, that is to prevent hypoxia and malperfusion. My standard maneuvers for TBI are to place a foley and an OG tube, tilt the head of the bed 30 degrees, start levetiracetam, and look for any obvious signs of elevated intracranial pressure.

Answer 684

Cushing’s triad with bradycardia and hypertension would be concerning. Other signs I would look for would be a dilated pupil or a unilateral gross neurologic deficit.

Answer 685

As long as he’s not hypotensive, I would give mannitol, 0.5 grams per kilogram. I would also check an INR in case I need to further reverse his coagulopathy. I would also make sure his platelets are normal and I would send a TEG. I would then order a repeat non-contrast CT head since he’s had a significant change in his exam. I would again call my neurosurgery colleagues to let them know about the change in his neurologic exam.

Answer 686

This makes me worried about intracranial hypertension. I would give him hypertonic saline, make sure he’s appropriately sedated with a propofol and fentanyl infusion. I think this patient really needs a neurosurgical intervention. I would ask the fellow to consider placing an EVD which can help measure his ICPs and potentially treat it if its elevated. He may also be a candidate for a craniectomy, but I would defer that decision to the neurosurgeon. And while I’m waiting for the hypertonic saline to work, I would hyperventilate him to a PaCO2 of around 32 but only transiently. The only two other things that may help would be a barbiturate coma or a paralytic. For the former, I would place continuous EEG monitors and give him enough barbiturates to suppress his brainwaves. The problem with this is it can last a long time and so it can become problematic getting a good neurologic exam. For that reason, I like to instead use a paralytic. For that I can use a peripheral nerve stimulator to measure the efficacy of the paralytic, and dial it down to get a neurologic exam, as long as his ICPs allow me to.

Answer 687

He needs to be monitored in the surgical ICU with q1 hour neurochecks. I would start a PPI and keep his sodium between 145 and 150. Depending on if he’s going to the operating room or not, I would want to start him on enteric feeding as soon as possible with a post-pyloric tube, if available. I would also ask the neurosurgery team to join me in a conversation with the patient’s wife and any other family members to discuss the diagnosis, possible treatment options, goals of care and his code status.

Answer 688

Yes – I would first make sure that there were no metabolic derangements or iatrogenic causes for the GCS of 3 including the administration of any medications like benzodiazepines or paralytics. I would make sure the temperature and blood pressure are normal, and if so I would then move on to a neurologic exam. I would check for a response to verbal or noxious stimuli, check to see if the pupils are fixed, confirm the absence of brainstem reflexes like the corneal, oculocephalic, oculovestibular, and gag reflexes. And if all those are absent, I would then perform an apnea test by first drawing an ABG to see what the baseline paC02 is, and then disconnecting the patient from the ventilator and providing blow-by oxygen around the endotracheal tube and rechecking an ABG at around the 8-minute mark. If the pac02 is greater than 60 and 20 points higher than the baseline pac02 then the apnea test is positive and suggestive of brain death. The neurologic exam will then need to be repeated by another physician and if they agree with my findings, the patient will then be considered brain-dead.

Answer 689

Yes – with a high spinal cord injury, the patient will be unable to breath on their own because of the loss of innervation to the diaphragm via the phrenic nerve, and so an apnea test would be unreliable. I would still perform a neurologic exam but in order to confirm brain death I would order an objective confirmatory study with either a 4-vessel cerebral angiography or a nuclear medicine cerebral blood flow study.

Answer 690

I use the NEXUS criteria. If he has a neurologic deficit, spinal tenderness, if he’s altered or intoxicated, or has a distracting injury, I would keep the c-collar on. You can argue that a femur fracture is a distracting injury so if the leg is quite painful for him, I would also get a CT c-spine.

Answer 691

I would mark the saphenous vein with an ultrasound on the contralateral leg in case I need to harvest it. I would prep and drape the bilateral lower extremities all the way to the groin. I would place the patient in a frog-leg position and get proximal and distal control of the popliteal artery. For proximal control I would make a medial longitudinal incision on the distal third of the thigh along the anterior border of the sartorious muscle. I would then dissect down towards the adductor magnus muscle, which along with the sartorious muscle comprises the lower edge of Hunters canal. And between the two muscles, I would find the vascular sheath. The artery is situated medial to the vein and is encountered first when opening the sheath. I would then place vessel loops. I would then get distal control of the infrageniculate popliteal artery by making a medial longitudinal incision one-thumb width posterior to the tibia. I would then expose the superficial posterior compartment and start taking the soleus fibers off the underside of the tibia to enter the posterior deep compartment. That should then get me access to the neurovascular bundle where I can find the artery. I would heparinize the patient with 100 units per kilogram and get proximal and distal control. I would then debride all devitalized tissues from both edges. I would use a Fogarty balloon to remove clot proximally and distally making sure there’s appropriate forward and backward bleeding. I would then place an arterial shunt to temporarily establish flow and allow orthopedic surgery to come in and do their part of the surgery.

Answer 692

I would use the largest argyle shunt possible that fits inside the vessel. I would place a silk suture in the middle of the shunt, insert the proximal end first followed by the distal end. I would then tie the shunt to the vessel on both ends trying to conserve as much of the vessel as possible for the definitive repair. I would then tie those sutures to the suture I previously placed in the middle of the shunt so that it doesn’t migrate.

Answer 693

Rib plating is never my first-line option. I only consider it in patients that have failed conservative management with a multimodal pain regimen including an epidural catheter that have either a flail segment or at least 3 or more rib fractures with bicortical displacement. Also, I think the posterior ribs, close to the spine get very little benefit from rib plating so that plays into my decision as well. Rib fractures in the anterolateral or posterolateral locations would benefit most from rib plating.

Answer 694

It will stabilize the chest wall and improve the mechanics of breathing and reduce pain. In doing that it might reduce the rate of intubation, ventilatory days, ICU length of stay and pneumonia.

Answer 695

I would make sure the patient’s type and crossed, gets VTE chemo prophylaxis and antibiotics preoperatively, and I would place a foley after he gets intubated. I would then position him in the left lateral decubitus position using a bean-bag making sure all pressure points are padded. In the posterior location I would dissect into the auscultatory triangle which is bordered by the scapula, trapezius, and latissimus. I would reduce the rib fractures and place a plate making sure its flush with the rib along the length of the plate. I would then fix it in place with at least 3 screws on either side of the fracture.

Answer 696

Veno-venous ECMO would be appropriate for this patient as he has a functioning heart, but his lungs aren’t able to oxygenate his blood. The ECMO unit will replace his lungs in that regard and oxygenate his blood. To be able to place a patient on VV ECMO you need to place two large catheters, 21 to 24 French, in two big veins. Either one in the right internal jugular going towards the right atrium and another in the femoral vein positioned right above the renal veins in the IVC. Alternatively, you can place two catheters in the femoral vein about 5 centimeters apart from one another with both above the renal vein and the return unit higher up towards the heart.

Answer 697

I would make a curvilinear incision above the umbilicus, open the fascia, grab the pylorus and open the serosa and muscle just proximal to the pyloric vein on the duodenum, and extend that incision onto the antrum. Once I see the pink mucosa bulging out, that’s when I would know that my myotomy is complete. I would complete a leak test by asking the anesthesiologist to inject some air while the pylorus is submerged under saline to look for bubbles.

Answer 698

That is consistent with a leak, and I would fix it. There are two options, one is to repair the mucosal defect with 4-0 absorbable suture, re-approximate the muscle and buttress the repair with omentum. You would then need to re-do a myotomy on the contralateral side. The other option is to repair the mucosal defect, keep the muscle open, and buttress the repair with omentum. I would probably elect to the latter if a repeat air-leak test demonstrates resolution of the leak.