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Oral Board Surgical Descriptions: Most Common and Most Feared (Podcast)
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Oral Board Surgical Descriptions: Most Common and Most Feared (Podcast)
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>> Behind The Knife, the surgery podcast where we take a behind the scenes intimate look at surgery from leaders in the field. [ Music ] OK. And welcome to another episode of Behind The Knife. Today, we have a special episode for you coming from Philadelphia. I'm here with my co-fellow, Matt Smith, and my former co-resident, Jeb Black, and we are about two days away from taking our oral boards.
And so, out of necessity, to learn all these procedures, we decided to sit down and write them out and then record them for all of you guys to benefit from. So we're going to cover about 20 to 30 scenarios that are the most likely scenarios we'll see on the oral boards. We'll try and make them as brief as possible. And we hope you guys get some benefit out of this. So thanks to Matt and Jeb for taking their Saturday night to record some oral board scenarios. I hope you guys enjoy.
>> Hi, everybody. This is Jeb. We're going to go through our first scenario. It's actually three scenarios in one. So we're going to cover hiatal hernia repair, repair esophageal hernias, as well as fundoplications because a lot of the steps are similar. So, initially, you're going to position the patient either supine with a footboard and lithotomy position or split leg. That's your personal choice.
Gain access into the abdomen, put in your liver retractor, and then you're going to begin by incising the gastro emphatic ligament and bluntly dissect until you can view the right crus of the diaphragm. Bluntly mobilize the esophagus circumferentially with care taken to isolate and not injure the vagus nerves. You should be able to visualize both crus of the diaphragm with a clear plane between the esophagus and the crura, put your pin rows around the distal esophagus to aid your retraction. And then perform your mediastinal immobilization such that you get at least three centimeters of intra-abdominal esophagus for a successful repair.
You may need to perform more mediastinal immobilization or perform a Collis gastroplasty if you can't get enough length, but that's rare that you need to do so. You're then going to reapproximate your crus using nonabsorbable sutures usually in a mattress type fashion and then decide whether or not you want to place a mesh for buttress. Then perform your fundoplication based on your manometry findings. If you're performing a 360 degree and you're going to need to take down your short gastric vessels, perform your shoe shine technique after you pass the fundus of the stomach around the back of the esophagus.
And then you create your fundoplication anteriorly with nonabsorbable sutures making sure you get about two to three centimeters. If you have impaired function, think about performing a door or a toupee. It doesn't really matter which one. Just pick one and go with it. And pour in additions for your paraesophageal hernia repair or to ensure that you have completely brought all the contents from the chest down into the abdominal cavity and resect your hernia sack. Additionally, if you happen to injure the esophagus during this repair, repair it in two layers, make sure you leave a drain, and place your NG tube past your injury.
Typically you can buttress that repair with your fundoplication. If you injure the pleura and have a capnothorax, you can attempt to repair the pleura or you can just place a red rubber catheter and evacuate the air as you're closing the abdomen by placing it under a water seal temporarily and then pulling it out. >> Hi. This is Matt. I'm going to explain both a Liechtenstein and a McVay repair, which should get you through a standard inguinal hernia repair in addition to a tissue repair to use in the setting of any infections. So, for your Liechtenstein [inaudible] and you're going to position the patient supine, prep and drape in the usual fashion.
You're going to make a curvilinear incision above the inguinal ligament and get down to the external oblique incising that. You'll find and preserve the ilioinguinal nerve. You're then going to clean off the shelving edge of the inguinal ligament down to the pubic tubercle, isolate the spermatic cord, and encircle that with the pin rows. You're then going to identify the hernia sack on the anterior medial aspect of the cord and dissect it off the cord structures down to the inguinal ring and putting it back into the abdomen.
You're going to protect the vas and vascular structures throughout this. At that time, you're going to take a split piece of mesh and fix it to Cooper's ligament with a single proline stitch and then use a running fashion to attach that piece of mesh to the shelving edge of the inguinal ligament inferiorly and then interrupted fixation of the conjoined tendons superiorly making sure not to entrap the nerve and to close the split portion of your mesh. You'll then close the external oblique. For a McVay repair, you're going to get into the abdomen and through the external oblique in the usual fashion, isolate your cord structures and bring them up off the floor.
You're then going to incise your inguinal floor in order to converge the possibility of a femoral hernia into a direct inguinal hernia. You're then going to use interrupted silk sutures to approximate the conjoined tendons starting medially to the Cooper's ligament and run it down to the lacunar ligament running literally to close the femoral canal. And then, with a transition stitch, approximating Cooper's ligament to the inguinal ligament and continue to run the conjoined tendon up the inguinal ligament. And then you'll close the external oblique as you would for the Liechtenstein repair.
>> OK. For this we're describing lower anterior resection, but you can really use this for a left colon or a sigmoid. It just depends on how far you dissect down onto the rectum. You're going to place the patient lithotomy, prep the abdomen and perineum. Then you're going to place the patient [inaudible]. Begin by mobilizing the sigmoid colon along the white line of Toldt and bluntly dissect it off the abdominal wall with care to identify the ureter. You're going to mobilize the left colon so that it'll adequately reach without tension to the pelvis with a splenic flexure mobilization.
You're going to score the sigmoid mesentery on the medial side from the sigmoid down to the rectum along the superior rectal artery. You're then going to divide the vascular pedicle to the sigmoid colon. You're going to elevate the rectum, which will allow identification of an areolar plane posteriorly. You're going to use an energy device circumferentially to free the rectum and surrounding tissue staying in a plane close to the rectum. You're going to do an anterior -- you're going to do your anterior dissection last as it holds the rectum in place to facilitate posterior dissection.
And this also helps avoid the risk of damage to the urethra. You're going to dissect two centimeters past the tumor and confirm with endoscopy that you are distal to your tumor. You're then going to use an articulating stapler to divide the rectum distally and a linear stapler to divide the colon proximally and pass off the specimen. You then perform a stapled EEA anastomosis through the rectum and do a leak test. >> All right. So now we're going to go through a bleeding trauma scenario. You're going to start like with every trauma with your AVCs and then do your adjuncts.
You're likely going to have a positive FAST. The patient's going to be hypotensive. You may get a chest x-ray, pelvis x-ray. And then you're going to start blood product resuscitation in a one to one to one ratio. Make sure you've got adequate access and then get the patient to the operating room. Prep them from neck to knees and then induce, intubate, ex-lap, evacuate all your blood, pack all four quadrants, let anesthesia catch up. If you need to get supraceliac aortic control for that to happen, go ahead and do that. Start to warm the patient.
And then you're going to start in the areas which do not seem injured and move towards the more injured areas. Remove your packs that aren't as bloody or contaminated. Stop bleeding as you go. Remove and staple off any contamination. And then get to the ICU with a temporary abdominal closure so you can warm and resuscitate the patient. If your spleen is bleeding, just go ahead and medialize with blunt dissection, which is probably mostly already done for you and then staple or clamp the hilum.
Make sure you leave a drain and watch for pancreatic leaks postop. If the liver is bleeding, it's anterior, you can see it, just start with packing above and below the liver. And then you can perform a Pringle maneuver to try and slow the inflow and try and suture repair with large kromex on a blunt needle or pack with omentum and suture over that. Lots of different ways to stop liver bleeding. If it's posterior bleeding, and the Pringle maneuver doesn't stop the bleeding, you can try and just tightly pack and hope that that stops.
However, if that doesn't work, then you need to do total vascular isolation of the liver, which equals a Pringle plus control of your infrahepatic IVC, which is probably easiest just under the inferior border of the liver, or even through the inferior border of the liver. And then superhepatic IVC control, which you're going to approach through the diaphragm. So, if there's a concern for pelvic bleeding, you're going to do pre-peritoneal packing. If you've already ex-lapped the patient, obviously you can just take down the peritoneum in that area, evacuate the clot, pack the pelvis, and then reapproximate part of the fascia to get your tension, or, if you didn't carry your ex-lap incision quite as low, then you're going to make a new incision, sweep the peritoneum down away, once you've gotten through the rectus muscle, and then pack three or four lap pads on each side, however many will fit.
Then you're going to get the patient off to IR for control. >> All right. Next you adrenals. A couple caveats for this. One, if it's a pheochromocytoma, make sure before you take your vein you let your anesthesiologist know as there's going to be pressure changes. And the second thing is remember if this happens to be a malignant lesion or -- and it looks like it's invading surrounding structures, then you alter this to do an m-blocker section of anything that looks attached.
So, starting on the left side, you're going to mobilize the literal attachments to the spleen and take down the pancreas. Once again, identify the inferior phrenic vessels as they trace down on top of the adrenal, which is sitting on top of the kidney. You're going to then identify, dissect, and secure the left adrenal vein on the inferior medial aspect of the adrenal and then you can use an energy device like a ligature to just encircle the adrenal from the surrounding [inaudible] and retina peritoneal attachments as there's nothing distinct about the arterial supply on that side, or on either side.
On the right side, you're going to place the patient in a right supine position with a bump under the right side, mobilize the hepatic flexure of the colon and the triangular ligament of the liver to the point of the inferior Gerota's vessels on that side. Then you're going to trace those down to the adrenal, which sits on top of the kidney. You're going to identify the sack and secure the adrenal vein as it enters the IVC and then, once again, use a ligature to free up the surrounding Gerota's and retroperitoneal attachments to the adrenal. >> OK. Next up is neck explorations and trauma.
You're going to place the patient supine, arms out. You're going to prep from neck to knees. You're going to do an extensile incision at the anterior border of the sternocleidomastoid. You're going to open the platysma and retract the sternocleidomastoid literally. You're going to identify the IJ and divide the facial vein, open the carotid sheath and deal with any vascular injuries. You're going to explore the esophagus. An NG or OG tube is helpful in identifying this. And then you're going to look at your trachea and sometimes you need endoscopy or bronchoscopy to help with this.
And you're always going to leave a drain after a neck exploration. If you have an injury to the esophagus or trachea to one side of it, you're likely to have an injury to the other side so you need to figure a way to explore that other side, whether you do a contralateral neck exploration or endoscopy to identify injuries on that side. And then, if you have any aerodigestive tract injuries, you're going to need to buttress it and a strap muscle is a good option for that. >> All right. So now moving on to thyroidectomies and parathyroidectomies.
So for your thyroidectomy, or for both of these really, you're going to place the patient supine with a bump under their shoulder, usually with arms tucked. Start with a collar incision. Raise your subplatysmal flaps. Retract those superiorly and inferiorly. Then bluntly separate the strap muscles and place a self-retaining retractor. For your thyroidectomy, you're going to start at the upper pole and bluntly separate the avascular plane. Carefully identify the superior pole vessels and then divide them close to the thyroid gland using bipolar cautery or maybe a harmonic scalpel.
And then you're going to rotate the thyroid gland anteriorly separating it from the surrounding tissue. Identify the recurrent laryngeal nerve in the tracheoesophageal groove and ensure you protect that throughout your dissection. Continue to follow your dissection medially, divide the ligament of Berry, and separate the thyroid from the larynx and trachea. Once you've completely immobilized one side, move to the other side and perform your dissection in the exact same fashion. If you're just doing a thyroidectomy, you want to make sure you identify the parathyroid glands, reimplant any if they are damaged.
For the parathyroid glands, you're going to start with the same initial steps, however, you're going to do blunt dissection medial to carotid and superior. And then you're going to identify your superior pole vessels, ligate your middle thyroid vein because that will help you with your visualization, and then you want to identify the location of all the glands and then resect them as needed. Send for frozen to confirm that it's a parathyroid, check whatever levels you need to check intraoperatively, and then you want to leave a small drain, close in layers, and then admit the patient for observation.
>> And now onto esophageal perforations. And so this is assuming a Hoerhaave's type patient with a distal left sided perforation. So you place the patient in right literal decubitus. You make an incision in the 7th left intercostal space. You'd harvest an intercostal muscle flap as you enter the chest to use for a buttress. Place retractors and immobilize the inferior pulmonary ligament. Open the mediastinum posteriorly and expose the esophagus and loop it out. Then you'd irrigate and debride. You'd extend outer muscular layer myotomy to fully visualize the mucosal defect.
You'd place an NG tube past the injury and then you'd want to make sure you considered and placed feeding access such as a G or J tube. You'd repair the inner mucosal layer with something like a 3OPBS absorbable suture. And then you'd repair the outer layer muscular with a 3O silk or nonabsorbable suture. And then you'd buttress the repair with your intercostal flap and you lay large-bore chest tubes posterior and anterior and close the chest. Now, if this was a perforation done for achalasia while dilating, you'd do the same repair, but you'd want to make sure you did a contralateral myotomy at the end of the procedure.
>> All right. Now moving onto quick descriptions of EGDs and colonoscopies. So for both of these, you're going to place the patient in an appropriate positioning with a monitoring in place to monitor their blood pressure, O2 sat, and pulse. Then you're going to start them on conscious sedation with your preferred regimen. Personally, I'm going to say Versed and Fentanyl, but you can use all kinds of things so whatever you prefer. For the EGD, important points I think are to place a bite block.
Now go ahead and intubate the esophagus. Get down, traverse the GE junction. And then you're going to traverse the pylorus and then inspect the duodenum. Then you're going to slowly withdraw the scope into the stomach and inspect the antrum, take biopsies as necessary. At that point, I would retroflex and inspect the fundus and GE junction from that side. Then you're going to continue to withdraw the scope with -- excuse me -- withdraw the scope and inspect the remainder of the stomach. Once you get back into the esophagus, inspect the GE junction from that side and then examine the rest of the esophagus on the way out.
For your colonoscopy, important to perform a DRE before you start your colonoscopy, then insert your scope and get to the cecum. You can retroflex either at the beginning or at the end, but make sure you do that. Then, once you get to the cecum, you can identify that by the appendiceal orifice and the convergence of the taenia as well as the entrance into the terminal ileum. You want to attempt to, and hopefully successfully, intubate the terminal ileum every time, and then you're going to slowly withdraw the scope inspecting 360 degrees to visualize all mucosa.
Take biopsies as necessary. Your interventions for bleeding during endoscopy, three main ones that I would mention personally. Inject epinephrine in a one to 10,000 ratio. Use Hemoclips or you can use electric cautery. >> All right. Next up, perforated ulcer disease. Starting off with a perforated duodenal ulcer. You're going to start with an upper midline laparotomy and evacuate all the contamination and irrigate the abdomen.
You identify the perforation and debride any necrotic tissue around that ulcer. Make sure to take biopsies for H. pylori and send it to pathology for concern about perforated cancer. Then immobilize the tongue of omentum, loosely approximate the ages of your cleaned up duodenal hole with 3OPDS leaving long tails on your sutures. Then take your tongue of omentum and lay it down on top of the hole and tie your sutures down. Don't forget to leave a drain. Also don't forget to treat your patient with a PPI, amoxicillin, and Clarithromycin until you get your results from your H. pylori back.
If a patient's already been on PPIs, consider doing a truncal vagotomy at the time and a pyloromyotomy. If this is a high duodenal perforated ulcer or perforated gastric ulcer, you can then do an antrectomy with a vagotomy. You're going to start by immobilizing the greater curvature of your stomach, free up the pylori's and duodenum from the surrounding tissues taking care not to damage any of the portus structures. Divide the stomach approximately halfway up the lesser curvature and then divide the gastro -- so the right gastric artery at the level of the pylori's followed by division of the duodenum just distal to where your ulcer is or distal to the pylori's, whichever is father down the duodenum.
And don't forget to over sew your duodenal sump to minimize blowout. Then you can perform a B2 or Roux-en-Y gastric jejunostomy and leave drains. For your vagotomy, start by opening up the gastro hepatic ligament and immobilize the esophagus with a Penrose drain and then identify those violin strings on the anterior and posterior sides of the esophagus. Resect a one to two centimeter portion and send them for pathology for confirmation. If this is a very large duodenal blot, consider pyloric exclusion with a staple or across the pylori's, at which point you need to reconstruct the gastrin using a gastric jejunostomy.
And then a primary closure of the hole or, better yet, use a serosal patch or place a duo-tube. >> All right. Moving onto common bile duct explorations. If you're laparoscopic and you've shot a cholangiogram and you've got a common bile duct stone, I would start by flushing with some saline and then give the patient one milligram of glucagon and flush again. Repeat your cholangiography. If your stone is still stuck, you're going to move on to a transcystic common bile duct exploration, if you have experience doing that.
If not, go ahead and just convert to open and do all these things open. If you do have experience performing this laparoscopically, then you're going to place a wire through your cystotomy under fluoroscopy, balloon dilate your cystic duct so that you can get your sheath in, and then you're going to place the sheath and then place a flexible cholodocoscope through your sheath. Attempt to identify the stone and retrieve it with either a basket Fogarty balloon, forceps, whatever available to you. If you're able to clear it, then great.
Re-sheet your cholangiogram, complete your cholecystectomy, move on. If you're not able to clear, then convert to open. Kocherize the duodenum and try [inaudible] the stones back. If they're still stuck, at that point, I would make a choledocotomy just past where your cystic duct comes off your common duct and attempt the same maneuvers as above via the cholodocoscope, but just in an open fashion. If you're still stuck at that point, then you're going to have to move onto a transduodenal sphincteroplasty through a literal duodenotomy.
Close that transversely and then leave a drain and complete your cholecystectomy. If you're still not able to get the stone out, the next maneuver would be either a choledochoduodenostomy if you're able to adequately immobilize the duodenum, or perform a choledochojejunostomy if you cannot get adequate duodenal immobilization. Make sure you repair your choledochotomy over a T-tube and it's always helpful to finish straight at the back end of that T-tube to make sure it's easier to take out.
>> OK. For a sentinel lymph node biopsy, this is very high yield. In the case that needs a sentinel lymph node biopsy, you're going to have them place the nucleated tracer generally the night before or the morning of. Along -- at that morning, when you meet them in pre-op, you're going to place the periareolar injection of the methylene blue and message it. This will allow a double agent identifier. You can use a probe to identify the counts to help direct your incision. Then you make a five centimeter incision in the axilla.
Dissect down through the clavipectoral fascia. You're then going to use your Geiger counter to find the hottest node and you're going to excise this node. And then you're going to get ex vivo counts of this node. Then you're going to remove any node that has 10% or greater count as that node that you have ex vivo. And then you're also going to remove any node that is clearly stained blue or grossly abnormal and send them for permanent. >> OK. This is for a bleeding duodenal ulcer.
This is once again after you have tried control of the bleeding by EGD as many as two times or by IR or if the patient's hemodynamically unstable. You're going to start with an upper midline laparotomy. Sometimes it helps to use an intraoperative EGD to find this ulcer to plan your incision over the duodenum. But, if not, just make a longitudinal duodenotomy over D1 to identify the bleeding. Once you have the duodenum open, place sutures superior and inferior to the bleeding ulcer making sure not to drive those stitches too deep as the common bile duct is right behind that area.
If the bleeding's not controlled with these available sutures, you can also isolate and ligate the GDA superior to the pylori's. Once again, just make sure that your sutures don't go too deep and you can protect the common bile duct by placing a Foley or a red rubber catheter into it and you can also just watch for bile coming out of the ampulla before closing your incision. If the patient has a history of refractory disease, just extend your duodenotomy up through the pylori's and close that transversely to perform a pyloroplasty and then perform your vagotomy at the conclusion of the case.
>> All right. Now we're going to ridicule cholecystectomy. So you're going to start placing the patient supine. Make an upper midline or subcostal incision and then you're going to look for peritoneal spread or metastases. If that's clean, then you're going to move onto your cholecystectomy or your liver bed resection if the patient had a prior lap chole. Taking approximately three to four centimeters of normal surrounding liver in a non-anatomic fashion.
You're then going to perform a regional lymphadenectomy including the choledocal, hylar, periportal, and high pancreatic lymph nodes. If they have had a prior laparoscopic cholecystectomy, make sure you excise all of the port sites full thickness and some sources will say to do a radical resection of the common bile duct with a hepaticoj reconstruction. However, I'm not sure I'd personally mention this on the boards. >> OK. Now onto our inguinal node dissection. So for this you're going to place the patient with a frog leg.
Then you're going to make a slight S-shaped incision from the ASIS to the -- just below the femoral triangle. You're going to raise flaps until you can identify the lymph containing tissues surrounding the femoral vessels. You're going to resect this tissue and this is your lymph node dissection for the superficial dissection. Now, if you're also doing a deep dissection, you're going to generally divide the inguinal ligament and you're going to immobilize the peritoneum and place it superior.
And you're going to immobilize the fatty tissue around the iliacs. And this is the lymph node dissection the deep lymph node dissection. And now that you have really no significant subcutaneous tissue covering your vessels, you're going to have a muscle flap to help protect your vessels from exposure and generally this is done with a Sartorius flaps. And then any lymph node discussion, you always want to lay a drain. >> OK. Moving onto an SMA embolectomy for acute mesenteric ischemia. You're going to do an exploratory laparotomy, elevate the transverse colon, and follow that middle colic down to the SMA.
You'll palpate for a pulse at the base of the transverse colon there and expose the SMA, take down ligaments of Treitz and open up the peritoneum over the artery. Make sure you get proximal and distal control with vessel loops and then don't forget to heparinize the patient. Make a transverse arteriotomy and use either a three or number two Fogarty balloon and do your embolectomy down distally and proximally up into the aorta. Make sure you have good back bleeding from your SMA and then close that arteriotomy with interrupted prolines. Make sure to examine the bowel for frank necrosis and palpate a pulse in the mesentery.
And then you can also [inaudible] antimesenteric side of the bowel. And then use a temporary closure of the abdomen and reexamine in 24 hours to make sure you don't have any undetected ischemic bowel. >> All right. Weekly we're going to review the Zenker's diverticulectomy. So you're going to start with the left neck incision, dissect medial to the carotid sheath with care to avoid the recurrent laryngeal nerve. Identify your diverticulum and then you're going to place a large burgee. Again, personally I'm going to say a 60 pharynge and then you're going to perform your stapled diverticulectomy and then perform a two to three centimeter myotomy on the cricopharyngeus muscle.
Leave a drain. Close in layers. >> OK. Real quick we're going to do the subxiphoid window if there's concern for pericardial tamponade. This is -- you're going to start this with an incision just over and extending below the xiphoid process. You're going to use blunt dissection under the xiphoid and sternum at an angle -- at about 45 degrees after the first few centimeters. And you're going to resect the xiphoid in most cases.
You're going to feel the heart against your finger and you're going to grasp the pericardial sack with an Alice clamp or tooth pickups and you're going to incise it with mets. If there's blood that comes out, you're going to do a median sternotomy because there is likely an injury to the heart. If it is clear fluid that comes out, you're done. You wash out and close. >> Now onto some of the more feared procedures. For the Whipple, you're going to start with either an exploratory laparotomy or diagnostic laparoscopy to inspect for metastatic disease.
If you find concerning diseased biopsies, send for frozen section. If it's positive, you're done. If there's no evidence of metastatic disease, then you're going to convert to a midline laparotomy or bilateral subcostal incision, whichever you prefer. Immobilize the hepatic flexure and reflect the transverse colon inferiorly. Then perform a Kocher maneuver medially until you identify the SMA and immobilize until you find the ligament of Treitz. Then identify the superior mesenteric vein by following the middle colic cephalad.
Free up the SMV and follow it to the inferior border of the pancreas. You then create your tunnel between the SMV and the posterior border of the pancreas. At the superior aspect of the pancreas, retract your duodenum inferiorly and dissect out the structures of the portal triad. Identify the GDA just cephalad to the pancreatic head, which will then be suture ligated with care taken to ensure that you are not ligating the proper hepatic artery. Perform your cholecystectomy. Identify the common bile duct literal to the portal vein and isolate this and divide it just before it enters the pancreatic head.
Send this for frozen section. Free the pancreatic head from the portal vein. Perform your distal gastrectomy with a GIA stapler and transect the pancreatic head over your tunnel that you created over the SMV. Divide the proximal jejunum with a GIA stapler and divide the mesentery with an energy device. Then free the uncinate process and pass the specimen off the table. You'll then reconstruct by bringing up a loop of jejunum, perform your pancreaticojejunostomy with invagination of the pancreatic remnant in an into side fashion.
And then perform your hepaticojejunostomy at approximately 20 centimeters distal to that. Perform your gastrojejunostomy. Leave a drain and close. >> OK. Now onto the ruptured triple A. So you're going to prep this patient from the knees to the neck. You're not going to induce them until they are prepped on the OR table. You're going to perform an ex-lap. You're going to get supraceliac control by opening the gastrohepatic ligament by pushing the esophagus to the left side.
You're going to eviscerate the bowel and pack it to the right outer abdomen. You can further immobilize the mesentery from the retroperitoneum to get better visualization. You're then going to open the retroperitoneum. You're going to identify the left renal vein and lift the renal vein to help identify the renal arteries. You're then going to move the aortic clamp down to infrarenal and dissect out both common iliacs and clamp them. And then, at the same time, you're going to be heparinizing the patients with 80 units per kilogram of Heparin.
You're then going to open the aneurysm sack and evacuate all the -- out all clot. You're going to perform an anastomosis using 3O proline first proximal and then distal with either a tube graft or bifurcated graft. You're going to reimplant the IMA if it's poor back bleeding and the patient is stable enough. No need to reimplant if pulsatile or thrombosed. You're going to close the aneurysm sack over the graft and you're also going to completely cover the graft with peritoneum. Check for distal pulses, relapse the bowel back into the abdomen, and close.
>> All right. So now a quick down and dirty on how describe a hepaticojejunostomy. So you're going to enter the abdomen and place a self-retaining retractor. Identify the common duct, likely this will be after some type of common duct transection probably from a laparoscopic cholecystectomy gone wrong. Once you identify the common duct, create you Roux-en-Y and then perform an end-to-side choledochojejunostomy with interrupted 5O PDS sutures and leave a drain.
>> OK. Transhiatal esophagectomy. You're going to completely immobilize the stomach preserving the right gastric and right gastroepiploic arteries. Then perform a Kocher maneuver and a pyloromyotomy. Place a Penrose around the esophagus at the GE junction and elevate it up out of the chest. And then use clips and cautery to take all the small vascular branches as far up into the posterior mediastinum as possible. You'll then use your hands to bluntly dissect around the anterior and literal aspects of the esophagus as high into the mediastinum as can be reached.
Then make a left neck incision at the anterior border of the sternocleidomastoid and get behind the created sheath to encircle the cervical esophagus, which can be looped with a Penrose and stapled off. Using a kissing hands technique, mobilize the superior portion of the esophagus until it's completely freed up from the mediastinum to remove. And then remove the specimen through the abdomen. Inspect the posterior mediastinum for bleeding and pack it as needed during which you can evaluate the length of your gastric conduit and transect the stomach about five centimeters distal to the GE junction making sure you have good margins of this for cancer.
You then transpose your gastric conduit up through the mediastinum into the left neck after removing your mediastinal packs. And then perform a side-to-side stapled cervical esophagogastric anastomosis. And don't forget to leave a drain in the cervical neck space. Place a J-tube for feeding and then get a chest x-ray before leaving the OR just in case you have a pneumothorax that needs to be treated. >> OK. For our axillary dissection, you're going to make an incision just below the hair bearing area of the axilla. And you're going to carry this through to the clavipectoral fascia.
You're going to identify the lymphatic fatty tissue in this area and, knowing your borders of the axilla, your medial border is your chest wall/serratus, your superior border is the axillary vein, and the literal border is the skin. And so you're going to follow the border of the pectoralis major up to the axillary vein, which is your superior border, as we stated. And you're going to open the fascia over the axillary vein. You're then going to identify the long thoracic and thoracodorsal nerves as they run along the chest wall and you're going to preserve them throughout.
You're going to remove all the lymph tissue, which is levels one and two within this triangle, and which extends underneath the pectoralis minor. You're then going to check for homeostasis, leave drains, and close skin. >> OK. Subclavian artery energy. First you're going to put the patient supine, put a shoulder roll under them, and rotate the head to the contralateral side of the injury. Prep and drape from at least the neck all the way down to the chest, but preferably all the way down to the thighs in case you need a saphenous vein. Proximal control on the left side is gained making a high left anterolateral thoracotomy in the second or third intercostal space.
This can always be converted to a trap door if you need more exposure. Distal control is a direct cut down over the axillary artery in the deltopectoral groove. On the right side, you're going to do a median sternotomy for proximal control and, once again, distal control is down to the axilla. Once you have proximal and distal control, you can enter the hematoma either above or below the clavicle as dictated by the injury. You may need to resect part of the clavicle. Make a super infraclavicular incision depending on wherever the trauma localizes. Remember, if you've got a subclavian artery injury, you need to be thinking about a forearm fasciotomy and if you're thinking about it, just do it.
Make a lazy S incision from just proximal to the antecubital crease distally through the wrist onto the palm. Make sure to open up that carpal tunnel to decompress the median nerve and then turn the arm over and make a second incision on the dorsal forearm to decompress that compartment. >> Now, if you got a gunshot wound to the duodenum, you're going to start with your standard trauma laparotomy, pack, and do whatever you need to do to initially contain contamination, fix bleeding. Then you're going to turn your attention to the gunshot wound in the duodenum.
kocherize the duodenum. You can extend down to a full right medial distal rotation if that's necessary. You're then going to evaluate for primary repair versus a more complex repair. If it's primary repair, then try and close it transversely. If it's more complex, you need to evaluate the patient's stability. If the patient is unstable, you're going to do wide drainage plus or minus a duodenostomy tube, place some feeding access, and get out and come back to fight another day. If the patient's stable, you need to evaluate the biliary and pancreatic ducts especially if the second portion of the duodenum is injured.
So do cholangiography via the infundibulum of the gallbladder or perform a cholecystectomy and do cholangiography through the cystic duct. The other option is to place a butterfly needle in the common bile duct and shoot your cholangiogram that way. If you have no ductile injury, then repair this with either a jejunal serosal patch or a Roux-en-Y reconstruction with the hood of the Roux limb placed over the duodenal injury. If you've got massive destruction to the ampullary region, you may eventually require a Whipple for reconstruction.
However, do not do this acutely. >> Real quickly the important points for you, lower extremity four compartment fasciotomy. You're going to make your medial and literal incisions on the literal side. You want to make sure that you make an H-type incision to identify the intramuscular septum and then perform extensive fasciotomies on either side of that septum to open the anterior and literal compartments. On the medial side, you make your incision and then you want to ensure that you take down the soleus muscle off the posterior tibia until you identify the deep neurovascular bundle to ensure that you've opened the superficial and deep posterior compartments.
>> OK. This is our final scenario. Hopefully I won't need one of these after the boards on Monday morning. It's resuscitative thoracotomy. You're going to do a splash betadine prep. Put that left arm up. Open the chest in the 4th or 5th intercostal space from the sternum all the way down to the table getting into the pleura. Place your retractor. Sharply take down the inferior pulmonary ligament just enough to get the lung to elevate up.
Make sure not to hit that inferior pulmonary vein. Then grab the peritoneum -- or that pericardium with an Alice. Open up the pericardium widely with scissors and use -- deliver the heart out of the pericardium. Do your cardiac message as needed. You're then going to chase the posterior ribs down towards the spine and incise the pleura. Use your finger or clamp to dissect around the aorta. An NG tube in the esophagus will help you recognize and protect that so you don't clamp it also. >> Wish us luck.
And best of luck to everyone out there. Thanks for listening. >> Until next time, dominate the day. [ Music ]