SCORE CORE 21-50

1. Lithotomy or prone jackknife
2. Anoscope to ID 3 hemorrhoidal pedicles
3. Band largest hemorrhoid first, above dentate line

1 Allis clamp on conjoined tendon (continuous musculoaponeurotic arch from lower fibers of transversus abdominis) and pull down
2. Create relaxing incision on fascia (as internal oblique and transversus abdomininus continue to midline as part of anterior rectus sheath) medial to repair
3. Suture conjoint tendon to inginal ligament with interrupted 0-0 silk sutures
4. Internal ring - males : leave opening to admit Kelly clamp ; females, close completely

1. Skin incision posterior longer than anterior flap
2. Incise anteriorly / laterally
3. Ligate GSV
4. Divide all soft tissues to tibia anteriorly , thorugh fascia of muscles laterally
5. Strip periosteum from tibia circumferentially
6. Divide tibia and fibula (several cm higher than tibia)
7. Smooth bone ends
8. suture ligate posterior tibial artery / vein
9. Posterior flap
10. Ligate lesser saphenous veins
11. Hemostasis, suture flaps and close in layers

1. ID trigone and ureteral orifices
2. 2-0/3-0 Vicryl running closure, then outer layer of running or interrupted Lembert sutures to invert suture line
3. Leave Foley for drainage, omentum over repair

1. Anterior longitudinal duodenotomy extending across pylorus to the distal stomach
2. The bleeding vessel often the GDA is ligated in the ulcer crater by placing a figure of 8 suture at the top and bottom of the ulcer to control the artery proximally and distally
3. A third suture is placed as a U-stitch underneath the ulcer to control the transverse pancreatic branches that enter the GDA posteriorly
4. The transverse duodenal incision is then closed vertically to constrct a Heineke Mikulicz pyloroplasty. Truncal vagotomy is then performed to reduce the risk of recurrent ulceration

1. Mobilize bladder pedicle
2. Find superior vesicle artery
3. Posterolateral bladder flap based on artery, width 4cm
4. Tubularize flap and create mucosa to mucosa anastomosis
5. Anchor base of flap to psoas muscle

1. Ultrasound to visualize lesion , mark overlying skin
2. Circumareolar incision, raise flaps 0.5cm thick
3. Retractors or traction figure of 8 suture around breast
4. Deliver wire into wound, excise tissue around wire with knife / Mayo scissors (can cut wire)
5. Orient specimen
6. Confirm presence of clip by US or x-ray, adequacy of resection
7. Check for palpably abnormal tissue, excise
8. Hemostasis , close incision

1. Visualize lesion with U/S (7.5 Mhz linear array transducer), sterilize field, ansethetize skin
2. Cyst - hypoechoic (black) , wider than tall, demarcated
3. Introduce needle, aspirate
4. Send fluid

1. Instill warm saline through warm channel and suction up
2. Balloon catheter for selective or suciton syringe

Flexible
1. Topical anethesia and sedation
2. Introduce fiberoptic through anesthtized nares or oral bite block
3. ID larynx / vocal cords, pass into proximal trachea

Rigid
1. Scope into mouth under direct visualization
2. Grasping forceps or Fogarty catheter
3. Racepmic epi and /or dexamethasone to reduce swelling of small airways in children

1. Head turned, neck extended, roll off shoulders
2. Prep / drape neck /chest
3. Oblique incision along anterior SCM, curve posteriorly at angle of mandible to avoid marginal mandibular nerve
4. Retract SCM, expose carotid sheath to explore contents
5. Proximal / distal control and then suture /vein patch or interposition saphenous vein graft w / w/o shunt
6. Retract thyroid medially , divide middle thyroid vein
7. Expose / inspect esophagus / trachea

1. Incision parallel to anterior SCM
2. Preserve greater auricular nerve
3. ID medial border of internal jugular , ligate facial vein
4. Expose common carotid, protect vagus/ ID hypoglossal (between IJ and common carotid) / ansa cervicalis (divide occipital branch artery as needed)
5. Mobilize proximal part of external carotid
6. Systemic heparin (5000 IU)
7. Clamp internal /common/ external carotid arteries
8. Arteriotomy on common carotid, extend to bifurcation
9. Shunting or selective EEG
10. Outer media is removed, leaving only undiseased circular muscle fibers and adventitia (Freer elevator)
11. Heparinized saline to flush (10U/ml)
12. Transect internal carotid off common carotid
13. Eversion endarterectomy of internal carotid, feather to endpoint and transect, separate and evert plaque (Dacron with 6-0 prolene)
14. Anastomosis from internal carotid to bifurcation , patch
15. Release clamps (external carotid first, internal carotid last to minimize cerebral embolization of debris)

1. Incision parallel to SCM
2. Identify Ij and facial veins, transect and suture ligate the facial veins
3. Expose and dissect common, internal ,and external carotid arteries
4. Identify and preserve vagus and hypoglossal nerve
5. Anticoagulate with heparin (30U/kg)
6. Cross clamp internal , common, external carotid
7. Shunt if needed
8. Endarterectomy (plaque transected in common carotid, in distal ICA , plaque feathered off , leaving a moosth endpoitn)
9. Assess endarterectomized surface and endpoints
10. Close arteriotomy with patch (Dacron / PTFE / vein / Bovine pericardium)
11. Backbleed the internal and external carotid arteries, forward bleed common carotid artery
12. Resume flow into the external and internal carotid arteries , assess reconstrution
13 .Secure hemostasi s

- 16-18 gauge needle on medial aspect of tibial metaphysis 1FB below tibial tuberosity
- 90 degree angle, introduce short large bone-marrow aspiration needle into skin and periosteum
- Direct 45 to 60 degrees away from epiphyseal plate and twistore into bone cortex and into the bone marrow

1. Head turned away, local anesthetic
2. Transverse skin crease incision over node of interest
3. Deepen through platysma
4. Retract SCM and expose node, remove node

1. Local anesthesia, prep chest
2. Incision below 4-5 interspace laterally between anterior and mid-axillary line, just ABOVE rib
3. Spread tissues, controlled clamp to pop into pleural space
4. Digitally explore to break up loculations / adhesions , guide chest tube in

1. 5-F to 8-F feeding tube to pass into cystic duct, confirm bile aspiration and saline injected easily
2. Contrast of 1:1 or 1:2 (8-12ml for small CBD), visualize CBD, intrahepatic biliary tree and distal CBD

1. Clean surface of distal bile duct, 2 stay sutures
2. 2cm longitudinal choledochotomy low on bile duct, bile duct exploration
3. Create transverse incision on upper part of duodenum
4. 2-layered anastomosis between duodenumile duct (4-0 silk Lembert posterior interrupted , 4-0 vicryl mucosal interrupted sutures, anterior row of interrupted 4-0 Vicryl and 4-0 silk)
5. Omentum around anastomosis
6. Closed suction drains

1. Side to side or side to end
2. Bring Roux loop of jejunum (40cm from LOT) up to choledochotomy, antecolic or retrocolic (to the right of the middle colic artery)
3. 2 layer side to side anastomosis with single layer of 4-0 PDS and 3-0 silk
4. Side to side anastomosis between proximal jejunum and side of distal segment (ligate jejunal branches of SMA to mobilize)

1. Rigid scope requires full kocherization, otherwise flexible scope
2. Slight bend on tip, traction sutures to "close" duct
3. Saline flowing the entire time to distend CBD, visualize ampulla
4. Fogarty catheter next to scope if stone or stone basket
5. Then pass scope into right / left hepatic ducts, pull back scope to visualize just adjacent to choledochotomy

1. Supine , trocars (umbilical, suprapubic, left lateral) . Tberg with right side up
2. Cecum/R colon on stretch to identify ileocolic, ligate with Ligasure after identify duodenum
3. Incise line of Toldt, mobilize colon, take hepatic flexure medial to lateral after entering lesser sac and identify transverse colon mesentery
4. Extend umbilical port, exteriorize right colon
5. Resect / control R branch of middle colic
6. Extracorporeal anastomosis - align antimesenteric borders of ileum /colon, linear stapler , inspect for hemostasis , approximate opening with Allis clamps and stagger staple lines, linear stapler below Allis

1. Modified lithotomy, trocars (umbilical, right lateral to umbilicus, LLQ, Tberg with left side up
2. Sigmoid colon mesentery on stretch to identify IMA
3. ID left ureter, ligate IMA with ligasure at inferior border of pancreas (duodenal-jejunal juncture) (if too high, damage sympathethic plexus, too low can get takeoff of left colic artery)
4. Mobilize descending colon / splenic flexure, divide colon (if difficult , enter gastrocolic ligament and work medial to lateral)
5. Extend umbilical incision, exteriorize for anastomosis with wound protector /Babcock
6. Purse string anvil, pass circular stapler, fire and inspect donuts for completion

1. Midline incision
2. Mobilize white line of Toldt
3. Identify and protect duodenum / ureter
4. Takedown hepatic / splenic flexure
5. Preserve middle colic for right / left hemicolectomy, take with extended right / left
6. Score peritoneum overlying mesenteric vessels, divide mesentery between clamps / ties
7. Divide bowel / create anastomosis

1. Midline incision.
2. Explore the abdomen.
3. Mobilize the right colon:• Identify and protect the right ureter and duodenum.
4. Mobilize the transverse colon by separating the greater omentum from the colon.
5. Mobilize the splenic flexure and left colon: Identify and protect the left ureter.
6. Identify points of transection at the terminal ileum and rectosigmoid colon.
7. Divide the terminal ileum with a linear cutting stapler.
8. Score the peritoneum overlying the intended line of mesenteric division.
9. Ligate and divide the mesenteric vessels sequentially from the terminal ileum to the sigmoid colon.
10. Identify the point of division on the rectosigmoid colon (in general above the peritoneal reflection, at the point where taeniae splay to form a continuous longitudinal muscle layer).
11. Divide the rectosigmoid colon with a linear cutting stapler and remove the specimen.
12. Check hemostasis.
13. EEA anastomosis . Create an abdominal wall defect in the right lower quadrant for ileostomy
14. Pass the terminal ileum through abdominal wall ensuring that the bowel is not twisted.
15. Close the abdomen.
16. Mature the ileostomy in a Brooke fashion.

1. Incise mucocutaneous border of colostomy
2. Cut any tacking sutures
3. Mobilize loop, close transversely with 3-0 Vicryl running connell suture and 3-0 silk lemberts

1. Mobilize hepatic flexure to expose duodenum, Kocher maneuver (mobilize duodenum to IVC, should be able to pass hand behind head of pancreas)
2. Palpate hepatoduodenal ligament for stones, head of pancreas for masses
Choledochotomy
1. Site low on bile duct, 2 x 4-0 silk stay sutures, make 2-3mm longitudinal slit in CBD with 11 blade scalpel, extend with Pott's scissors until 1cm
2. Non dominant hand behind duodenum to straighten duct for easier passage of instruments
3. Explore distal duct first (temporarily occlude proximal duct with peanut sponge tagged wtih 2-0 silk / clamp to prevent back flow of stones)
4. Stone retrieval with scoops, stone forceps or biliary Fogarty catheters, #3 BAKES dilator into duodenum
5. Explore proximal duct
6. Visualize proximal and distal duct with choledochoscope

1. If large duct, choose 14F T-tube (10-16F), cut cross bars of T short
2. Cut back wall or V into back wall so cross arms bend easily when tube is pulled
3. Confirm patency of both ends by injecting saline
4. Insert and it should slide freely
5. Running lock stitch 4-0 Vicryl full thickness bites at inferior margin of choledochotomy and proceed up to T tube
6. Run simple running stitch back and tie to itself
7. Inject saline to check for leaks
8. Completion cholangiogram through T tube to confirm all stones removed and duct not narrowed
9. Closed suction drain near choledochostomy and place omentum into subhepatic space

1. IV sedation, left lateral decubitus
2. DRE, lubricated scope
3. Angles : sigmoid colon, splenic flexure
4. 3 haustra in triangle = transverse colon
5. Angle : hepatic flexure
6. Convergence of teniae at cecum
7. Biopsy forceps, polypectomy snare (pull away from wall), if lose polyp, strain stool

1. Leg (30mmHg)
- Anterior : 1cm lateral to anterior tibia
- Deep : posterior fibula border
- Lateral : just anterior to posterior fibula border
- Superficial : transverse line level of proximal / middle 1/3 leg

1. Weck knife for excision down to fascia
2. Prepare with sterile mineral oil / saline
3. Dermatome for set width / depth, uniform thickness
4. Secure graft with interrupted sutures / staples
5. Pressure dressing / bolster / suction dressing

1. Transverse incision over superior part of cricoid cartilage rather than inferior part of thyroid cartilage (superior thyroid artery)
2. Stab into membrane, spread and insert cuffed ETT tube through Seldinger technique

1. Laparoscopic access
2. Retract liver
3. Excise esophageal fat pad and clean peritoneum from anterior surface of esophagus
4. Myotomy (release circular muscle fibers) 6cm on esophagus, extend distally 1.5-2cm on stomach
5. EGD (leak test)
6. DOR or Toupet (divide short gastrics to mobilize stomach)

1. Viscera protected by omentum
2. Holes in large plastic drape to pack abdomen
3. Surgical towels, NGT x2 in gutters --> adhesive drape
4. Temporary vacuum sponge device

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. Esophagoscopy was performed and the diverticulum was identified and packed with gauze to
assist during surgical exposure. Then an esophageal dilator and a nasogastric feeding tube were
inserted under direct vision.
2. A transverse incision was done along a skin crease between the hyoid and clavicle, raise subplatysmal flaps, divide straps . Divide anterior belly of omohyoid, identify RLN. Retract thyroid and trachea medially.
3. Identify esophagus, diverticulum was then identified and freed it from the surrounding tissues down to its base attachment to the esophagus.
4. A long cricopharyngeal myotomy was performed and the pouch was then excised with a linear stapler/excised and closed in layers with sutures/inverted and tacked to the precervical fascia so that the mouth of the diverticulum was dependent

1. Insert a bivalved laryngoscope or a diverticuloscope into the oral cavity to expose the common wall between the esophagus and the diverticulum (with the endotracheal tube anterior to the anterior flange of the scope).
2. Advance the lower flange of the diverticuloscope until it inserts in the diverticulum and the upper flange in the esophagus.
3. Use a rigid 0 or 30° telescope connected to a video camera to magnify the view.
4. Examine the diverticular pouch carefully for any lesions. Biopsy any suspicious lesions.
5. Expose the diverticular common wall with the flanges of the scope.
6. Divide the diverticular common wall with a disposable Endo GIA stapler by placing the blade containing the cartridge into the esophageal lumen and the opposite blade into the diverticulum.
7. Activate the stapler (repeated firing may be needed).
8. Use the scope again to examine the diverticulum, esophagus, and the incision for any
perforation or foreign bodies.
9. Remove the diverticuloscope under vision

1. In an open reduction, a transverse right lower quadrant incision is made. The cecum and terminal ileum are delivered through the incision, and the extent of the intussusceptum is evaluated.
If the intussusceptum reaches the distal colon, extension of the incision may be necessary.
2. Once the leading edge of the intussusceptum is identified, it is milked slowly in a retrograde fashion while exerting minimal traction on the proximal bowel.
3. Care should be taken to avoid excessive pulling on the bowel as it enters the cecum because this may lead to perforation of the edematous bowel within.
3. This process requires constant pressure on the leading edge and patience. If successful, the bowel can be warmed with saline-soaked laparotomy sponges and closely observed when viability is questionable.