Know Procedures:

parotidectomy

radical neck dissection

esophagectomy

thyroid

-parathyroid

-malrotation

pyloromyotomy

intususception

mastectomy

sentinal node biopsy

subxiphoid pericardial window

thoracotomy for trauma

total gastrectomy

-total colectomy

whipple

-distal pancreatectomy

-APR/LAR, right colon, transverse, left colon

left and right hepatectomy

adrenalectomy

-aortic aneurysm

-fem-pop, fem-distal bypass

Non surgical topics:

1. end of life care
2. ventilator management (initiate, continue, wean, terminal wean)
3. blood transfusion issues (jehova’s witness, minor children of jehovah’s witnesses)
4. getting autopsies
5. care of the AIDS patients
6. getting a second opinion on patients (give 2 names not in my group)
7. post-transplant patients
8. portal HTN
9. Sengstaken-blakemore tube= inflate gastric balloon in stomach to 500cc air (slowly and monitor pressure to be sure not in esophagus), apply 1kg traction, can inflate esophageal tube for additional bleeding; deflate esophageal 5min every 6hrs; can leave in place 24hrs
10. Electrolyte abnormalities in adults / peds

1. Pyloric stenosis
2. Hypokalemia= 0.1 meq/kg/d for every 1K
3. Hypocalcemia= 200mg/kg/d (give over 10min for tetany)

11. Recent MI

1. Bare metal stent can have surgery after 4 weeks with asa/plavix held
2. Coated stent needs 1yr of asa/plavix
3. Preoperative B-block

12. Febrile postop patient
13. Postop oliguria
14. Postop hypotension:

1. DDx: MI, CHF, PE, bleeding, coagulopathy, sepsis, meds, malignant hyperthermia, blood transfusion reaction
2. Workup: foley, cxr, ekg, cbc, cmp, pt/ptt/inr, Echo, cardiac enzymes

1. have blood available, good IV access, central line, monitors, pulse ox
2. ask about drain output
3. can fluid challenge 1L saline
4. give blood if suspect anemia

3. MI suggested with elevated PCWP, elevated PAP, EKG changes

1. Need enzymes
2. Cardiology consult
3. B-blocker, ASA, morphine, O2, heparin if tolerate
4. Cardiac cath
5. Consider IABP

4. Fever suggests transfusion rxn, malignant hyperthermia, or adrenal insufficiency
5. Transient responder or non responder need OR exploration suggest bleeding or sepsis (if not MI/CHF/PE)

1. Antibiotic prophylaxis prior to surgery
2. Caudery
3. Topical hemostatics
4. Damage control

6. Keep patient warm

15. Consider DVT prophylaxis prior to surgery
16. In RYGB, requiring reoperation, consider gastrostomy tube to study afferent limb/anastamosis and decompress

Notes

-make sure ask PMH, PSH, meds, bleeding problems, anesthesia problems, allergies

-prophylaxis (DVT, abx, GI, b-blocker)

-get UPT on all women of child bearing age

Neoadjuvant therapy

1. Esophageal cancer= T2, T3, or N1 disease

1. 5FU and cisplatin and XRT

2. Rectal cancer= T3 or N1 on TRUS

1. 5FU, leukavorin and xrt for 4wks, wait 4wks, then surgery

3. Breast cancer= inflammatory, adherent to chest wall, possible candidates for lumpectomy but too big

1. Adriamycin, cyclophosphamide (AC)
2. Herceptin for 1yr if HER2neu +
3. Tamoxifen for 5yrs in premenopausal for ER+ or PR+
4. Anastrazole (Arimidex / aromatase inhibitor blocks peripheral estrogen) for postmenopausal for 5yrs for ER+ or PR+

4. Lung cancer= pancoast

Adjuvent therapy

1. Colon cancer= any node +; consider if T3/T4 with obstruction, perforation, or <50yo

1. 5FU, leukovorin, oxaliplatin (FOLFOX) for 6 mo
2. Avastin for metastatic or recurrent= Do not operate for 4 weeks on avastin due to bleeding and poor healing

2. Pancreas= node positive or positive margins

1. Gemcitabine (Gemzar) and XRT

3. Melanoma= node positive

1. Interferon

4. GIST= >5cm, high mitotic index, or metastatic

1. Gleevec (imatinib)

5. Breast= 6 mo cyclophosphamide, adriamycin (AC)

1. > 2cm all get
2. >1cm if ER/PR negative

6. Lung

1. Cisplatin, etoposide, xrt

7. Gastric

1. Chemo & XRT for T2, node positive, or R1 (residual dz)
2. 5FU
3. Unresectable if peritoneal involvement, mets, local invasion, encasement of vessels

GYN

1. Ovarian mass in postmenopausal

1. peritoneal washings with saline
2. TAH/BSO
3. complete omentectomy
4. Pelvic and periaortic LN sampling
5. Biopsy of anything else suspicious
6. chemo (taxil/carboplatinum)

2. Premenopausal with incidental mass can have postop workup

Gallstones found during other surgeries

1. stone > 2cm
2. aneurysmectomy after graft is totally covered

Breast

1. Hx= any pain, family, menstruation (early menarche or late menopause inc risk), age of 1st pregnancy, previous breast problems, or estrogen HRT

1. Risks= female, menarche <12yo, menopause >50yo, previous breast ca, HRT for >5yrs, family history, delayed pregnancy (>30yo), prior radiation, obesity

2. Px= breasts, lymph nodes, skin, liver
3. Studies:

1. FNA a palpable mass= 23G needle, 10cc syringe on negative pressure, 6 passes, stop sxn and withdraw

1. Cyst with clear fluid disappears= observe
2. Cyst with blood= path and excisional bx
3. Cyst with clear fluid recurs >2x= excisional biopsy
4. Solid= path, will need biopsy (core or excisional)

2. Core biopsy= 14G, 5 samples
3. Stereotactic biopsy= only seen on MMG

1. Lie prone with breast in MMG unit, moves to give stero view
2. Machine sets axis
3. Vacuum assisted core biopsy

4. Bilateral MMG

1. 10% false neg and false pos
2. Cluster calcifications (>4 microcalcs in 1cm square), calcs along ducts, irregular or pleomorphic  calcs have 15-25% risk of cancer

5. Breast US to differentiate cyst v. solid

1. Good for women < 30yo
2. Characteristics of breast cancer on US:

1. Taller than fat
2. Irregular
3. Uneven echotexture

6. MRI

1. Helps determine extent of cancer in breast to determine BCT versus mastectomy
2. Helps with implants

4. Benign conditions:

1. Fibroadenoma- excision and follow
2. Cystosarcoma phyllodes- WLE with 1-2cm margins

1. Doxorubicine and ifosfamide for >5cm or stromal overgrowth

3. Fat necrosis and sclerosing adenosis- local excision
4. Plasma cell mastitis, duct ectasia, and subareolar chronic abscess- antibiotics, I&D, elective subareolar excision of ducts
5. Fibrocystic disease- reassurance, but can have inc cancer risk in dysplasia or papillomatosis

1. Open bx for dysplasia or papillomatosis
2. Caffeine reduction
3. Primrose oil 1000mg TID for 2-4mo
4. Danazol 100mg qday
5. Bromocriptine 5mg qday
6. Mastectomy only for severe unrelenting pain (must r/o other pathology)

5. Palpable breast mass not seen on imaging studies

1. Can f/u in 1 mestrual cycle
2. If persists, get core or excisional biopsy

6. BCT

1. Contraindication:

1. Inability to get negative margins (optimal is 1cm)
2. Inability to get radiation (lumpectomy has 40% recurrence, addition of radiation decreases risk to 12%)
3. Multicentric or multifocal
4. Diffuse microcalcifications
5. Inflammatory breast cancer

2. Relative contraindications

1. Retroalreolar tumor
2. Collagen-vascular disease
3. Extensive
4. Large tumor:breast ratio
5. Pregnancy in 1st/2nd trimester
6. BRCA 1 (breast, ovarian) or 2 (breast, ovarian, pancreatic, male breast)
7. Pt’s choice

7. Postmastectomy XRT for:

1. >4 positive lymph nodes
2. Tumors that involve skin or chest wall

8. LCIS= observe q6months with MMG; can consider clinical trial

1. Has 20-40% lifetime risk of cancer (12% in nl population)
2. Prophylactic tamoxifen
3. Can genetic test if has risk factors for BRCA
4. Bilateral prophylactic mastectomy with reconstruction if pt desires

9. DCIS= can become invasive in 50%

1. Need size, multifocal/unifocal, comedo necrosis, differentiation,
2. SLNB for high grade or comedo necrosis

1. Do ALND if path shows invasive cancer
2. Has 2% local recurrence

3. Total mastectomy for diffuse disease
4. Breast conservation (BCT)

1. Local recurrence 12%

5. Tamoxifen decreases recurrence if ER+, but must be ER+

10. Breast cancer in pregnancy

1. SLNB:

1. No blue die
2. No SLNB before 30wk

2. Chemo

1. AC after 1st trimester

11. Invasive breast cancer

1. Workup: CBC, CMP, CXR, bilateral MMG

1. Bone scan if alk phos or calcium is elevated
2. CT a/p if LFTs abnormal

2. BCT= mobine, <4cm, not central, not too small/large breast, can get negative margins
3. Total mastectomy with SLNB
4. SLNB= lymphazurin blue dye and technetium labeled sulfur colloid
5. ILC is more diffuse and more difficult to see on MMG than IDC

12. Disseminated breast cancer

1. ER/PR positive get estrogen suppression (tamoxifen, Lupron, aromatase inhibitor)
2. ER/PR negative get AC chemo

13. Paget’s disease of the nipple:

1. Exam and get Bilateral MMG
2. No mass palpated or on MMG:

1. Full thickness biopsy of NAC to confirm Paget’s diagnosis
2. Tx: Simple mastectomy with SLNB

3. Mass

1. Excisional biopsy and full thickness biopsy of NAC
2. Tx: simple mastectomy with SLNB or BCT with excision of NAC

1. If do BCT, need SLNB only if mass is invasive ca (no SLNB if mass is DCIS)

14. Bloody nipple discharge

1. Hx: spontaneous, both breasts, consistency

1. Bilateral clear needs endocrine workup

2. Localize lesion:

1. Px: try to milk areolar quadrants to determine which one has the lesion
2. Bilateral MMG
3. Ductogram

3. Have quadrant but no mass subareolar wedge resection of ductal system
4. Have quadrant and a mass subareolar wedge and excisional biopsy
5. No identifiable quadrant observe for a few weeks (pt can try to localize) and then do complete subareolar duct excision if still unable to localize

15. Local recurrence

1. Must rule out distal mets

1. Previous stage of cancer, ER/PR status
2. CBC, CMP, CXR, bone scan, CT a/p

2. Can do FNA in office
3. Small/mobile resection (completion mastectomy for prior BCT), XRT, systemic therapy
4. Large/fixed core needle biopsy to get ER/PR, systemic therapy, XRT, possible resection
5. XRT is to chest wall for chest wall recurrence or to the axilla to axillary recurrence

16. Axillary lymph node

1. Hx: cause for infection, neoplasm, lymphoma
2. DDX: ipsilateral breast Ca (25%), lymphoma, melanoma, lung ca, GI cancer
3. Px: chest, lymph nodes, lung, guiac/rectal exam, palpate abdomen
4. Core bx- look for ER/PR (breast) or mucin stain (if+ r/o melanoma and lymphoma)
5. Studies for adenocarcinoma:

1. PSA
2. MMG
3. CXR
4. CT a/p
5. Bone scan
6. UGI and colonoscopy

6. Tx: if no localization, can do MRM

17. Breast cancer >5cm, adhered to chest wall, or fixed LAN

1. Hx, Px, Labs, Metastatic workup
2. Core biopsy
3. Induction chemotherapy, follow response with US (3-4 cycles)
4. TM with SLNB followed by XRT
5. Completion chemo (6-12 cycles)
6. Tamoxifen

18. Inflammatory breast cancer

1. DDX: mondor, mastitis, abscess
2. Full thickness skin biopsy
3. Metastatic workup (CBC, CMP, CXR, CT a/p, bone scan)
4. Tx:

1. Neoadjuvent AC
2. Mastectomy with SLNB if good response

1. If not responding, add XRT prior to TM

3. Complete 12 cycles of chemotherapy
4. Adjuvant XRT
5. Tamoxifen

19. Breast cancer in pregnancy (can use 5FU, A, C= FAC)

Head and Neck

1. Never to open biopsy of lateral neck mass
2. Workup

1. Location is key

1. Zones of neck

2. Bronchoscopy, esophagoscopy, laryngoscopy
3. FNA (likely indeterminate)
4. Melanoma of scalp / ear can drain to lateral neck

1. must do superficial parotidectomy with neck dissection for metastatic nodes

3. MRND

1. Leaving spinal accessory n. does not effect prognosis
2. Can also leave SCM and IJ

4. Thyroid

1. Thyroid storm

1. Lugols solution

2. MEN syndromes
3. Complications

1. Hypocalcemia
2. Hematoma with stridor
3. Laryngeal n. injury
4. Hypoparathyroidism
5. Superior laryngeal n. injury

5. Parathyroid

1. Postop hypocalcemia
2. Can’t locate all 4 glands= look in mediastinum (thymus), tracheoesophageal groove, and may do lobectomy if 3 other glands are normal.
3. Postop hypercalcemia with EKG changes (bradycardia, shortened qt interval)
4. Postop stridor
5. MEN syndrome

GI Surgery

1. Esophagus

1. Cancer Workup

1. H&P
2. CBC, CMP
3. Barium swallow
4. Endoscopic US, CT c/a/p
5. Stress test, PFT

2. Esophageal Cancer Management

1. Postop leak

1. Open cervical leak at bedside
2. If septic, in ab/chest, need operative drainage
3. If late need diverting esophagostomy

2. Tracheal injury
3. Unresectable disease

1. Distant mets
2. Paratracheal, celiac, or mediastinal LN’s (not paraesophageal)
3. Bronchoesophageal fistula / tracheal invasion

4. Neoadjuvent therapy for= T2, T3, or N1 disease

1. 5FU and cisplatin and XRT

3. Zenker’s Diverticulum

1. Tx: diverticulectomy and crycopharyngeus myotomy through left neck
2. Postop leak/dysphagia
3. Esophageal perforation
4. Drain

4. Heller myotomy

1. Achalasia mannometry has LES >30mmHg, incomplete relaxation of LES, aperistalsis
2. Extend 2cm onto stomach, 4cm along esophagus
3. Do anterior (dor) or posterior (toupe) partial fundoplication
4. Postop reflux up to 40%, most need only PPI, lifestyle changes
5. Postop dysphagia reimage with UGI, endoscopy, may need dilation, re-myotomy if incomplete, esophagectomy as last resort.

5. GERD

1. Workup: H&P, cxr, barium swallow, upper endoscopy and:

1. Manometry

1. LES < 6mmHg
2. LES< 2cm length
3. LES< 1cm intraabdominal length

2. 24hr pH probe

1. pH < 4 for for more than 1.5hrs
2. establish relationship btwn symptoms and reflux

3. Endoscopic staging:

1. 1= erythema
2. 2= mild ulceration
3. 3= extensive ulceration, cobblestoning
4. 4= stricture, fibrosis

2. GERD with stricture get several sessions of dilation preop, if unable may need short esophagectomy
3. Surgery for:

1. Persistant symptoms for >6mo despite medical tx
2. Complications (pneumonia, barretts, stricture)

4. Nissen improves sx and complications better than meds; may reverse Barretts’, but unsure

6. Barrett’s esophagus

1. 5-10% can get low grade dysplasia
2. 2% can get esophageal cancer
3. Workup: barium swallow, endoscopy, manomery, pH probe
4. Operate on:

1. Symptomatic barretts  nissen
2. Severe dysplasia confirmed by 2 pathologiests  esophagectomy
3. Undilatable stricture  esophagectomy
4. Perforation of barretts  esophagectomy

5. Emergency surgery for perforated barrett’s= segmental esophagectomy, gastrostomy, cervical esophagostomy, delayed reconstruction

7. Esophageal Perforation

1. Dx: gastrograffin swallow study
2. Early (<24hrs) without shock can get repair

1. Mass or stricture needs resection or myotomy
2. Bolster repair with intercostals muscle flap or stomach wrap
3. Drain with 2 chest tubes and NG tube

3. Late (>24hrs)

1. Shock or unstable= NPO, abx, left posterolateral thoracotomy with drain in perforation, chest tubes
2. Stable= NPO, abx, segmental esophagectomy, cervical esophagostomy, gastrostomy

8. Gastric Cancer

1. Risk factors: pernicious anemia, blood group A, smoker, eats nitrates, genetic
2. Workup: CT c/a/p, CXR, EKG,
3. Surgery:

1. Wide excision 6cm margin, get frozen section
2. Omentectomy
3. D1 lymphadenectomy, can also get periportal and peripancreatic LN’s
4. Roux-en-y gastrojejunostomy or estophagojejunostomy

1. Roux en y is ~30cm from LT then a 45cm roux limb

4. Adjuvent therapy: 5FU, XRT

9. Esophageal Varices

1. Acute bleeding
2. Child’s C cirrhotic
3. TIPS
4. Emergency shunt procedure

1. H type Mesocaval=  8mm prosthetic graft from IVC to IMV just distal to uncinate process

5. Algorhythm

10. Hiatal Hernias

1. Sliding v. paraesophageal

1. Type I= GE junction in chest (sliding)
2. Type 2= nl GE junction
3. Type 3= combined 1 & 2 (advanced type 2 where shortening brought GEJ into chest)
4. Type 4= another organ in the chest

2. Anemia, perforation, gastric volvulus risk with paraesophageal
3. Can’t close defect mesh
4. If stomach needs anchoring, I do stamm gastrostomy; I do Nissen wrap
5. Type 3 may need colles gastroplasty (can do through left chest if needed)

11. Duodenal ulcer disease

1. Criteria for operation on bleeding

1. >6units PRBC in 24hrs
2. Re-bleeding in hospital
3. Rebleeding after treatment
4. Shock

2. Operate on perforated ulcers
3. Recurrent ulcer disease

1. Workup: fasting gastrin, cmp, PTH, H pylori (biopsy, urea breath test for test of cure)

4. Obstructing duodenal ulcer- NGT for 5 days, UGI, IVD, PPI, electrolyte replacement

1. Do gastrojejunostomy with parietal cell vagotomy if not improved

5. Difficult duodenal stump- lateral duodenostomy
6. Risk of recurrence with ulcer procedures:

12. Gastric Ulcer

1. Types:

1. Type 1= lesser curve
2. Type 2= body and duodenal (ACID)
3. Type 3= prepyloric (ACID)
4. Type 4= lesser curve, NSAID

2. H pylori tx= amox, clarithramycin, and PPI for 14d
3. Biopsy gastric ulcers

1. If indeterminant, re-endoscopy and biopsy in 6 weeks
2. If not resolved in 6 weeks of treatment, will need resection

4. MALT get H pylori treatment
5. Bleeding  wedge resection, type 2/3 get pyloroplasty and TV if stable
6. Perforation wedge resection and gram patch (can just biopsy and patch if not stable); pylorplasty and TV in type 2/3
7. Chronic biopsy up to 10 samples, if persist despite H pylori tx, stop NSAID, PPI for > 6 weeks will need excision

1. Type I gets antrectomy, B1
2. Type 2/3 gets V&A, B1 or 2
3. Type 4 gets resection

2. GI bleeding

1. Cancer v. fistula v. fissure
2. Fissure

1. Botulinum toxin
2. Contralateral lateral internal fissurotomy

3. Bowel obstruction

1. Check for hernias

4. Bowel cancer

1. Ureteral injury

1. Below pelvic brim reimplant with stent
2. Mid ureter repair over a stent, reimplant with psoas hitch with stent
3. Upper ureteral transureteroureterostomy, nephrostomy and wait for GU

5. Abdominal Pain

1. Suspected appendicitis

1. Find terminal ileitis- if cecum is ok, remove appendix; if cecum is involved leave appendix
2. Nl appendix= look at adnexa, uterus, look for meckles, look at stomach
3. Mass in appendix=

1. Appendiceal adenocarcinoma right hemicolectomy
2. Carcinoid

1. Appy if not at base and < 2cm
2. Right hemi if at base or >2cm

2. PID and tubo-ovarian abscess

1. Give antibiotics: cefoxitin and doxycycline
2. Salpingooophorectomy only if septic

3. Diverticulitis

1. OR for:

1. Free perforation with peritonitis
2. Failure of medical management
3. Multiple recurrent attacks

4. Rectal cancer

1. Rectum is 12 cm from anal verge proximally
2. Do APR for lower 5cm
3. EEA stapler with incomplete donut do proximal diversion and leave anastamosis intact

6. Liver and bile ducts

1. Workup of jaundice

1. Parenchymal= hepatitis; no dilated ducts
2. Obstructive= dilated ducts, more direct hyperbilirubinemia

2. CBD injury during cholecystectomy

1. If < 50% transected can repair and place T-tube above or below (not at site of injury)
2. Complete transaction do Roux-en-y hepaticojejunostomy

3. Cholangitis
4. Impacted stone in CBD

1. ERCP
2. Transhepatic stent
3. Choledochoduodenostomy= low longitudinal 2cm incision on CBD, longtitudinal incision on duodenum (perpendicular), close both together with 4-0 PDS

5. Liver mass

7. Pancreatitis

1. Ranson’s criteria= best for alcoholic pancreatitis

1. 1st 24hrs

1. Glucose > 200
2. AST > 250
3. LDH > 350
4. Age > 55
5. WBC >16

2. 2nd 24hrs

1. Calcium <8
2. Hct fall >10%
3. pO2 < 60
4. BUN rise >5
5. Base deficit > 4
6. Fluid sequestration > 6L

3. Mortality: 0-2 is 2%, 3-4 is 15%, 5-6 is 40%, 7-8 is 100%.

2. Gallstone pancreatitis should have MRCP, ERCP, or IOC

8. Pancreatic cancer

1. Workup: cbc, cmp, CA-19-9, CEA, CT c/a/p
2. Don’t drain duct if operative candidate
3. Paliate with ERCP stent, transhepatic stent, roux-en-y choledochojejunostomy with gastrojejunostomy
4. Complications of whipple

1. Pancreatic fistula  drain, octreotide
2. Gastric outlet obstruction

9. Pancreatic pseudocyst- biopsy cyst to ensure not Ca

1. ERCP
2. Treat for:

1. >6cm
2. Symptomatic

3. Communicating:

1. ERCP with sphincterotomy
2. Internal drainage
3. Surgical drainage

4. Non communicating

1. Internal drainage
2. Percutaneous drainage
3. Surgical drainage

5. Chronic pancreatitis with pseudocyst and enlarged duct may benefit from lateral pancreatico jejunostomy

Small Bowel and Colorectum

1. Crohn’s Disease= skip lesions, granulomas

1. Workup: AXR, colonoscopy (cx, biopsy)

1. Meckel’s scan can r/o bleeding from meckel
2. UGI with SBFT
3. CT a/p

2. Initial tx:

1. Sulfasalazine 0.5mg TID, or 5ASA
2. Prednisone for flares
3. Flagyl for rectal and anal dz
4. AZA or 6MP for resistance (results in bone marrow suppression and pancreatitis)
5. Steroid enemas
6. Lomotil
7. Low residue diet, B12
8. Remicade

3. Surgery for:

1. Obstruction
2. Bleeding
3. Perforation
4. Non-healing fistula
5. Abscess

4. In surgery:

1. Resect grossly involved bowel
2. Gastrojejunostomy to bypass involved duodenum
3. Fistula take down and resect small bowel (leave colon/bladder)
4. For intractable colon  proctocolectomy with permanent ileostomy
5. Perianal complications  I&D and fistulotomy, rarely do proctocolectomy

2. Ulcerative Colitis= rectum always involved, continuous proximally, mucosa and submucosa only

1. Workup= AXR, colonoscopy (cx, biopsy)

1. Toxic megacolon gets ICU, abx, IVF, T&C, steroids, npo, serial exam/xray

1. OR if no improvement in 24-48hrs
2. Get subtotal colectomy and ileostomy

2. Less acute gets: UGI with SBFT to r/o crohns

2. Medical Tx:

1. Sulfasalazine
2. 5ASA
3. Steroids
4. AZA
5. 6MP
6. Lomotil

3. Surgery for acute complications:

1. Perforation
2. Non-improving toxic megacolon
3. Severe bleeding
4.  all get subtotal colectomy with end ileostomy.

4. Surgery for chronic disease

1. Get anal manometry before resection
2. Normal anal sphincter  total colectomy with anorectal mucosectomy and ileorectal pull through.

1. Complications: 5-7BM per day, loose BM, anal leakage, incontinence, pouchitis, anastamotic leak, sexual dysfunction

3. Rectal incontinence or severe rectal disease total proctocolectomy with ileostomy.

3. Large Bowel Obstruction= cancer, diverticulitis, volvulus, adhesions

1. Workup: CXR, EKG, AXRs

1. CT a/p rectal contrast
2. Gastrografin enema
3. Sigmoidoscopy- for low obstruction and no peritoneal signs, can look for obstruction, volvulus

2. Tx: resuscitate and go to OR if not volvulus or diverticulitis

4. Colonic Pseudo-obstruction

1. Workup: NGT, NPO

1. AXRs
2. CT a/p with rectal contrast- r/o mechanical obstruction
3. Gastrografin enema can r/o obstruction
4. Sigmoidoscopy- r/o ischemic colitis

2. Tx:

1. If cecum >10cm and no peritonitis can do colonoscopy and decompression
2. If peritonitis need laparotomy

1. Cecal perforation right hemicolectomy with mucus fistula
2. No cecal perforation cecostomy tube

3. If cecum < 10cm and no peritonitis can observe off meds with neostigmine (contraindicated in bradycardia, renal failure, bronchospasm, or mechanical obstruction)

5. Ischemic colitis

1. Workup: stool guiac

1. AXRs
2. Colonoscopy
3. ***angiogram not helpful b/c occlusion is in small arterioles**

2. Tx:

1. Stable with no transmural ischemia observe, NPO, abx, IVF, serial exam
2. Worsening or transmural ischemia laparotomy with colon resection, usually left hemicolectomy

6. Small Bowel Obstruction

1. Can wait 2-3 days with NGT, IVF if there is previous surgery, no sign of bowel ischemia, or hernias
2. Obturator hernia has fluid (bowel) outside of pubic ramus
3. Gallstone ileus is treated with longitudinal incision proximal to the stone, transverse closure
4. Femoral hernia- plan transverse incision just above bulge under inguinal ligament; open sac; if viable reduce, resect sac, and close cooper lig to inguinal lig; if non-viable hold bowel and do lower midline incision for bowel resection.
5. Inguinal hernia without mesh- conjoint tendon to poupart ligament;

1. Modified Bassini: Imbricate transversalis fascia with continuous 2-0 prolene; then continue running suture to close conjoint tendon to iliopubic tract and inguinal ligament. If find strangulation, need lower midline incision

7. Carcinoid tumors

1. Carcinoid syndrome= flushing, dermatitis, diarrhea, dementia (3D’s)

1. Increased 5HIAA in 24hr urine; negative in hindgut carcinoid
2. Chromogranin A

2. Localization:

1. Octreotide scan, MIBG
2. Endoscopy
3. CT/ MRI
4. IOUS
5. Echo

3. Ask about MEN I symptoms
4. Appendix < 2cm and not base can get appy
5. Rectum < 2cm can get local excision

1. APR for >2cm, muscularis mucosa invasion, or recurrence

6. Small bowel gets resection with LN’s
7. Duodenum <2cm gets local resection unless invading muscularis mucosa

1. Whipple if near ampula, >2cm, or invades muscularis mucosa

8. Liver resection or ablation
9. Paliation: somatostatin, debulking with cholecystectomy
10. Chemo: streptozocin.
11. Can do radiation

8. Right lower quadrant pain

1. Meckel’s diverticulitis  segmental bowel resection
2. Ectopic pregnancy:

1. Unruptured salpingotomy, evacuate, repair
2. Reuptured unilateral salpingectomy

3. Tubo-ovarian abscess

1. Peritonitis unilateral salpingo-oophorectomy, lavage, leave drain
2. If no peritonitis can do ceftriaxone/flagyl

4. Twisted ovarian cyst unilateral salpingo-oophorectomy

9. Colon Polyps

1. Surgery for polyposis syndromes

1. Proctocolectomy, mucosectomy, and ileoanal pull-through:

1. Total colectomy with transaction of rectum ~4cm above dentate line
2. Mucusectomy by inverting anus, inject diluted epi submucosal and bovie mucosa off muscular layer from dentate line to staple line
3. Create J-pouch from ileum (~15cm limb)
4. EEA stapler to anastamose and re-enforce with interrupted vicryl
5. Diverting loop ileostomy
6. Has 10% risk of sexual dysfunction, 7-10 BM/day

2. Total proctocolectomy with ileostomy
3. Subtotal colectomy with frequent endoscopy and polypectomy= least risk of impotence

2. Surgery for polyps with cancer:

1. <2mm margin
2. Lymphovascular invasion
3. Not well differentiated
4. Sessile

3. Rectal polyp unable to fully excise but < 7cm from anal verge:

1. Can do trans rectal excision, but if >T1 (submucosa) will need APR
2. Lithotomy for posterior lesion, prone jack-knife for any other
3. Pudendal / perianal block
4. Mark 1cm margin with bovey
5. Suture in superior most aspect
6. Full thickness excision into perirectal fat
7. Full thickness closure

10. Colorectal cancer

1. Workup: CBC, CMP, CEA, CXR, EKG, CT a/p

1. Complete colonoscopy
2. TRUS for rectal ca

2. Tx:

1. Neoadjuvent chemo XRT for T3 rectal
2. Use no touch technique
3. Colectomy gets 1 vessel above and 1 vessel below

1. Cecum/ascending  right colic, right branch of middle colic
2. Hepatic flexure / TV colon right colic, middle colic
3. Splenic flexure middle colic, IMA
4. Descending IMA, left branch of middle colic
5. Sigmoid sigmoidal and superior hemorrhoidal branches of IMA
6. Rectal sigmoidal and superior hemorrhoidal branches of IMA

4. Elevated CEA in followup:

1. Repeat CEA in 2 weeks, check CT c/a/p, colonoscopy, PET,
2. Unresectable disease needs chemo
3. Unresectable recurrence found during exploration:

1. Consult radiation oncologist for brachytherapy or intraop tumor marking for future XRT

4. If unable to localize, need exploratory lapratomy

1. Search liver, lymph nodes, retroperitoneum, all surfaces

11. Cecal volvulus

1. Attempt colonoscopic detorsion to make elective procedure (same hospital stay)
2. Do right hemicolectomy

12. Rectal Prolapse:

1. Workup:

1. Colonoscopy
2. Anorectal manometry (70% will regain continance with repair)
3. Colonic transit study

2. Medical tx:

1. Biofeedback
2. Fiber

3. Tx:

1. Type I= prolapsed mucosa only; get hemorrhoidectomy
2. Type II= full thickness prolapsed; transabdominal rectopxy, can do sigmoid resection for redundant sigmoid
3. Type III= full thickness with perineal hernia; modified Altmeyer procedure

1. Prone Jack-knife position
2. Lone star retractor
3. Full thickness incision 1cm above dentate line
4. Open hernia sac anteriorly and free rectum circumferentially
5. Plicate levator muscles
6. Hand sewn anastamosis
7. ** can’t do this after prior sigmoidectomy due to blood supply***

13. Anal Cancer

1. Anal margin  0.5cm margin WLE
2. Anal canal (SSC)

1. Colonoscopy, FNA any suspicious inguinal nodes
2. Nigro protocol with XRT flanked with 5FU+mitomycin C
3. Re-examine / biopsy suspicious areas, re-FNA node if remain enlarged
4. Can repeat nigro
5. Re-examin  if positive needs APR, if node remains positive need inguinal lymph node dissection
6. Superficial groin dissection:

1. 
2. Raise flaps just deep to scarpa’s fascia

1. Laterally to sartorius
2. Medially to aductor magnus
3. Inferiorly to apex of above muscles

1. Divide saphenous v. here

4. Superiorly above inguinal ligament

3. Excise fatty tissue above the SFA adventitia
4. Work inferior to superior, then lateral to medial
5. Divide saphenofemoral junction
6. Reach cloque’s node under inguinal ligament

7. Deep groin dissection:

1. Retroperitoneal dissection
2. Circumferential dissection of nodes off external iliac to the common iliac

14. Rectovaginal fistula

1. Low= obstetric injury, less complex
2. High= diverticulitis, cancer, crohns; more complex
3. Workup: CTa/p with rectal contrast, colonoscopy; look for possible incontinence:

1. Anorectal manometry
2. Transanal ultrasound= look at internal and external sphincter dysfunction
3. Pudendal nerve studies

4. Tx:

1. High likely need sigmoidectomy
2. Advancement flap:

1. Prone position, prep anus and vagina
2. Elevate trapezoidal flap with apex at fistula to include mucosa, submucosa, and circular muscle (internal sphincter)
3. Mobilize surrounding internal sphincter to close longitudinally with 2-0 dexon
4. Flap excess (including fistula) excised and closed with 3-0 dexon
5. 

3. Can also do placation sphincteroplasty

15. Anal incontinence

1. Workup:

1. Manometry
2. Transanal ultrasound= can identify sphincter defect
3. Pudendal nerve studies

2. Tx:

1. 30g fiber/day
2. Avoid caffeine
3. Antidiarrheals
4. Regular enemas

3. Plication sphincteroplasty:

1. Lithotomy position
2. Semicircular incision anterior to anus
3. Elevate anoderm in submucosal plane
4. Deep identify internal sphincter
5. Laterally identify transverse perineal muscle (avoid pudendal nn.)
6. Deep to internal sphincter identify levators

1. Plicate levators
2. Plicate transverse perineal muscle
3. Plicate internal sphincter

16. Bowel ischemia
17. Enterocutaneous fistula:

1. FRIEND= foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction
2. Workup: h/p, quantify, CT look for abscess
3. Contain infection and optimize nutrition
4. Surgery for:

1. Failure of medical management
2. Bleeding
3. Infection not controlled
4. Complete distal obstruction
5. Removal of foreign body

18. Radiation enteritis:

1. Dx:

1. Colonoscopy with bx shows obliterative endarteritis, necrosis, ulceration

2. Start

1. TPN, NPO
2. Methylprednisolone

3. Surgery for:

1. Non healing fistula
2. Obstruction

4. Surgery

1. Consider ureteral stents
2. Resect/anastamosis if possible; bypass if not
3. Don’t do stricturoplasty if resection possible
4. Can do frozen section prior to anastamosis

Biliary Surgery

1. Post-cholecystectomy jaundice

1. Workup:

1. Admit, LFT, cmp, cbc, lipase, amylase, hepatitis panel
2. CT a/p
3. HIDA
4. ERCP if leak/stricture/obstruction

2. IR drain a fluid collection
3. ERCP with stent/sphincteroplasty for leak, if doesn’t improve in 3weeks will need RY choledocojejunostomy
4. PTC for comlete occlusion and plan delayed RY choledocojejunostomy

Liver

1. Right lobectomy:

1. Bilateral subcostal incision
2. Take down right triangular ligament and coronary ligament
3. Cholecystectomy
4. Portal dissection:

1. Ligate right hepatic duct
2. Ligate right hepatic a.
3. Ligate right portal v.

5. Posterior mobilization and ligation of right hepatic v.
6. Transect liver just to right of line of demarcation
7. Staple bile ducts
8. Omentum placed against raw surface

2. Left lobectomy

1. Bilateral subcostal incision
2. Take down left triangular ligament
3. Cholecystectomy
4. Portal dissection:

1. Ligate left hepatic duct
2. Ligate left hepatic a.
3. Ligate left portal v.

5. Transect along a line from the left side of GB fossa to the left of the IVC
6. Ligate left hepatic vv. after liver transaction

3. Mass:

1. CT differentiates:

1. Hemangioma- peripheral nodular enhancement
2. FNH- central scar
3. Adenoma- mixed fat, hemorrhage, necrosis
4. HCC- venous washout

4. Abscess:

1. CT can’t tell pyogenic from amebic
2. Technecium 99 scan only lights up pyogenic abscess
3. Flagyl for enterameba histolytica

5. Cyst:

1. Echinococcal serology
2. Mabendazole for Echinococcus, but often need surgical excision (pack abdomen with hypertonic saline soaked laps)

Endocrine surgery

1. Gastrinoma:

1. Workup:

1. Fasting gastrin > 100 (>500 is diagnostic)
2. Secretin stim test (gastrin increases with gastrinoma)

2. Localization

1. CT a/p
2. Octreotide scan
3. IOUS
4. Duodenoscopy

3. Tx:

1. Duodenum  enucleate (can consider whilpple)
2. Mets to liver debulk, PPI, somatostatin, streptozotocin
3. Can’t find it duodenotomy, IOUS, consider acid reducing operation, somatostatin

2. Insulinoma

1. Symptoms improve with glucose
2. Elevated insulin, low glucose, C-terminal peptide also elevated
3. Ddx of hypoglycemia:

1. Cirrhosis
2. Gauches (glycogen storage disease)
3. Large tumors

4. Localization

1. CT a/p
2. Octreotide scan
3. Arteriogram
4. IOUS

5. Tx: diazoxide or somatostatin until surgery

1. Enucleate
2. If can’t find, can do distal pancreatectomy, Frozen section ; if still negative, do subtotal pancreatectomy (not sure I agree with blind distal pancreatectomy)
3. MEN I should have subtotal pancreatectomy.

3. Adrenal incidentaloma:

1. Biochemical eval:

1. 24hr urine cortisol
2. 24hr urine metanephrine, normetanephrine
3. Aldosterone/rennin if HTN and hypokalemic (abnl is >20)

2. Radiology: < 4cm can watch; >4cm needs excision

1. Adenoma is <10 hounsfield units, fatty
2. Adrenal carcinomas have necrosis, calcifications, hemorrhage

3. Lap Adrenalectomy (<6cm, not cancer)
4. anterior adrenalectomy

1. survey abdomen
2. Left= take down splenic flexure
3. Right= take down hepatic flexure and kocherize the duodenum, and take down right triangular ligament
4. Enter gerota’s fascia

1. Start cephalad and dissect towards renal hilum
2. Dissect between adrenal and

1. L- pancreas/spleen (retract spleen and pancreas up)
2. R- liver

5. Identify adrenal vein and ligate

1. Left- to renal v
2. Right- short and comes off posterior surface of IVC

6. Continue dissection over renal capsule using ligasure/cautery/or harmonic
7. Remove retroperitoneal fat with the adrenal gland

Skin and Soft tissue

1. Melanoma

1. ABC

1. Asymmetry
2. Border
3. Color variance
4. Diameter > 6mm
5. Evolution or change in lesion (esp if goes away)

2. Types

1. Superficial spread 70%
2. Nodular 30%
3. Lentigo maligna 5%
4. Acral lentiginous 40-70%
5. Desmoplastic 2%

3. Biopsy all suspicious lesions

1. < 1.5cm get excision
2. >1.5cm get punch (include nl skin, do 2 areas, include thickest area)

4. Margins

1. Tis= 0.5mm
2. <1mm thick= 1cm
3. 1-2mm= 2cm
4. >2mm= 2cm

5. Subungual and digital melanomas

1. Hutchinson’s sign= pigment changes of cuticle
2. Worse prognosis
3. Remove nail to biopsy
4. Tx: amputate one joint proximal to tumor

6. SLNB for:

1. > 1mm thick
2. Ulceration
3. Clark level IV
4. Regression
5. Incomplete staged (ex shaved biopsy)
6. Discuss option for all invasive melanoma, <1mm has < 5% chance

7. Positive sentinel node gets:

1. Regional LN dissection
2. 1yr of interferon alpha

2. Sarcoma

1. Biopsy any mass > 2cm (core or incisional) before excisional biopsy

GYN surgery

1. Ovarian cyst

1. Premenopausal

1. < 5cm observe on US
2. >5cm do 500cc NS washings, eval pelvic/periaortic nodes, omental bx, cystectomy

2. Postmenopausal

1. Washings, look at pelvic / periaortic nodes, omental biopsy, BSO

2. Ovarian mass

1. Premenopausal

1. Washings, eval pelvic/periaortic nodes,omental biopsy,  frozen section biopsy

2. Postmenopausal

1. Washings, eval pelvic/periaortic nodes, omental biopsy, BSO

3. Advanced ovarian cancer:

1. Biopsy, washings, come back

Trauma

1. Retroperitoneal hemoatoma
2. Pelvic hematoma
3. Compartment syndrome

1. Forearm compartment syndrome= Volar and dorsal compartments, only the volar incision needed (dorsal will decompress through this)

1. 
2. Thenar extension
3. Distal ulnar
4. Proximal radial

2. Thigh compartment syndrome= anterior, posterior, and medial compartments

1. Anteriolateral incision along iliotibial tract

1. Decompress quads anteriorly and hamstrings posteriorly

2. Anteriomedial incision over adductus group

3. Leg compartment syndrome=

1. Medial incison for deep and superficial posterior
2. Lateral incision for lateral and anterior compartments

1. Deep peroneal n. lies in anterior compartment  foot drop, 1st-2nd web space sensation

4. Aortic transaction
5. Neck injury
6.  Head trauma

1. Dilated pupil

1. Epidural hematoma (middle meningeal a) ipsilateral side, lucid interval, contralateral posturing
2. Subdural hematoma (venous bleeding)

2. Dilated both pupils= brainstem herniation, death, pharmacologic
3. Brain death= no flow on brain scan, no brainstem reflexes

7. Vascular trauma:

1. Hard signs: pulseless, expanding hematoma, arterial bleeding, bruit, distal ischemia

Vascular

1. Postop loss of pulse
2. Leaking AAA
3. AAA with bloody diarrhea postop

1. Dx on sigmoidoscopy
2. If not septic can do abx (no transmural necrosis)
3. If septic need OR for sigmoidectomy

4. Infected graft
5. TIA
6. Carotid artery disease

1. CEA Indications:

1. Asymptomatic > 70%
2. Symptomatic (TIA, recent cva) >70%
3. Symptomatic ulcerative plaque or sx despite ASA > 50%
4. NASCET / ECST- symptomatic >70%, possibly for >50%
5. ACAS / ACST- asymptomatic > 60% if periop strok rate < 3%
6. Duplex velocities and setnosis:

1. Nl        ICA PSV < 125                ICA EDV <40
2. 50-70        ICA PSV 125-230        ICA EDV 40-100
3. >70%        ICA PSV >230                ICA EDV >100

2. CEA procedure:

1. Incision along anterior border of SCM
2. Retract SCM laterally
3. Ligate facial vein
4. Isolate CCA at level of omohyoid
5. Continue dissection distally
6. Can retract hypoglossal n. anteriorly off ICA

1. Can divide digastrics
2. Can dislocate mandible

7. Dissect out ECA to its first branch (superior thyroid)

7. Popliteal exposure:

1. Above knee

1. Medial thigh incision
2. Sartorious muscle retracted posterior
3. Adductor magnus m. retracted anterior
4. Enter popliteal fossa

2. Below knee

1. Medial lower leg incision 1cm below the medial border of the tibia
2. Gastrocnemius retracted posterior
3. Enter popliteal fossa

 Thoracic

1. Lung abscess:

1. Indications for drainage:

1. >6cm
2. Not responding to medical therapy (8wk)
3. Immunocompromised, critically ill
4. empyema

2. Indications for surgery:

1. Hemoptysis
2. Can’t exclude cancer
3. Bronchopleural fistula

3. OR: thoracotomy cut down on percutaneous catheter and place chest tube

1. Lobectomy required for complications

2. Lung cancer

1. Contraindication to resection:

1. T3, T4, N3
2. < 2cm from carina, invading structurs
3. Contralateral nodes or scalene nodes

2. Chemo= cisplatin & etoposide

3. Mediastinal mass:

1. Dx:

1. Tumor markers= AFP, bHCG, Thyroid function, Urine catecholamines
2. CT

2. Anterior mediastinum= Thyroid, parathyroid, thymus, thymoma, teratoma
3. Middle mediastinum= bronchogenic cyst, pericardial cyst, lymphoma, sarcoma, granuloma
4. Posterior mediastinum= esophageal duplication cyst, lyomyoma,