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Surgeries Flashcards

1
Q

Open Inguinal Hernia Repair

A
  1. Oblique incision above inguinal ligament
  2. Cut external oblique
  3. Dissect cord structures free from hernia sac
  4. Reduce sac
  5. Polypropelene mesh secured to pubic tubercle medially, inguinal ligament (shelving edge) inferiorly, and rectus sheath/internal oblique superiorly
  6. External oblique re-approximated
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2
Q

Laparoscopic TAPP

A
  1. 3 ports triangulating to inguinal region
  2. Peritoneal flap
  3. Pre-peritoneal space bluntly dissected to expose myopectineal orifice
  4. Hernia sac dissected/reduced
  5. Mesh to cover entire MPO
  6. Peritoneal defect is closed with tacks
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3
Q

Paraesophogeal hernia repair

A
  1. Reduction of herniated contents
  2. Start at pars flaccida to the right crus
  3. Division of bilateral phreno-esophogeal ligaments
  4. Identification of anterior and posterior vagus nerves and crural decussation
  5. Penrose
  6. Mediastinal dissection with 3 cm of intra-abdominal esophagus
  7. Division of short gastric vessels and mobilization of the fundus
  8. Posterior cruroplasty
  9. Fundoplication with 56F bougie
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4
Q

Laparoscopic Splenectomy

A
  1. Right lateral decubitus position
  2. Ports along the costal margin
  3. Divide gastro-splenic ligaments (with short gastrics)
  4. Divide spleno-renal and spleno-colic ligaments
  5. Endoscopic stapler across the hilum
  6. Morsellate and remove specimen
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5
Q

Laparoscopic appendectomy

A
  1. Triangulate ports
  2. Divide any lateral attachments
  3. Mesoappendix window
  4. Divide the base of the appendix
  5. Divide the meso-appendix
  6. Remove via 12 mm port site
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6
Q

Laparoscopic/Open Omental patch repair

A
  1. Isolate the perforated segment
  2. Harvest a lip of omentum
  3. Take seromuscular bites on each side then synch down the lip
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7
Q

Truncal vagotomy and pyloroplasty or antrectomy

A

Truncal vagotomy:
1. Divide phreno-espohogeal ligament bilaterally
2. Downward traction of GE junction to identify anterior and posterior vagus nerves
3. Dissect both nerves, clip, and resect

Pyloroplasty:
1. Kocherize 2D
2. 5 cm incision from the antrum to the duodenum
3. Take seromusuclar bites and close transversely
4. Lemert the closure

Antrectomy:
1. Kocherize the duodenum
2. Divide gastrocolic ligament to enter the lesser sac
3. Mobilize greater curve. Ligate R gastroepiploic vessels at pylorus.
4. . Divide G-H ligament along the lesser curve.
5. Divide the right gastric at pylorus
6. Staple across the duodenum and the stomach. Avoid portal triad.
7. Retro-colic loop of jejunum through bare area of mesocolon
8. 2-layer G-J at the gastric pouch
9. Close the mesenteric defect

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8
Q

Total gastrectomy

A
  1. Midline laparotomy
  2. Mobilize GE junction
  3. Seperate omentum from transverse colon
  4. Divide short gastrics
  5. Skeletonize celiac, splenic, and common hepatic arteries taking their lymph nodes
  6. Ligate left and right gastric and gastroepiploic arteries at their bases
  7. Roux-en-y esophagojejunostomy
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9
Q

Lap Chole

A
  1. Triangulate ports
  2. Retract fundus cranially. Infundibulum laterally.
  3. Divide the peritoneum on each side
  4. Establish critical view of safety: only 2 structures. Elevate lower 1/3 off the liver
  5. Clip and divide
  6. Elevate gallbladder off the fossa
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10
Q

Open CBD exploration (choledochotomy approach)

A
  1. Upper midline laparotomy
  2. Retract liver cephalad and colon caudad
  3. Divide gallbladder “dome-down”
  4. Divide cystic artery
  5. Follow cystic duct to the CBD
  6. Cholecystectomy
  7. Longitudenal dochotomy 1-2 cm distal to CD/CBD conflence
  8. Clear CBD with fogarty catheter
  9. Close dochotomy over a T-tube with absorbable suture
  10. Leave a drain
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11
Q

Lap chole in preggo

A
  1. Bump on right side
  2. Port placement based on fundal height via Hassan
    - 12 wks: pubic symphysis
    - 20 wks: umbiliicus
    - 36 wks: xiphoid process
  3. Proceed with operation in normal form
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12
Q

Open femoral hernia repair

A
  1. Oblique inguinal incision
  2. Expose and divide EO aponeurosis
  3. Divide the ilioinguinal nerve
  4. Mobilize the cord structure around a penrose
  5. Open the transversalis fascia
  6. Relaxing incision at anterior rectus sheath
  7. Conjoint tendon/transversalis flap is sutured to Cooper’s ligament
  8. Transition stitch - transversalis fascia to femoral sheath and inguinal ligament
  9. Suture is run to the internal ring
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13
Q

Bassini repair

A
  1. Oblique incisions over the inguinal ligament
  2. Expose and divide EO aponeurosis
  3. Divide the ilioinguinal nerve
  4. Mobilize the cord structure around a penrose
  5. Reduce the hernia
  6. Conjoint tendon (IO, TA, TF) to shelving edge/pubic periosteum
  7. May perform relaxing incision at conjoint tendon
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14
Q

Laparoscopic/Robotic Sigmoid colectomy

A
  1. Lithotomy position, Trendelenburg
  2. Triangulate ports to LLQ
  3. Pull small bowel superiorly
  4. Retract rectosigmoid to find spacebetween meso-rectum and retroperitoneum
  5. Dissect along the plane, identify ureter and sweep downward
  6. Mobilize and divide the IMA
  7. Continue medial to lateral dissection and move superiorly and inferiorly
  8. Take down white line. Thin the rectal mesentery and make a mesenteric windown. Perform distal transection where tenia splay
  9. Identify proximal transection point. Make sure it reach to the rectal stump. May require splenic mobilization and IMV division.
  10. Make pfannestiel incision and extra-corporealize the specimen
  11. Place in anvil. Milk it proximally. Divide at proximal transection point. Push head of anvil through the bowel
  12. Replace stump with anvil into the abdomen
  13. Perform EEA anastomosis. Leak test.
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15
Q

Hartmann’s procedure

A
  1. Lithotomy position
  2. Midline laparotomy
  3. Mobilize colon along the white line from rectosigmoid junction to splenic flexure
  4. Identify and protect the ureters
  5. Determine proximal and distal transection points and divide
  6. Ligate mesenteric vessels with energy device
  7. Create a colostomy through the left rectus
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16
Q

Duodenal ulcer hemostasis

A
  1. Upper midline laparotomy
  2. Kocherize the duodenum
  3. Longitiduenal pyloroduodentoomy
  4. Biopsy the ulcer bed (posterior ulcer bed is usually from gda)
  5. 3-point GDA ligation (superior, inferior, and medial). Beware CBD posteriorly
  6. Approximate the ulcer bed
  7. Transverse clsoure in layers
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17
Q

Total abdominal colectomy

A
  1. Lithotomy
  2. Colonscopy for source of bleeding
  3. Mobilize ascending colon, hepatic flexure. Avoid urter.
  4. Ligate ileocolic pedicle and divide ileum
  5. Divide gastrocolic ligament
  6. Mobilize splenic flexure, descending colon. Avoid ureter.
  7. Ligate IMA and middle colic vessells
  8. Mobilize mesorectum. Divide at the upper rectum where teniea splay
  9. Ileorectal anastomosis or end ileostomy
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18
Q

Roux-en-y hepaticojejunostomy

A
  1. Right subcostal incision
  2. Portal dissection to identify the hepatic duct confluence
  3. Roux-en-y limb via right mesocolic defect (bare area right of middle colic vessels)
  4. Biliary enteric anastamosis using absorbable monofilament
  5. Drain
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19
Q

Open hepatic resection

A
  1. Right subcostal incision
  2. Assess for metastatic disease
  3. Mobilize the liver as needed
  4. Ultrasound assessment to plan resection
  5. Encircle porta with penrose to allow for pringle maneuver
  6. Ligation of segmental portal structures (hepatic artery, portal vein, then hepatic vein)
  7. Parenchymal transection
  8. Meticulous hemostasis. Oversew any leaks.
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20
Q

Pancreaticoduodenectomy (Whipple)

A
  1. Expose infra-pancreatic SMV
    - midline laparotomy
    - divide gastrocolic ligament to enter lesser sac
    - SMV at inferior border of the pancreas
  2. Mobilize R colon and Kocherize the duo to expose the IVC
  3. Cholecystectomy, portal dissection
    - divide CBD. ligate the GDA
    - Create tunnel between neck of pancreas and PV/SMV
  4. Antrectomy
  5. Divide jejunum 10 cm LOT
    - Take down LOT. Jejunum then passed BEHIND the root of the colon mesentery
  6. Transect HOP and removal specimen
  7. Reconstructions
    - PJ: 2-layer, end-to-side, duct-to mucosa
    - HJ: 1-layer, absorbable
    - GJ: 2-layer, ante colic, end-to-side,
  8. Drain
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21
Q

Open distal pancreatectomy w/ splenectomy

A
  1. Upper midline incision
  2. Divide gastrocolic ligament to enter lesser sac
  3. Continue upwards and take the short gastric vessels
  4. Splenic artery freed from superior portions of the pancreas, ligated and divided at origin from celiac trunk
  5. Pancreas and spleen are rotated and medialized
  6. Splenic vein ligated and divided
  7. Divide pancreas with linear stapler
  8. Leave a drain
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22
Q

Open cystogastrostomy

A
  1. Upper midline incision
  2. Cholecystectomy with IOC.
  3. Anterior gastrotomy to define posterior gastric wall
  4. Aspration of pseudocyst/WON
  5. Electrocatery to enter the collection
  6. Bx the pseudocyst wall. Debride any necrosis
  7. Anastamosis with locking PDS suture
  8. Close anterior gastrotomy in layers
  9. Leave a drain
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23
Q

Spleen preserving distal pancreatectomy

A
  1. Upper midline incision
  2. Divide gastrocolic ligament to enter lesser sac
  3. Continue upwards and take the short gastric vessels
  4. Splenic vein and artery freed from posterior pancreas
  5. Small branches lighted and divided
  6. Linear stapler to staple across pancreatic tail and splenic hilum
  7. Divide pancreas with linear stapler
  8. Leave a drain
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24
Q

Splenic flexure/Transverse colon mass surgery

A

(Extended right colectomy)
1. Lithotomy
2. Midline incision
3. Lateral to medial right colon mobilization
4. Enter lesser sac at hepatic flexure. Follow along the gastrocolic ligament
5. Mobilize the splenic flexure
6. Divide ileum and desceing colon
7. Divide the ileocolic, right colic, middle colic, and ascending branch of L colic
8. Ileocolic anastomosis

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25
Ulcerative colitis surgery
1. Subtotal colectomy with end-ileostomy - Divide at ileum and rectum (where tenia splay) - Fashion an end ileostomy at pre-marked spot 2. Proctectomy with IPAA and loop ileostomy - Proctectomy posteriorly first along the TME plane to the levator ani muscles. Finally lateral stalks, then anterior dissection - Divide rectum 1-2 cm above anal transition zone (digital exam/level of the levators) - Mobilize the small bowel/mesentery - If reach is inadequate divide peritoneal lining, selectivel ligate the mesentery, or create an alternative pouch shape - Create a 20 cm J by stapling ileum to itself. Place anvil through bent opening. - Perform EEA anastamosis - Fashion a loop leostomy 3. Loop ileostomy takedown - Lay the two barrell side to side - Use GIA to create a common channel - Close the common enterotomy with a TA
26
Ileocolic resection for Crohn's
1. Triangulate to RLQ 2. Medial to lateral mobilization of R colon 3. Protect the duo 4. Divide ileocolic vessels 5. Divide ileum and mid-ascending colon 6. Ileocolic anastamosis
27
LAR for rectal cancer
1. Make incision at meso-rectum at sacral promontory 2. Medial to lateral dissection. Push down hypogastric nerves and left ureter 3. Mobilize and divide the IMA 4. If needed continue cephalad and take the IMV 5. Perform lateral dissection along white line. Take down splenic flexure if needed. 6. Pull up mesorectum. Take down pre-sacral space. Push down hypogastric nerves. Go down to levators. 7. Take down lateral stalks. Then anterior plane. Below the tattoo (at least 1 cm) 8. Divide the rectum. 9. Chooose proximal transectikon site 10. Make pfannestiel incision and extra-corporealize the specimen 11. Place in anvil. Milk it proximally. Divide at proximal transection point. Push head of anvil through the bowel 12. Replace stump with anvil into the abdomen 13. Perform EEA anastomosis. Leak test.
28
APR for rectal cancer
1. Make incision at meso-rectum at sacral promontory 2. Medial to lateral dissection. Push down hypogastric nerves and left ureter 3. Mobilize and divide the IMA 4. If needed continue cephalad and take the IMV 5. Perform lateral dissection along white line. Take down splenic flexure if needed. 6. Pull up mesorectum. Take down pre-sacral space. Push down hypogastric nerves. Go down to levators. 7. Take down lateral stalks. Then anterior plane. Below the tattoo (at least 1 cm) until the pelvic floor 8. Divide the colon proximally. Fashion end colostomy. 9. Elliptical incision around the anus and outside the external sphincter muscles. 10. Identify the levator muscle and dissect to the point of insertion of the muscle on the pelvic sidewall 11. Close peritoneal wound in layers
29
Partal mastectomy with SLNBx
1. Wire localization and clip (mammo, US guidance, or MRI) 2. Peri-areolar blue dye and radiotracer injection 4. Incision over the tumor 5. Skin flaps bilaterally 6. Core out the lesion to margin of no ink (ca) or 2mm (dcis) 7. Ink the edges. Get a specimen radiograph look at margin and clip. Orient the specimen. 7. Scan axilla with gamma detector 8. Cut over the hottest area, dissect down, and ID the lymph node. Excise it 9. Removal all nodes >= 10% of sentinel node signal
30
Simple mastectomy
1. Elliptical incision to include the nipple–areolar complex 2. Formation of superior and inferior skin flaps 3. Extended superiorly to clavicle, inferiorly to the inframammary fold, laterally to the anterior border of the latissimus dorsi, and medially to the lateral edge of the sternum. 4. Dissection breast off of the chest wall taking the pectoralis fascia with the breast specimen. 5. Hemostasis. 6. Placement of a drain. 7. Closure—with resection of additional skin if needed to avoid dog-ears or excess skin on the chest wall.
31
Axillary node dissection
1. Curvilinear incision inferior to hear-bearing area 2. Creation of skin flaps 3. Incision of clavipectoral fascia (lateral edge of pec minor) and identification of the axillary vein. 4. Preserve thoracodorsal neurovascular bundle laterally 5. Preserve long thoracic nerve medially. 6. En bloc removal of all level I and II lymph nodes as defined by the pectoralis minor muscle. 8. Palpation of level III nodes and Rotter’s node with potential excision if suspicious. 9. Hemostasis. 10. Placement of a drain. 11. Closure of the clavipectoral fascia and skin.
32
Surgery for inflammatory breast cancer
Modified radical mastectomy 1. Ellipitical incision over the NAC with lateral extension under the axilla 2. Creation of skin flaps 3. Extended superiorly to clavicle, inferiorly to the inframammary fold, laterally to the anterior border of the latissimus dorsi, and medially to the lateral edge of the sternum. 4. Dissection breast off of the chest wall taking the pectoralis fascia with the breast specimen. Take muscle en-block if involved 5 . Incision of clavipectoral fascia (lateral edge of pec minor) and identification of the axillary vein. 6. En bloc removal of all level I and II lymph nodes as defined by the pectoralis minor muscle. 8. Palpation of level III nodes and Rotter’s node with potential excision if suspicious. 9. Hemostasis. 10. Placement of a drain. 11. Closure of the clavipectoral fascia and skin.
33
Total thyroidectomy or hemithyroidectomy
1. Neck extended 2. NIMS device 3. Collar incisions. 4. Subplatysmal flaps 5. Strap muscles dividied at the median raphe 6. Retract strap muscles laterally 7. Divide middle thryoid vein 8. Divide upper pole close to the gland. Divide upper pole vessels. 9. Identify the RLN in the TE groove (NIMS) 10. Mobilize the inferior pole and vessels. 11. Divide isthmus off the trache or divide ligament of berry 12. Perform identical contralateral resection
34
Surgery for MTC
Total thyroidectomy with central and lateral neck dissection: 1. Total thyroidectomy 2. Central neck dissection: Remove all fibroadipose tissue between the 2 carotid sheaths (including the thymus) 3. Lateral neck dissection: removal all fibroadipose tissue along the anterior and posterior triangles
35
Parathyroidectomy
1. Neck extended 2. NIMS device 3. Baseline PTH. Collar incisions. 4. Subplatysmal flaps 5. Strap muscles dividied at the median raphe 6. Retract strap muscles laterally 7. Divide middle thryoid vein 8. Retract the thyroid medially 9. Idetify the RLN in the TE groove (NIMS) 10. Superior PT is posterior to RLN 11. Inferior PT is anterior to RLN 12. Clip the pedical and excise 13. Get IO PTH. If > 50% drop then close. Otherwise explore other glands
36
Parathyroidectomy alternate situations: 1. Carcinoma found 2. Can't find superior gland 3. Cant find inferior gland 4. 4 glands removed but still high PTH
Parathyroidectomy alternate situations: 1. En-block resectioon with ipsi thyroid lobe 2. Retroesophogeal space, open carotid sheath, 3. Explore the thymus 4. Supranumary thyroid. Perform bilateral thymectomy
37
Lap adrenalectomy (left)
1. Right lateral decubitus 2. Mobilize the splenic flexure 3. Mobilize the spleen and tail of the pancreas 4. Divide left adrenal vein at junction with left renal vein 5. Take arterial branches circumferentially (from inferior phrenic, aorta, and renal arteries) 6. Remove specimen
38
Lap Adrenalectomy (right)
1. Left lateral decubitus 2. Mobilize right lobe of liver medially by dividing R triangular ligament 3. Divide right adrenal vein at junction with IVC 4. Take arterial branches circumferentially (from inferior phrenic, aorta, and renal arteries) 5. Remove specimen
39
McKeown esophagectomy
1. Left lateral decub position. Intubated with bronchial blocker 2. Divide IPL. Mobilize esophagus. Penrose proximal and distal 3. Complete lymph node dissection (15 nodes) 4. Abdominal entry. Enter pars flaccida. Mobilize lesser curve. Divide L gastric pedicle. Mobilizie the hiatus. Find the penrose. 5. Nodal dissection of celiac trunk 6. Mobilize greater curve and short gastrics. Preserve R gastroepiploic from GDA takeoff 7. Create conduit by stapling along incisura then along the greater curve to the angle of his 8. Sew conduit to specimen 8. Reposition supine. Incision along SCM 9. Reflect carotid sheath laterally. Grab penrose 10. Mobilize cervical esophagus and pull through cervical wound 11. Proximal transection and do a stapled anastomosis with a drain 12. J tube
40
Perforated esophagus
1. Thoracotomy (left- neck, right- mid, left-distal) 2. Harvest intercostal muscle flap 3. Mobilize the esophagus 4. Myotomy to see extent of mucosal injury 5. 2-layer closure with intercostal muscle flap 6. Drain 7. J tube
41
Heller myotomy with Dor
1. Enter at pars and identify right crus 2. Anterior esophagus is bluntly dissected. 3. Excise GE fat pad. Avoid vagus posteriorly. 4. Use hook to divide longitudinal and circular muscle fibers 5. 6 cm on esophagus and 2 cm onto stomach 6. Leak test at myotomy site. 7. Mobilize short gastric vessels. Perform Dor fundoplication.
42
Pulmonary nodule or bleb excision
1. Lateral decub. Double lumen ETT 2. Triangulate ports to the lesion 3. Resect with endoscopic stapler 4. Remove with a specimen bag 5. Send for frozen 6. For pleurodesis: spread talc or scratch with bovie pad 7. Place chest tube
43
EVAR
1. Choose endograft based on 3D CT 2. Bilateral CFA cut down 3. Heparinize 4. Bilateral wires. Then bilateral sheaths. 5. Aortogram to identify renal artery take-off 6. Endograft deployed just below renal arteries 7. Contralateral graft deployed 8. Balloon angioplasty to sinch everything down 9. Completion Angio. Remove wires/sheaths 10. Close arteriotomies. Protamine
44
Ruptured AAA repair
1. Midline laparotomy 2. Supra-celiac control by dividing GH ligament and left crus of diaphragm 3. Take down LOT and retract the duo to the right 3. Incise peritoneum over infrarenal aorta from renal vessels to aortic bifurcation - left renal vein may be divided if needed for exposure 4. Heparinize for ACT > 250. Mannitol, lasix. Clamp bilaterally iliacs distally. Aorta proximally (let Kindey's drink) 5. Open aneurysm sac oppposite the IMA. Remove thrombus. 6. Prosthetic graft sewed proximally then distally with 3-0 monofilament 7. Ligate IMA if good back-bleeding. Ligate any lumbar branches. - re-implant IMA if poor back-bleeding or colon surgical history 8. Protamine 9. Close aneurysm sac and retroperitoneum over the graft 10. Close abdomen and check pulses - if supra-renal aneurysm can divide the renal vein and re-implant the renal arteries
45
Infra-inguinal bypass with vein
1. Expose inflow artery 2. Expose target artery 3. Harvest contralateral saphenous vein. Flush with hep-saline and reverse orientation. 4. Create a subcutaenous tunneel 5. Heparinize to ACT > 250 6. Clamp inflow proximally and distally. Arteriotomy. Fashion vein to match. Running 5-0 polypropelene anastamosis 7. Bring graft through the tunnel. Ensure pulsatile flow. 8. Clamp inflow proximally and distally. Arteriotomy. Fashion vein to match. Running 6-0 polypropelene anastamosis 9. Confirm flow via duplex. Angio if unclear.
46
Open femoral thromboembolectomy
1. Heparinize on diagnosis 2. Vertical incision over femoral pulse 3. Ligate lymphatics 4. Loop out CF, SF, and profunda 5. Heparinize to ACT > 250. Clamp 6. Transverse arteriotomy 7. 4 to 5F fogarty. Proximal. Then distal. 2x clean pass. 8. Close arteriotomy with 5-0 prolene 9. Close in layers 10. Consider fasciotomies
47
CEA
1. Anterior SCM incision 2. SCM retrated laterally 3. Facial vein ligated 4. Open carotid sheath. 5. Loop out ICE 6. Heparinize. Clamp ICE 7. Arteriotomy from CCA to ICA 8. Shunt 9. Endarterectomy. Tap down intimal flaps. 10. Bovine pericardial patch. Remove shunt before last stitch 11. Unclamp in E, C, I order 12. Close in layers. Sub-platysmal drain.
48
SMA Revascularization
1. Midline laparotomy 2. Retract transverse colon cephalad. Mobilize LOTz 3. Follow middle colic to find the SMA. 4. Heparinize to ACT > 250 5. Clamp proximal and distal SMA - Transverse arteriotomy for embolectomy (embolus) - Vertical arteriotomy for bypass (thrombosis) 6. Embolectomy with 4F fogarty and close 7. If inflow is not re-established must perform a retrograde SMA bypass. Complete a cattell-brasch maneuver 8. Harvest saphenous vein and suture on distal aspect of SMA 9. Proximal anastomosis and the right common iliac artery 10. Assess bowel viability and close
49
Surgery for chronic mesenteric ischemia
1. Midline laparotomy 2. Supra-celiac aorta control by dissecting the crura of the diphagram 3. Celiac exposed in lesser sac above the pancreas 4. SMA is exposed at root of mesentery 5. Retropancreatic tunnel 6. Heparinize the patient and clamp 7. Bifurcated graft sewn to the supra-celiac aorta, then celiac, then retr-pancreatic to SMA with running monofilament 8. Close in layers
50
Brachial-cephalic fistula
1. U/S to mark course of cephalic v. 2. Transverse antecubital incision through crease 3. Brachial artery exposed by incising the bicipital aponeurosis 4. Vein is ligated and mobilized 5. Heparinize and clamp the brachial artery 6. Arteriotomy 7. 6-0 running monofilament for anastamoisis
51
Brachial-bassilic fistula
1. Longitudinal incision in the upper arm over the previously mapped basilic vein from the axilla to the antecubital fossa. 2. Brachial artery and basilic vein are dissected, mobilized, and secured using vessel loops 3. Heparinize and clamp 4. Arteriotomy is made in the proximal brachial artery and then flushed with heparinized saline. 5. A curved tunneler is used to create a subcutaneous tunnel along the anterior aspect of the upper arm 6. The distal basilic vein is ligated and divided and then tunneled laterally and superficially in a curved fashion. The end of the basilic vein is spatulated to match the size of the arteriotomy, and an end-to-side anastomosis is performed using a running nonabsorbable monofilament suture. **May superficiliaze in a second operation
52
Surgery for pyloric stenosis
Laparoscopic pyloromyotomy 1. Treat electrlytes 2. Trinagulate ports towards the pylorus 3. Score serosa starting 2 mm proximal to pre-pyloric vein of mayo and extended to gastric antrum (at least 2 cm) 4. Blunt instrument used to divide underlying circular fibers and expose the mucosa 5. Leak test via NG tube 6. Close
53
Ladd's procedure
1. Midline laparotomy 2. Counter-clockwise rotation of bowel 3. Take down ladd's bands 4. Appendectomy 5. Broaden small bowel mesentery 6. Place SB on the right, colon to the left 7. Close
54
Surgery for Wilm's tumor
1. Midline laparotomy 2. Right or Left medial visceral rotation 3. Mobilize tumor and kidney without exposing the capsule 4. Control hilum. Divide artery before vein. Feel for tumor at the vein. 5. Mobilize ureter into the pelvis to divide en-block 6. Aorto-caval lymph node sampling
55
Surgery for intususspection
1. Trainagulate towards the intususpected bowel 2. Gently unfold the distal piece while holding the proximal piece steady 3. If cannot reduce peform ileocolic resection 4. Look for lead point. Lymphoid thickening at TI is normal. Do not bx.
56
Surgery for NEC
1. Resuscitate 2. Midline laparotomy 3. Resect necrotic areas 4. Create ostomies 5. 2nd look operations
57
Surgery for Meckel's
1. Trainagulate ports towards RLQ 2. Assess the diverticulum 3. Segmental resection if bleeding or wide base - Diverticulectomy if tall and narrow base without blood 4. Primary anastamosis - appendectomy as well if exploratory surgery for presumed appe ended up being meckels - If incidental: resect meckel's in kids, leave in adults.
58
Melanoma Surgery
1. Pre-op radionuclide lymphoscintography 2. Radial ellipital incision down to fascai 3. Gamma probe used to confirm serntinal nodes 4. Isosulfan blue injected around biopsy site 5. Targeted lymph node dissection using gamma probe and blue dye 6. Sentinal node dissection complete only when background signal < 10% of hottest node 7. Closure 8. If SLN+: consel on completion lymph node dissection vs. active nodal surveillance - nodal U/S of basin q3m x 3 years. q6m x 2 years. Then annually. 9. Consider PD1 inhibitor: ipilimumab or pembrolizumab
59
Completion lymph node dissection for malenoma
- if SLN+ and they choose no active surveillance - if palpable node with FNA+ 1. Axilla: levels 1, 2, and 3 2. Groins: superficial nodes within femoral triangle - go after deep if: +cloquet or 3 nodes + on CT - cloquet's node is first node when you divide the inguinal ligament - deep dissection: divide inguinal ligament and iliac/obturator nodes taken - Close femoral vessels with sartorius flap
60
Sarcoma resection
- < 3cm: excisional bx - > 3 cm: core needle (preferred) or incisional 1. Pre-op MRI 2. Review at tumor board. Consider neo-adj XRT 3. Surgical incision along long axis of extremity 4. Take specimen with 1 cm margin 5. Place marking clips for future XRT 6. Close over drain
61
Resuscitative thoracotomy
1. Left thoracotomy from 4-5th intercostal space to the bed 2. Finochietto retractor 3. Open the pericardium longitudenally 4. Divide IPL and cross clamp the aorta 5. Clambshell if contralateral hemothorax
62
Pulmonary Tractotomy for Penetrating Lung Injury
1. Anterolateral thoracotomy. Control pulmonary hilum with finger occlusion or a clamp. If unable to control - Satinsky clamp around the entire hilum. - twist the lung to rapidly control the hilum without a clamp. 2. GIA stapler through the entrance and exit wound of the lung 4. Fire the stapling device to fully expose the injury tract 5. Directly ligate bleeding vessels or exposed bronchi with 3-0 Vicryl figure-eight sutures.
63
Zone 2 neck exploration
1. Incsion along anterior border of SCM 2. Open carotid sheath. Divide fascial vein to expose carotid artery 3. Vascular injury - Repair all CC and IC injuries. Ligate EC - Heparinize if no brain injury. Don't need to shunt. - Use saphenous vein if require interposition - Vertebral vessels need IR 4. IVC injury: primary repair or ligate 5. Esophageal injury - Mobilize esophagus with penrose if injured - Repair in 2 layers. Drain widely. 6. Tracheal injury: - Single layer repair with absorbable suture - Don't trach them 7. Performed EGD or bronch if necessary
64
Inhalation injury
1. 100% O2 via NRB 2. Intubate if hypoxia, cyanosis, stridor, significant edema 3. CO: ABG with Co-oximetry to evaluate for CO. 100% 02 until COHb < 5%. Consider hyperbaric O2. 4. CN: hydroxycobalamin if high lactate, acidosis, persistent hypoxemia 5. Fiberoptic bronchoscopy
65
Burn wound care
1. Resuscitate. Calculate extent 2. Topical anti-microbial like silver sulfa 3. OR within 24 hours 4. Excise all deep 2nd and 3rd degree burns 5. Hemostasis with cautery and epi soaked gauze 6. Cover with split-thickness skin graft. Staple on. 7. Dress with non-adherent dressing. Immobilize for 48 hours
66
Complex liver injury
1. Laparotomy and pack. Anesthesia resuscitation 2. Electroucatery, argon beam 3. Push ➡ Pack ➡ Plug ➡ Pringle 4. Consider partial hepatectomy 5. Retrohepatic IVC: take down falciform and triangular ligament. Clamp suprahepatic and subhepatic vena cava. Repair. 6. Leave a drain
67
Complex duodenal injury
1. Kocher and Cattel-Brasch maneuver 2. Divide LOTs to expose 3D and 4D 3. Assess duodenal papilla. If injury unclear perform chole and on-table cholangiogram 4. Place biliary fogarty to assess distance of injury from ampulla 5. Options for repair: - simple primary closure (<50% circumference) - simple repair with pyloric exclusion with TA stapler with draining GJ - REY-DJ - Duo diverticularization: antrectomy, resect damaged portion, oversew duo stump and leave drain through abdominal wall, loop GJ - Whipple 6. Use T tube for biliary injury and later RYJB or whipple 7. Distal feeding access
68
Complex pancreatic injury
1. Kocher and Cattel-Brasch (head and neck) 2. Divide gastro-colic ligament (body and tail) 3. Distal drainage if no duct injury or any head injury. Resection if duct injury distally 4. Drain widely
69
Pelvic trauma
1. Pelvic binder 2. CTA. Angioembolization if stable and available 3. Pre-peritoneal packing: lower midline incision. Avoid peritoneum. 3 packs on each side. 4. Ex-fix if possible 5. Laparotomy. Oversew the hypogastric arteries
70
ARDS management
1. CXR to show infiltrates. Echo to r/o cardiac cause 2. Lung protective ventilation: 4-6 ml/Kg 3. PEEP enough to maintain O2 4. Paralyze 5. Prone 6. Inhaled prostcylin or NOp
71
PD catheter insertion
1. Mark cateter entry (peri-umbilical) and exit site (2-3 cm superolateral to entry) 2. Stiff stylet through entry site 3. Double-cuffed catheter is then introduced through the entry site to space of Douglas guided by stiff sylet 6. The distal cuff of the PD catheter should be outside the peritoneum/retroctus space 7. Create subcuatenous tunnel to exit site and park proximal cuff in subucatenous tissue
72
IOC and CBD exploration
1. Supine. L arm tucked for C arm 2. Mobilize gallbladder and cystic duct. Proximal close as close as possible to infundibulum 3. Ductotamy. Insert cathter. Inflate balloon 4. 1:1 dilute contrast. Must see: - CD, L and R hepatic ducts, Passage of contrast into duo, No filling defect 5. FIlling defect: saline flush ➡ glucagon x 2 6. Choledochoscope with retrieval basket 7. Choledochotomy with T-tube closure
73
Zencker's management
<3cm: open approach 1. Incision along anterior border of SCM 2. Divide platysma 3. Retract strap muscles and thyroid lobe. Divide omohyoid 4. Identify esophagus via previously placed bougie 5. Divide cricopharyngeus muscle. 6. Staple the diverticula closed >3cm: endoscopic approach 1. Rigid endoscopy 2. Expose common wall between esophagus and diverticulutm 3. Stapling device to dividie the septum
74
Perforated stomach ulcer
1. Biopsy to ulcer site 2.Divide gastroepiploics 2. Divide R gastric 3. Dividie 2 cm distal to pylorus and at the antrum encompassing the ucler 4. RYGB 5. Vagotomy if stable, refractory to PPI, and known h. pylori eradication - perform pyloroplasry after
75
Perofrated duodenal ulcer
< 2 cm- graham patch repair > 2 cm- pyloroic exclusion with GJ anastamosis and primary repair of the ulcer - Vagotomy if stably, refractory to PPI, and known h. pylori eradication - perform pyloroplasry after
76
Colon resections arterial supplies
1. R hemi- ileocolic, R Colic, RB of MC 2. Extended R- ileocolic, R Colic, M Colic (splenic flexure mass) 3. L hemi- LB of MC, L Colic 4. Sigmoid- IMA (with L colic and superior rectal branches)
77
Anal sphincterotomy
1. Prone jacknife 2. Incision laterally along intershiphincteric groove 3. Lifter internal sphincter from external sphicnter and divide to the dentate line 4. Close with running 3-0 chromic
78
Excisional hemorrhoidectomy
1. Prone jackknide 2. Hill-Ferguson retractor 3. Grasp hemrrhoidal bundle under forceps 4. Diamond incision encompassing bundle 5. Dissect bundle off the internal sphincter 6. Clamp the apex. Oversew and divide the bundle. Using same suture to close the mucosa and skin incision
79
LIFT procedure
1. Develop intersphincteric plane 2. Loop out and ligated the intersphincteric tract 3. Curette external opening and remnant fistual tract 4. Close the intersphincteric incision
80
Tracheostomy
1. Supine with neck extended. Bring Fio2 down 2. Incision overlying 2nd/3rd tracheal ring 3. ETT defalted and pulled back slightly 4. Under bronchiscpoic guidance place introducer needle, then wire, then subsequent dilators 5. Advanced ETT and secure
81
Breast duct excision
1. Mammo and US 2. Ductography to map the ductal tissue 3. Incision along areolar edge. Preserve subc fat 4. Cannulate involve duct with lacrimal probe 5. Areolar skin flap 6. Dissect and divide the entire duct bundle 7. Close in layers
82
Thyroid U/S requiring FNA
1. > 1 cm 2. Hypoechoic/solid 3. Taller than wide 4. Irregular border 5. Calcs
83
Transcutaenous pacing
1. place pads in AP position (black on anterior chest, red on posterior chest) 2. connect ECG leads 3. set pacemaker to demand 4. turn pacing rate to > 30bpm above patients intrinsic rhythm 5. Set mA to 70 6. Start pacing and increase mA until pacing rate captured on monitor 7. if pacing rate not captured at a current of 120-130mA -> resite electrodes and repeat the above. once pacing captured, set current at 5-10mA above threshold
84
Escharotomy
1. incision along the longitudinal axis of the limb either in the mid-lateral or mid-medial line 2. Should be down to but not including the muscle fascia. 3. Avoid flexural creases 4. Once there is an adequate release of tissues, the incisions can be dressed with alginate dressings. 5. Adequacy of escharotomy: regular assessment of perfusion, and compartment pressure, respiratory effort, circulatory status, and bladder pressure
85
4c fasciotomy
1. Lateral incision one finger in front of the fibula from below fibula to above lateral malleolus. 2. Expose lateral and anterior compartments. Avoid lesser saphenous vein and peroneal nerve 3. H incisions to expose intermuscular septum. Fasciotomize 1 cm in front and behind the septum. 4. Medial incision one fingerbreadth below the medial edge of the tibia 5. Identify and preserve the GSV, 6. Open the fascia overlying the superficial posterior compartment which contains the soleus and gastrocnemius muscle 7. Dissect solus bridge off of tibia to enter the deep posterior compartment. Identification of the posterior tibial neurovascular bundle confirms that the compartment has been entered.
86
Ureteral repair
1. Mobilize the ureter to obtain adequate length for repair without devascularization. 2. Resect and spatulate the edges to viable tissue 3. Place double J stent 4. Use interpuppted absorbable suture for tension free anastamosis 5. Leave a drain and close the retroperitoneum
87
AKA
1. Tourniquet 2. Fishmouth incision 2/3 down the femur 3. SFA and SFV are suture ligated 4. Femur transected two fingerbreadths proximal to the skin incision 5. Sciatic nerve is ligated, divided sharply, and allowed to retract. 6. Edges of the transected femur are smoothed with a rasp or file. 7. Close muscle and fascia. Close skin.
88
BKA
1. Skin incisions 10 cm distal to tibial tuberosity. Anterior flap takes up 2/3. Posterior flap 1/3 but longer. 2. Divide anterior and lateral compartments 3. Divide tibia 2 fingers proximal to skin incision. Beveled to eliminate sharp edges. 4. Fibula is divided with a saw 1 to 2 cm proximal to the tibial transection site. 5. Posterior flap is completed by dividing the residual posterior compartment musculature at a plane just deep to the tibia and fibula with a long amputation knife. 6. Ligate and divide the AT, PT and peroneal 7. Ligate and divide Tibial and peroneal nerves 8. Close muscle, fascia and skin using posterior flap
89
Aortobifem
1. Infra-umbo groin incision. Loop out CF, SFA, and profunda. 2. Ex-lap. Retract transsverse colon. Small bowel shifted right. LOT mobilized. 3. Retroperitoneum opened to expose aorta 4. Tunnel bilaterally to the femoral regions tracking anterior to external iliac 5. Aorta side-biting Satinsky clamp 6. Heparize. Clamp. Proximal anastmosis with 5-0 monofilament 7. Heparize. Clamp. Distal anastmosis with 5-0 monofilament 8. Close in layers. Protamine.
90
Ax-bifem
1. Transverse infraclavicular incision approximately two fingerbreadths below the clavicle.Divide pec minor and major. 2. Mobilize axillary vein infeiorly to access to the artery. 3. Exposure of femoral artery with logitiudenal infrainguianl incision. Loop out the CF, Produnda, and SFA 4. Create a midaxillary tunnel, lateral to the nipple and from the axillary incision to the femoral incision. Pass PTFE graft. 5. If necessary, create a femoral-to-femoral tunnel superior to the pubic bone for a bifemoral reconstruction. 6. Heparize. Clamp. Proximal anastmosis with 5-0 monofilament 7. Heparize. Clamp. Distal anastmosis with 5-0 monofilament 8. Close in layers. Protamine.
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Vascular exposures: 1. Femoral 2. AK pop 3. BK pop and TP trunk
1. Femoral: curvilinear incision 1 cm inferior to inguinal ligament. Divide femoral sheath. Change in caliber at bifurcation. 2. AK pop: medial incision between vastus medialis and sartorius. Incise the deep fascia. Enter pop fossa. 3. BK pop: medial incision 1 cm medial to the tibia. Avoid GSV. Divide fascia to enter deep posterior compartment. Divide solus to get to TP trunk (AT comes off her). Follow distally to get to PT (Medial) or peroneal (Lateral)

1. CE prep (3 decks)

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