SCORE CORE 1-20

1. Ultrasound to mark common femoral artery bifurcation
2. Prep nipple to knees
3. 2 percutaneous closure devices with 9-Fr sheaths exchanged over micropuncture / 6-Fr sheaths
4. Systemic heparin
5. Guidewire / catheter into proximal thoracic aorta and exchange wire
6. Fluoro to exchange for large bore sheaths (18-24F for main body, 12-24F for contralateral limb)
7. Advance main body of endograft, pull sheath back
8. Contralateral sheath with dilator into contralateral gate, pull into EIA and deploy
9. Deploy endograft just below the lowest renal artery and deploy main body
10 Perform completion angiogram
11. Check distal pulses
Embolization of mural thrombus to renal artery - suction thrombectomy / stenting

Transperitoneal
1. Midline incision xiphoid to below umbilicus
2. Reflect transverse colon cephalad, duodenum / SB to the right after dividing LOT , descending colon the left
3. Isolate proximal / distal aneurysm
4. Heparinize patient (100U/kg)
5. Clamp aorta proximally and distally
6. Open anterior wall (longitudinal incision, T-ed across at superior/ inferior ends)
7. Remove mural thrombus, suture-ligate lumbar vessels
8. Suture ligate IMA from inside aneurysm wall
9. Anastomose graft to proximal aorta using running suture 3-0 prolene
10. Flush and clamp graft distally
11. Distal anastomosis with 4-0 prolene with parachute technique, flush and open clamps to aortic bifurcation or iliacs
12. Close aneurysm sac over anastomosis in 2 layers with 2-0 vicryl

- Lithotomy, lower midline
- Mobilize left colon by incising lateral peritoneal reflection, incise peritoneum over right side
- Identify both ureters
- Divide sigmoid with linear cutting stapler
- Clip branches of middle artery
- Male : dissect in plane posterior to seminal vesicles , female : excise portion of posterior vaginal wall adjacent o tumor
- Plane anterior to aorta entered and colon, mesenteric fat were mobilized from the retroperitoneum, mesorectum mobilized until levator sling visualized.
- Divide lateral attachments
- Complete dissection down to levator sling
- Elliptical incision - divide posterior tissues until anterior to coccyx, divide puborectalis, abdomen entered posterior to anus. Divide levators
- Pass specimen through perineum and divide anterior attachments
- End sigmoid colostomy
- Closed suction drains, close abdominal and perineal wounds

- Fish mouth incision
- ligate GSV
- divide muscles to expose femoral artery / vien
- Suture ligate femoral artery /vein
- divide remaining muscles
- periosteal elevator to clean bone, divide
- ligate profunda femoris artery / vein
- divide sciatic nerve

1. Open abdomen at site above / below incision, carefully lyse adhesions from underside of abdominal wall
2. Lyse adhesions between loops of bowel
3. Side to side bypass (dilated proximal, collapsed distal segment, ensure no distal obstruction, sutured/ stapled anastomosis)
4. Laparoscopy if bowel decompressed (Hasson)

1. Lateral postiion
2. 4 ports 2 FV below costal margin from midline to anterior flank
LEFT
1. 30 degree scope
2. Mobilize splenic flexure, retract spleen / colon medially
3. Kidney, incise Gerota's on the medial aspect
4. Retract adrenal anteriorly , divide adrenal vein
5. Retrieve galnd in specimen bag

1. Lateral postiion
2. 4 ports 2 FV below costal margin from midline to anterior flank
RIGHT
1. Mobilize hepatic flexure
2. Incise right triangular ligament , retract liver / colon medially
3. Work along superior / lateral borders, moving adrenal gland laterally
4. Divide adrenal vein
5. Retrieve gland

- Supine, midline or subcostal incision

LEFT
- Divide gastrocolic omentum and stomach cephalad
- Pancreas and transverse colon cephalad
- Kidney , incise Gerota's on medial aspect
- ID and divide left renal vein
- ID and divide left phrenic artery / vein

RIGHT
- Reflect hepatic flexure down and mobilize duodenum
- Retract liver cephalad
- Right kidney, adrenal medial
- Expose adrenal gland, ligate right adreanl vein

1. Tennis racquet shaped incision along base of affected toe
2. Clear soft tissues
3. Spare digital artery of next toe
4. Divide metatarsal midshaft
5. Smoooth bone ends
6. Hemostasis and close

1. Metatarsal head incision, longer posterior flap
2. Divide soft tissues to bone
3. Secure digital arteries
4. Periosteal elevator to clear soft tissues
5. Divide metatarsals just beyond heads
6. Smooth bone ends
7. Divide plantar fascia, hemostasis and close

1. Right lateral decubitus / prone jackknife
2. Enter presarcral space an mobilize tumor
3. Transverse incision over sacrococcygeal joint, enter retrorectal space ,separate tumor from rectal wall
4. Place 2-0 silk stay sutures on superior / inferior aspect of tumor for retraction
5. Close incision with Dexon sutures

1. Prone jackknife / lithotomy
2. Anal retractor
3. Probe fistula tract (peroxide angiocatheter PRN), assess extent of sphincter involvement
4. Minor sphincter (<20%) : fistulotomy
5. Substantial sphincter (>20%) : cutting seton (vessel loop) on muscle portion after dividing epithelial layer and conective tissue ; draining seton (leave epithelial layer / connective tissue intact), ligation of intersphincteric fistula tract (LIFT) , endorectal advancement flap, fistula plug

1. Prone jackknife / lithotomy position
2. Visualize sphincters, palpate intersphincteric groove
3. Right lateral incision at intersphincteric groove and divide connective tissue overlying
4. White lines of IAS vs. pink fibers of EAS , divide IAS fibers up to proximal end of fissure

1. Prone jackknife, lithotomy or lateral position
2. Anesthetize skin overlying abscess
3. Proctoscopy
4. Electrocautery excision of skin disk
5. Drainage, break up loculations
6. Horse shoe abscess (deep postanal space and both ischioanal fossa) accessed in posterior midline, two counter incisions in anterolateral quadrants
7. Submucosal abscesses are drained into rectum

1. Expose femoral vessels with incision over each pulse (inguinal ligament downward x10cm)
2. Isolate / control femoral arteries and branches (ligate circumflex femoral vein as crosses origin of profunda for xposure)
3. Arteriotomy on CFA (SFA often diseased), may need to preferentially extend onto profunda to direct flow
4. Retroperitoneal tunnels over anterior iliac and femoral arteries, keep ureters anterior
5. Midline exposure to expose aorta
6. Clamp proximal aorta, femoral arteries
7. Aorta end-to-end or side-to-end with running 3-0 prolene
8. Flush and inspect for leaks
9. Femoral vessels end to side, spatulate ends and 5-0 prolene for distal anastomosis
10. Close aneurysm sac / peritoneum in 2 layers of 2-0 vicryl
Check bowel dopplers. Reimplant IMA - excise circular cuff of aortic wall with IMA orifice, reimplant on left graft = Carrell patch
Palpate and doppler DISTAL pulses too
If injure left renal vein, ligate as close as posible to IVC due to collaterals for drainage

1. Supine, arms tucked, 3 trocars, explore abdomen with Tburg and right side up
2. Grasp base of appendix, create window in avascular base of mesentery
3. Divide appendix with EndoGIA stapler (GI load)
4. Divide mesentery with Endo-GIA stapler (vascular load)
5. Remove appendix from 10mm trocar in specimen bag
6. Irrigate and close (if appendix normal : check pelvic organs in female, run SB for 120cm to check for Meckel, pay attention to fludi)
- For retrocecal appendix, release peritoneum lateral to cecum to roll cecum to visualize appendix

1. Oblique incision over McBurney point, divide each layer (muscle splitting), incise fascia
2. Deliver appendix into wound, divide mesentery to mobilize
3. Serially clamp / tie appendiceal artery
4. Crush base of appendix with clamp and ligate with 0-0 chromic suture
5. Amputate appendix
6. Invert stump with purse string
7. Suction and irrigate field
8. Close incision in layers

1. Allen test - patient make fist and occlude radial and ulnar pulses ,release ulnar and hand should pink in 3 seconds (use Doppler)

2. Secure wrist slightly cocked

3. Introduce catheter or transverse incision cutdown

1. Longitudinal incision lateral to radial artery at wrist
2. Identify and mobilize vein, ligating collaterals
3. Mobilize radial artery
4. Divide, spatulate vein
5. End vein to side artery anastomosis with 6-0 prolene

1. Transverse incision 1 FB below antecubital joint crease
2. Expose brachial artery, median antebrachial vein, median basilic vein, median cephalic vein
3. Mobilize brachial artery
4. Anastomose spatulated ends

1. 6mm, nonringed PTFE graft, 10-12cm long, 5-6cm wide for loop graft
2. Systemic heparin, arterial anastomosis (6-8mm arteriotomy with running 6-0 prolene)
3. Venotomy 6-10mm, 6-0 prolene running anastomosis

1. Supine, arm out
2. Oblique incision along lateral edge of pec major
3. Raise flaps
4. Identify pec major /m inor, dissect under pec minor
5. ID axillary vein, trace laterally and clear tissue with retraction on tissue cephalad
6. ID long thoracic , incise fascia and mobilize nerve medially with retraction of nodal tissue laterally
7. ID thoracodorsal nerve bundle and preserve
8. Sweep all nodal tissue inferior/ lateral , orient
9. Closed suction drains, close

1. Supine, arm out
2. Lymphoscintigraphy with colloid
3. Inject blue dye 0.5ml in 4 quadrants intradermally
4. Prep/ drape axilla, retract breast medially as needed
5. Sterile gamma probe to ID location for incision along Langer's lines, avoid hair bearing areas
6. Open axillary fat / enter axillary fascia
7. Excise blue / radioactive / abnormally palpable nodes
8. Clip / divide lymphatics
9. Ex vivo count, background <10%
10. Accuracy 97% , false negative 10%