Component separation

Separation of parts procedure. Transverse incision located at the inferior aspect of the rib cage facilitates the exposure of the semilunar line. Skin vascularity is intact because of preservation of periumbilical perforators. The external oblique muscle is divided off of the rectus fascia at the anterior extent of the muscle fibers.

Pilonidal sinus: Karydakis procedure

GA
Prone
Buttocks strapped apart
Buttocks shaved fully
Methylene Blue inserted to outline track
IV antibiotics (cephazolin & metronidazole)
Aim is to lateralise the natal cleft
see photos for margins
Undercut the flap: 2cm wide, 1cm deep, the whole length of the wound
Use 2 layers of 0 vicryl to secure the flap with deep sutures. Follow the curvature of the sacrum. Sacral bites are closer together. Lower sutures are almost horizontal
Hold all sutures before tying and cutting.
Suture base of flap to midline: assistant advances base across as knot tied
Insert 10Fr suction drain then do second layer (undersurface of flap to halfway up other side
Avoid any suture hole or drain hole near midline
Padded dressing
Aim is well lateralised wound 2cm to left or right
Beware the difficult lower end where failures occur if wound reaches the midline
Undercut edge of flap if tending to invert

Post op
2 days RIB
Then drain out and home
Sutures out 10 days
Shave twice weekly one month only

Packing liver

place rolled packs in subphrenic and subhepatic space
avoid IVC compression
effective packing is a wrap not a sandwich
pack early (packing relies on clot formation)

if still bleeding despite packing:
technical error
packs do not control arterial bleeding:
inflow occlusion needed (in trauma usually venous)
if bleeding looks arterial despite inflow occlusion the hepatic artery may have an anomalous origin (left hepatic from left gastric in 15% Right hepatic can arise from SMA. Supra coeliac cross clamp will help)
if dark blood gushes from behind the liver: dealing with retrohepatic venous injury: divide falciform and push liver posteriorly to compress
Do not mobilise when there is a suspicion of a retrohepatic venous injury: you will lose control

If packs dont fully control bleeding: send to angio for embolisation

ED thoracotomy

Indication
penetrating trauma with less than 10 mins CPR
5th ICS sternum to bed down on to rib
cut down to pleura and through small area laterally then use fingers and scissors to extend
chest wall restractor
open pericardium (root of aorta to apex)
repair heart foley catheter or staples
clamp thoracic aorta
clamp lung root (can twist hilum)
rapid transfer to OT

Damage control laparotomy

Three dark angels: acidosis, coagulopathy, hypothermia

Indications
SBP<90
Temp<34
APTT>60
pH<7.2
Pattern recognition
Lactate >5
Inability to achieve haemostasis owing to coagulopathy
time consuming procedure (>90 min)
inaccessible major venous injury
life threatening injury in second location
planned reassessment of abdominal contents
inability to close abdomen

Aims:
Control haemorrhage: pack all quadrants
must control surgical bleeding definitively
pack medical bleeding
simple vascular ligation, balloon tamponade or shunting
perform rapid exploration
control contamination
staplers or tapes
don't waste time creating stomas
drain tubes for biliary or urological injuries
pack abdomen
perform temporary abdominal closure
avoids compartment syndrome

procedure
aim <1hr
warm theatre to 27
have packs available
prep from neck to knees
full length incision to fascia then through fascia
avoid sucker use initially
scoop out blood and pack abdomen

Definitive haemostasis
Splenectomy (can be done <2mins)
clamp mesenteric bleeding
nephrectomy
packing of liver and adjuncts
if unable to gain control: cross clamp aorta
control bleeding from visible vessels
consider temporary vascular shunts
Balloon occlusions of vessels
Can tie off IVC below renal vessels (consider lower limb fasciotomies)
drainage for pancreatic injuries
washout
Close: towel clips
Bogota bag
VAC
Remember angiography esp for pelvis and liver

When to reoperate
lactate <4
base excess >4
normalised coagulation profile

Relook
perform definitive operations before pack removal
restore intestinal continuity
'tertiary' survey

complications
most common is compartment syndrome (15%)
(renal failure occurs when pressure >25mmHg)
infection
-associated with packing itself, not just contamination. Also with hepatic artery ligation

Fasciotomy

clinical exam
intra compartmental pressures >30mmHg
perfusion pressure <30-40mmHg (ie DBP-compartment pressure)

Two incision technique
Anterolateral incision
15cm incision 2cm anterior to fibular shaft over anterior intermuscular septum
transverse incision is made over septum to allow access to both compartments
Visualise septum
identify superficial peroneal nerve near septum
Maintain tension on the fascia with a Kocher clamp
Open the fascia proximally and distally with Mayo scissors
Proximally aim for the patella and distally for the centre of the ankle to stay in the anterior compartment
Avoid straying too medially to avoid injuring dorsalis pedis
Lateral compartment fasciotomy is made in line with fibular shaft
Distally aim for lateral malleolus to stay posterior to the superficial peroneal nerve

Posteromedial incision
Deep and superficial posterior compartments
15cm incision
2cm posterior to edge of tibia
Once down to fascia, undermine to tibial edge: this will avoid long saphenous vein and nerve
Retract saphenous vein and nerve and release fascia over superficial compartment. Keep tension on fascia with a Kocher
Soleus origin is from posterior 1/3 of tib/fib and covers proximal portion of deep compartment
Detach soleal bridge to expose fascia FDL and tibialis posterior
Neurovascular bundle is between tibialis posterior and soleus
In the distal half of the tibia the deep compartment is subcutaneous: again releasing the fascia over FDL is required to access the deep compartment
Fascia is opened distally and proximally under the belly of soleus

Subclavian artery trauma

Anatomy:
3 parts
1st: origin to scalenus anterior
2nd: medial SA to clavicle
3rd: clavicle to medial pec minor

Area of SC artery to be exposed:
Proximal left: left lateral thoracotomy and supraclavicular incision or trapdoor
Proximal right (first portion): median sternotomy with right cervical extension
Second portion either side: Supraclavicular incision with infraclavicular extension (s shaped incision)
Right or left third portion: as above

clavicle may need to be disarticulated
If stable: perform trapdoor/left lateral thoracotomy
If unstable: left anterolateral thoracotomy, apply pressure apex pleural cavity, clamp origin
repair primary anastomosis or interposition graft

Liver anatomy

VATS

•Choose the side you plan to biopsy eg R side
•Left side down, lateral position
•No need to break the bed
•Lower border of the scapula is the land mark for thoracotomy to access the lung (classically the thoracotomy is done 2 finger breaths under the scapular).
•Place the first 12 mm port into the high anterior axillary line, corresponding to the lower border of the scapula. If an open thoracotomy needs to be done this port incision can be extended around to follow the rib back below the scapula. This port will become the position for the anterior/apical chest tube. Place the skin incision (horizontal) anterior and lower to the planned entry into the chest wall, so that the apical ICC can be angulated this way and remain in place.
•The lower anterior 12mm port should be placed below and lateral to the first port, corresponding to the mid-to-posterior axillary line, roughly 2 rib spaces below. Place the skin incision along the same rib space a bit anterior so that the ICC can be placed on the angle and sit postero-lateral.
•These 2 ports tend to be more constant so that they correspond to 2 ICC (some will only need 1 ICC). The 3rd port can be placed under vision once the area to be biopsy has been visualised and the appropriate site planned. For example the 3rd port can be placed posteriorly to triangulate the position of the ports.
•Wedge resect with stapler, remove the sample through the ports.
•Close the unused ports in two layers using Vicryl and nylon.
•For the ICC site place a mersilene horizontal matress suture and then the ICC and wrap the Mersilene around the ICC and secure it

•Post Op:
•Check CXR in recovery
•Place the ICC on 20 mmHg of suction
•Keep the ICC in till no air leak for 24 hours

Jaboulay procedure

Need to exclude testicular tumour first. Do U/S
Aspiration and scrotal approach contra indicated until proven not tumour. Beware hernia can transilluminate as well therefore aspiration again a bad idea.


Grasp scrotum firmly in one hand to stretch scrotal skin.
6-10 cm incision may on anterior surface of scrotum over most prominent part of hydrocoele, well away from testicle which lies posteroinferior.
Skin, dartos and thin cremasteric fascia are incised and reflected back together as a single layer from the underlying parietal layer of the tunica vaginalis which is the outer wall of the hydrocoele.

When hydrocoele well separated laterally and medially from overlying layers, it is grasped with 2 Allis forceps and a trocar is inserted to aspirate the fluid. With one finger inside the sac, dissect it free from the overlying scrotum so that spermatic cord and testicle with attached hydrocoele lie free in operative field.

Hydrocoele sac is then opened completely. Testicle is then carefully inspected and palpated. Redundant wall sac is trimmed leaving a margin of 2cm.

Great care must be taken with haemostasis. Sac is then everted behind testis with interrupted suture.

Close in layers.

Lords procedure:
•Do not deliver the hydorocele out intact b/c less chance of bleeding

Laparoscopic Tenckhoff insertion

•Preoperative marking of the site (usually on the pts left side and just below the level of the umbilicus) so that it does not sit in a crease or belt line
•Preop shave and betadine prep
•Betadine prep and square drape
•Ioban
•Surgeon stands on pts right and the tower is at the pts feet.
•If the preop marking is on the pts right side then all the ports and surgeon positions is opposite.
•Most of the tubes/wires come from the feet and place the quiver at the pts left hip.
•First incision is left and caudal of the umbilicus, transverse incision just a bit off the midline to go through the left rectus sheaths.
•Local anaesthetic in skin and peritoneum
•Transverse incision and use S shaped retractors to retract tissue
•Hold up the ant sheath with a stay 3/0 dexon suture on each side of the planned longitudinal incision. Incise the rectus sheath longitudinally b/w the stay sutures.
•Part the rectus muscle with blunt parting dissection of the scissors and S retractors.
•Get down to the post sheath and place an artery forcep in the planned entry point of the port and hold it up, place a running dexon suture around the planned port site as a purse string stitch.
•Incise into the post sheath and place a 12mm port in. This will be the camera port.
•Hold the port in with the ant dexon stay sutures and tie it to the port and hold it anteriorly together with one artery clip.
•Place the other 5 mm port site on the pts right side, one at the level of the 12mm port and the other in the RIF.
•Before putting in the ports using the endoclose. To place a dexon tie in one angle and out another so that the peritoneum can be sealed appropriately at the end. The port is passed through the dexon tie.
•Place the suture through the end of the tenchoff catheter, flatten the needle so that it can come out a 5 mm port. Now pass the suture in through the 12 mm port, place a stitch into the dome of the bladder and bring out of the 5mm RIF port. On the other end of the catheter place a dexon tie.
Use the x2 5mm working ports to place a stitch into the dome of the bladder or the uterus (preferably), so that the catheter stays in the pelvis. Place the stitch first and once it has been passed out of the RIF port then pass the catheter into the 12mm port and adjust the position of the catheter accordingly and bring the other end of the stitch out the RIF port.
•Bring out the stitch through the RIF port and do an extra-corporeal knot and pass it down with a knot pusher, will need 5 throws on maxon or PDS sutures.
•Once secured then bring out the tail end of the catheter making sure that no loops of bowel are caught up in it.
•Make sure the cuff is just above the post sheath and place one throw. Test the catheter and irrigate peritoneal dialysis fluid into the peritoneum 20mls x3 at a time till the fluid out is clear or coming freely.
•Then put the trochar on the end of the catheter and pass it up behind the ant rectus sheath and down and around to the X mark on the skin. Making sure the second cuff on the tenchoff is at least an inch away from the skin.
•Then irrigate dialysis fluid in for 2 minutes and check the outflow. If the fluid coming out is still heavily blood stained then peritoneal irrigation will need to be started in recovery to prevent blockage of the catheter.
•Close the anterior sheath with running maxon suture. Then close the fat with maxon and then skin with a continuous dexon subcuticular stitch.
•Close the other port sites with the dexon ties on the peritoneum with the aid of a stitch pusher and then the skin.

Post op issues:
oIf the peritoneal fluid is blood stained than the peritoneum will need to be washed several times in the post op recovery to prevent clotting
oIf catheter is blocked than it can be mechanical or clot blocking the catheter
oTrial of urokinase can sometimes work to unblock it
oDialysis does not start up for roughly 3 weeks

Lichtenstein IHR

Cremasteric artery is a branch of the inferior epigastric. This is a collateral supply to the testis. Preserve it in case of accidental ligation of testicular artery

Transduodenal sphincteroplasty

Indications:
1.Impacted stone at ampulla of Vater
2.Papillary stenosis
3.Recurrent pancreatitis with multiple CBD stones

Contraindications:
1.CBD greater 2cm diameter
2.Long distal CBD stricture
3.Perivaterium duodenal diverticulum
4.Severe inflammation of duodenal wall or pancreatic head

Procedure for impacted stone:
1.Usually follows choledochotomy
2.Extended Kocherisation of duodenum
a.Peritoneum lateral to D2 incised
b.D2 retracted medially and inferiorly
c.Plane behind head of pancreas developed by blunt dissection
3.Longitudinal duodenotomy opposite ampulla of Vater at anterolateral aspect
a.Ampulla of Vater usually between upper 2/3 and lower 1/3 junction of D2
b.Exact location may be facilitated by palpation of stone or balloon Fogarty catheter passed down via cystic duct
c.Place stay sutures either side of planned incision to hold wall apart
d.Incise with diathermy through full thickness of duodenal wall
4.Locate ampulla of Vater
a.Usually mucosa folds circumferential in duodenum but this is lost at ampulla
b.Stay sutures are place either side of ampulla to elevate it
5.Ampulla is incised at 11 o’clock with needle tip diathermy
a.A small catheter is placed into the ampulla to facilitate incision on top of it
b.Incision of 5mm is made initially and fine 4-0 or 5-0 absorbable sutures are placed every 1.5mm incorporating duodenal mucosa and CBD mucosa. These are initially not tied and clamped by artery forceps to facilitate traction to open the CBD.
c.The incision is carried 5mm at a time for the length of the intramural portion of the CBD, which may be as long as 3cm.
d.The impacted stone may be extracted or pushed down by a probe passed from the choledochotomy
e.The incision stops when the mucosa of the CBD leaves the duodenum
f.Sutures are continued to the apex
6.Pancreatic duct opening is localised at 4 to 6 o’clock position
a.Once identified medial sutures are placed so as not to occlude it
b.Pancreatic duct orifice identification may be facilitated by giving Secretin 75 unit/kg iv to induce pancreatic secretion
c.If duct cannot be identified sutures are avoided between 3 and 6 o’clock
7.Once completed further choledochoscopic inspection is performed to ensure duct clearance
8.Longitudinal duodenotomy is closed with 3-0 PDS Lembert sutures in single layer
9.Choledochotomy is closed with 4-0 Vicryl interrupted sutures over a T-tube

Complications:
1.Acute pancreatitis
2.Bleeding
3.Duodenal leak from suture line

Abdominal mesh rectopexy

Lithotomy
Pfannenstiel
Alexis wound retractor
Mobilise rectum as per Anterior resection to levator
2-0 prolene suture prolene mesh to sacrum using 3 interrupted sutures in midline
Wrap and trim mesh around rectum, but do not create 360 degree wrap.
Suture wings of mesh to rectum
Close peritoneum
looped PDS to skin

On table lavage

Mobilise caecum
Perform appendicectomy
3-0 PDS purse string
21G three way foley into caecum and tie snugly
distal end into anaesthetic tubing
Irrigate 8L warmed saline until clear

Palliative upper GI bypass

Biliary bypass adds 2-5 months life
Surgical bypass procedure of choice cf stenting in patient fit for surgery with > 4month life expectancy, although failure rate still 25%

Obviously need GB filling on ERCP before cholecystojejunostomy

20% patients with pancreatic cancer will develop gastric outlet obstuction

Hydration important in jaundiced patients

Laparoscopic partial gastrectomy

GIST (b/w muscularis propria and muscularis mucosa, controversial to resect laparoscopically if over 5cm as higher malignancy rate, endoscopically have central punctate ulcer)
Carcinoid only if LN metastases unlikely

Position as for Nissen
Stand between legs
Nathanson
Divide gastrocolic omentum
Dissect down toward pylorus and divide right gastroepiploic
Divide lesser omentum and clip right gastric artery
25mm bumgun stapler with anvil in duodenum for Bilroth 1 (need pliable duodenum with stomach remnant that will come down without tension

12% leak rate in one series

Distal pancreatectomy

Oversewing pancreatic duct is associated with a lower pancreatic stump leakage rate

Laparoscopic Hellers myotomy

Beanbag
Stirrups
20-30 Reverse Trendelenburg
Compression stockings
Stand between legs
Nathanson
Divide gastrohepatic ligament
Separate right crus from diaphragm with blunt dissection
transect peritoneum and phreno-oesophageal membrane
Separate left crus by blunt dissection
Continue into posterior mediastinum to expose 6-7cm of oesophagus
Identify and preserve anterior and posterior vagal divisions
Divide short gastrics all the way to the angle of His
Hook diathermy myotomy to submucosal plane 2cm down onto stomach to 5cm past GE junction
Avoid diathermy if bleeding encountered as can cause delayed perforation
If perforation suspected, intstil saline and blow air down orogastric, if found repair with 3-0 PDS
Combine with fundoplication
Ba swallow only if perforation suspected
Avoid meat or bread for 2 weeks

PEG

Contraindictions
Acites: can leak and cause peritonitis
Inability to transilluminate (can cutdowm to fascia to facilitate or can use bedside US)

Several different techniques: push, pull or Seldinger

Proc
Give Abx
Thorough endoscopy
Insufflate until rugal folds disapear
Transilluminate skin and bounce finger
Infiltrate with LA, bigger skin incision than PEG to allow infection to drain
Introduce needle 45 deg cephalad
Pass wire and grasp with endosnare
Push or pull PEG
Visualise with endoscope, button should rotate freely to avoid gastric wall necrosis


Complications
15% total
10 infection rate if antibiotics used
Leak is usually caused by too much tension causing gastric necrosis
Confirm with fluoroscopy or CT
If confirmed, pull PEG and place NG
Pneumoperitoneum may persist for several weeks
Progressive enlargement of stoma is usually due to excess movement of PEG. Need to correct movement rather than placing bigger PEG
Gastrocolic fistula is rare. Be suspicious if patient develops perifeeding diarrhoea several weeks after placement
Fuoroscopy is diagnostic
Rx is removal of PEG

ICP monitor

Indications
GCS 3-8 and abnormal CT
If normal CT, rate of elevated ICP is 10-15% so add:
GCS <8, Normal CT, and two of:
Age >40
SBP<90
Inability to monitor neuro status eg GA

Types
Gold standard is fluid coupled EVD (can also drain CSF, but can get blocked and be hard to place in high ICP where ventricles are small)
Intraparenchymal Bolt is a fibreoptic non fluid filled system

Bolt
Place on Right side (usually non dominant)
Mark Kochers point (2-3cm lateral to midline (approx mid pupillary line) and 1cm anterior to coronal suture
Need to make small incision in dura

Complications
3% major haemorrhage rate
Infection rises significantly after 5 days

Intra abdominal pressure monitoring

Foley
Pressure transducer zeroed at level of symphisis and inserted into aspiration port of IDC
Clamp catheter
Instil 50-100mL of saline
Can measure indirectly by placing U shaped loop in Foley with apex of loop at level of symphisis (10mmHg = 13.6cm H20)

Abdominal compartment syndrome occurs in a graded manner
Anuria is usuallt present by 30mmHg

30cm H20 (22mmHg) is a critical level requiring therapy used by some
Clinical judgment is required
Sequentially rising measurements in the face of pulmonary, renal and cardiovascular compromise may necessitate decompressive laparostomy

DPL

midazolam/morphine
LA infiltration with adrenaline
3cm vertical midline incision 2cm below umbilicus (above if preganant or pelvic fracture)
Dissect to linea alba (self retainer helpful)
If kit, grasp and lift fascia then insert needle 45 deg inferiorly, pass into peritoneal cavity and slide over wire. Aim for rectovesical pouch
Aspirate, if 10mL blood found then arrange laparotomy
If not then infuse bag of saline in but do not allow to empty completely.
Put catheter bag on floor: need to get 300-350ml back for analysis
Controversy over what is positive: >500WCC/mm3 suggests small bowel or colon injury
>100 000 RBC/mm3 widely accepted but some have used 20 000

Gastrojejunostomy

Alternative to pyloroplasty in obstructing duodenal ulcer (more effective) and less morbid than antrectomy.

Need to add vagotomy to prevent marginal ulceration

Upper midline incision
Clear dependent portion of greater curvature of omentum
Divide gastroepiploic arcade
Retrocolic probably gives better functional result
Clear window in mesentery, usually to left of middle colics
Usual anatomosis
Once complete, pull anastomosis back through mesocolon, then tack stomach to transverse mesocolon to prevent slippage
If chronically distended stomach, consider tube gastrostomy to avoid long term NG

POST OP
Maintain on PPI to prevent marginal ulceration

Diaphragmatic hernia repair

Trauma laparotomy
1 Ethibond figure 8 interrupted suture
Right side may be better to approach thorascopically

Ileoanal pouch

Controversies
1. Timing of surgery
Total colectomy/end ileostomy (suture stump end to abdominal wound) if:
-Diagnostic dilemma of Crohn's disease
-High PNL requirement
-Toxic colitis and megacolon
-Malnutrition

2.Type of pouch
Functional results the same
J pouch easy to consruct
S pouch if difficulty reaching pelvis (2-4cm extra length as anastomosis is done on end of colon)

3.Type of anastomosis
Controversy leaving cuff of 1-2cm of ATZ
cuffitis and malignancy versus poor continence, increase sepsis
(probably favour stapled, but studies equivocal: ?type II error)
Mucosectomy and hand sewn if dysplasia in lower 2/3 of rectum or rectal cancer

4.Omission of ileostomy
May omit if stringent criteria met re nutrition, PNL, tension etc

Preop
Full colonoscopy
Stomal therapist
Bowel prep
Iv ab
Lloyd Davies, Trendelenburg, IDC, compression stockings
Standard proctocolectomy (high ligation if dysplasia or long standing)
Can gain extra length on ileum by dividing ileocolic and scoring mesentery (see photo)
100mm linear cutter to construct J pouch with 15-20cm limbs
Purse string at apical enterotomy
Ensure anal sphincters are not included in anastomosis. Avoid creating iatrogenic pouch-vaginal fistula (traverse initial staple line posteriorly with bum gun trocar

Post-op
Invariably patients will have high ileostomy outputs as stoma is proximal: make pateients aware of dehydration and ask them to avoid high fibre diets
See @ six weeks to arrange contrast enema and do DRE to break down web like stenosis (easier than treating fibrous stenosis later)
If anal transition zone left, need to do pouch endoscopy and ATZ biopsy

Colostomy/Ileostomy

30-50% of all stomas will become permanent
An ileostomy is better than a transverse colostomy (should be avoided at all costs)

End Colostomy
Where possible pre-op marking by stomal therapist
Be aware of belt lines, skin creases
Draw triangle between ASIS and umbilicus
Stoma should be slightly above centre of triangle, through rectus abdominus muscle.
If obese, multiple lower abdominal scars or cord injury, site above umbilicus

Dissect colon sufficient to bring 3-4cm of colon above skin (further dissection will lead to prolapse)
May need to divide IMA and mobilise splenic flexure for extra mobility
IMA division should be proximal to left colic to preserve flow through proximal arcades

Kocher/Allis on fascia and skin to ensure stoma takes direct route through abdominal wall
Cut skin disc with Kocher and eye of artery forcep
Linear cut through abdominal fat and anterior sheath 2-3cm and blunt dissection through rectus
Pack under abdominal wall and incise posterior sheath. 2 finger size hole.
Babcock on colon and bring through abdominal wall. Ensure bowel is not twisted.
Close midline incision

Four everting sutures in north, south, east, west position, incorporating dermis, then seromuscular layer 3-4cm from end, then full thickness through terminal end of bowel. Tie after placing all four. Complete with one or two sutures between each.

The obese patient
Consider whether primary anastomosis is better than a difficult stoma
Principles are:
Resect all inflamed tissue
Mobilise splenic flexure
May need to transect IMA
May need to widen trephine
If impossible then can create 'pseudoloop' with a more proximal segment of bowel, using antimesenteric border of bowel (see figure above)

Construction of an 'end loop' colostomy may obviate need for formal laparotomy for closure (distal end as mucous fistula)

An endoscopic assisted stoma can be created obviating need for laparotomy. It is important to ensure correct end has been brought out by insufflating air into distal limb with colonoscope.

Fasciotomy

Upper limb
•Arm – make a longitudinal incision laterally from deltoid insertion to lateral epicondyle. Identify the intermuscular septum and divide fascia anterior and posterior to this, decompressing both compartments. The radial nerve crosses the septum posterior to anterior halfway down the arm.
•Forearm – make an incision longitudinally across the wrist and divide the carpal tunnel. Extend this incision transversely down to the ulnar border of the wrist, run up the ulnar border of the forearm and then transversely across the cubital crease. Divide the bicipital aponeurosis as necessary. To release the dorsal compartment, make a longitudinal incision down the length of the forearm.

Lower limb
•Thigh – Make an incision from the greater trochanter to the lateral condyle of the femur and incise the iliotibial tract. Reflect the vastus lateralis off the intermuscular septum and incise the septum longitudinally the whole length of the septum. To decompress the medial compartment a separate incision is required.
•Leg – Two incision technique.
oMake an incision longitudinally through skin and fascia centred between the fibula and the tibial tuberosity. Decompress the anterior compartment in line with tibialis anterior. Identify the lateral septum and superficial peroneal nerve and decompress the lateral compartment.
oMake a second incision longitudinally, 2cm medial to the subcutaneous medial border of the tibia. Release the superficial compartment and the deep compartment over the FDL. Identify tibialis posterior and release its fascia.

Popliteal artery relations
AVN(posterior tibial) from medial to lateral, NVA in lower part.

Below knee amputation

1.Position the patient supine with foot wrapped in drape/crepe.
2.Make an incision (Burgess) a hands-breadth or 10cm below the tibial tuberosity. Ligate the long saphenous vein.
3.Divide through anterior compartment with anterior tibial artery and deep peroneal nerve situated on the interosseus membrane. Ligate large vessels and nerves. Divide through lateral compartment ligating superficial peroneal nerve in the substance of peroneus longus.
4.Define the level of transection of bone with a periosteal elevator. Divide the fibula at a more proximal level (at least 1.5cm) using bone cutting forceps. Transect the tibia with a Gigli saw and bevel the edges round.
5.Divide through posterior compartment (On entering the popliteal fossa, in the upper part the relationship is AVN(tibial) from medial to lateral whence it arches laterally midway and in the lower part of the fossa reassumes its previous relationship i.e. NVA and crosses the soleal arch) ligating posterior tibial artery and tibial nerve medially with peroneal artery adjacent to the medial aspect of the fibula on the posterior surface of tibialis posterior.
6.Create a long posterior myocutaneous flap, consisting of muscular fibres of gastroecnemius NOT tendon, supplemented with soleal fibres if needed. Ligate short saphenous vein and sural nerve in the subcutaneous tissue at the inferior apex of the flap.
7.Place an epineural catheter near the stump of the tibial nerve and infiltrate bupivacaine.
8.Close in layers using 3/0 vicryl/monocryl.

Above knee amputation

1.Position the patient supine with the leg wrapped in drape/crepe.
2.Make a fish-mouth incision at the level of intended amputation (supracondylar, diaphyseal or sub-trochanteric) usually a hands-breadth or 10cm above the upper border of patella, ligating the long saphenous vein medially.
3.Divide through the anterior compartment and contained quadriceps, sartorius and subsartorial canal with ligation of femoral vessels and saphenous nerve. Deep to the quadriceps and on adductor magnus, adjacent to the femur ligate the profunda femoris vessels. Bevel the muscle down to the femur proximally.
4.Divide through the posterior compartment and ligate the sciatic nerve.
5.Transect the femur with a Gigli saw and bevel the edges round with a rasp.
6.Place an epineural catheter near the stump of the sciatic nerve and infiltrate bupivacaine.
7.Close in layers using 3/0 vicryl/monocryl.

Brachial embolectomy

1.The arm is usually more resistant to critical ischaemia therefore hand remains viable and surgery can be performed at earliest convenience not emergency.
2.Make a transverse incision 1cm distal to cubittal skin crease over the medial side of the forearm.
3.Make a longitudinal incision through fascia and bicipital aponeurosis
4.Identify the brachial artery (N(median)AV from medial to lateral) and venae comitantes.
5.Isolate the brachial artery proximally and sling to allow control, then follow the brachial artery distally to expose bifurcation into ulnar and radial (note may be trifurcation with deep interosseus artery) and sling distally.
6.Administer IV heparin at 100units/kg and then pull up and clip slings to drapes – no clamps on small arteries.
7.Make a transverse arteriotomy just proximal to bifurcation and assess inflow and backflow.
8.Perform a Fogarty balloon embolectomy proximally (size 3 or 4 proximally) until two clear passes and reassess inflow.
9.Similarly, perform a distal embolectomy (size 3) down each branch until two clear passes.
10.Flush with heparinized saline and assess resistance to flow.
11.Close the arteriotomy with 6/0 prolene continuous (begin at each apex and tie in middle). Release slings prior to tying to ensure do not narrow the artery
12.Drain and close

Femoral Embolectomy

1.Position the patient supine.
2.Prepare the entire limb on the involved side only.
3.Make a vertical incision over the mid-inguinal point and insert a self-retaining retractor (Weitlander).
4.Dissect down to the femoral artery/profunda trifurcation. Administer 5000u of heparin and then encircle the vessels with vascular slings.
5.Make a longitudinal arteriotomy at the trifurcation with a clamp on the patent vessels.
6.Insert a Fogarty balloon catheter (size 4 or 4mm calibre) and perform an antegrade embolectomy to beyond the popliteal trifurcation if possible. If there is an occlusion beyond which the catheter will not pass it may be at the adductor hiatus (try again with the tip bent) or because of atheroma. Similarly, perform a retrograde embolectomy (using a size 5 catheter).
7.Remove clot ahead of the embolectomy balloon with a vascular sucker, with a right angled clamp at the ready. If there is steady back bleeding, conclude the embolectomy.
8.Perform an on-table angiogram to determine patency of vessels.
9.If flow is still inadequate leave a catheter in situ for a urokinase infusion.
10.Close the arteriotomy with double armed 4/0 prolene.
11.Close wound in layers.

Varicose Veins

1.Obtain a pre-operative US of incompetent perforators and have them marked on the skin. Mark individual varicosities with a permanent marker with the patient standing.
2.Position the patient supine, exsanguinate the limb with an Esmarch bandage and prepare the entire lower limb from groin downwards.
3.Make an oblique groin incision in line with a skin crease over the site of the SFJ (3.5cm below and lateral to the pubic tubercle) measuring 4-5cm.
4.Dissect down to the SFJ and delineate tributaries to be divided once SFJ has been identified. The tributaries are superficial circumflex iliac, superficial epigastric, superficial and deep external pudendal, a deep vein that pierces the fascia over adductor longus, anterolateral and posteromedial (accessory saphenous) thigh veins.
5.Dissect the SFJ and divide between artery forceps having clearly identified the femoral vein and ensured there is not a deep external pudendal vein entering the femoral vein as this can lead to recurrent vulval varicosities. Transfix the SFJ using 3/0 vicryl. Then individually ligate tributaries.
6.Insert a vein stripper without the bulky head attachment into the cut end of the saphenous vein and run it down as far as the upper third of the tibia if possible. Below this level the saphenous nerve is closely associated with the vein and a subsequent greater incidence of neuralgia. Make a 1cm incision over the site of the stripper pointing and extract it. Suture the end of the stripper at the cut superior end and strip the length of the vein with an assistant putting pressure on the thigh.
7.Perform haemostasis of the groin wound and close in layers.
8.Perform stab avulsions over the marked individual varicosities via 5mm incisions and small Kocher forceps.
9.Close the stab wounds with steristrips and dress with gauze, velban and crepe from ankle to groin (leave intact for 1-2 days then discharge home or arrange RDNS home visit at 1-2 days for removal of dressing and application of full length graduated compression stockings).

AAA

Patient supine.
Prep from lower chest to mid thighs
Check status of lower limb pulses preoperatively

Large midline incision
2.Place a self-retaining Buchwalter retractor and reflect the transverse colon upwards and SB to the right in a bowel bag. Have assistant hold the colon or pack intra-abdominally
3.Mobilize to some degree the D3 and D4 off the aorta.
Incise the peritoneum jst to the left of the duodenum
4.The inferior mesenteric vein is usually a barrier to continued division of peritoneum, although this can usually be divided, it is close to the upper limit of direct vision anyway as the inferior border of the pancreas comes into view.
5.The left renal vein is then seen to cross the front of the aorta. This is dissected to provide access to the aorta up to the renal artery origin (L2) below which clamps can be placed to obtain proximal control following administration of heparin 5000U.
6.Distal control is achieved with clamps after dissecting (not encircling) the distal CIA on both sides mindful of the common iliac veins lying deeper and to the right, as well as the ureter. Also be mindful of the parasympathetics overlying the left CIA. Clamp CIA first.
7.The peritoneum overlying the aneurysm can then be opened and the aneurysmal sac entered to the right of the midline. Suction clot away.
8.All posterior parietal branches and IMA (L3) may continue to back bleed and these must be suture ligated.
9.A suitable aortic/bifurcate graft (Dacron, 20mm wide) is placed and sutured to normal proximal aorta using a continuous 4/0 prolene (double ended). This is done always starting at the posterior wall using a parachute technique, working around diameter and closing anteriorly.
10.Clamps can then be let down to test patency. Further bleeding points on the anastomoses can be reinforced with sutures. If there is general ooze, Surgicel can also be used. If haemostasis is satisfactory then move the clamps distally and place them on the graft itself.
11.Similarly anastomose the distal end of the graft to healthy distal aorta or common iliac if bifurcate. Ensure the anastomosis is posterior to the ureters. Release iliac arteries sequentially after informing anaesthetist
12.The aneurysm sac is then closed over the graft using vicryl.
13.The small intestine is removed from the bowel bag and viability confirmed.
14.The abdomen is lavaged to remove stagnant blood/clot and a closed suction drain placed along the posterior abdominal wall.
15.Close in layers.


Special comments for ruptured AAA
Do not induce anaesthetic until patient prepped and draped.
If unstable, or free intra abdominal bleeding, or haematoma extends to the level of the renal vein, then apply supracoeliac clamp.

Supracoeliac clamp
Avascular portion of the gastrohepatic ligament is incised.
Large bore NGT inserted
+/- retract left lobe of liver
Manually control aorta
Blunt finger dissect through crura
Place aortic clamp superior to fingers
You now have control but you also have a visceral ischaemic time
Alternative is to place Foley catheter with 30ml balloon through incision in aneurysm and inflate

Anal fissure: Lateral sphincterotomy and Botox

Sphincterotomy
1.Position the patient in lithotomy.
2.Perform a EUA including a digital and rigid sigmoidoscopy. Determine the status of the fissure.
3.Curette the base of the fissure and send the material for histopathology.
4.Identify the intersphincteric groove laterally on the left side while placing the sphincter on stretch using a Pratt or Eisenhammer speculum and make a1.5cm incision after infiltrating with LA.
5.Dissect the internal sphincter to the determined level and place artery forceps to this (should be at the level of the apex of the fissure and no higher than the dentate line). Divide the muscle with scissors. An alternative method is to bring out the length of internal sphincter via the incision and divide with diathermy on the artery forcep.
6.Dress with Unitulle following haemostasis.

Botox
Eisenhammer
Palpate intersphincteric groove.
Inject 25IU into 3 o'clock and 25IU into 9 o'clock positions
Peak onset is 7 days but can work as early as 3 hours

Rectal Prolapse

Operation to choose:
Old, small prolapse: Delormes
Old, bigger prolapse: Altemeier
Young, no constipation: Abdominal rectopexy
Young, constipation: Resection rectopexy

Suture/mesh rectopexy
1.Position patient in lithotomy, Trendelenberg with yellowfin boots.
2.Low midline incision, can also use a Pfannensteil.
3.Place a Balfour self-retaining retractor and conduct a laparotomy and confirm absence of co-incident disease.
4.With the small bowel packed away in the upper abdomen, incise the pelvic peritoneum on either side of the mesorectum extending down to the deepest part of the cul de sac.
5.Retract the redundant rectum upwards which should by now have an anterior surface denuded of peritoneum.
6.Dissect the mesorectum staying in the plane outside the mesorectal envelope.
7.Once the mesorectum is free, place a 10X5cm vicryl mesh posterior to the rectum. The upper level of this mesh should be 5cm below the sacral promontory. Secure the mesh to the sacrum using sutures or staples (usually just the one or two large prolene sutures to the sacrum).
8.Wrap the mesh around to the antero-lateral surface of the rectum and secure with sutures (three on each side) leaving a gap anteriorly to allow distension of the rectum. In the Ripstein operation, similar to above but mesh is placed on the anterior surface of rectum and sutured posteriorly 2cm from the midline of the sacrum.
9.Close the pelvic peritoneum.
10.Mass abdominal closure and staples/monocryl.

Delormes
1.Position patient in lithotomy, Trendelenberg with yellowfin boots
2.With a lone star retractor in place, begin by infiltrating a small amount of LA with adrenalin to define the correct plane.
3.Make an incision 2-3cm above the dentate line on the prolapse and begin to mobilize a flap of mucosa circumferentially in a submucosal plane, retracting the edges with artery forceps. Avoid full thickness defects in the muscle wall and if occurs, repair immediately but should not be a cause for concern as it will be taken up in the plication.
4.Extend the flap tube to the distal extent of the prolapse.
5.Excise redundant mucosa at this stage. Place plicating sutures of 3/0 vicryl in the muscular tube starting near the dentate line and ending at the apex of the prolapse including mucosa at the ends and place these in the lone star retractor for control. Place sutures as such along the entire circumference.
6.With all sutures now in place, tie them sequentially bunching the muscle deep to mucosa. The prolapse will automatically reduce.
7.Inspect the wound to confirm satisfactory repair, placing additional sutures if required.

Perineal rectosigmoidectomy (Altemeier)
1.Position patient in lithotomy, Trendelenberg with yellowfin boots
2.The prolapse will usually be evident as the main indication for this procedure is a strangulated prolapse.
3.Make a full thickness incision 2-3cm above the dentate line circumferentially and evert the outer tube for ease of dissection.
4.Retract any redundant sigmoid downwards and include it with the excision specimen. Divide any blood vessels close to the bowel wall.
5.Incise the inner tube starting anteriorly.
6.Place circumferential 3/0 vicryl sero-muscular sutures in sequence with further division of the inner tube and hold within a Lone Star retractor.
7.Tie the sutures once all in place and inspect the repair for satisfactory apposition, placing additional sutures as necessary.

APR

Described by Miles in 1925

Anatomy: Denonvilliers fascia:The consensus is that this fascia represents the fusion of the walls of the peritoneal cul-de-sac that extends down to the pelvic floor in the fetus. This fascia forms the glistening white surface of the anterior aspect of the mesorectum and is removed as an integral component of the resected package in total mesorectal excision

Waldeyers fascia:The rectosacral fascia, often referred to as Waldeyer's fascia (although Waldeyer did not describe it as such in his anatomic report published in 1899), was characterized by Crapp and Cuthbertson. The thickness of this fascia varies from a thin transparent membrane to a thick, tough, opaque fascia. In the latter instance, unless the rectosacral fascia is deliberately divided, the surgical plane of dissection may erroneously extend anteriorly into the mesorectum, resulting in its incomplete excision, or stray posteriorly through the presacral fascia with consequent troublesome bleeding from presacral veins. We do not believe that the depiction of this ligament on MRI has been previously described.

The inferior hypogastric plexus also provides branches to the rectum, which may be accompanied by a middle rectal artery, but this artery is often absent or very small. Traction on this neurovascular bundle produces the so-called lateral ligament, the size of which depends on the presence or absence of the middle rectal vessels. Previous studies have shown that the middle rectal vessels are not consistently shown either in cadaveric dissections or on angiography

Indications:
Sphincter involvement by tumour
Crohns proctitis
Ulcerative colitis with poor sphincter function

Preop stomal therapist
Accurate Staging

1.The abdominal phase of this operation is conducted as described above down to the levators.
Midline laparotomy
Lateral mobilisation along line of Toldt including splenic flexure
First tubular structures will be gonadal vessels, ureter will be medial to these below IMA
Then create window underneath superior haemorrhoidal vessels at level of sacrum. Open peritoneum distally to enlarge window. Continuing superiorly will lead to IMA origin
Then divide IMV and continue dividing sigmoid mesentery and divide proximal limit of resection with linear cutting stapler

Then mobilise rectum in embryonic avascular fusion plane, beginning posteriorly and preserving hypogastric nerves. St Marks retractor in surgeons hand will help get lift and define areolar plane

Mobilise laterally, the plane of dissection anteriorly will depend on whether the tumour is posterior, if it is, then can dissect on the rectal side of Denonvilliers fascia to preserve nerves. If tumour is adherent to posterior vaginal wall, then a posterior vaginectomy should be performed.

2.Divide the sigmoid colon at a point that allows it to be brought out of the abdomen as an end colostomy without tension.
3.Tie a betadine soaked gauze to the clamp at the end of the specimen and move to the perineal dissecting table.
4.Close the anus with a 1-ethibond suture and make an elliptical incision beginning 3-4cm anterior to the anal orifice and ending at the tip of the coccyx. In females with anterior lesions, leave a patch of anterior vagina attached to the specimen along with the posterior portion of the introitus.
5.Incise down to the perirectal fat and grasp the ellipse in Allis tissue forceps. The anterior plane of dissection should be posterior to the superficial transverse perineal muscles. Dissect down to the level of the levators. You may encounter branches of the inferior rectal vessels and the internal pudendal nerve just superficial to the levators. These can usually be controlled with diathermy.
6.Divide the anococcygeal ligament and Waldeyers fascia using diathermy. This should lead to the pelvic cavity superiorly. It is easier to find the right plane if Waldeyers fascia is divided from the abdomen.
7.Place your left index finger around the left levator and divide. Similarly, place your right index finger around the right levator and divide this muscle. Continue this division around to the puborectalis sling anteriorly. Delay this step to last.
8.Deliver the transected recto-sigmoid specimen through the levators into the perineal wound.
9.Palpate the prostate anteriorly and divide the recto-urethralis muscle attaching it to the front of the rectum. Divide any remaining attachments to the prostate.
10.Irrigate and close in layers leaving the vaginal mucosa open to heal by secondary intent.
11.Close the abdominal wound following lavage and placement of a pelvic drain. Mature the end colostomy with 3/0 chromic gut.

Complications
Perineal wound breakdown 10% (30% if NAXRT)
Urinary
Sexual
Recurrence 5-10%

Open Right Hemicolectomy

ANATOMY
Ileocolic is a constant vessel
Right colic is a direct branch of SMA in only 13% cases. Middle colic forms a vascular arcade with ileocolic constantly.
Middle colic branches 2cm from origin (it is a single vessel from SMA in only 45% cases)the most common variation is 2 middle colics
Usually one branch running between ileocolic and SMA

1.Position the patient supine.
2.Prepare the abdomen and square drape using Ioban
3.Standing on the patients left side make a midline incision centered on the umbilicus. (transverse incision if pulmonary impairment)
4.Place a Balfour self retaining retractor and conduct a laparotomy to determine the extent of peritoneal disease and liver metastases.
5.Start to mobilize the right colon by dividing the peritoneum of the right paracolic gutter from the caecum to the hepatic flexure taking care to avoid the duodenum and overlying veins superiorly.
6.Control the veins superficial to the plane of the duodenum with serial clamping with Fraser forceps and vicryl ties or alone with diathermy if not significant.
7.Divide any adhesions to the gall bladder.
8.Mobilize the greater omentum off the transverse colon (if for a hepatic flexure tumour, resect omentum en bloc) up to the point of intended division of the transverse colon and enter the lesser sac.
9.Complete the mobilization the right colon/terminal ileum by dissecting it off the posterior abdominal wall, aided by retraction. The ureter and gonadal vessels should fall posteriorly.
10.Ligate the right branch of the middle colic artery for a caecal cancer and the main trunk for a cancer at the hepatic flexure (beware of collateral veins from the middle colic to the pancreatico-duodenal).
11.Ligate the ileocolic vessels at their origin.
12.With the colon mobilized, prepare the ends of the ileum and colon for anastomosis by ligating the marginal artery and clearing the colon and ileum of mesentery.
13.Divide the terminal ileum between Kocher forceps and a soft bowel clamp placed proximally. (can do this with GIA/TLC)

Anastomosis is variable

14.Place the anvil of a CEEA circular endo-luminal stapler (size 28) in the stump of the terminal ileum and secure with a 4/0 PDS pursestring.
15.Place a soft bowel clamp quite proximal to the site of intended anastomosis on the colon. Make an enterotomy proximal to the site of anastomosis and insert the head of the CEEA stapler bringing out the spike at the site of the intended anastomosis.
16.Perform the anastomosis and then resect the specimen by dividing the colon proximal to the anastomosis with a linear stapler (Tyco autosuture GIA 60 or 80 or TLC 50, 75, 100 (Ethicon), with 3.8mm staples) incorporating the enterotomy within the specimen.
17.Reinforce the anastomosis and end staple line with inverting Lembert (burying or staple line inversion suture) or Cushing sutures.
18.Lavage with water and close the mesenteric defect with vicryl.
19.Mass abdominal closure and staples or monocryl.

Total Gastrectomy

1.Prep and square drape, ensure NGT
2.Upper midline incision
3.Place a fixed retractor such as omnitract to aid in retraction of the liver. You may need to mobilise left lobe of liver by dividing the left triangular ligament
4.Conduct a laparotomy to confirm resectability.
Place a pack behind the spleen to bring it forward and help mobilise the spleen
5.Dissect the greater omentum off the transverse colon in order to include it with the specimen. At this point inspect the posterior surface of the stomach to ensure resectability.
6.Divide the gastro hepatic ligament to enter into the lesser sac of the abdomen and double ligate the right gastric artery sweeping nodes en bloc with the stomach.
7.Perform a truncal vagotomy (legacy). This is performed by incising the peritoneum over the abdominal oesophagus and identifying the crura. Insert your right finger aroung the back of the oesophagus to encircle it. There are often 1-2 anterior vagal (left) trunks. Divide and ligate these between artery forceps. The posterior vagal trunk is identified by encircling the oesophagus deeply across the front of the aorta to the deep surface of the right crus and then flexing the finger around. The posterior trunk should then be contained (i.e. it is often much posterior to the right surface of the oesophagus). It can also be found by inserting a finger above the left gastric artery and drawing it downwards, pulling the posterior vagus taut. A selective vagotomy (legacy) refers to a vagotomy just beyond and conserving the hepatic branch of the vagus. A highly selective vagotomy (legacy) refers to selective division of all the vagal branches to the stomach along with the branches of the left gastric artery, barring those to the distal antrum and pylorus. You need to identify the crow’s foot to determine the correct level. Pay attention to the criminal nerve of Grassi, which is a branch given off from the posterior vagus higher to the posterior cardia. Oversew the gastric lesser curve if performing a selective vagotomy only. Send a segment of the nerves for histological confirmation in order to confirm vagotomy. An endoscopic congo red test can also be performed by administering SC pentagastrin and 20 min later lavaging the stomach with 200ml congo red (vagally innervated parietal cells will turn black).
8.Divide the gastrosplenic ligament, the short gastric and left gastro-epiploic vessels.
9.Lift the stomach upwards to gain access to its posterior wall and divide the right gastro-epiploic vessels between it and the pancreas.
10.Divide the left gastric artery at its origin as well as its ascending branch to completely devascularize the stomach.
11.Divide the distal resection margin (duodenum) with a TA60 (3.5mm staples) linear stapler/scalpel division on the proximal side between an Allen clamp (this is aided by partially Kocherizing the duodenum that may also require mobilizing the hepatic flexure). Divide the proximal resection (having withdrawn the NGT) similarly between a TA60/right angled clamp with scalpel division on the proximal side of the stapler. You may re-inforce the duodenal stump closure with 3/0 PDS.
12.Place a pursestring at the distal oesophagus of 3/0 PDS and secure the anvil of a CEEA 28mm circular stapler
13.Create a roux limb by division of jejunum between a TA60/Allen clamp (dividing the bowel distal to the stapler and bring it up in an antecolic fashion.
14.Insert the circular stapler through the open cut end of the roux limb after placing a soft bowel clamp distally on the roux limb and fashion an end to side oesophago-jejunal anastomosis. Use a linear stapler to resect the redundant jejunum to complete the anastomosis. Oversew all staple lines with 4/0 PDS. A hand sewn end to end anastomosis can also be fashioned using interrupted 3/0 PDS. Place the posterior wall sutures first and parachute them down, then tie, completing the anterior layer subsequently. Be sure to pass a nasogastric tube down to the jejunum across the anastomosis.
15.Place soft bowel clamps at the site of intended jejuno-jejunal anastamosis (ensuring a 75cm roux limb). Create an end to side anastomosis using interrupted 4/0 PDS.
16.Haemostasis, drain the duodenal stump and oesophago-jejunal anastomosis.
17.Closure with 1/0 nylon and staples.

Complications
Early HIDA (Overall per-operative mortality 5-10% with an overall 50%5YS)
1.Haemorrhage
2.Intra-abdominal sepsis
3.Duodenal stump leak
4.Anastomotic leak

Late post-prandial sequelae SDHDB
1.Satiety
2.Dumping
3.Hypoglycaemic attacks
4.Diarrhoea VDOS due to vagotomy (mechanism unknown), as part of a dumping syndrome, bacterial overgrowth, steatorrhoea.
5.Bilious reflux.

Nutritional problems
1. Malnutrition
2. Specific deficiencies – Fe/Vit C supplements for 12 months, B12, Calcium (Vit D malabsorption) in post-menopausal and over 70

Distal Gastrectomy

In general perform a laparoscopy first if cancer operation. No need if if clear indication for palliative resection ie bleeding etc.

Resection provides better relief for obstruction than bypass

Distal gastrectomy for benign disease (Bilroth I or II)
1.Supine position
2.Upper midline incision. (Consider rooftop if wide xiphisternal angle)
Thorough laparotomy
3.Incise the gastro-hepatic omentum and place a hand behind the antrum to lift it off the mesocolon and the middle colic artery. The plane is easier to find on the left
4.Begin to mobilize the antrum by dividing the branches of the right gastro-epiploic as close to the anterior surface of the pancreas as possible (so as to include the infrapyloric nodes) staying within the arcade for its preservation up to a point half way up the stomach. The left side of the omentum is separated from the spleen dividing the gastrosplenic ligament including the left gastro-epiploic vessels
5.Divide the left gastric artery about halfway along the lesser curve leaving a stump of the left gastric artery at least 1cm in length (a small accessory left hepatic artery may be ligated, but a larger one may need preserving to prevent hepatic necrosis. Lesser omentum is divided along the left side of the hepatoduodenal ligmaent.
6.At the proximal margin, divide the stomach using a GIA80 (4.8mm staples) stapler over the right half and between two Allen clamps over the left half, the length of which is the approximate diameter of the duodenum. Make sure you have withdrawn the NGT prior to division. Oversew the staple line or hand sew the whole thing if thickened.
7.Identify and ligate the right gastric artery from the anterior aspect where it originates from the proper hepatic artery. Reflect antrum rostral and to the left. Do not divide short gastrics along proximal greater curvature.
8.Apply traction on the specimen to display the posterior wall of the duodenum and dissect out 1.5cm to allow anastomosis. There are often some vessels coming up from the pancreas that will require ligation.
9.To perform a Bilroth I anastomosis, divide the duodenal resection margin between Allen clamps and fashion an end to end hand-sewn anastomosis using 3/0 PDS if there is at least 1.5cm of duodenum to suture to.
10.To perform a Bilroth II (Polya), use a TA60 (3.5mm staples) to divide the duodenal resection margin and perform a gastro-enterostomy using a retrocolic (may also be antecolic, but limb will need to be longer) loop no more than 15cm from the ligament of Trietz in two layers using 3/0 PDS in the standard manner. Advance the NGT down the afferent limb (one book says don't need to do this). Oversew the previous staple line and re-inforce the angle of sorrow.(this is the angle of the lesser curvature which is prone to ischaemia. Note Hofmeister variation (only anastomosing jejunum to greater curvature half of stomach of Bilroth II (Polya) picture above.
11.Oversew and drain the duodenal stump, lavage and close.


Subtotal or distal gastrectomy for malignancy (Bilroth II or Polya)
1.Conduct a laparotomy and confirm resectability.
2.Start with mobilizing the greater omentum off the transverse colon (the blood supply of the gastric remnant is to be from the short gastric arteries). Can either take the omentum or not: no difference has been shown in recurrence. The right gastro-epiploic artery is divided at its origin while sweeping all nodes towards the specimen. Similarly ligate the left gastroepiploic artery while mobilizing the left side of the greater omentum along the line of gastric transection.
3.Lift the stomach upwards and to the right to identify the left gastric artery and the adjacent coronary vein at the top end of the lesser curvature via the undersurface. Doubly ligate this with vicryl and divide. All nodal tissue is not only swept upwards towards the specimen, but if involved followed to the celiac nodes. Can then skeletonise the coeliac, splenic and common hepatic artery to perform D2 lymphadenectomy. This also involves dissecting the proximal lesser omentum to harvest the right cardia nodes.
4.Replace the stomach down and incise the lesser omentum down to the pylorus. Identify the ascending branch of the left gastric artery and ligate it at the cardia.
5.Extend the incision over the left gastric artery along the hepatic artery in the posterior wall of the lesser sac in order to identify the origin of the right gastric artery. Ligate and divide the right gastric artery.
6.Perform a Kocher maneuver and mobilize the duodenum off the pancreas for a distance of 5cm.
7.Use a TA60 stapler or scalpel between Allen clamps to divide across D1 and a GIA80 (4.8mm staples) to divide across stomach having withdrawn the NGT. Consider frozen section to ensure tumour margins clear. 5cm proximal margin for cancers. 5cm distal margin not always possible.
8.Reconstruct using a handsewn Bilroth II gastrojejunostomy with 3/0 PDS (or a stapled gestro-enterostomy using the GIA80 and oversew the staple line using 3/0 PDS) using an antecolic roux loop. May need to re-inforce the angle of sorrow.
9.Feed a nasogastric tube down the afferent limb of the gastroenterostomy prior to completing the anastomosis as far as possible to drain the duodenal stump. Lavage, drain and close.

Post op care
NG out on first or second day
Evidence that oral (500-750mcg) B12 is sufficient
Need iron replacement
Adjuvant chemotherapy should be considered routinely
No advantage to frequent follow up to detect recurrence
CT when symptomatic
Gastroscopy for stump cancer in long term survivors

Principles
Inspect posterior surface of stomach before ligating an vessels to confirm resectability

Perforated Peptic ulcer

Perforated peptic ulcer
1.Position the patient supine.
2.Make an upper midline incision
3.Conduct a laparotomy to determine the cause for the patient’s illness by examining the colon, SB, GB.
4.Follow the lesser curve of the stomach to find the site of perforation. If no disease is found examine the posterior surface of stomach and lesser sac.
5.Once perforation identified and any gross contaminating fluid aspirated, place three plication sutures in the long axis of the duodenum and hold them with an artery forcep.
6.Isolate a viable segment of omentum and secure it to the defect using the previously placed sutures. (Graham patch 1937) Alternatively can use piece of falciform
7.Lavage and mass abdominal closure (don’t usually drain)

Options for a difficult duodenal stump
1.Nissen Cooper technique whereby the anterior and posterior walls of the duodenum are sutured to the distal lip of the ulcer. A further layer of sutures is placed in the pliable anterior wall of the duodenum, suturing it to the proximal lip of the ulcer in an inverting manner.
2.Catheter duodenostomy (14F whistle-tip or Foley catheter brought out through the defect in the stump) to protect the integrity of a difficult stump closure.
3.Closure with a TA60 (4.8mm staples) stapler generally requires at least 1.5cm of pliable duodenum, in which case you should be able to do a Bilroth I.

Options for a bleeding duodenal or pyloric ulcer
1.Make a longitudinal gastroduodenotomy directly over the pyloric ring and oversew the bleeding point as well as in four quadrants around this point.
2.Repair with either a Heinecke-Mikulicz pyloroplasty or a Finney pyloroplasty.

Giant ulcer
10Fr Foley retrograde into 2nd part duodenum with distal feeding jejunostomy

Laparoscopic repair
Stapler or suture repair

Laparoscpic Nissen fundoplication

Indications include oesophageal pH <4, recorded 5cm above a manometrically defined LOS, present for >4%/24hrs,
Complicated - oesophagitis/stricture/Barretts on endoscopy,
Uncomplicated - failure to respond to conservative measures, desire to discontinue lifelong medication.

1.Position the patient in low Lloyd -Davies, reverse Trendelenberg
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.If the greater omentum is obstructing the view it can be picked up in a suture and brought out through one of the left sided ports.
5.Commence by identifying and dissecting the left crus with the assistant retracting the fundus downwards, extending the incision to the left over the fundus of the stomach. At this point it is also convenient to divide the short gastric vessels to enable a mobile fundus if required.
6.Divide and open gastro-hepatic omentum. The hepatic vagal branch in the lesser omentum may have to be sacrificed; however a smaller window prevents the wrap from slipping caudally.
7.Dissect the right crus, while retracting the oesophagus.
8.There should now be an adequate posterior window created in the retro-oesophageal space. Bring a grasper through to the left of the oesophagus staying close to the posterior wall of the oesophagus.
9.Place a Penrose drain in the abdomen and bring it through around the oesophagus to be used as a retractor.
10.Complete the definition of the left crus.
11.Perform the crural repair with 1-3 sutures (3/0 prolene). A bougie (56 or 58F) in the oesophagus can be used as a guide but I don’t normally use this.
12.Bring the fundus around the back of the oesophagus and get the assistant to hold the fundus at the site of intended wrap.
13.Fix the right side of the wrap to the right crus with 1-2 sutures to prevent the wrap from falling back around.
14.Complete the wrap by suturing the right and left sides of the fundus across the front of the oesophagus with three sutures (posterior partial or 270 degree wrap also known as Toupet).

Complications PPPPDBV
1.Paraoesophageal hiatus hernia upto 5% (routine hiatal repair dramatically reduces)
2.PE
3.Pneumothorax in up to 2%
4.Perforation up to 1%
5.Dysphagia in nearly all
6.Bilobed stomach by using to distal stomach for wrap
7.Vascular injury rare.

Open Gastrostomy (Stamm)

1.Short upper midline incision
2.Choose area of mid-stomach, closer to greater curve and place a pursestring suture of 2cm diameter using 3/0 PDS or prolene.
3.Grasp left side linea alba via incision using Morrisons forceps and make a stab wound through skin and middle third of rectus opposite pursestring in stomach wall.
4.Pass Fraser forceps from peritoneal side through stab wound and bring through a 18F Foley catheter.
5.Perform gastrotomy through previously placed pursestring and insert Foley into stomach, then tie the pursestring.
6.Place a second row of pursestring suture to invert first pursestring.
7.Inflate Foley balloon and draw up to anterior abdominal wall.
8.Place four sutures of prolene on four sides of Foley catheter between stomach and anterior abdominal wall.
9.Close abdomen in layers.
10.The gastrostomy can be used immediately.

Oesophagectomy (Ivor-Lewis)

1.Double lumen tube. Conduct a laparotomy and assess resectability. Determine adequacy of right gastric and right gastroepiploic vessels.
2.Mobilize the stomach by dissecting the omentum off the transverse colon as well as the gastrohepatic omentum. The left lobe of liver may also require mobilization by dividing the left triangular ligament.
3.Divide the left gastric from the undersurface; and then the left gastro-epiploeic and short gastric vessels (preserve the arcade of the lesser and greater curves of the stomach, i.e. the main trunks of the right gastric and right gastro-epiploic)
4.Sweep the nodes en bloc with the vessels.
5.Perform a Kocher manouvre to mobilise the duodenum, this will give mobility to the right gastric vessels. Occasionally, the right gastric will need to be sacrificed for greater mobility.
6.Divide the phreno-oesophageal ligament and mobilize the cardio-oesophageal junction. You may need to divide the right crus to ensure there is no constriction of the gastric tube. Loosely suture the tube to the distal resection margin so you can retrieve it later.
7.Perform a pyloromyotomy by making an incision longitudinally across the pylorus.
8.Fashion a jejunal feeding tube before closing the abdomen. Make a trephine in the abdominal wall at a suitable site, insert a Fraser forcep from inside out and bring the feeding in through the abdominal wall. Place a pursestring at a suitable site in the jejunum, making an enterotomy, inserting the jejunal feeding tube heading distally and then tying the pursestring. Place a further pursestring to invert the previous one and then tunnel the feeding tube within an invagination longitudinally sequentially heading proximally along the jejunum with interrupted Lembert sutures. Finally suture the jejunum with feeding tube in situ to the abdominal wall in the three quadrants superiorly opposite the jejunal invagination (i.e. on the proximal side). This tube is to remain in situ for 3/52.
9.Perform a mass closure of the abdominal wall and close skin.
10.Turn the patient over to the left lateral position for a right posterolateral thoracotomy in the 5th intercostal space. The space is usually just below the inferior angle of the scapula.
11.Divide through skin, subcutaneous tissue, latissimus. Reflect any fibres of serratus off the 6th rib without division.
12.By lifting up the scapula, you can count the ribs to confirm the right intercostal space (usually the 2nd rib is the highest palpable rib). Elevate the periosteum over the 6th rib with a periosteal elevator.
13.Divide the intercostals at the upper margin of the 6th rib and resect a 2-3cm fragment of rib posteriorly.
14.Insert a Finochietto retractor to separate the ribs and enter the pleural cavity asking the anaesthetist to now ventilate the opposite lung.
15.Retract the lung antero-superiorly with an Allison lung retractor and make an incision in the mediastinal pleura. Dissect and ligate the azygos vein to gain better access to the oesophagus. Mobilize the oesophagus up to 10 cm above the tumour. Secure the tumour by ligating the oesophagus above and below using umbilical tape.
16.Bring the mobilized stomach into the chest and fashion the neo-oesophageal tube using a GIA80 (green cartridge 4.8mm staples). Reinforce the staple line with a continuous Cushing suture.
17.Perform an end-to-side oesophago-gastric anastomosis using either a hand-sewn 4/0 PDS in two layers or a CEEA28 circular stapler via a gastrotomy. Oversew all staple lines.
18.Check for a chyle leak – administer cream via the feeding jejunostomy at the conclusion of the abdominal phase to aid identification of the thoracic duct, which is routinely ligated.
19.Place two intercostal catheters and close the thoracotomy with 1/0 ethibond (figure of 8 sutures) and vicryl to reconstitute the latissimus and subcutaneous tissue/ skin. An alternative is to bury the rib by suturing the intercostals above and below the thoracotomy

Leave NGT in situ for 1/52 and perform a GG swallow prior to starting oral intake.

Complications: ACRGS
1.Anastomotic leak <5%, early – re-explore, late – conservative treatment unless gastric resection line
2.Chyle leak 2-3%, transhiatal upto 10% - Test the fluid for fat, decreased serum lymphocytes (CD4). Treat conservatively if after 1 week, early leaks and prolonged leaks require re-operation to ligate the thoracic duct. High amount of leaks lead to loss of lymphocytes, immunosuppression (pneumocystis) and nutritional deficiency.
3.RLN palsy in cervical anastomosis (rare in Ivor-Lewis).
4.Gastric outlet obstruction – prevented by routine use of a pyloroplasty. Reflux I also common. Dumping symptoms resolve after 12 months.
5.Stricture (benign) related to stapled (higher rate) or handsewn.
6.Other- operative mortality of 5-10% overall with overall 20% 5YS, significant respiratory complications in 25-50%.

Laparoscpic Oesophago-myotomy

1.Position the patient in lithotomy, reverse Trendelenberg.
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.You will also need extra room at the head end of the table for a UGI endoscopy setup.
5.Begin by mobilizing the oesophagus as for Lap Nissen, however attempt this with minimal posterior dissection. It will decrease the incidence of post-operative reflux.
6.Pass a grasper under the oesophagus across to the left of the oesophagus and bring a Penrose drain around to be used as a retractor, lengthening the segment of intra-abdominal oesophagus.
7.Find a convenient point in the middle of the thickened segment of oesophagus and divide with diathermy scissors.
8.Atraumatic graspers can then be used to pull down on the longitudinal muscle to reveal the underlying thickened circular muscle layer.
9.Similarly divide the circular layer and watch the layer spring apart. Atraumatic graspers are adjusted to hold the divided circular fibre layer.
10.The epithelial tube can be protected by pushing it down with a right angled grasper. Extend the myotomy proximally and distally (should extend 1cm on to the stomach) until the muscle appears to thin out.
11.Irrigate with saline and fill the LUQ. Insufflate the oesophagus with the endoscope and watch for any leaks.
12.Perform an anterior partial wrap (Dor) if there is a leak once repaired with interrupted 3/0 PDS or a partial posterior wrap as it is supposed to help keep the edges of the myotomy apart.
13.Close in layers.

Zenkers diverticulum

Repair of pharyngo-oesophageal diverticulum
1.Position the patient supine on a head ring facing the right side with a sandbag between the shoulder blades.
2.Make an incision along the anterior border of the SCM for a variable distance depending on the size of the diverticulum, through skin and platysma.
3.Free the anterior border of SCM, retracting it laterally and divide the omohyoid muscle.
4.Continue dissection in the plane between the SCM and the thyroid medially and ligate the middle thyroid veins as they are usually in the way.
5.Identify the ITA and RLN, and then ligate the ITA (usually necessary).
6.Grasp the fundus of the diverticulum and dissect down to its neck using sharp dissection.
7.There may be some fibrous tissue at the neck of the diverticulum, divide these to visualize the fibres of crico-pharyngeus.
8.Insert a right angled clamp between the mucosa and the crico-pharyngeus to perform a cricomyotomy using diathermy for a distance of 5-6cm.
9.With the mucosa bulging, apply and fire a TA30 stapler across the neck of the diverticulum, amputate the diverticulum.
10.Ensure haemostasis and close in layers.

PS For endoscopic stapling use Collard 93 stapling device.

Open splenectomy

Preop
Vaccinations: meningococcal, haemophilus, pneumovax
steroids in ITP
Antibiotics

1.Position patient supine with the left side raised in a bean bag.
2.Make a left subcostal incision.
3.Start by mobilizing the splenic flexure.
4.With the left hand retract the spleen medially and divide the lieno-renal ligament until the spleen is free from Gerota’s fascia and the diaphragm. This manouvre will deliver the spleen into the wound.
5.An alternative approach is to begin anteriorly and encounter the left gastro-epiploic vessels outside the arcade along the greater curvature and ligate them. Within the posterior wall of the lesser sac, you should be able to visualize the splenic artery which can be controlled with a silastic sling. Continue division of the gastro-splenic ligament and divide any short gastric vessels you encounter.
6.Ligate the main trunk of the splenic artery at the hilus. (spleen will shrink 15-20%)
7.Search the posterior aspect of the splenic hilus for the tail of the pancreas and dissect it away, ligating any vessels to the gland. This will give the spleen an opportunity to decrease in size.
8.Ligate the splenic vein at the hilus.
9.Examine the greater curve and if there is any suspicion of damage, invert the stomach with Lembert sutures.
10.Lavage and close.

Operations for splenic trauma
1.Preservation techniques
oSuperficial injuries – APC
oTransverse fractures – splenorrhaphy or hemisplenectomy
oLongitudinal fracture – pedicled omental patch
oStellate fractures – suture/tisseel duo or vicryl mesh wrap
2.Splenorrhaphy following complete mobilization by debriding edges and suturing lacerations between Teflon felt or a vicryl mesh wrap.
3.Partial splenectomy – complete the division of the remaining spleen ensuring that it will be viable, ligating vessels on the cut surface and then repair cut end of organ between Teflon felt.

Operations for pancreatic and duodenal trauma

Duodenum
•Primary repair +/- gastro-enterostomy
•Roux limb
•Jejunal serosal patch
•Damage control oversew with catheter duodenostomy, diversion of stomach by stapling across D1 without division and gastrojejunostomy (+/- T tube drainage for associated CBD injury as a ?Hugh-Devine type procedure)
Pancreas
•With Lucas grade III injuries or extensive damage to the pancreatic head, perform debridement as a damage control procedure or Whipple if well.
•With Lucas grade II, debride/drain (usual for grade I), a roux-en-y longitudinal pancreaticojejunostomy or distal pancreatectomy

Pancreatic necrosectomy

1.Position the patient supine.
2.Upper midline incision (or rooftop).
3.Conduct a laparotomy. If the GB is still present, perform a cholecystectomy and cholangiogram.
4.You may need to mobilize both colonic flexures. Enter the lesser through the gastrocolic omentum and begin to debride necrotic pancreas with blunt finger dissection and a Yankauer sucker.
5.Insert a feeding jejunostomy.
6.Further options include
•Multiple closed drains. This may require further second look laparotomy.
•Open packing and laparostomy with multiple planned re-look laparotomy until granulation tissue forms. This is only done if there is extensive bleeding.
•Closed lavage using multiple large bore suction drains and continuous lavage using CAPD dialysis fluid at 500ml/hr (Beger).
•Others – Fagniez flank approach, minimally invasive approaches.

Distal pancreatectomy

1.Position the patient supine.
2.Make a subcostal or midline incision.
3.Conduct a laparotomy.
4.Dissect the greater omentum off the transverse colon and mobilize the splenic flexure of colon.
5.Incise the peritoneum over the inferior border of the tail of the pancreas. Identify the inferior mesenteric vein and dissect in a plane deep to this. Insert your right index finger behind the tail of pancreas (deep to the splenic vessels) and use your finger tip to raise the peritoneum over the superior border of the tail mindful of the splenic artery and vein lying deep to the pancreas and incise this layer.
6.Now examine the body and tail of pancreas, possibly using IOUS to confirm resectability.
7.Palpate the splenic artery at the upper border of the neck of pancreas, open the peritoneum here, encircle and doubly ligate in continuity.
8.Retract the spleen to the patient’s right and incise the lienorenal ligament. Extend this incision superiorly to free the spleen from the diaphragm and inferiorly to free any remaining attachments to the splenic flexure of colon.
9.Divide the gastrosplenic ligament and the short gastric, left gastro-epiploic vessels.
10.Dissect along the deep surface of the pancreas in order to free it from Gerota’s fascia. Identify the inferior mesenteric vein at the inferior border and ligate it.
11.With continued posterior dissection identify the junction of the splenic and portal veins. Encircle and doubly ligate the splenic vein 2cm proximally.
12.Ligate the splenic artery again and then divide distal to the two ties that are to stay.
13.Apply a TA60 (3.5mm staples) across the neck of the pancreas and staple. Deliver the specimen. You may also sometimes oversew the pancreatic duct using 4/0 PDS along with any other vessels (superior pancreatic artery).
14.Lavage, large bore suction drain to pancreatic remnant and close.

A pancreatic fistula should usually heal in 4-6/52 but will require ongoing drainage.

Liver abscess / Hyatid cyst

Salient facts about liver abscesses and hydatid cysts

•Amoebic abscesses do not require aspiration or drainage/treat with AB’s only.
•Pyogenic abscesses are managed with drainage and AB’s. Indications for surgical drainage being failed drainage, multiple abscesses, liver or systemic disease.
•Hydatid cysts are no longer managed by instillation of hypertonic saline, alcohol, etc into the cavity as can cause sclerosing cholangitis. Pack the small bowel away with hypertonic saline soaked packs. Marsupialize the cyst ensuring all daughter cysts are removed. Pack the residual cavity with pedicled omentum.

Biliary bypass

Salient facts about Choledochoduodenostomy
•Requires a CBD of at least 15mm diameter.
•Must Kocherize the duodenum to have a tension free anastomosis.
•Patients can get a sump syndrome that is managed by converting the side to side choledochoduodenostomy into an end to side or a roux en Y.


Roux-en-Y hepaticojejunostomy
1.Depending on the scenario, the incision may be a right subcostal or midline.
2.In the setting of pancreatic cancer, the root of the mesentery may be involved in which case a cholecystojejunostomy may be a better option.
3.If proceeding with a roux limb, inspect the jejunal mesentery looking for the second jejunal branch from the SMA. The marginal arcade can be clearly seen beyond this level.
4.Divide the jejunum with a linear stapler beyond this second branch and continue the incision distally down to but not necessarily including the fourth branch, ligating these branches but not the arcade.
5.This should provide a loop long enough to reach the hepatic ducts (75cm).
6.Create a window in the transverse mesocolon to the right of the middle colic vessels (retrocolic loop).
7.Depending on the situation, you can then perform an end to side (preferred if hepaticojejunostomy) or side to end. Perform the anastomosis using a single layer 5/0 PDS.
8.In the setting of pancreatic cancer, perform a gastrojejunostomy (60cm from the hepaticojejunostomy) with 3/0 PDS.
9.Perform the entero-enterostomy with 4/0 PDS.
10.Lavage and close in layers.