SCORE 1-3

1. Proper head positioning
2. Marking or cannulation of the tract if possible. A lacrimal probe or monofilament suture may help to cannulate the tract.
3. Optimal planning of skin incision. The recommended skin incision is a horizontal (along Langer lines) elliptical incision around the cutaneous opening.
4. Dissection along the tract - will encounter hypoglossal nerve
5. Extent of the fistula. Manual palpation with a finger, or use of a bougie in the pharynx, may facilitate identification of the upper extent of the fistula. This should be ligated with an absorbable suture.

When a long tract is encountered, be able to recognize the utility of a second "step ladder" incision to facilitate exposure and maximize cosmesis. If required, the additional "step ladder" incision is positioned 3 to 4 cm cephalad and parallel to the initial incision.
The risk of postoperative wound infection is 5% to 10%.
The risk of recurrence is generally 2% to 12% but can be up to 20% if the lesion is actively infected at the time of resection.

1. The external ostium of these remnants is located along the anterior border of the sternocleidomastoid muscle, usually in the vicinity of the upper half to lower third of the muscle.
2. The course of the fistula must be anticipated preoperatively because stepladder counterincisions are often necessary to excise the fistula track completely.
3. Typically, the fistula penetrates the platysma, ascends along the carotid sheath to the level of the hyoid bone, and turns medially to extend between the carotid artery bifurcations.
4. The fistula then courses behind the posterior belly of the digastric and stylohyoid muscles to end in the tonsillar fossa

Pneumatic (air) enema or hydrostatic (liquid) enema are used for reduction.
In a pneumatic enema, air is insufflated using a rectal tube with a pressure of 80 mm Hg for younger infants and 120 mm Hg for older infants.
In a hydrostatic enema, saline or water-soluble contrast is administered. Barium has fallen out of favor because of concerns for barium peritonitis in the event of bowel perforation.

1. Counter clockwise rotation
2. Divide Ladd's bands
3. Widen mesentery
4. small bowel to the right
5. colon to left

Dicuss ECMO
1. Steps of an open approach for the repair of CDH include appropriate positioning, laparotomy incision (usually subcostal)
2. reduction of herniated contents, exposure of the posterior rim of the diaphragm, assessment of the defect, primary closure versus fashioning/fixation of the patch/muscle flap, and abdominal closure, with careful monitoring throughout the case.

1. Pertinent local anatomy includes the platysma, hyoid bone, and thyroid gland.
2, There can be multiple branches and secretory glands that come together into a single duct at the hyoid bone.
3. The central portion of the hyoid bone is excised, usually including 1 cm on either side of the midline. Some recommend removal of the entire hyoid bone to prevent recurrence (this is controversial).
4. Wide dissection deep to the hyoid up to the level of the foramen cecum is performed so as to include any residual tracts and branches.

1. Carotid
2. Open AAA
3. Ruptured AAA
4. Fem-pop bypass
5. Insertion of port-a-cath
6. Thrombectomy

1, Symptomatic patients (such as those presenting with TIAs associated with the carotid artery in the form of ipsilateral amaurosis fugax or contralateral weakness or numbness symptoms) have been shown to benefit from CEA if there is 50% or greater stenosis of the ipsilateral carotid artery.
2. Asymptomatic patients have been shown to benefit from CEA if there is 60% or greater stenosis.

Symptomatic >50% , asymptomatic >8%

HTN , HLD, diabetes, smoking, family history, heart disease
Any history of prior operation / radiation

1. General anesthesia, beach chair
2. Dissect anterior border of SCM
3. Divide facial vein
4. Dissect out CCA, ICA , ECA, avoid vagus
5. Dissect "patient away from carotid"
6. Obtain control
7. Heparin (100U/kg) and MBP>90
8. Control ICE
9. Arteriotomy
10. Shunt
11. Patch - Bovine pericardium
12. Flush, close, drain

A line, Foley,
Midline incision , RP exposure
Dissect up to renals
Get control of iliacs
Heparin (100U)
Open aneurysm, evacuate thrombus, suture ligate lumbars, place graft
Close peritoneum over top of graft
Return to ICU

1. To isolate the artery proximally, an incision is made along the anterior border of the sartorius muscle, and it is retracted posteriorly. The vastus medialis is retracted anteriorly, and the fascia between the adductor magnus and intermuscular septum is divided.
2. Distal popliteal artery exposure is achieved through an incision 1 to 2 cm behind the tibia. The fascia is incised, and the gastrocnemius muscle is retracted posteriorly. Soleus muscle attachments to the tibia and tendons of the semitendinosus, gracilis, and sartorius muscles are divided. The vein is medial and encountered first within the neurovascular bundle. It can be retracted posteriorly to expose the infrageniculate popliteal artery.

Medial exposure of the suprageniculate and infrageniculate popliteal artery is performed.
To isolate the artery proximally, an incision is made along the anterior border of the sartorius muscle, and it is retracted posteriorly. The vastus medialis is retracted anteriorly, and the fascia between the adductor magnus and intermuscular septum is divided.
Distal popliteal artery exposure is achieved through an incision 1 to 2 cm behind the tibia. The fascia is incised, and the gastrocnemius muscle is retracted posteriorly. Soleus muscle attachments to the tibia and tendons of the semitendinosus, gracilis, and sartorius muscles are divided. The vein is medial and encountered first within the neurovascular bundle. It can be retracted posteriorly to expose the infrageniculate popliteal artery.
The popliteal aneurysm is left in situ and bypassed using a segment of saphenous vein.
The graft can be positioned anatomically adjacent to the popliteal artery or tunneled subcutaneously. An anatomic placement allows less potential for kinking around the knee.
Extensive aneurysmal degeneration or atherosclerotic disease affecting the proximal superficial femoral artery or the distal popliteal artery may necessitate bypassing from the common femoral artery or extending the graft distally to the tibial vessels.
The popliteal artery is ligated proximally and distally, close to the aneurysm, to exclude it from the circulation.

1. Mobilize greater curvature with division of left gastroepiploic cand short gastrics
2. Infrapyloric dissection and ligation of RGE
3. Suprapyloric dissection and ligation of RG
4. Duodenal transection
5. D2 lymph node dissection
6. Gastric (or eosphageal transection)
7. Reconstruction by B2 or R-Y GJ or EJ

1. Veress (aspirate to confirm absence of succuslood, saline flows freely) or Hassan entry into the abdomen at the umbilicus or Palmer's point --> routine check for evidence of injury during trocar placement
2. Additional working ports (below umbilicus at the midline or lateral to inferior epigastric arteries)
3. Explore upper abdomen in steep reverse T , right side up to examine right side, run bowel with two atraumatic graspers, left side up to examine left side (orogastric tube to decompress stomach)
4. Anatomic complications - superior and inferior epigastric vessels, laterally musculophrenic arteries down to deep circumflex iliac artery

1. Foley catheter
2. 5cm lower midline incision (4-5cm below umbilicus, use RUQ if pelvic fx), identify and lift up peritoneum
3. 1-2cm incision and insert catether directed to pelvis, purse -string. Confirm entry into peritoneum with free flow of IVF
4. Aspirate (blood or succus) = +
5. 1L LR/NS for 5 minutes, bag to gravity and send effluent
6. IF solutions does not flow, stop incision / cut purse string / remove catheter, check incision into peritoneum by visualizing omentum / bowel, replace catheter

1. Lacrimal duct
2. Circumareolar (<50% nipple to prevent devascularization) or radial ellipse incision
3. Elevate flaps between SC and breast parenchyma
4. Ligate duct proximally and distally at undersurface of nipple and do wedge resection proximally
5. Orient specimen
6. Hemostasis, closure
7. If purulence, close mid portion of lens radial incisoin and pass 1/4 inch Penrose drain underneath for drainage

1. Upper midline incision, explore and cleanse abdomen
2. Elevate liver and expose duodenum
3. Visualize perforation, close with 3-4 2-0 silk sutures, pass omentum under sutures
4. Graham patch - suture omentum using 2-0 silk
5. Test with air down NGT with abdomen filled with saline
6. Irrigate, drain , close
Also biopsy !

Bleeding
- 2-0 silk above and below bleeding GDA
- 3rd 2-0 silk on pancreas side for transverse pancreatic artery - U stitch

1. Mobilize hepatic flexure
2. Line of Toldt, reflect colon and SB mesentery superiorly
3. Wide Kocher maneuver
4. Repair injury, place omentum , place retrograde duodenal tube
5. Mobilize distal stomach / pylorus
6. Distal gastrectomy with B2
7. Truncal vagotomy
8. Closed suction drains, close

1. Mobilize duodenum, close injury
2. Anterior gastrostomy
3. Mobilize pylorus and fire noncutting linear stapler across or close with running 2-0 Vicryl suture
4. Anterior gastroJ with loop of jejunum
5. Omentum over duodenal repair
6. Spontaneously reopens or cut suture endoscopically after duodenum healed

1. Vertical midline incision, retract omentum and transverse coloncephalad, SB caudad and to the right
2. Mobilize LOT
3. Middle colic artery ,tract to root to locate SMA
4. Incise peritoneum longitudinally, dissect out SMA
5. Systemic heparinization
6. Transverse arteriotomy with 11 blade, extend with Potts scissors
7. 3-F Fogarty catheter proximally and distally or limited endarterectomy with Freer elevator
8. Flush with heparinized saline
9. Close arteriotomy with interrupted 6-0 Prolene or GSV vein patch
10. Check doppler

1. Retract left lobe of liver cephalad,open lesser sac. Divide right crus of diaphragm and peritoneum overlying aorta. Expose supraceliac aorta
2. Expose SMA
3. Retropancreatic tunnel from aorta to SMA by blunt finger dissection behind pancreas
4. Harvest saphenous vein (longitudinal incisoin on medial aspect of leg), lyse valves if not reversed
5. Systemic heparin
6. Partial occlusion clamp (Lemole-strong) over supraceliac aorta
7. Aortotomy wiht 11 blade, extend with Potts . Spatulate vein graft and anastomose with 5-0 Prolene
8. Flush graft
9. Vein graft behind pancreas (retropanceatic tunnel)
10. Longitudinal arteriotomy on SMA, cut vein to proper length to reach SMA
11. Spatulate distal end and sew vein to SMA in end to side running 6-0 Prolene
12. Release all vascular clamps, check Doppler for all small and large bowel vessels, inspect bowels

1. Sniffing position, cervical stabilization
2. Sedation / relaxation meds (etomidate 0.3mg/kg, succinylcholine 1mg/kg)
3. (cricoid pressure)
4. Laryngoscope blade (Macintosh in front of epiglottis), lift larynx anteriorly
5. Pass ETT through cords, inflate cuff
6. Confirm placement (CO2 colorimeter)
7. CXR : ETT 2.5cm above carina

1. Extend opening (longitudinal myotomy) to expose entire extent of mucosal laceration
2. Layered repair
3. Reinforcement : lower esophagus (stomach), thoracic esophagus (pleura or intercostal muscle) - wrap around repair and tack in place with multiple sutures
4. Drain (chest tube)
5. Thoracic repair through RIGHT chest, cervical esophagus through LEFT neck
6. If not amenable to repair, T-tube to converte to controlled fistula (esophagostomy + G/J tubes)

1. Topical anesthesia to oropharynx, IV sedation
2. Left lateral decubitus, bite block
3. Scope into mouth , slight curve
4. Pass through upper esophageal sphincter as patient swallows
5. Cardioesphageal junction at 40cm from incisor teeth (eosphagus = 25cm long)
6. Inflate stomach, retroflex to see cardia
7. Pass pylorus (antrum - paucity of folds)
8. Anatomy - circopharyngeal junction 15cm , aortic arch 22cm, left mainstem bronchus 27cm, diaphragm 40cm)
9. Duodenum - 25cm long
10. If intraop, compress SB to prevent passage of air from insufflation

1. Xiphoid to pubis
2. LUQ -> left lobe of liver (esophageal hiatus , diaphragm) --> RUQ ight liver, epiploic foramen --> RLQ --> LLQ
3. Duodenum at LOT, run small bowel
4. Abdominal aorta and iliac arteries
5. Posterior stomach : open gastrocolic omentum (expose body/tail of pancreas)
6. Duodenum : line of Toldt, reflect colon and SB mesentery to midline and superiorly

1. Full lateral decubitus, prep and drape widely
2. Anterior axillary line (6th intercostal) to 2cm inferior to inferior angle of scapula, then angle cephalad to end midway between spine of scapula and vertebral column
3. Divide SC tissues (lat dorsi, trapezius)
4. Enter chest through 3-5 intercostal spaces , divide intercostals, 2 rib spreaders
5. Elevate lung, fire stapler across region
6. Remove rib spreader, approximate ribs wtih figure of 8 pericostal sutures
7. Bupivacaine in intercostal spaces 2-3 above and below incision, chest tubes

1. Single lung ventiltaion, lateral decubitus position
2. 2 ports- anterior axillary line at 5-7th intercostal space, additional ports, 30 degree scope, another posterior below scapula
3. Chest tube placement, close incisions

1. Supine position
2. 10cm transverse infraclavicular incision, expose axillary artery / vein
3. Longituindal incision over femoral vessels, expose CFA/PFA/SFA
4. SC tunnel clavicle to groin in mid axillary line, counter incision midway
5. Sytemic heparin
6. Proximal / distal axillary artery control, 2cm arteriotomy
7. Beveled anastomosis of 8mm PTFE graft to axillary artery 5-0 prolene
8. Release distal then proximal clamps
9. Pass graft through tunnel
10. Control femoral artery, 2cm arteriotomy extending onto profunda
11. Anastomosis, release distal and then proximal clamps
(Bifem)
12. 2cm arteriotomy on medial side of graft
13. 8mm graft
14. Tunnel SC to other side, create distal anastomosis
15. Heparinized saline flush
16. Close
17. Completion angio / dopplers ? Fasciotomy ?

1. Medial incision along edge of tibia (superficial/deep) separate fibers of gastrocnemius / soleus to get to deep posterior
2. Lateral incision along anterior edge of fibula (lateral/anterior) , dividing the intermuscular septum
3. Preserve GSV, peroneal nerve, saphenous nerve

Femoral hernia repair - above

1. Local anesthesia, old / fail
2. Incise directly over femoral hernia, 2cm below and parallel to inguinal ligament (if necessary, incise inguinal ligament to vertically enlarge canal)
3. Isolate sac, reduce, twist/suture ligate/ amputate sac
4. Rolled cigarette of permanent mesh (Marlex) insert into canal and suture in place
5. Suture inguinal ligament back togehter , close
6. Will need to ligate several veins off saphenous
7. Must ligate the "artery of death" below inguinal ligament if found (off pubic branch if inferior epigastric artery)

Superior - inguinal ligament
Medial - lacunar ligament
Posteriorly - pectineal ligament (Cooper's ligament)
Laterally - femoral vein

1. Widely expose floor of inguinal canal
2. Open floor of canal to expose femoral region
3. ID sac, open and reduce contents and pull down
4. Allis clamps on conjoined tendon and pull down
5. Create relaxing incision on anterior rectus sheath
6. Clean Cooper ligament of overlying tissue, suture conjoined tendon to Cooper ligament (transition to inguinal ligament near femoral vein)
7. Must ligate the "artery of death" below inguinal ligament if found (off pubic branch of inferior epigastric artery)

1. Expose GSV
2. Dissect CFA, SFA, PFA and suprageniculate popliteal
3. Enter poplitea lfossa anterior to sartorius, continue dissection posterior to femur
4. Divide venous tributaries crossing popliteal artery
5. 1cm posterior to tibia and 2cm distal to medial femoral condyle incision
6. Divide vein at saphenofemoral junction (retrograde valvulotome or reversed vein)
7. Proximal anastomosis, tunnel vein subsartorially into popliteal fossa
8. Doppler and completion angio

1. 3-5MHz transducer
2. Subxiphoid - epigastric area, downward pressure to go under xiphoid (blood between liver/heart - dark shadow)
3. RUQ : midaxillary line subcostal - R kidney, liver (blood between)
4. LUQ : midaxillary line subcostal - L kidney, spleen (blood between - normal - bright crescent)
5. Suprapubic : bladder full - 2 fossae either side (dark shadow posterior abnormal)

1. Identify the proximal resection margin. The incisura is generally recognized as the proximal extent of resection in an antrectomy. However, if needed, carry the proximal dissection superior to the confluence of the gastroepiploic vessels to obtain a sufficient margin.
2. Mobilize the greater omentum (figure 3) from the transverse colon to remove it with the specimen for tumor resection. The extent of omentectomy is determined by the proximal extent of the gastric resection. The omentum can be left in situ in the case of antrectomy for benign disease.
3. Identify the pylorus. Ligate and divide the right gastric and gastroepiploic vessels at the pylorus.
4. Skeletonize and transect the duodenum just distal to the pylorus using a linear stapler. Care should be taken to avoid injury to the structures of the portal triad.
5. Oversew the duodenal stump using a running, permanent suture (eg, 3-0 Prolene) on a noncutting needle.
6. Carry the dissection cephalad along the greater and lesser curves of the stomach.
7. For a subtotal gastrectomy, the distal left gastroepiploic arcade and some of the short gastric vessels will need to be ligated.
8. Transect at the proximal stomach margin using a linear gastrointestinal stapler.
9. For patients requiring a D2 nodal dissection, send the named nodal basins along the vascular arcades of the stomach as separate, labeled specimens for pathologic examination.

1. Supine, upper midline incision
2. Stomach into wound
3. 2 concentric purse-string sutures (2-0 silk) on anterior stomach wall, keep needles on
4. Skin incision, deliver catheter into peritoneal cavity, into stomach incision
5. Tie sutures
6. Tack stomach to anterior abdominal wall at 4 points (prior sutures serve as two of stitches
7. Close incision and anchor catheter

1. Lithotomy or prone jackknife
2. Place anal retractor
3. Kelly to retract hemorrhoid
4. Suture ligature at apex of hemorrhoidal pedicle
5. V-shaped incision to excise hemorrhoid, send for pathology
6. Bury ligated stump, close mucocutaneous defect with absorbable running suture or leave open
7. Hemostasis , rolled Gelfoam

1. Right subcostal incision
2. Localize abscess by inspection, U/S or needle aspiration, send cultures from unroofed abscess
3. Suction / lap pads to minimize spillage, irrigation
4. Evaluate for bile leak / hemostasis
5. Leave drains
(pringle if bleeding : finger behind foramen of Winslow , open gastrohepatic ligament, vessel loop around portal triad) or pack / temporary closure

1. Position the patient supine with the right hand under the head.
2. Identify the lesion of interest with percussion and ultrasound guidance.
3. Inject lidocaine over the upper border of the rib to avoid the subcostal vessels.
4. Use a scalpel to create a small skin incision and then pass the needle through the skin and subcutaneous tissue into the lesion of interest under ultrasound guidance.
5. Obtain the biopsy using a core or Tru-Cut needle while the patient is holding his or her breath.

Place a camera port plus one to two additional ports depending on the location of the lesion, usually in the subcostal and epigastric area, for retraction and to complete the biopsy.
Once the lesion is adequately exposed, biopsy it, usually with a Tru-Cut or core needle.

1 Depending on the location of the lesion, make a right subcostal or upper midline laparotomy incision with placement of appropriate retractors (Thompson, Bookwalter).
2. After the round and falciform ligaments are taken down, they may be used for retraction. Depending on location, it may be necessary to divide the triangular and coronary ligaments to aid in exposure.
3. After adequately exposing the lesion, biopsy it, usually with a Tru-Cut or core needle or wedge resection. Attempt to identify all relevant anatomic structures, including the hepatic veins, inferior vena cava, porta hepatis, and so on.

1. Postbiopsy hemorrhage can be controlled with cautery, argon laser, or hepatorrhaphy with #1 chromic and/or topical sealants.
2. With a major hemorrhage, packing and a Pringle maneuver should be performed by gaining access to the lesser sac via hepatoduodenal ligament and applying a Rummel tourniquet.

1. Upper midline, OMNI retrctor, reverse T
2. Expose esophageal hiatus (mobilize left lobe of liver - triangular ligament)
3. Incise peritoneum over esophagus
4. Isolate esophagus from surrounding tissue and pass Penrose drain behind it , noting the vagus nerve
5. Divide short gastrics to mobilize stomach
6. Pass 56-F dilator down esophagus
7. Pass stomach behind esophagus
8. Suture stomach to itself over esophagus and dilator (4-5 0-0 2-0 silk Lembert stitches)
9. Anchor wiht 1-2 sutures that include esophageal wall

First branch of the right vagus - a potential cause of recurrent ulcers when left undivided

Truncal vagotomy and selective vagotomy.

Highly selective vagotomy does not require a drainage procedure, preserves vagal innervation to antrum and pylorus

Type II and III ulcers

Antrectomy with bilroth I, II, R-Y.
Type II and III require vagotomy, associated with increased acid

1. Divide gastrohepatic ligament, elevate left lobe of liver with a liver retractor, incise peritoneal reflection (phrenoesophageal ligament) over distal esophagus
2. Divide left and right vagus nerves above the GEJ (MC performed for duodenal ulcer disease)

1. Divide gastrohepatic ligament, elevate left lobe of liver with a liver retractor, incise peritoneal reflection (phrenoesophageal ligament) over distal esophagus
2. Divide main right and left vagus nerves distal to celiac and hepatic branches

Highly selective vagotomy divides only the vagus nerves supplying the acid-producing portion of the stomach within the corpus and fundus.
Need to divide criminal nerve of Grassi from posterior trunk (right vagus) will predispose to recurrent ulcer disease if left intact

1. Inguinal incision
2. Identify and protect ilioinginal nerve, ID spermatic cord
3. Deliver testis / cord into surgical field, noncrushing clamp on cord
4. Open hydrocele
5. Biopsy and frozen section suspicious area
6. Release clamp if not cancer
7. Excise redundant tissue leaving cuff around testis
8. Oversew cut edge of hydrocele with running lock stitch or bottle operation (inside out fashion approximateion of edges)
9. Return cord /testis to scrotum, close incision

1. Lithotomy position, Foley
2. Transverse incision (Pfannenstiel), incise fascia / peritoneum vertically
3. Uterine fundus wiht 2 Kelly clamps and elevate
4. Ligate round ligaments
5. Incise broad ligament lateral to tube / ovary
6. Identify and protect ureter
7. Secure uterine vessels
8. Continue dissection along broad ligament overlying bladder, free rectovaginal fascia to uterine cervix and ivide vaginal cuff closed wtih running lock stitch
9. Close abdomen

1. midline incision
2. stoma aperture with rectus splitting technique (2cm disc at ostomy marking, reveal underlying anterior rectus, 2-cm vertical incision, expose posterior rectus and incise, check 2-3 finger breadths)
3. Exteriorize ileum so proximal limb cephalad, transverse incision on antimesneteric portion of distal bowel
4. Mature stoma - 3-0 chromic anchoring quadrant sutures, interrupted sutures

1. Circumstomal skin incision 2-3mm from bowel
2. Dissect bowel from SC tissue / fascia
3. Inspect bowel for injury
4. Anastomosis - approximate antimesenteric areas, GIA stapler into each limb and join stapler arms, linear or TA stapler beneath Allis clamps approximating open edges
5. Close fascia, purse string dermis of wound

1. Skin incision over mid -inguinal area
2. Divide scarpa
3. Preserve ilioinguinal nerve, isolate sac from cord structures
4. Females : divide / ligate round ligament / sac ; males : transect sac and stuure ligate --> twist sac and suture ligate wtih 3-0 / 4-0 vicryl for high ligation
5. Scrotal contents back into scrotum
6. Close
*No inguinal floor repair is required * except - very large / long standing hernias, chronic ventilatory requirements, VP shunts, CF

Can assess contralateral side for inguinal hernia repair using laparoscope - put laparoscope into hernia sac and tie sac with laparoscope

1. Most common due to inadequate sac dissection
2. Possibility of a femoral / direct hernia defect
3. Recognize utility of laparoscopy when evaluating a recurrent hernia and availability of laparoscopic erpair as an option when open repair was previously performed

1. Following incision and division of Camper fascia, Scarpa fascia must be divided, and it can be thick in children.
2. The external oblique aponeurosis is divided in the direction of the external ring and often has the ilioinguinal nerve on its undersurface, which should be protected.
3. Cremasteric fibers are present on the cord and must be spread or divided.
4. Identify the hernia sac and separate the sac from the vas deferens and vessels without excessive manipulation.
5. The hernia sac lies anteromedial to the other cord structures and can be grasped and elevated to carefully dissect the vas deferens and vessels away.
6. Carry the dissection of the hernia sac up to the internal ring and safely ligate the sac without injury to the vas deferens or the proximal hernia sac. In female children, precautions should be taken to avoid injury to the fallopian tube in a sliding hernia.
7. Care is necessary in dissection of the proximal hernia sac so that adequate separation of the sac from cord structures is obtained without injuring those structures or creating additional openings in the sac.
8. The fallopian tube may be adherent to the proximal hernia sac, resulting in a sliding hernia. The tube must be carefully dissected off the sac prior to high ligation to avoid entrapment.

If the hernia is easily reduced an elective hernia repair may be scheduled on an outpatient basis. If it is reduced with difficulty there are some who would admit the patient to the hospital for an urgent repair. If the hernia remains incarcerated or there is concern for strangulation or an injury during the attempted reduction (e.g. fever, tachycardia, leukocytosis, emesis, severe pain, prolonged history of bulge and erythema) immediate surgery is warranted.

If a perforation occurs during attempted radiographic reduction and the patient subsequently has hemodynamic or respiratory compromise, needle decompression with an 18-G angiocatheter above the umbilicus directed cranially can be performed to decompress the abdomen. Remove the needle after placement, leave the angiocatheter in place, and plan for operative exploration.

If a perforation occurs during attempted radiographic reduction and the patient has no significant hemodynamic compromise, plan for operative exploration.

1. Upper midline incision
2. Ligament of Treitz, trace to loop 40-60cm distal to reach abdominal wall
3. 3-0 silk purse string suture on anti-mesenteric border
4. Incise center of purse string
5. Pass catheter, confirm by free injection / aspiration of air
6. Tie purse string
7. Witzel - multiple Lembert stitches over catheter site and along course of catheter for 1.5-2cm
8. Tack jejunum to anterior abdominal wall

Supine, arms out and right sided up reverse T , give Abx ppx, SCDs in place
1. Laparoscopic access (10mm umbilicus / epigastric, 5mm right midclavicular line) and inspect abdomen
2. Grasper on fundus of GB and pull up /over liver, 2nd grasper on GB infundibulum
3. Expose cystohepatic triangle
4. Incise peritoneum over GB
5. Identify cystic duct / artery ; divide
6. Dissect GB off liver bed, retrieve GB with specimen bag

1. 30 degree flexible scope
2. Clean anterior surface of bile duct 1-2cm and place 2 stay sutures
3. Choledochotomy 0.5-1cm
4. Pass choledochoscope and remove stones directly askets / Fogarty balloon
5. Insert T tube (secure with 2-3 interrupted 3-0 /4-0 Vicryl suture and close CBD)
6. Completion cholangiogram
7. Place omentum and closed suction drain

1. Supine position, trocars at umbilicus, R/L paraumbilical , angled 30/45 degree scope
2. Incise peritoneum from medial unbilical ligament to ASIS and peel down
3.Flaps and reduce sac
4. Secure mesh (at least 11x6cm) with tackes / staples along superior edge of mesh and iliopubic tract medially
5. Close peritoneum over mesh
6. INternal ring : male - convergence of ductus deferens and testicular arteries, female - only round ligament points the way

1. Entry into preperitoneal space , dissect preperitoneal fat from fascia, use dissecting balloon to develop space
2. Additional trocars
3. Separate sac from underlying structures
4. Place mesh

1. Laparsocopic access , 5 ports (camera, liver retractor, along left subcostal region, midclavicular RUQa), 45 degree scope, reverse T
2. Retract liver towards diaphragm
3. Grasps esophageal fat pad and retract it inferiorly to expose esophageal hiatus
4. Incise phrenoesophageal ligament
5. Clean bilateral crura, visualize vagus nerves, retract esophagus
6. Pass instrument behind esophagus , then Penrose
7. Close esophageal hiatus defect, close crura with 3-4 interrupted non-absorbable suture
8.Divide short gastrics
9. Pass gastric fundus behind esophagus
10. Suture stomach to itself
11. Completion EGD

1. Split leg position
2. Laparoscopic access, 5 ports, 30 degree scopes
3. Incise gastrohepatic and phrenoesophageal ligament
4. Excise / reduction hernia sac and mediastinal adhesions, Harmonic scalpel
5. Reduce herniated viscera from chest
6. Expose R/L crura , divide pars flacida (careful of left hepatic artery)
7. Divide short gastrics
8. Mobilize distal esophagus, assess length (at least 3cm), and need for Collis gastroplasty (blue load 3.5mm endoGIA staplers
9. Don't violate pleura membrane with phrenoesophageal space
10. Approximate esophageal hiatus CRURAL REPAIR with interrupted permanent sutures
11. 6x8cm mesh, keyhole, secured wtih 3 permanent stitches
12. Nissen FUNDOPLICATION with 56 or 58F bougie in place
13. EGD (Z-line, tight wrap, leak test?)

1. Topical anesthesia of oropharynx
2. Tongue blade , head lamp
3. Dental mirror warmed, observe vocal cords and posterior pharynx

1. Lidocaine : onset 30-60 seconds, lasts 30-90 mins
(4.5mg/kg w/o epi , 7mg/kjg w/ epi)
2. Bupivacaine : onset 10-20 mins , lasts 2-4 hours
(2.5mg/kg w/o epi, 3mg/kg with epi)

1. Transverse incision above umbilicus
2. Eviscerate abdomen contents
3. Counterclockwise detorsion of bowel
4. Divide Ladd's bands , widen mesentery
5. Appendectomy
6. SB in right lateral gutter, colon in left lateral gutter, close abdomen

1. Position patient with arm out
2. Elliptical incision around NAC, develop flaps (sternum medially, clavicle superiorly , rectus inferiorly, latissimus laterally)
3. Elevate breast from pec major, leave fascia
4. Leave breast attached at lateral aspect, incise pec fascia at lateral edge of pec major and elevate muscle to remove all node bearing tissues, sweep fatty tissue laterally from long thoracic, downwards from axillary vein, take nodal tissue medial to pec major as well
5. Preserve median pectoral nerve, long thoracic nerve, thoracodorsal nerve
6. ID / ligate perforating branches of internal thoracic vessels
7. Closed suction drains

1. Position patient with arm out
2. Elliptical incision around NAC, develop flaps (sternum medially, clavicle superiorly , rectus inferiorly, latissimus laterally)
3. Elevate breast from pec major including pectoralis fascia
4. ID / ligate perforating branches of internal thoracic vessels
5. Closed suction drains

1. Make an incision below the axillary hairline (if using separate incision). This can be performed using a slightly S-shaped incision along the pectoralis muscle and along the latissimus dorsi muscle.
2. Incise the clavipectoral fascia to expose the axillary tissue.
3. Define the pectoralis muscles and preserve the medial pectoral neurovascular bundle.
4. Identify the latissimus dorsi muscle.
5. Carefully dissect superiorly along the latissimus dorsi muscle to visualize the axillary vein.
6. Identify the long thoracic nerve along the serratus anterior muscle and thoracodorsal neurovascular bundle along the latissimus dorsi muscle.
7. Identify the intercostobrachial nerves and preserve them if possible.
8. Once the neurovascular bundles and axillary vein have been identified, complete the dissection and excise all nodal tissue (levels I and II).
9. Typically, leave a negative pressure drain in the axilla.