Surgeries

Question 1

Expose peroneal / PT artery

Answer 1

Detatch the soleus from the tibia

Question 2

Surg for Esoph Perf

Answer 2

Right lateral decubitus (unless mid esoph)
Single lung ventilation
7th intercostal space, harvest flap
Mobilize esophagus
Debride to healthy tissue
Vertical myotomy to assess mucosa
Vicryl inner layer, silk outer layer
Buttress with muscle
Leak test and pass NGT past injury
J tube
Irrigate chest - leave chest tube x 2
Repeat E-gram in 5 days and remove NGT
**can consider esophageal stent

Question 3

T 1 B GB cancer

Answer 3

Invading muscle, 2 cm margin of liver and portal LND

Question 4

CBD exploration

Answer 4

Kocherize duo
Vert incision on anterior duct, distal to cystic duct
Flush basket fogarty glucagon
Try primary closure but unlikely to do without tension
Close over 14 Fr t tube
Cholangiogram 2 weeks out before clamping
Remove at 6 weeks to 3 months

Question 5

When can you do fistulotomy

Answer 5

If only internal sphincter involved
no active infeciton / abscess

Question 6

Low Anterior Resection

Answer 6

Inspect abdomen
Early ureteral ID
Divide either Sup Rectal or IMA for LND High ligation
Mobilize left colon with take down of splenic flexure
Divide IMV at inferior border of pancreas
Divide mesocolon out to the bowel
Elevate rectum anteriorly and perform TME excision by entering plane between visceral and parietal layers of endoplevic fascia
Divide mesorectum out to distal transection site
DIvide proximal and insert ancil - purse string
Double stapled anastomosis under direct vision
Air leak test
DIverting loop

Question 7

3 stage surgery in sickest UC

Answer 7

Total abdominal colectomy
Ileoanal Anastomosis with diverting loop
Reverse ileostomy

Question 8

Esophagectomy

Answer 8

Begin abdominal with patient in split leg with head elevated
Mobilize greater curvature, protect right gastroepiploic / gastric artery
Kocherize in order to provide length to reach chest
ligate left gastric artery - send ln with specimen
Hiatal dissection after mobilizing stomach
gastric conduit starting 5 cm distal to tumor
Suture gastric conduit to specimen
Reposition in left lateral decubitus for thoracotomy
Mobilize esophagus by ligating azygos vein
Anastomose stomach to cervical esophagus in the neck

Question 9

Heller Myotomy / Ant Dor Fundoplication

Answer 9

48 hrs liquid diet
NGT pre induction
Triangulate to hiatus
Expose GE junction / protect vagus nerves
Divide circular / longitudinal uscles and free from underlying mucosa – 6cm up esophagus and 2 cm onto stomach
Leak test via EGD
Anterior 180 deg fundoplication
If tear - repair with 4-0 pds, close muscle injury and perform contralateral myotomy
Post op e-gram day 1, soft foods day 5

Question 10

Right Hemicolectomy

Answer 10

Laparoscopic
Identify hepatic flexure
Medial to lateral dissection and perform high ligation of the ileocolic pedicle and right colic artery
Identify the duo prior to starting medial to lateral dissection
Protect ureter and kidney
Incise white line of toldt laterally and take down gastrocolic ligament to enter the lesser sac
Extended right – include right branch of middle colic artery

Question 11

Distal Pancreatectomy

Answer 11

o Camera at umbilicus with 4 additional ports triangulate to LUQ
o Look for metastatic disease
o Enter the lesser sac via the gastrocolic ligament
o Retract stomach to expose pancreas and RP
o Identify the splenic artery along superior border of pancreas
o With energy device open lower border of pancreas
o Expose length of pancreas by mobilizing the splenic flexure
o Dissect the splenic vein away from overlying pancreas out to the splenic hilum over the course of the pancreas – take all branches from splenic vein to panc
o Dissect splenic artery away from pancreas
o Divide the panc at the neck with stapler and remove in endocatch bag
o Perform intra-op frozen section to rule out high grade dysplasia at the margin
 If neg or low grade dysplasia – no further dissection
o Leave close suction drain – check amylase on day 1 and 3 with plan to remove drain if under 30 cc / day, and the amylase is negative with no signs of pancreatic fistula

Question 12

Whipple

Answer 12

o Diagnostic laparoscopy – look for occult mets anywhere in abdomen
o Midline laparotomy
o Take down attachments of greater omentum and transverse colon to enter lesser sac
o Trace middle colic vein to identify the smv at inferior border of panc and develop this plane – then encircle the pancreas with umbilical tape
o Mobilize hepatic flexure and perform Kocher maneuver to palpate the SMA course
o Perform cholecystectomy and portal dissection and divide common hepatic duct
o Identify and ligate the GDA
o Transect distal stomach
o Divide small bowel distal to ligament of Treitz, mobilizing distal duodenum from mesentery
o Divide pancreatic neck and send distal duct for frozen assessment
o Divide uncinate process attachments adjacent to SMA adventitia
o When path is confirmed to have negative margins then go to reconstruction
o Tension free duct to mucosa pancreaticojej, hepaticojejunostomy and gastrojej
o Leave closed suction drains near all anastomoses
o Check amylase at day 1 and 3 with plan to remove the drain by discharge
o Major pieces of surgery
 Can be done in many ways
 Check for resectability between neck and portal vein and SMA
 Perform en-bloc resection – so know technical maneuvers
 Know what reconstruction will entail