SCORE 100-150

The superior epigastric artery is the terminal branch of the internal thoracic artery.
The inferior epigastric artery originates from the external iliac artery and enters the rectus sheath at the arcuate line.

1. The typical approach for surgical ligation is via midline laparotomy with entrance into the posterior rectus sheath.
2. Ligation of either the superior or inferior epigastric vessels is usually tolerated well due to collateral flow from the other epigastric vessel on the same side, as well as the epigastric vessels on the contralateral side.

1. CT A/P
2. Obtain tissue diagnosis - core needle biopsy

1. Resection with negative margins .
2. Resection of abdominal wall desmoid --> full thickness of abdominal wall , reconstruction requires mesh placement to prevent a hernia
3. Intra-abdominal desmoid requires concomitant bowel resection

1. Watch and wait approach (with repeat imaging in 3-6 months) --> will eventually regress
2. Intra-abdominal desmoid associated with FAP / Gradner is often unresectable , recommend conservative management
3. Adjuvant treatment - Radiation therapy, NSAIDS and tamoxifen ,cytotoxic chemotherapy

1. Complete cytoreduction is the surgical goal, where resection of gross disease greater than 2 mm in size is possible. This can be limited by extensive small bowel or porta hepatis involvement.
2. Cytoreduction with associated peritonectomy of involved areas must be completed to achieve a cytoreduction goal.
3. Cytoreduction is measured by a cytoreduction score (CC score).
The role of heating the chemotherapy is to increase the depth of penetration of the chemotherapy agents on residual disease. However, disease greater than 2 mm in depth will not be adequately treated with HIPEC. Thus, cytoreduction of all disease greater than 2 mm in thickness on peritoneal surfaces must be completed to ensure HIPEC effectiveness.
The most common HIPEC chemo - mitomycin-C , doxorubicin, oxaliplatin

A 3- to 5-cm midline or paramedian skin incision is made. Implanting the catheter off midline minimizes the risk of pericatheter leak and hernia.
A 2- to 3-cm incision is made through the fascia or through the anterior and posterior rectus sheath to reach the peritoneum. A small hole is made in the peritoneum.
A purse-string suture of 4-0 absorbable suture is placed around the peritoneal opening.
A stylet is placed into the catheter and inserted into the peritoneal cavity, directed to the pelvis to the right side of the rectum.
A purse-string suture is cinched around the catheter, below the Dacron cuff, and the fascia is closed around the catheter with interrupted nonabsorbable suture.
A subcutaneous tunnel is made, and the catheter is tunneled, leaving the superficial Dacron cuff 1 to 2 cm deep to the skin.
The catheter is flushed with heparinized saline.

The most common complication is peritoneal dialysis–associated peritonitis. Primary pathogens are gram-positive cocci, enteric gram-negative bacteria, and fungi.
Diagnosis is suspected with abdominal pain and cloudy dialysate. The white blood cell count is more than 100/mm3 with a differential of more than 50% polymorphonuclear leukocytes.
Treatment includes intraperitoneal administration of a cephalosporin or vancomycin combined with an aminoglycoside.
The catheter does not need to be removed unless there is no response within 4 to 5 days of treatment, fungal peritonitis, or peritonitis associated with intra-abdominal pathology.

The only absolute contraindication to peritoneal dialysis is lack of a peritoneal membrane.
Prior abdominal surgery, hernias, ostomies, and adhesions are not contraindications, although they may cause problems with filling and solute clearance.

Anterior : inguinal ligament
Posterior : Pubic rami (Cooper ligament)
Medial : lacunar ligament
Lateral : femoral vein

1. Through a lower midline transverse incision, incise anterior rectus sheath, muscle tracted medially, develop preperitoneal space wtih blunt dissection (direct exposure to transversalis fascia)
2. Identify hernia sac and reduce the herina sac
3. Identify the myopectineal orifice and close the myopectineal orifice, develop to the pubis and both Coper ligament

external oblique muscle and aponeurosis
internal oblique muscle
transversus abdominis muscle
transversalis fascia
peritoneum

Pain (postoperatively acute and potentially chronic)
Hernia recurrence
Infection, seroma (buildup of fluid in the groin), hematoma (bleeding and bruising in the groin), injury to the spermatic cord, injury to the testicle, or death (0.1% for elective repair)

1. 2cm inferior to the ASIS and 2cm medial to ASIS

Access to the preperitoneal space is achieved through an infraumbilical incision.
The anterior sheath overlying the rectus abdominus muscle is incised, and the rectus is reflected laterally.
Mesh should be placed so that it covers all three potential hernia spaces (direct, indirect, and femoral) with overlap. Anchor it to the pubic tubercle medially and along the superior edge to the conjoint tendon superiorly, with a keyhole for the spermatic cord. Avoid tacks inferior to the iliopubic tract to avoid the risk of neurovascular injuries in the so-called triangle of doom and triangle of pain.

Approximate the edge of the transversus abdominis aponeurosis to the Cooper ligament.
At the medial aspect of the femoral canal, a transition suture is placed to include the Cooper ligament and the iliopubic tract.
Working laterally, the transversus abdominis is secured to the iliopubic tract.
A relaxing incision is made by reflecting the external oblique aponeurosis superiorly and medially to expose the anterior rectus sheath. The incision is made in a curvilinear direction, 1 cm above the pubic tubercle toward the lateral border of the anterior sheath.
This is a tissue-based repair that provides appropriate coverage of a femoral hernia defect.

A pocket is formed by separating the internal oblique from the overlying external oblique aponeurosis.
A sheet of polypropylene mesh is fit to the inguinal canal with a slit or keyhole in its lateral aspect for the spermatic cord. Mesh should overlap the pubic tubercle by approximately 2 cm.
The inferior and superior edges of the mesh are sutured to the internal oblique, and the two “tails” are sutured to the inguinal ligament to recreate the internal ring.
The external oblique is closed over the mesh and spermatic cord, taking care to avoid cord and nerve during closure.

A defect in the fascia between the rectus muscle and the semilunar line
Develops at or below the arcuate line
Caused by lack of posterior sheath below the arcuate line
The hernia sac dissects posteriorly to the external oblique.
A bulge is typically not palpable.

Defect through the obturator membrane (between the pubic bone and ischium)
The obturator nerve and vessels may be compressed by an obturator hernia.
Patients will present with pain or paresthesia in the medial thigh.
Given the small space, obstruction is common

Both open and laparoscopic parastomal hernia repair adhere to the general principles of hernia repair:
Reduction of the hernia contents
Excision of the hernia sac
Tension-free closure of the fascial defect (if possible)
Possible mesh reinforcement
Mesh placement, in a retrorectus or intraperitoneal underlay position, reduces recurrence rates. In emergent or contaminated cases, suture repair alone with or without absorbableiologic mesh placement may be the preferred option.
A "keyhole" mesh can be fashioned, allowing passage of the stoma conduit through the mesh. Alternatively, a modified Sugarbaker-type mesh repair can be used, where the ostomy is lateralized using a noncircumferentially secured underlay mesh.

A preperitoneal or intraperitoneal approach is best (either laparoscopic or open).
Reduction of hernia contents and sac
The obturator foramen can be opened posterior to the nerve and vessels.
Repair with placement of a pre-peritoneal mesh

Obtain exposure via a self-retaining anal retractor (such as Lone Star® with a lighted anoscope).
Use electrocautery to demarcate a 10-mm margin around the lesion.
Perform a full-thickness excision, and orient the specimen for pathology.
Perform primary transverse closure with absorbable sutures.
Ensure patency of the rectal lumen.

Superficial T1 rectal cancer
Less than 3 cm in diameter
Less than 30% of bowel circumference
Tumor is mobile and nonfixed
Ability to achieve clear margins (>3 mm) with full-thickness local excision
Favorable histologic features on biopsy (moderately to well-differentiated, no lymphovascular or perineural invasion)
No radiographic evidence of pretreatment lymph node involvement or metastatic disease
Patient compliant with aggressive postoperative surveillance

Intraoperative complications
Peritoneal entry: Perform watertight transanal closure with absorbable sutures, and consider diagnostic laparoscopy.
Rectal stricture with defect closure: Remove the suture line, and allow the defect to heal by secondary intention.
Vaginal injury: Perform layered closure of the posterior vaginal wall, rectovaginal septum, and rectal wall with absorbable sutures.
Postoperative complications
Urinary retention: This is the most common complication. Perform straight catheterization.
Suture line dehiscence: Evidenced by dark blood with bowel movements, fever, and rectal pain. Rule out abscess or sepsis with CT of the abdomen and pelvis.
Rectovaginal fistula: This is a rare complication. Control sepsis, and perform transperineal repair, possibly with ileostomy.
Bleeding

1. Patients with unfavorable histology (T2 or greater, positive margins, poor differentiation, or lymphovascular or perineural invasion) should undergo transabdominal surgery, preferably 1 to 8 weeks after transrectal resection.
2. Patients should also undergo proctoscopy or flexible sigmoidoscopy with pelvic MRI or endorectal ultrasound every 3 to 6 months for 3 years and every 6 to 12 months through 5 years. Colonoscopy (years 1, 4, and 9) and CT chest/abdomen should be performed annually.
3. Most recurrences occur between 12 and 24 months.
4. Immediate reoperation for unfavorable histology is associated with a better survival than salvage surgery after a local recurrence.

1. To diagnose a diaphragmatic hernia, meticulous inspection of the diaphragm intraoperatively is necessary.
2. Debridement of devitalized tissue is required.
3. Small defects can be repaired primarily with nonabsorbable suture, using interrupted, running, or figure-of-eight suture techniques.
4. Larger defects may require repair with prosthetic mesh. Use of biologic mesh has been reported in the setting of concomitant hollow viscus injury and concern for mesh infection.
5. Chest tube placement at the time of repair is advisable to minimize postoperative complications of pneumothorax or effusion.

1. The right phrenic nerve passes lateral to the right side of the heart and descends through the vena cava hiatus, and the left phrenic nerve terminates at the central tendon of the diaphragm.
2. An elevated hemidiaphragm after diaphragmatic hernia repair may be indicative of phrenic nerve injury.
3. Most cases of unilateral phrenic nerve injury do not require operative intervention.
In severe cases in patients who have hypoventilation or dyspnea, diaphragmatic plication or pacing may be attempted for improvement in function

1. creation of subcutaneous flaps
2. division of the external oblique aponeurosis lateral to the semilunar line, and development of the plane between the external oblique aponeurosis and the internal oblique muscle laterally.
3. Mesh reinforcement can then be placed in an underlay or overlay position.

1. opening the retrorectus space medially and creating the posterior plane between the rectus muscle and the posterior rectus sheath
2. The posterior rectus sheath is then incised again just medial to the laterally perforating neurovascular bundles. 2. The underlying transversus abdominis muscle can be divided (TAR), and dissection is carried laterally to mobilize the transversalis fascia and peritoneum off of the overlying muscle.

1. Incision and gaining access to the peritoneal cavity
2. Lysis of adhesions to free intra-abdominal contents from the mesh and gain adequate working room laterally on the abdominal wall
3. Removal of infected mesh and nonabsorbable sutures
4. Assessment of ability to close fascia or need for component release
5. Closure of the abdominal wall with or without the aid of a biologic or synthetic absorbable mesh

1. Signs and symptoms of surgical site infection include wound erythema, purulent drainage from the wound, and chronic draining sinus tracts.
2. Nonoperative management includes antibiotics and local wound care. Ongoing signs and symptoms of mesh infection indicate failure of nonoperative management.
3. Local measures may be sufficient for mesh infections involving macroporous mesh made from polypropylene or polyester, although mesh removal may be required. Nonoperative strategies are unlikely to be successful in treating microporous or PTFE prosthetic infections.
4. Imaging and diagnostic findings of mesh infection include contrast computed tomography demonstrating fluid collection, with signs of infection including rim enhancement and gas, as well as positive culture from surgical site fluid collection in continuity with mesh.

For an open procedure, the patient should be supine with the arms out. For a laparoscopic procedure, the patient should be positioned supine with both arms tucked.
Sequential compression device (SCD) stockings and chemoprophylaxis should be used for prevention of venous thromboembolism. Appropriate antibiotics should be administered within 1 hour of incision. Gram-positive coverage is sufficient for a clean case.
If a longer duration case is anticipated or the operative field includes the space of Retzius (retropubic space), a Foley catheter should be placed.

1. An IOC is performed as above.
2. When a bile duct stone is identified, irrigation of the duct and intravenous glucagon administration can be attempted. Glucagon causes relaxation of the sphincter of Oddi.
3. A balloon catheter or wire basket can be passed under fluoroscopic guidance to extract the stone if the previous step fails to cause stone passage. If this fails, proceeding to choledochoscopy is another option.
Access into the biliary tree:
4. The transcystic approach involves dilation of the cystic duct to allow passage of a choledochoscope through a Seldinger technique or balloon catheter.
5. The choledochotomy approach involves a longitudinal incision made in the CBD below the cystic duct with placement of stay sutures on either side of the choledochotomy. A choledochotomy should be considered if the cystic duct is friable, CBD stones are large/numerous, or stones are present in common hepatic duct.A flexible choledochoscope is passed into the bile duct, and a wire basket is passed. Stone removal is attempted by withdrawing the basket and choledochoscope together.
6. If a choledochotomy has been performed, a T-tube should be placed and the bile duct closed with absorbable sutures.
7. Completion cholangiography should document stone removal.

All patients with acute cholangitis should have blood cultures drawn, and antibiotic therapy with coverage of gram-negative (eg, Escherichia coli, Klebsiella), gram-positive (eg, Enterococcus), and anaerobic bacteria should be initiated.
A patient with acute cholangitis and no evidence of organ failure (TG18 grades I or II) should receive fluid resuscitation and appropriate antibiotic therapy and observation for improvement within 12 to 24 hours.
A patient with severe acute cholangitis (end-organ dysfunction, TG grade III) should undergo biliary drainage.
A patient who has acute cholangitis in the setting of an indwelling biliary catheter or is immunocompromised warrants antifungal therapy until blood and/or bile culture results are available.
A patient with a capped percutaneous biliary drainage tube who presents with obstructive symptoms or acute cholangitis should have the tube opened and placed to gravity drainage.

1. Ligation: ducts smaller than 3 mm that drain a single hepatic segment or subsegment
2. Repair over a T tube: injuries less than or equal to 50% of the circumference not caused by cautery
3. End-to-end repair with transanastomotic T tube: defect less than 1 cm and away from the bifurcation
4. Hepaticojejunostomy: any cautery injury or transection of more than 50% circumference where a primary, end-to-end anastomosis cannot be performed without undue tension. This includes injuries at or near the bifurcation.
5. Choledochoduodenostomy: as above (hepaticojejunostomy) but only injuries to the distal bile duct

If repair is not possible or the surgeon is not capable of repair, then the surgeon should insert drains to control an anticipated bile leak and arrange for immediate transfer of the patient to a referral center.

1. Cross-sectional imaging (most commonly liver protocol computed tomography [CT] or magnetic resonance imaging (MRI) if CT is contraindicated).
2. Complete staging should include a CT of the chest and pelvis.
3. Endoscopic ultrasound is reserved for equivocal cases based on cross-sectional imaging.
4. Routine position emission tomography is not recommended.
5. Elevated cancer antigen (CA) 19-9 and carcinoembryonic antigen levels may be suggestive (but are rarely diagnostic) of gallbladder cancer.

1. Liver enzymes, including alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase, as well as bilirubin should be obtained, with the awareness that these enzymes may be normal in intrahepatic cholangiocarcinoma.
2. A quadruple-phase CT scan of the abdomen with liver protocol remains the gold standard for assessing resectability. MRI should be reserved for patients in whom CT is contraindicated.
3. Endoscopic ultrasound is generally reserved for more distal lesions.
4. CA 19-9 is routinely obtained; however, it has a sensitivity of 50% to 90% and a specificity of 60% to 99%.
5. Tissue diagnosis is not required prior to surgery but should be obtained when considering nonoperative treatment or if the diagnosis is uncertain (previous biliary surgery, stone disease, primary sclerosing cholangitis).

1. Polyps greater than 2.0 cm should be considered malignant, and appropriate workup is warranted to assess for cancer (see Learning Objective 4b), followed by resection.
2. Polyps 1.0 to 1.9 cm have increased risk of being malignant, and simple cholecystectomy should be recommended.
3. Polyps less than 1.0 cm that are detected on CT scan are more likely to represent cholesterol polyps.
4. Polyps 0.6 to 0.9 cm should be followed with yearly ultrasounds (American Society for Gastrointestinal Endoscopy [ASGE] guidelines).
5. Polyps less than 0.5 cm warrant a repeat ultrasound in 1 year, and if they are stable, then no further follow-up is required.

1. Simple cholecystectomy for disease confined to the lamina propria (T1a) is curative provided the cystic duct margin is negative.
2. Tumor involving the muscular layer or deeper (T1b+) generally requires an extended cholecystectomy, including a portion of segment IVb/V along with a portal lymphadenectomy.
3. A cystic duct margin should be sent for frozen section and if positive, a common bile duct resection with Roux-en-Y hepaticojejunostomy should be performed.
4. Cases of gallbladder cancer should be referred to a hepatobiliary surgeon and discussed in a multidisciplinary cancer conference.

The approach to hepatic surgery involves preservation of inflow, outflow, biliary drainage, and adequate future liver remnant.
In patients with hilar cholangiocarcinoma, often biliary drainage of the caudate lobe is compromised, requiring a caudate resection.
Caution must be exercised, in hilar cholangiocarcinoma particularly, when performing an extended left hepatectomy to avoid compromise to the right hepatic artery, which courses near the common hepatic duct bifurcation.
Transplantation in hilar cholangiocarcinoma is possible in node-negative patients, without intrahepatic/extrahepatic disease, size less than 3 cm, and otherwise unresectable primary disease according to the Mayo protocol.

Care of patients with intrahepatic cholangiocarcinoma should be performed in a multidisciplinary setting.
Surveillance could include a CT of the chest, abdomen, and pelvis every 6 months for 2 years, and then annually, for a total of 5 years.
The most common pattern of recurrence is local, and the risk is elevated with lymph node–positive disease and/or positive margins.
Distant recurrence occurs in the liver or peritoneum most commonly.

Type I: cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy
Type II: resection of the diverticulum off the side of the common bile duct
Type III: endoscopic sphincterotomy versus transduodenal excision and sphincteroplasty
Type IV: cyst excision followed by Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy. Hepatic resection should be considered if cysts are limited to one lobe.
Type V: typically, liver transplant required to treat entire disease

1. Perform an extensive Kocher maneuver.
2. Make a transverse or longitudinal duodenotomy on the lateral duodenal wall at the junction of the lower one-third and upper two-thirds of the duodenum.
3. Identify the papilla.
4. Cut the ampullary sphincter in the 11 o'clock position on the papilla using cautery or scissors.
5. Extend this to include the entire common tract of the sphincter of Oddi. The pancreatic duct is typically located at the 5 o’clock position and can be opened into the bile duct.
6. Suture the wall of the common bile duct to the duodenal mucosa using interrupted fine absorbable sutures.
7. Close the lateral duodenotomy.

Increased risk of gallbladder carcinoma and cholangiocarcinoma
Recommend interval imaging – ultrasound or MRI every 6 months to 1 year
Interval lab testing including CA 19-9
Cholecystectomy for patients found to have gallbladder masses
Colonoscopy every 1-2 years after diagnosis of PSC due to association with UC

Ultrasound - May see abnormal bile ducts with wall thickening and focal dilations
MRCP - Multifocal, short strictures giving the appearance of beads
ERCP - Multifocal strictures and dilations (Test of choice) , Also able to perform interventions
Percutaneous transhepatic cholangiography - Used in patients who cannot have ERCP

Endoscopic - Dilation, Stenting
Biliary reconstruction - Able to be performed if there is a dominant stricture at the hepatic bifurcation with resection and reconstruction using silastic stenting
Orthotopic liver transplantation - Better outcomes than biliary reconstruction, Offered to patients with MELD ≥ 15

Utilizing the open technique, a purse-string suture is typically placed in the fundus of the gallbladder for control prior to trocar placement. This suture may be used to secure the cholecystostomy tube after placement.
If gallstones are easily visible in the absence of gangrene or empyema, forceps or a scoop may be utilized to remove these stones before cholecystostomy tube placement.
A 20F or 24F catheter may be used for an open cholecystostomy tube placement—as opposed to an 8F or 10F catheter used with percutaneous cholecystostomy tube placement.

1. Divide the ligamentum teres (round ligament) and take down the falciform ligament.
2. Leave a tie (0 silk) on the round ligament and use it to retract the liver’s inferior edge cranially to help expose the visceral surface of the liver and improve access to the structures of the porta hepatis.
3. Divide the lesser omentum to help expose the caudate lobe and celiac nodes, beware of a replaced/accessory L hepatic artery (LHA); hilar masses tend to abut the caudate lobe, so careful examination is important.
Isolate distal CBD at the level of the pancreas; frozen section to ensure negative margins; retract cephalad, dissect CBD off the PV (posterior) and CHA (medially); perform cholecystectomy.
4. Lower the hilar plate to expose the confluence of the hepatic duct and expose L and R hepatic duct; when adequately exposed; frozen sections are sent to ensure negative proximal margins and the ducts are transected.
5. Portal lymphadenectomy is carried out during the dissection.
6. Reconstruction with Roux-en-Y to each duct; if necessary, a pancreaticoduodenectomy can be performed in patients with distal extension.
7. If needed, a R or L hepatectomy is performed by further isolating the appropriate inflow, mobilizing the falciform and triangular ligaments, gaining exposure/control of the hepatic veins.
8. Once inflow/outflow control is optimized, resection, ligation ensues, and various different methods of hepatic parenchymal transection are utilized to divide the appropriate lobe.
9. A caudate lobectomy is generally required; care is taken when dissecting the caudate lobe free of IVC as many small perforating veins drain directly to the IVC.
10 A Pringle maneuver should be performed as needed for bleeding.

1. After incision and exposure, it is often necessary to lower the hilar plate by elevating the quadrate lobe and incising Glisson’s capsule at its base to expose the hepatic hilar structures.
2. The ducts proximal to the injury are circumferentially dissected out carefully to ~5 mm, not greater, as this risks vascular injury to the proximal duct.
3. Once the proximal ducts are dissected free, 5-0 traction sutures are placed, and the anterior surface is spatulated; the ducts are probed, and silastic stents or catheters can be placed at this time.
4. A Roux limb is prepared and positioned correctly; fine suture (5-0) is used for the end-side anastomosis; typically, the posterior row is completed first, knots tied on the inside, followed by the anterior row.
5. Leaving stents varies based on surgeon and institution; generally, smaller ducts benefit from postoperative stents, larger ducts may not need them.

1. Injuries A-C deal w/ cystic duct leaks or accessory/aberrant hepatic ducts; if < 3 mm and cholangiogram shows segmental or subsegmental drainage, ligation is appropriate intraoperatively, and if discovered later, the operative area should be drained. If > 3 mm, the duct likely drains multiple segments and therefore requires operative repair.
2. Type B injuries generally present after years with segmental cholestasis, cholangitis, and R lobe atrophy; treatment is hepaticojejunostomy +/- segmentectomy of affected lobe.
3. Type D can usually be temporized with stents; however, they are at risk for developing strictures over time.

1. E1 injuries with > 2 cm of healthy CHD can be repaired with Roux-en-Y hepaticojejunostomy.
2. E2 or E3 injuries with < 2 cm healthy CHD, exposure of the hepatic duct confluence by lowering the hilar plate to perform a biliary-enteric anastomosis is required for repair; transanastomotic stents may be used.
3. E4 injuries that completely separate L and R hepatic ducts need separate biliary-enteric anastomosis to each duct; if inadequate extrahepatic ducts remain, intrahepatic duct can be isolated through the hepatic parenchyma and used for anastomoses; stents may be used.
4. E5 injuries typically require the use of transanastomotic stents in addition to a biliary-enteric anastomosis.

1. Explore for signs of metastatic disease in the remnant segment of liver, in the peritoneum and pelvis, and on the undersurface of the diaphragm. Perform palpation of the porta hepatis and perigastric nodal stations, depending on the location of the tumor.
2. Assessment of resectability is a part of this step and involves isolation of the inflow and outflow to ensure the surgical plan can be accomplished.
3. Perform partial hepatectomy with adequate inflow and outflow control.
4. Perform parenchymal division using whatever method the surgeon feels adequate to minimize blood loss.
5. Label the specimen to be sent to pathology.
6. Close the abdomen.

Explore for signs of peritoneal spread or intrahepatic metastases.
Resect the bile duct with frozen section assessment of proximal and distal margins.
Perform with cholecystectomy (if the gallbladder is present).
Dissect the portal lymph node.
Perform a Roux-en-Y hepaticojejunostomy.

1. Explore for signs of peritoneal spread or intrahepatic metastases. Perform the Kocher maneuver to expose the entire common bile duct as well as allow for palpation and selective harvesting of retropancreatic or para-aortic lymph nodes (N2) that would render the patient unresectable.
2. Lower the hilar plate at the base of the quadrate lobe (segment IV[B]) to palpate the proximal extent of the tumor at the hilum.
3. Perform distal common bile duct division at the top of the pancreas (cholangiocarcinoma can travel down the d. uct), and attain an intraoperative frozen section on the margins. Some surgeons would wait to perform this distal division until they are sure the intrahepatic dissection is possible.
4. Dissect and expose the porta hepatis with lymphadenectomy.
5. Assess proximal tumor extension along the biliary tract.
6. Perform partial hepatectomy with adequate inflow and outflow control and parenchymal division.
7. Divide the hepatic duct proximally.
8. Consider caudate resection (more likely to be performed for left-sided hilar cholangiocarcinoma than for right-sided).
9. Perform portal lymph node dissection.
10. Perform end-to-side Roux-en-Y hepaticojejunostomy to the remnant biliary duct.

This plan could involve either an intraoperative biliary diversion with a hepaticojejunostomy or postoperative endoscopic drainage (via ERCP and metal stenting) or percutaneous transhepatic biliary drainage (PTBD) to decrease the risk of progressive complications of biliary obstruction.
Be aware that if PTBD is chosen, patients may have blockage of the catheter, electrolyte disturbances, and trouble with tube care.
If biliary decompression is not planned at the time of surgical exploration, progressive complications of biliary obstruction include cholangitis, pruritus, and liver dysfunction.

Patients with metastatic disease and frail patients are contraindicated.
If there is hepatic arterial or portal vein involvement, there needs to be reconstructable disease.
Patients with cholangitis should have the biliary system drained first.
Reconsider a surgery-first approach in the case of radiologic lymph node–positive disease.

Metastatic disease including lymph node disease outside of the N1 basin (para-aortic disease)
Inability to reconstruct vascular local invasion of portal bifurcation, main portal vein
Involvement of second order bile ducts bilaterally
Undrained remnant liver
Insufficient hepatic remnant volume (calculate preoperatively, and consider portal vein embolization)
High risk surgery: hyperbilirubinemia, cholangitis, and major hepatectomy (>3 segments)
Frail patient

Metastatic disease including lymph node disease outside of the N1 basin (para-aortic disease)
Multifocal lesions, particularly in the contralateral lobe
Insufficient functional hepatic liver remnant
Inability to maintain hepatic inflow, outflow, and biliary continuity
Frail patient

Patient workup should rule out extrahepatic primary malignancy that is metastatic to the liver and include upper and lower endoscopy and CT of the chest, abdomen, and pelvis. In female patients, workup should include a mammogram and a gynecological examination.
Workup should also rule out hepatocellular carcinoma by screening for risk factors for cirrhosis, such as alcohol abuse, IV drug use, and obesity.
A laboratory evaluation should be performed, including hepatitis serologies and alpha-fetoprotein level.

Nonthermal injuries that involve less than 50% of the duct circumference may be considered for primary repair over a T tube. Injuries caused by electrocautery or those that involve more than 50% of the duct circumference require major biliary reconstruction.
Defects shorter than 1 cm and distal to the hilum and hepatic duct bifurcation may be repaired with end-to-end choledocho-choledochostomy if adequate mobilization can be performed to allow a tension-free anastomosis. A transanastomotic T tube should be placed through a separate vertical choledochotomy.
Distal bile duct injuries can be reimplanted in the duodenum (choledocho-duodenostomy) if a tension-free repair can be achieved with a Kocher maneuver. This allows for future endoscopic access to the biliary tree but is associated with a higher risk of anastomotic leak than a Roux-en-Y choledocho-jejunal anastomosis.

Staging laparoscopy should be performed for advanced T-stage tumors.
Appropriate re-resection includes resection of segments IVb and V of the liver.
Routine port-site or bile duct resection should not be performed.
Portal lymphadenectomy should be performed routinely.
Hepatic inflow occlusion of the porta hepatis with a Pringle maneuver should be considered.
Hepatic parenchymal transection can be performed using a variety of techniques, including the Kelly crush method and use of a harmonic scalpel or vascular-load stapler.

If GB cancer in situ - send frozen section analysis of cystic duct margin

1 . REsect short segment of ileum and perform end to end anastomosis or linear stapler to transect
2. Secure mesentery to diverticulum

1. Orient along Langer lines
2. 1-2cm margins, elliptical incision
3. Excise down to muscle fat
4. Close in 2 layers

1. Left lateral decubitus, 3 port (5th intercostal at anterior axillary line, 7th intercostal at midaxillary line, posterior axillary line at 5th intercostal)
2. Retracting stitch on diaphragm inferior / anterior
3. Esophageal / paraesophageal tissue mobilized from diaphragm through thoracic inlet, 28F chest tube through 7th intercostal space, ports closed
4. Dissection of proximal esophagus to azygos vein careful of RLL
5. Aortoesophageal and lymphatic vessels to thoracic duct carefully clipped

1. Supine position
2. J tube
3. Mobilize stomach (divide short gastrics, gastrocolic omentum) preserving R gastroepiploic
4. Esophagus circumferential dissection, divide left gastric wtih stapler
5. Kocher to mobilize pylorus
6. Mediastinal dissection as far proximally as visualized
7. Pyloromyotomy
8. No less than 5cm gastric conduit width starting 6cm from pylorus, sutured to specimen
9. Mobilize cervical esophagus, bring gastric conduit into cervicla incision
10 . Sharp trasection of esophagus, stay sutures on esophagus / stomach, Lemberts stomach staple line, makes the gastrostomy, put si n the posterior layer, fires a 45 purple GIA stapler for side to side anastomosis and tehn 2 running Maxons / Lembert over Lembert, Methylene blue leak test
11. Reapproximate hiatus
12 . Neck JP drain , close platysma

1. Mobilize spleen /pancreas to expose left Gerota fascia
2. Mobilize kidneys
3. ID ureters and transect at midpelvis

1. Palm down
2. 5-10ml syringe of local wihtout epi and 27 gauge needle
3. Enter webspace in the loose skin overlying dorsum, inject 2-4ml after aspiration, perpendicular

1. right subcostal incision
2. divide ligamentum teres
3. kelly clamp on fundus of GB (decompress first if tense)
4. Divide omental adhesions, pack away omentum/ colon
5. Incise peritoneum between GB and liver , dissect in submucosal plane of GB from top/down
6. Leave backwall if necessary
7. Secure cystic duct from inside GB wtih temporary 2-0 silk purse string suture if cholangiogram, 3-0 suture ligate if definitive, ligate cystic artery with 2-0 / 3-0 silk
8. Destroy remaining mucosa of GB with electrocautery
9. Place omentum and closed suction drain

1. Inguinal incision(avoid tumor emboli in venous / lymphatic system with manipulation of testis)
2. ID and protect ilioinguinal nerve ,ID spermatic cord
3. Deliver testis / cord into surgical field, noncrushing clamp on cord
4. Divide gubernaculum at inferior pole
5. Double clamp / tie vas deferens / vessels, remove testis
6. Ligate remaining structures
7. Remove cord /testis together
8. Release clamps
9. Close

1. Laparoscopic access
2. Take down splenic flexure
3. Divide gastrocolic ligament to expose pancreas in lesser sac (flip stomach up)
4. Preserve short gastrics
5. Isolate SMV (convergence of gastroepiploic and middle colic vein)
6. Free inferior edge of pancreas, ID splenic vein/ IMV
7. Free superior edge of pancreas, ID splenic artery / L gastric artery / vein
8. (Intraoperative US)
9. Divide pancreas at level of SMV, ID and divide small branching vessels being careful of splenic artery /vein

1. Diagnostic laparoscopy, small incision to palpate liver
2. Open greater omentum and lesser sac
3. Divide gastroepiploic vessels, preserve short gastrics
4. Mobilize back wall of stomach from pancreas and inferior border of pancreas from transverse mesocolon
5. Tunnel behind pancreas over SMV
6. Secure gastropancreatic arteries and divide pancreas
7. If splenectomy - ligate splenic artery, then vein, move medial to lateral and perform splenectomy

1. Drain into cavity
2. Patient on beanbag to elevate entry site
3. Small incision along drain, deepen through muscle /fascia
4. Enter cavity, debride with ring forceps
5. Laparoscopic inspection / irrigation

1. Midline incision, avascular region of transverse colon, enter gastrocolic omentum
2. Drain / debride behind head of pancreas, lesser sac toward hilum of spleen
3. Send cultures
4. Lay drains

1. Preop ERCP to see if communication with duct
2. Upper midline incision, check location of cyst
3. 2- 2-0 silk stay sutures on anterior surface of stomach, 5-6cm longitudinal gastrotomy
4. 18G needle into pseudocyst, aspirate and confirm no blood (erode into splenic artery --> close and angio or widely open cyst through gastrocolic omentum and direct suture control)
5. Drain cyst , should have no residual mass (otherwise 2nd pseudocyst)
6. Full thickness of biopsy of cyst wall for frozen section
7. Oversew edge of cystogastrostomy wtih running 2-0 Vicryl lockstitch
8. Check hemostasis, close gastrostomy and cover with omentum
9. (Cyst duodenostomy - wide Kocher, probe down bile duct to protect this area, then make duodenotomy) / R-Y 2 layer jejunal anastomosis

1. Supine with slight reverse -T
2. Upper midline, orogastric tube
3. Retract left lobe of liver (triangular ligament) to expose hiatus
4. Incise gastrohepatic / phrenoesophageal ligaments
5. Reduce stomach
6. Dissection / excision of hernia sac after incising peritoneum overlying right crus
7. Divide gastrosplenic ligament and ligate short gastrics to mobilize stomach
8. Mobilize distal esophagus
9. Close hiatal defect
10. Biomesh (keyhole patch or posterior patch, Strattice or Alloderm)
11. Fundus of stomach behind esophagus
12. 56 or 58F bougie
13. Complete fundoplication wtih 2-0 silk, need for anchoring wrap / gastric fixation
14. Anatomy (left hepatic artery (retract out of field or incise gastrohepatic artery above it), vagal trunks

1. Incision transversely next to ostomy, dissect down to fascia and reduce hernia
2. Several interrupted sutures to narrow fascial ring, close skin around ostomy
Mesh repair
1. Midline incision, adhesiolysis
2. Close fascial defect, mesh around ostomy tunnel, secure circumferentially

1. Dorsally extend neck on donut
2. Incision 1cm below cricoid cartilage, through platysma and raise subplatysmal flaps, retract strap muscles
3. Ligate middle thyroid vein and retract gland medially
4. ID/preserve recurrent laryngeal nerve
5. ID all parathyroid glands about 1cm from inferior thyroid artery and RLL (superior : dorsal to RLL and posterior to upper thyroid capsule, inferior : anterior to RLL and near lower thyroid pole)
6. Ectopic superior : neck (TE groove, retroesophageal space, carotid sheath) , thyroid , AP window, posterior mediastinum
7. Ectopic inferior : neck (TE groove, carotid bifurcation), thyrothymic ligament --> thymectomy, ipsilateral thyroidectomy, anterior mediastinum
8. Subtotal : clip across gland, leave 50mg behind and if remains viable, remove other glands
9. Autotransplantation : remnant minced into 15 1mm pieces, implanted into 2-3 separate pockets in brachioradialis muscle of nondominant hand. Close with 3-0 prolene and mark with clip

1. Hyperextend neck
2. Preauricular incision, raise flaps
3. Greater auricular nerve, divide facial vein, preserving retromandibular vein
4. Posterior belly of digastric, follow periosteum of mastoid process
5. Expose main trunk of facial nerve
6. Elevate parotid gland and dissect in plane of facial nerve to remove
7. Drain and close

1. EGD, transilluminate anterior stomach
2. Anesthetize area of stomach wall
3. Introducer, pass monifilament suture into needle and endoscopist snares
4. Pulls suture /scope back, PEG tube looped onto suture and pulled back into stomach by surgeon
5. Confirm good position

1. Short midline incision just above xiphoid extending 5cm inferiorly
2. Resect xiphoid process
3. Suture ligate small branches off inferior phrenic artery
4. Sweep diaphragm / preperitoneal fat inferiorly to expose pericardium
5. Elevate pericardium and incise sharply for 2cm defect
6. Explore pericardium
7. Suture edges of defect, leave 1-2 chest tubes/ drains

(Femoral : longitudinal incision 1FB distal to inguinal ligament, incise femoral sheath, arteriotomy near bifurcation. Popliteal : longitudinal incision 1cm posterior to tibia, divide pes anserinus for further exposure, divide soleus)

- Transverse arteriotomy
- Embolectomy with Fogarty catheters (2-4Fr for SFA / popliteal, 2-3Fr for tibial)
- Primary arteriotomy closure or patch angioplasty
- Angiogram

1. Small paramedian incision to access peritoneal cavity, small 4-0 Dexon purse string suture in peritoneum
2. Insert catheter using guidewire into rectovesical pouch (males) or rectouterine pouch of Douglas (females)
3. One cuff in SC tissues, second just superficial to peritoneum
4. Instill fluid and no leaks
5. Tie purse string and close fascia, tunnel exit site

1. Prone jackknife position, tape buttocks open
2. Cannulate tract, inject 50:50 methylene blue / hydrogen peroxide
3. Marsupialization: open wound, curette, suture skin edges to edges of cyst and back
4. Z-plasty : excise tracts down to fascia, Z-flaps at fascia level and transpose flaps to close over drain

1. Right subcostal incision, divide ligamentum teres
2. Mobilize duodenum to clear portal vein
3. Clear IVC
4. Clamp and ligate portal vein
5. Oversew portal vein at hilum
6. End to side anastomosis with IVC - longitudinal venotomy, 2 corner stitches and back wall with 5-0 prolene tying knots on outside, interrupted sutures in front side to allow ballooning out
7. Omental pressure should be lower
8. Feel anastomosis at end of case - should be soft, firm = thrombus

1. Rectal dissection to 4-5cm from dentate line, transect with GIA stapler
2. Mobilize ileum, incise mesentery
3. Rectal mucosectomy through dilated anus (evert rectal stump, inject diluted epi in submcuosa and perform mucosectomy with Bovie from dentate line upward leaving 4-5cm muscular cuff)
4. Fold 18cm of distal ileum for J pouch
5. 3cm enterotomy at J apex, GIA stapler through rectal muscular cuff to the anus
6. 3-0 Vicryl anastomosis of the enterotomy at the apex of the J pouch to the anus at the dentate line
7. SB proximal 15cm to J pouch for loop ileostomy
8. Drains, close

1. Left lateral decubitus or prone jackknife
2. DRE
3. Introduce scope, remove obturator
4. 15cm : peritoneal reflection, sharp angulation for sigmoid
5. Rectum appears larger, more commodius hollow viscus, less likely to collapse, rectal valves of Houston

1. Suture bladder to ipsilateral psoas muscle, sutures parallel to muscle fibers to prevent injury to genitofemoral nerve
2. Contralateral supravesicle pedicle ligated to mobilize bladder (anterior cystotomy to displace bladder towards repair)
3. Stent and Foley

1. Umbilical incision, deliver hypertrophied pylorus
2. Longitudinal incision along anterior wall, spread and divide all CIRCULAR fibers

1. Lembert suture to anastomose distal antrum to proximal duodenum
2. Incision from antrum --> pylorus --> onto duodenum
3. 2 layer anastomosis

The key is the pylrous is incised

1. 2 stay sutures on pylorus to elevate
2. Longitudinal incision from antrum --> pylorus --> onto duodenum
3. Close transversely

Side to side gastroduodenostomy between anterior surfaces of stomach and duodenum, pylorus is not incised
1. Lembert sutures to anastomose distal antrum to proximal duodenum
2. 2 incision, one on prepyloric antrum, other onD1
3. 2 layer anastomosis

1. Complete mobilization of rectum down to levator complex , with lateral ligaments left intact
2. Elevation of rectum with suture fixation to presacral fascia just below sacral promontory
3. Obliteration of culdesac wth suturing the endopelvic fascia anteriorly to rectum and
4. Resection of redundant sigmoid colon with an end to end anastomosis

1. Mobilize bowel to expose renal vein and artery in midline
2. Open Gerota's fascia to expose kidney, lateral to medial
3. Isolate renal artery / vein and place Silastic loops for control
4. Enter hematoma and mobilize kidney
5. Occlude renal artery / vein if major hemorrhage
6. ID injury and determine if collecting duct injured -close with running Vicryl ; parenchyma close with interrupted sutures with Teflon pledgets / omentum / perinephric fat
7. Drain
8. Partia lnephrectomy : ligate branch of renal artery / vein , ligate ureter low on termination at the bladder. Sharply amputate devascularized portion, then close like above

1. Tc99m labeled sulfur colloid injection in 4 quadrants
2. Hand held gamma counter to ID nodes
3. Inject 0.5ml isosulfan blue dye in 4 quadrants
4. ID hot / blue nodes, take out until background count <10%

1. Incision of transversalis fascia in direction of its fibers, reflect superior leaf and ID arch of aponeurosis of transversalis fascia
2. Running monofilament suture (2-0 to 3-0 prolene) from pubic tubercle toward internal ring, suture arch of poneurosis to iliopubic tract (2-3mm whitish band, thickening of transversalis fascia near inguinal ligament) - transversalis to transversalis
3. At internal ring, run suture line back toward pubic tubercle, suture free edge of superior leaf to inguinal ligament and tie to itself (transversalis to inguinal ligament)
4. 3rd suture line at internal ring, suture conjoined tendon to inguinal ligament, at pubic tubercle, return suture line back to internal ring and tie suture back to itse

1. Midline incision
2. Run SB from LOT to ileocecal valve
3. Avascular window in mesentery
4. Straight bowel clamps
5. Divide bowel
6. Divide mesentery in V-shaped fashion
7. Anastomosis : 3-0 silk corner stitches, backrow Lembert sutures, inner layer wtih 3-0 Vicryl running locking suture, inner layer as running Connell, Lembert front wall
8. Close mesenteric defect

1. Ports (umbilicus, epigastric, RUQ, 2 in LLQ)
2. Lateral decubitus, left side up ; reverse Trendelenburg
3. Rotate colon medially and inferiorly out of the field
4. Divide gastrocolic ligament and short gastrics with Ligasure
5. Rotate stomach medially out of field
6. Isolate and divide hilar vessels with staplers (vascular cartridge)
7. Incise lateral peritoneal attachments and remove spleen in specimen bag
8. Check for accessory spleen

1. Midline incision (left subcostal, left paramedian)
2. Divide gastrocolic omentum; enter lesser sac
3. Incise peritoneum lateral to spleen, develop plane deep to spleen /tail of pancreas
4. Divide attachments to splenic flexure of colon / short gastric vessels
5. ID tail of pancreas , protect
6. Ligate splenic artery, then vein close to hilum (careful of blood supply to distal pancreas), remove spleen
7. Check hemostasis , accessory spleens
(<3cm purple nodules around splenic hilum, tail of pancreas, gstrocolic omentum, mesentery, left ovary / uterine tube / scrotum)

1. Midline incision
2. Ligate hilar vessels going to damaged part of spleen
3. Divide spleen along line of demarcation
4. horizontal mattress sutures for hemostasis along division site

1. Left subcostal incision
2. Gastrocolic omentum to enter lesser sac
3. Elevate pancreas and splenic vessels
4. Mobilize splenic vein (ligate IMV and left gastric vein)
5. Divide splenic vein, oversew pancreatic side
6. Partially occlude renal vein
7. End to side anastomosis to renal vein

1. Midline incision , mobilize spleen (ligate short gastric if necessary, if capsular avulsion, apply pressure x 5 mins or use microfibrillar collagen sponge and apply pressure, argon beam (not electrocautery that often rebleeds in this area)
2. Lacerations : 4-0 chromic , pledget / horizontal mattress sutures, omentum to buttress repair
3. Mesh : absorbable mesh with diameter 2x maximum dimension of spleen
4. Run purse string suture along peirphery of mesh circle, place spleen in center and tie purse string stuure around hilum
5. Close abdomen

1. expose supraceliac artery (retract left lobe of liver cephalad, open lesser sac, divide right crus and peritoneum overlying aorta) and SMA
2. Greater saphenous vein - longitudinal incision on medial thigh (prosthetic if bowel contamination, reversed or non reversed (lyse valves with valvulotome)
3. Systemic heparinization
4. Partial occlusion with clamp (lemole strong) on supraceliac aorta
5. Aortotomy with 11 blade, Potts
6. Spatulate proximal end of vein graft and anastomose graft wiht continuous 5-0 Prolene
7. Flush graft
8. Pass vein behind pancreas with vei ndistended
9. Longitudinal arteriotomy on SMA
10. Spatulate distal end and sew vein to SMA in end to side manner using 6-0 prolene
11. Release all vascular clamps

1. Midline incision
2. Retract omentum / transverse colon cephalad, SB down and to the right
3. Mobilize LOT, palpate middle colic artery and trace to root of mesentery to locate SMA
4. Incise peritoneum, dissect SMA and preserve branches
5. Systemic heparinization
6. Transverse arteriotomy with 11 blade knife and extend it with Potts scissors (longitudinal if concern for narrowing)
7. Fogarty catheter (3F ) proximally / distally
8. Flush with heparinized saline
9. Close arteriotomy wiht interrupted 60 monofilament (prolene)
10. Assess doppler signals
11. Evaluate bowel for viableility, need for 2nd loook

1. Neck extended , scapula roll
2. EMG electrodes with ETT, nerve stimulator
3. Incision 1cm lower than cricoid cartilage , subplatysmal flaps , divide strap muscles
4. Mobilize thryoid medially and divide middle thryoid vein, mobilixr thyroid medially and divide middle thyroid vein , mobilize superior pole and inferior pole
5. ID rLL and parathyroid glands
6. Divide branches of inferior thyroid artery
7. Lobectomy : clamp /ligate isthmus on contralateral side
8. Subtotal : leave 4g remnant superioly / posteriorly
9. Close strap muscles / platysma and incision

1. IJ access
2. hepatic vein, create tunnel to portal vein
3. Covered stent
4. Pressure <12mmHg

1. hyperextend neck, test balloon
2. Incision 1FB above suprasternal notch
3. Divide tissues, retract thyroid isthmus
4. Expose trachea, transverse /H incision between 2nd and 3rd tracheal rings
5. Tracheal hook and insert tube (#7-8 in adult) after withdrawal of ETT

1. Large >3cm defects
2. 20F malecot, secured with 3-0 PDS purse string, wrap omentum
3. Closed suction drain near repair
4. 6 weeks to left track form, then clamp for 2-3 days before removal

I : proximal / distal ends (angioplasty / stent)
II : retrograde collaterals through sac (self limited, resolve coagulopathy)
III : holes / defect in stent / graft material (new stent raft)
IV : porosity of graft (self limited, resolved coagulopathy)
V : endotension from enlarging sac without visible endoleak (re-do stent/ graft)

1. Incision in umbilical crease
2. ID and reduce hernia, preserve sac if possible
3. Close fascia in direction of least tension
4. Mesh if >3cm
5. Tack underside of umbilicus to fascia to recreate normal appearance
6. Cirrhosis : incarcerated hernia, incise fascia transversely in corner of defect, NO synthetic mesh, peritoneal drain to decrease risk of ascites leak , close peritoneum as separate layer with running absorbable suture, close fascia in "vest over pants" fashion or running fashion, close SC and running skin closure

1. Umbilical crease incision, divide SC tissues
2. Plane between rectus sheath and hernia sac
3. Clear fascia circumferentially, close transversely in interrupted fashion with PDS suture
4. Tack base of umbilical skin

1. Expose ureter by mobilizing colon
2. Incise peritoneum over ureter
3. Freshen ends, spatulate ends
4. Double-J ureteral stent
5. Proximal into renal pelvis, distal end into bladder
6. Multiple interrupted sutures to close ureter
7. Cover with omentum, closed suction drain

1. Transfemoral or IJ approach
2. Access vein (0.018 inch wire into 21 gauge Seldinger type needle), exchange for 0.035 inch wire in IVC
3. Cavogram, contrast then heparinized saline
4. Dilators
5. Measure IVC diameter (max =2.8cm)
6. ID renal veins
7. Deploy device

Large IVC : bird's nest, IVC in each iliac vein
Use IJ approach if thrombus in IVC

Below knee rather than ankle to decrease saphenous vein injury

1. Preop duplex
2. 3-4cm transverse incision in inguinal crease 1cm medial to femoral pulse
3. Ligate / divide GSV 2cm distal to saphenofemoral junction, suture ligate
4. 1cm incision over GSV below knee, ligate and apply to stripper
5. Stripper through distal incision to groin to extract vein
6. ID / preserve saphenous nerve
7.. Irrigate nd close

1. Saphenofemoral junction through Seldinger/US
2. Trendenlenburg
3. Tumescent anesthesia
4. 2 20s ablation for first 7s, and 20s for remaining segments
5. Recheck saphenous vein by US for clot
6. Postop duplex for DVT

1. Incision over hernia, staying in preperitoneal plane
2. Dissect circumferentially around sac, then down to the neck. Preserve and repair sac, reduce with hernia and free fascial edges
3. Raise skin flaps in all directions to identify all defects, past lateral edge of rectus / linea semilunaris
4. Relaxing incision through external oblique aponeurosis 1-2cm lateral and parallel to edge of rectus msucle, incision posterior sheath if needed
5. Close fascia in midline ,secure Underlay mesh to fascia
6. Retrorectus mesh : plane of dissection between peritoneum and transversus abdominis, may need to dissect behind xiphoid/pubis, omentum over bowel, close peritoneum and posterior rectus --> wide underlay mesh circumferentially of at least 5cm, U-stitches through mesh with large curved needle lateral to division of external oblique aponeurosis , close fascia over mesh
7. Intrapeirtoneal mesh : transfascial U stitches with sutures in periphery to prevent migration no wider than 1.5-2cm apart to avoid bowel herniation
8. Suction drains above fascia bilaterally

1. Thyroplasty
- Small incision in skin near larynx
- Remove small piece of thryoid cartilage and replace with silatsic
- Act as a shim to push VC towards midline
- Under fiberoptic scope

1. Diagnostic laparoscopy
2. Chevron incision
3. Full abdominal exploration
4. Clockwise resection
- Cattell-Braasch (ligate middle colic vein, expose SMV)
- Kocher maneuver (ligate right gonadal vein)
- GB and portal dissection (ligate GDA, check to make sure not coming off SMA to feed R ehpatic), transect CHD proximal to cystic duct
-5. Transect stomach (confluence of gastroepiploic vein on greater curvature)
6. Transect jejunum 20cm distal to LOT
7. Transect pancreas at level of portal vein
8. Frozen section of margins
9. PJ 2 layers end to side, choeldohoJ end to side, 1 layer. GJ end to side 2 layers . Drains, close