CS Emergency General Surgery

1. Lithotomy position or supine with split leg position
2. Exploration for source of bleeding (colonscopy, enteroscopy, bimanual palpation)
3. Mobilize ascending colon and hepatic flexure, ligate ileocolic vascular pedicle, divide ileum
4. If preserving omentum, separate from transverse colon, if resecting omentum, divide and ligate outside the gastroepiploic arcade
5. Mobilize sigmoid and descending colon, take down spenic flexure, ligate inferior mesenteric and middle colic vascular pedicles
6. Mobilize and ligate upper mesorectum, and divide across upper rectum
7. Construct ileorectal anastomosis or ileostomy

1. Localize hiatus
2. Open phrenoesophageal ligament
3. Encircle esophagus with penrose
4. Identify nad dissect anterior and posterior vagus, beware of crminal nerve of Grassi
5. Clip vagal nerves proximally and distally about 4-6cm proximal to GEJ , excise 2-3cm of vagus nerve and send for histologic confirmation

1. Exploratory laparotomy through and upper midline incision
2. Localization of pylorus and duodenum
3. Generous Kocher maneuver
4. Biopsies of ulcer bed (if not performed endoscopically previously)
5. 3 point ligation of the gsatroduodenal artery. Assure complete hemostasis . Beware of CBD posteriorly
6. Approximation of ulcer
8. Trnasverse closure of gastroduodenostomy (Heineke-Mikulicz pyloroplasty) in one or two layers

1. General anesthesia, supine position, NG decompression
2. Supraumbilical vertical midline incision
3. Kocher maneuver
4. Divide gastrocolic ligament to enter the lesser sac
5. Examine the stomach and identify the region of the ulcer to determine appropriate extent of resection
6. Divide the greater omentum along the greater curve from duodenum halfway to the GEJ
7. Ligate and divide right gastroepiploic vessels near the GDA
8. Incise the gastrohepatic ligament
9. Ligate and divide the right gastric artery proximally
10. Divide the duodenum and stomach with a stapling device
11. Oversew both staple lines, leaving a portion of gastrotomy closure available for reconstruction
12. Reestablish GI tract continuity either via a Bilroth I or II reconstruction

1. Extensive incision
2. Aggressive excision of all necrotic tissue
3. Excision margin to grossly normal tissue
4. Consideration of Guillotine amputation or disarticulation in presence of systemic toxicity and hemodynamic instability
5. Frequent assessment of wound for progression of infection despite initial debridement
6. Repeat surgical debridement until infection controlled
7. Reconstruction with skin graft or flap

1. Midline laparotomy and full exploration, examining for viability of bowel
2. Place warm saline soaked laparotomy sponges on any dusky appearing bowel and recheck periodically for improving perfusion
3. Identify areas of torsed mesentery and redundant bowel and prepare to resect, including areas of nonresolving ischemia
4. Identify and appropriate proximal and distal anastomotic site and divide the sigmoid vessels and the intervening mesentery without detorsing
5. Divide the bowel proximally and distally, passing off the specimen
6. Perform anastomosis if clinical parameters are suitable (CV function, nutritional status, absence of bowel necrosis, or gross contamination) and remaining bowel appears healthy and without tension
7. If the clinical parameters for an anastomosis is not suitable, perform an ostomy and end mucus fistula
8. If an anastomosis was performed, examine it closely for evidence of adequate perfusion, anastomotic patency, and absence of leaks if possible

1. Position the patient in modified lithotomy position
2. Make a midline laparotomy incision
3. Explore the abdomen and evacuate any free fluid
4. Mobilize the colon. Incise the white line of Toldt . Carry the peritoneal incision from the rectosigmoid junction to the splenic flexure
5. Blunt dissection should be used to dissect the sigmoid colon if there is severe inflammation
6. Identify and protect the ureters
7. After the colon is mobilized, determine the proximal and distal points of bowel transection
8. Resect the diseased colon by dividing the mesenteric attachments from colon wall. Ligate the mesenteric vessels
9. Remove the specimen
10. Create an end colostomy and close the rectal stump
11. Irrigate abdomen and pelvis. Close the abdomen
12. Allow colostomy to mature

1. Position patient in lithotomy
2. Place patient in slight Tberg position
3. Maintain pneumoperitoneum and insufflate ports
4. Inspect 4 quadrants of abdoen and pelvis
5. Retract rectosigmoid and dissect along the plane behind the mesosigmoid to level of IMA
6. Identify the left ureter and then define the vascular pedicle
7. Continue medial to lateral dissection from the posterior lateral edge of the descending colon down into rectosigmoid
8. Determine the proximal transection point. Splenic flexure may need to be mobilized. Clamp the colon and divide at this point
9. Distal transection is divided at the proximal rectum
10. Mesentery of specimen is then divided
11. Remove the specimen
12. Create and anastomosis and follow with an air-leak test
13. Conclude with a final inspection of the abdomen. Then close the extraction site and port site

1. Cutdown technique for laparoscopy
2. Abdominal exploration
3. Steep table positioning to identify terminal ileum
4. Assurance of correct proximal and distal orientation of ileostomy
5. Irrigation by gravity drainage into the colon
6. Closed suction drain for ascites collection
7. Maturation of ileostomy

1. Make a right subcostal incision
2. Pack viscera and uterus from the operative field
3. Grasp gallbladder and dissect via top-down approach
4. Use electrocautery to dissect the gallbladder from the liver fossa
5. Identify the cystic duct and cystic artery just beyond GB neck
6. Ligate and divide the cystic duct and cystic artery
7. Close abdomen in 2 layers

1. Position patinet in supine position , and a left lateral recumbent position for third trimester patinets
2. Appropriate port placement based on fundal height of uterus preferably through an open Hasson technique
3. Insufflate abdomen 10-15mmHg , 12mmHg in patients wtih restrictive lung physiology
4. Adequately retract GB from abdominal wall
5. Dissect peritoneum from GB neck to CBD in order to gain critical view of safety
6. Identify the cystic artery as it courses from the right hepatic artery to the GB
7. Divide and ligate the cystic duct and cystic artery
8. Use electrocautery / Harmonic scalpel to dissect GB from liver fossa
9. REmove ports under direct visualization and close port sites

1. An upper midline incision or right subcostal laparotomy
2. Self retaining retractor used to lift lier cephalad and retract colon caudally
3. Gallbladder dissected using domw down technique until Calot's triangle is identified. Cystic artery is ligated and divided
4. Cystic duct is followed antegrade to the comon bile duct, which is dissected anteriorly
5. Cholecystectomy is completed
6. A longitudinal choledochotomy is made 1-2cm distal to the confluence of the cystic duct and the common bile duct
7. The common bile duct is cleared wtih irrigation or a Fogarty catheter
8. The choledochotomy is closed using absorbable suture over a T tube and a closed suction drain is left in the area of the choledochotomy

1. Acccess peritoneum
2. Place ports
3. Retract GB fundus cranially and infundibulum laterally to open triangle of Calot
4. Incise and divide the peritoneum overlying the gallbladder and triangle of Calot
5. Establish critical view of safety : completely dissect the triangle of Calot until the cystic duct and cystic artery are the only structures remaining . Elevate lower third of GB off liver
6. Clip and divide the cystic duct and artery only after critical view of safety has bee ndefinitively achieved
7. Elevate GB off liver bed with electrocautery
8. Place GB in a specimen bg and then remove from abdmen
9. Assure hemostasis, release the pneumoperitoneum ,close all port sites

1. Run the entire small bowel, multiple points of obstruction can be present
2. Assess the bowel blood supply. If there is uncertainty, consider a "second look" operation
3. Carefullly inspect for potential enterotomy. Missed enterotomy is a devastating postoperative complication
4. Preserve as much bowel as possible. With an intact duodenum and colon, 200cm or more of residual small bowel is usually sufficient to prevent symtpoms of short gut syndrome . If extensive small bowel must be resected, the remaining length should be measured to aid in identification of patients at risk of short gut

1. Expose and stabilize the ovarian mass
2. Create a superficial incision in the ovarian serosa over the anterior surface of the mass
3. Use blunt and sharp dissection to identify the mass and separate it from its serosal and stromal attachments
4. Hemostasis within the remaining ovarian cavity is achieved with either ligation or using fine absorbable suture or with cautery
5. The ovarian serosa can either be left open or reapproximated with absorbable suture

1. Expose pelvic sidewall and identify infundibulopelvic and round ligaments
2. Incise peritoneum approximately 1cm lateral to infundibulopelvic ligament and develop the pararectal space
3. Identify important retroperitoneal structures including - ureter, external and internal iliac arteries, and external iliac vein
4. Create a window through the peritoneum isolating the ovarian vessels from the ureter
5. Ligate and divide the ovarian vessels
6. Place the ovary and fallopian tube on anterior traction while transecting the inferior peritoneal attachments toward the utero-ovarian ligament
7. Ligate the fallopian tube and utero-ovarian ligaments close to the uterine cornua

1. Divide the lesser omentum from the lesser curvature
2. Encircle the trunks with Penrose drain and apply tension to facilitate exposure of branches
3. Dissect and ligate neurovascular branches of the vagal trunks proximal to the crow's foot of the nerve of Laterjet
4. Skeletonize the distal 6cm of esophagus to ensure complete division of criminal nerve of Grassi

1. Free the greater curvature of the stomach
2. Dissect D1 from pancreas
3. Divide stomach
4. Ligate right gastric at level of pylorus
5. Divide duodenum distal to pylorus , send duodenal stump margin for pathology
6. Complete with either a B1 / B2 anastomosis

1. Isolate the distal esophagus
2. Identify, dissect and transect the vagal turnks - send nerve biopsy to pathology
3. Dissect the distal 6cm of esophagus to ensure complete division of vagal fibers
4. Mobilize the duodenum
5. Make a longitudinal incision from antrum onto the proximal duodenum
6. Place stay sutures at either end of the incision to facilitate transverse closure

1. Laparoscopic or open approach
2. Fix omental pedicle in place
3. No need to suture perforation closed
4. Irrigate peritoneal cavity

1. Skin incision at McBurney's point or point of maximal tenderness
2. Open external oblique aponeurosis and bluntly separate internal oblique and transverse abdominis muscles
3. Incise peritoneum
4. Identify appendix and deliver into operative field
5. Divide mesoappendix
6. Place purse-string suture around base of appendix
7. Clamp crush base of appendix and ligate and divide appendix at its base
8. Invaginate appendiceal stump into base of cecum
9. Close peritoneum, fascia, and skin in individual layers