please answer all questions one
TRANSCRIPT
1
Please answer All questions
A/ MCQ's Choose ONE correct answer (in the attached buble sheet: (28.5
marks Each 0.5 marks)
1. The total volume of gas needed in normal size human abdominal cavity;
a. 1.5 liter CO2 to achieve intra-abdominal pressure of 12 mm Hg
b. 3 liter of CO2 to get desired pressure of 12mm Hg
c. 5 liters of CO2 to get desired pressure of 12mm Hg
d. 6 liters of CO2 to get desired pressure of 12mm Hg
2. Umbilicus is good site for laparoscopic access because it is:
a. thinnest part of abdominal wall
b. cosmetically better and no significant blood vessels
c. center point of abdomen
d. all the above
e. none of the above
3. which is true about closed 1ry port placement:
a. The greater the gas bubble & abdominal wall tension the less the risk of bowel
injury
b. An intra-abdominal pressure of 20–25 mmHg should be achieved before
inserting the primary trocar
c. The distension pressure should be reduced to 12–15 mmHg once the insertion
of the trocars is complete
d. Once the laparoscope has been introduced it should be rotated through 360
degrees to check for any adherent bowel
e. All the above
4. Avoid hernia risk by closing sheath if:
a. Midline port sites > 7mm & Lateral port sites > 5 mm
b. Midline port sites > 5mm & Lateral port sites > 7 mm
c. Midline port sites > 7mm & Lateral port sites > 3 mm
d. Midline port sites > 3mm & Lateral port sites > 5 mm
5. High pressure is registered when CO2 is insufflated in the Veress Needle
before the needle has been placed in the body.
a. Veress needle may be blocked
b. The gas tap may not be opened
c. Gas tube may be kinked.
d. All the above
Medical Research Institute
Experimental and Clinical Surgery department
Program : Doctorat in experimental surgery
Course title: Laparoscopic Surgery II
Course Code: 1714814 Time: 1 hour
Type exam: Full term--Spring
Date: 25.7.2020
Academic year: 2019-2020
Total marks: 60 marks ( pages)
2
e. a + c
6. In right hemicolectomy which of the following is the best patient position
during ileocolic dissection:
a. Reversed Trendelenburg with left side of table down
b. Trendelenburg with left side of table down
c. Reversed Trendelenburg with right side of table down
d. Trendelenburg with right side of table down
e. None of the above
7. Which of the following statements regarding post splenectomy sepsis are not
true?
a. The incidence in children is generally reported as less than 5%
b. Haemophilus influenzae, Streptococcus pneumoniae and Neiseria
meningitidis are the most common causative organisms
c. Autotransplantation techniques eliminate this risk
d. The mortality rate is now approximately 50%
e. The incidence in adults in approximately 1%
8. During the evolution of the understanding of hematologic diseases, the
indications for splenectomy have changed. The most common indications for
splenectomy are, in descending order of frequency:
a. Traumatic injury, immune thrombocytopenia, hypersplenism.
b. Immune thrombocytopenic purpura, traumatic injury, hypersplenism.
c. Hypersplenism, traumatic injury, immune thrombocytopenia.
d. Immune thrombocytopenia, hypersplenism, traumatic injury.
9. As the functional anatomy of the spleen is divided into red pulp, white pulp,
and marginal zone, what function is incorporated into the anatomy of the
cortical zone that relates to infection control?
a. Filtration of red cells, encapsulated bacteria, and other foreign material.
b. Red pulp for formation of red cells.
c. White pulp for its role in formation of granulocytes.
d. Gray areas, so formed because of the production of platelets.
e. Fibrous trabeculae.
10. The following statements about splenosis are correct:
a. Autotransplantation of splenic tissue is an etiology.
b. May protect against OPSS.
c. May over time be “born again” and regain some immune function.
d. May produce tuftsin and properdin.
e. All of the above.
11. A 30 years old female patient presented with regurgitation and chest pain,
and dysphagia. The first recommendation would be:
a- Upper GI endoscopy
3
b- Esophageal manometry
c- ECG
d- Cardiac enzymes
e- PPIs
12. The best treatment for achalasia of the cardia is:
a. Savary dilatation
b. Nissen fundoplication.
c. Botulinum injection
d. Heller myotomy with anterior fundoplication
13. Choose the correct choice:
a. In order to avoid post operative dysphagia, nissen fundoplication would be
done around a bougie
b. The gold standard diagnostic tool for gastro-esophageal reflux is esophageal
manometry
c. Oral fluids could be offered for patients after heller myotomy on the same day
of operation.
d. All the above
e. A + C
14. Approaches for laparoscopic right colonic resection
a. Lateral to medial approach
b. Medial to lateral approach
c. Caudal-cranial approach
d. None of the above
e. All the above
15. Causes of sudden collapse during insufflation for laparoscopic surgery:
a. Vaso-vagal shock due to peritoneal irritation
b. CO2 embolism either by direct entry of gas into vessel or through
absorption.
c. Hypercarbia due to systemic CO2 absorption results in respiratory
acidosis, pulmonary hypertension leading to cardiac dysrhythmia
d. Arrhythmias - AV dissociation, junctional rhythm, sinus bradycardia and
asystole due to vagal response to peritoneal stretching.
e. All are true statements
16. Which of the following comments does not describe hypersplenism?
a. It may occur without underlying disease identification.
b. It may be secondary to many hematologic illnesses.
c. It is associated with work hypertrophy from immune response.
d. It requires evaluation of the myeloproliferation.
e. It is associated with antibodies against platelets.
17. A lady presented in the emergency department with a stab injury to the left
side of the abdomen. She was hemodynamically stable and a contrast enhanced
CT scan revealed a laceration in spleen. Laparoscopy was planned, however,
the patients PO2 suddenly dropped as soon as the pneumoperitoneum was
created. What is the most likely cause?
4
a. Gaseous embolism through splenic vessels b. Injury to the left lobe of the diaphragm c. Inferior vena cava compression
d. Injury to colon e. none of the above
18. Shoulder pain post laparoscopy is due to:
a. Subphrenic abscess b. CO2 retention c. Positioning of the patient
d. Compression of the lung e. none of the above
19. In Duodenal switch operation, which of the following is not done?
a. Cholecystectomy b. sleeve gastrectomy c. Jejunoileal anastomosis
d. Distal gastrectomy e. Appendectomy
20. Peterson hernia
a. An internal hernia occurring behind Roux-en-Y limb
b. An internal hernia occurring through window in the transverse mesocolon
c. Hernia through the defect in conjoint tendon just lateral to where it inserts with
the rectus sheath d. hernia containing the appendix e. None of the above is true
21. Vertical banded gastroplasty also known as stomach stapling is done for:
a. Gastric carcinoma b. Achalasia cardia
c. Perforated gastric ulcer d. Morbid obesity e. b + d
22. All of the following are primarily restrictive operations for morbid obesity,
except:
a. Vertical band gastroplasty b. Duodenal switch operation
c. Roux-en-Y operation d. Laparoscopic adjustable gastric banding
23. Bariatric surgery which results in maximum weight loss:
a. Biliopancreatic diversion b. Gastric sleeve
c. Gastric banding d. Gastric bypass
24. Most commonly performed and acceptable method of bariatric surgery is:
a. Biliopancreatic diversion b. Biliopancreatic diversion with ileostomy
c. Laparoscopic gastric banding d. Roux-en-Y gastric bypass
25. A mill-wheel type of murmur during laparoscopy suggests:
a. Tension pneumothorax b. Intra-abdominal bleeding
c. Gas embolism d. Pre-existing valvular disease e. none of the above
26. Which of the following statements regarding the pathogenesis of
appendicitis is false?
a. Luminal obstruction is always the cause of acute appendicitis
b. Luminal obstruction leads to increased pressure and distention of the appendix
c. Obstruction of venous outflow and then arterial inflow results in gangrene
d. Obstruction of the lumen may occur from lymphoid hyperplasia, inspissated
stool, or a foreign body
e. Viral or bacterial infections can precede an episode of appendicitis
5
27. Prospective studies have shown incidental appendectomy to be advantageous
in which of the following patient groups?
a. Children undergoing staging laparotomy for malignancy who are then to enter
chemotherapy
b. HIV infected patients
c. Patients over 50 years of age
d. Patients with spinal cord injuries
e. None of the above
28. A 26-year old woman in her first trimester of pregnancy presents with a 2-
day history of right lower quadrant pain and fever. Physical examination reveals
a tender, palpable, right lower quadrant mass. There is no evidence of peritonitis
or systemic sepsis. Laboratory evaluation is remarkable for mild leukocytosis,
and abdominal ultrasound demonstrates an inflammatory mass but no evidence
of abscess. As the surgeon on call, your recommendation would be:
a. Intravenous hydration, antibiotics, bowel rest, and interval appendectomy in 4 to 6
weeks.
b. Intravenous hydration, antibiotics, and appendectomy if no improvement in 12 to
24 hours.
c. Intravenous hydration, antibiotic prophylasis, and urgent appendectomy.
d. Intravenous hydration, antibiotics, and interval appendectomy when fever has
subsided, leukocyte count has returned to normal, and the patient is pain free
e. Emergent obstetrical consultation for evaluation and treatment of possible ectopic
pregnancy
29. The potential causes of post-laparoscopic sleeve gastrectomy gastric leak are
the following except?
a. Mid-sleeve stenosis
b. Staple line near GE junction
c. Use of a large-size bougie
d. Staple on the migratory crotch staple
30. It is very important to set realistic expectations before starting medical
treatments of obesity. What would be a realistic weight loss goal known to
reduce the cardiovascular risk of patients?
a. 5–15 %
b. 3–10 %
c. 5–7 %
d. 15-20%
31. Which of the following sentences is false when we speak of lifestyle
modifications?
a. Changes in dietary behavior, the stimulation of physical activity, and emotional
support continue to be the mainstays for the management of obesity in adults,
children, and adolescents.
b. Lifestyle interventions alone result in long-term weight loss and the
majority of dieters do not return to baseline weight within 3–5 years.
6
c. The improvements described in morbidly obese patients using behavioral
therapy as an element of an intensive lifestyle intervention could benefit a huge
number of people.
d. Lifestyle interventions can be provided at the hospital or primary care setting
32. Revisional surgery after Laparoscopic Adjustable Gastric Banding:
a. Is required by an average of 28 % of patients 10 years after the primary
procedure
b. Has a higher mortality than the primary procedure
c. Leads to poor weight loss compared with prior to the procedure
d. Conversion to an alternative bariatric procedure should be preferred
33. What is the expected weight loss with intragastric balloons?
a. 5 % total weight loss
b. 12 % total weight loss c. 50 % excess weight loss
d. 30 % total weight loss
34. Which of the following statements regarding adipokines and gut hormones is
correct?
a. Circulating leptin levels are consistently low in obese individuals, compared to
normal-weight controls.
b. Resistin, a cysteine-rich protein secreted primarily by adipose tissue, promotes
insulin sensitivity and is anti-inflammatory.
c. CRP is an independent predictor of future cardiovascular risk in
asymptomatic women and has been observed to fall significantly in the
months after bariatric surgery.
d. GLP-1 agonists are a group of new diabetes medications that show significant
reductions in glycemic parameters but with the adverse effect of weight gain in
many patients.
e. Ghrelin is the gut hormone with the strongest evidence for mediation of the post-
RYGB effects on glycaemia.
35. The treatment options of post- laparoscopic sleeve gastrectomy obstruction
are the following except:
a. EGD + dilatation ± stent
b. Laparoscopic strictuloplasty
c. Laparoscopic RYGB
d. Laparoscopic feeding jejunostomy
e. Laparoscopic seromyotomy
36. Regarding laparoscopic ventral hernia repair, all of the followings are not
true except:
a. Ventral and incisional hernias centered around the umbilicus and on or close
to the midline are not good indications for the laparoscopic approach.
b. Lateral hernias close to bony structures (ribs, pubis, iliac crest) or
following incisions on the flank are difficult and require special techniques
c. If the hernia being repaired is in the lower abdomen, a Foley catheter should
not be placed to prevent bladder injury.
7
d. The patient should be in the prone position on the operating room table with
both arms tucked. This will give the surgeon and assistant/camera holder sufficient
room to stand on the same side
37. All of the following statements concerning the abdominal wall layers are
correct except: a. Scarpa's fascia affords little strength in wound closure.
b. The internal abdominal oblique muscles have fibers that continue into the scrotum
as cremasteric muscles.
c. The transversalis fascia is the least important layer of the abdominal wall in
preventing hernias. d. The lymphatics of the abdominal wall drain into the ipsilateral axillary lymph
nodes above the umbilicus and into the ipsilateral superficial inguinal lymph nodes
below the umbilicus.
38. Staples may safely be placed during laparoscopic hernia repair in each of the
following structures except:
a. Cooper's ligament.
b. Tissues superior to the lateral iliopubic tract.
c. The transversus abdominis aponeurotic arch.
d. Tissues inferior to the lateral iliopubic tract.
e. The iliopubic tract at its insertion onto Cooper's ligament.
39. Regarding laparoscopic ventral hernia repair, all of the following statements
are true except:
a. A full dose of a parenteral antibiotic with activity against staphylococci and
common aerobic gram-negative coliforms such as Escherichia coli should be
administered with induction of anesthesia.
b.Both of the patient's arms should be tucked at the side.
c. Stomach and bladder decompression with an orogastric tube and Foley catheter
should be done preoperatively.
d.Meticulous adhesiolysis and reduction of incarcerated bowel should be
performed.
e. Use ePTFE Dual-Mesh, fashioned so as to overlap all defects by at least 2
cm in all directions.
40. The initial step in colorectal carcinogenesis is :
a. the APC mutation of chromosome 5q
b. K-ras mutation
c. Chromosome 18 loss
d. P 53 mutation
41. Polyps less than 1cm in size:
a. 10% risk for developing into cancer in 10 years
b. 1% risk for developing into cancer in 10 years
c. 10% risk for developing into cancer in 5 years
d. Has no risk for developing into cancer
8
42. Site of injury of autonomic nerve :
a. At the aorta during ligation of IMA
b. At the bifurcation of the aorta
c. Lateral wall of pelvis
d. Post-lateral position of the mid rectum
e. a + b + c
43. Port-site metastasis is lap colectomy
a. Is significantly more common than open surgery
b. Is non preventable
c. Is as common as wound metastasis in open surgery
d. Is not related to the techniques
44. In case of severe acute inflammation of the gall bladder, dissection is best
carried out by:
a. sharp dissection
b. Using a hook
c. Blunt dissection like a metallic suction cannula and jet water
technique
d. All the above
45. Achalasia of the cardia:
a. Mucosal perforation is the most common complication during surgery
b. Has an absence of ganglion cells in Auerbach’s plexus and may presents in
children with dysphagia
c. Diagnosis is confirmed by oesophageal function tests
d. Cardiomyotomy may not totally relieve symptoms
e. All are true
46. Pneumothorax
a. is not uncommon during laparoscopic hiatal dissection and esophageal
mobilization (5%–10%).
b. is usually small and self-limited.
c. They are best recognized on a postoperative chest film
d. Intervention is rarely needed, as the lung re-expands rapidly as carbon
dioxide is absorbed.
e. All are true
A 32years old female is presenting to the ER department with abdominal pain,
palpitations and fever. She gave history of lap. Sleeve gastrectomy 9 days earlier.
On-examination: Pulse: 110 BPM, B.P: 75/35, Temp. 38.5
47. What is the most appropriate first step in her management?
a. Request urgent ultrasound abdomen
b.Request plain X-ray erect abdomen
c. Request urgent CT abdomen & pelvis
d.Start IV fluids.
e. Insert Nasogastric tube
48. What is the most appropriate diagnostic tool in such case:
a. Plain CT abdomen & pelvis
b. Plain CT chest + Ultrasound abdomen & pelvis
9
c. CT abdomen & pelvis with IV contrast
d. CT abdomen & pelvis with oral & IV contrast
e. Upper GIT endoscopy
Enumerate 3 possible differential diagnoses: (answer here) (1.5 marks)
i. Post-Sleeve gastric leak
ii. Post-Sleeve infected haematoma
iii. Injury to another bowel during trocar insertion
A 26 years old female with history of laparoscopic cholecystectomy 6 days ago is
presenting to an outpatient clinic with palpitations, fever & abdominal
distension. On examination: Temp: 38 - Pulse: 110 – B.P: 110/70
Abdomen is distended with right hypochondrial tenderness, guarding, sluggish
peristalsis and icteric tinge.
49. Is this patient indicated for hospital admission?
a. Yes b. No
50. After requesting lab. Investigations what is the most important radiological
investigation to ask for?
a. Ultrasound abdomen & pelvis
b. Plain x ray abdomen standing
c. CT abdomen & pelvis with IV contrast
d. MRCP
e. HIDA scan
After completing investigations you have found that: There is moderate intra-
abdominal collection with no air foci, leukocytosis, high bilirubin level (both total &
direct) and low albumin level,
51. what is the next step:
A . Laparoscopic exploration b. Midline exploration
c. Radiological guided pig tail drainage of the collection
d. Conservative management
52.What is your most possible diagnosis:
a. Duodenal injury
b. Biliary injury
c. Colonic injury
d. Post cholecystectomy bleeding
e. Drug induced hepatitis
Intra-operative emergency call from one of your fellow surgeons in your
hospital. When you have arrived the surgeon was performing a laparoscopic
cholecystectomy and he noticed fresh bile in the operative field after he has
finished the cholecystectomy.
53.What is the first step you would consider:
a. Convert to open surgery
b. Put tube drain and end the surgery
c. Perform an intra-operative cholangiogram
d. Don’t put drain and end the surgery
Enumerate Four classifications for such condition (names): (answer here) (2
marks)
I Strasberg II Bismuth Corlette III Hannover IV Stewart way V Mattox
10
54. During insertion of the primary trocar (supra-umbilical) for a lap.
Cholecystectomy you have noticed a gush of fresh blood from the trocar. What is
the first step to do:
a. Remove the trocar and re-insert it in another position
b. Remove the trocar and convert to open surgery
c. Leave the trocar in place and convert to open surgery
d. Leave the trocar in place and ask for blood transfusion
31 years old female is seeking advice 10 days after lap. cholecystectomy with
Tube drain draining bile. All laboratory parameters are within normal. MRCP
shows complete cut of common hepatic duct <2cm from the confluence with
normal caliber CHD stump.
55. What is the best timing for corrective surgery:
a. Immediately with no delay
b. 2 weeks from the primary surgery
c. 6 weeks from the primary surgery
d. One year from the primary surgery
e. No surgery is needed
56. Preset pressure:12, actual pressure;12, flow rate;1L/min and total gas 1 Lit
with unilateral distension are indicative of which area Veress needle is placed?
a. Bowel
b. Block
c. Preperitoneum
d. Vena cava
57. Epigastric port should be placed in relation to …….. falciform ligament?
a. the right b. the left c. in the falciform ligament d. below the ligament
B/Which of the following statements is correct (Mention True Or False):
(answer in the buble sheet if True select a if False select b ) (3 marks) (0.25
marks each)
58. The inferior epigastric vessels can be clearly visualized by trans-illumination of
the abdominal wall - FALSE
59. A volume of 2-3 litres of CO2 gas is sufficient to allow safe entry of the
laparoscope - FALSE
60. The open laparoscopy or Hasson technique reduces the risk of bowel injury -
TRUE
61.. Incisional hernias can occur into 10 mm or 12 mm lateral trocar sites – TRUE
62. The risk of significant complication during diagnostic laparoscopy is
approximately 1 in 1000 - TRUE
63. Secondary trocars should be inserted under direct vision - TRUE
64. Experimental evidence in animals has shown that direct insertion of the trocar is
associated with fewer bowel injuries than after conventional pneumoperitoneal
insufflation - FALSE
65. If 5 mm secondary trocars are utilized, the rectus sheath needs to be sutured in
addition to the skin incision - FALSE
66. Intra-abdominal adhesions occur rarely in the left hypochondrial region - TRUE
11
67. After insertion of the Veress needle, moving the handle in an arc to ensure free
movement of the needle tip can check satisfactory positioning – FALSE
68. The use of the hook can be summarized as - “HOOK, LOOK, COOK” True
69. Palmer's point access of Veress needle is contraindicated in splenomegaly and
previous gastric surgery and adhesions False
C/ Short answers (answer here) 6 marks
1)Mention five tests that should be performed after Veress needle insertion to
confirm proper placement of the needle. (1.5 marks)
Hiss Test, Aspiration Test, Negative Pressure Test, Early Insufflation Pressures,
Volume Test.
2) Adequate retraction of the gallbladder is a prerequisite of laparoscopic
cholecystectomy. Many factors could make retraction difficult: Mention 6
factors: (1.5 marks) 1. A grossly distended gallbladder is impossible to grasp without risk of rupture
and should be aspirated under visual control with a needle inserted at the fundus.
Bile leak from the puncture site can be prevented by grasping the fundus at the
puncture site.
2. A contracted fibrosed gallbladder does not permit the grasper on the fundus to
push it upwards to retract the liver. This may require a 5th trocar in the left
hypochondriac region for direct liver retraction.
3. A very thick-walled gallbladder may require a toothed grasper for retraction.
4. A stone impacted in the neck of the gallbladder with dense surrounding
fibrosis and adhesions is, a major obstacle to retraction. The main purpose of
retraction is to retract the neck of the gallbladder laterally to place the cystic duct
and artery on the stretch, and maintain the cystic duct at right angles to the CBD
Adhesions and fibrous thickening around the neck make this very difficult.
Dissection should commence at the gallbladder neck and move medially mm by
mm.
5. Anterior and superior surface of the liver adherent to the anterior abdominal
wall/diaphragm cause difficulty in retraction. These adhesions should be severed
to permit free liver movement upwards. Most of these adhesions are avascular and
can be easily divided by sharp dissection.
6. A fibrotic cirrhotic liver adds greatly to the difficulties already present by the
greatly increased vascularity of portal hypertension. The grasper on the fundus
cannot push the rigid liver upwards. We invariably use a 5th port for retracting the
liver with a suction tube which helps maintain a clear dissection field.
3) Indications and technique diagnostic laparoscopy and cancer staging
---Indications for laparoscopic staging of abdominal tumors: (1.25 marks)
• Preoperative assessment prior to major extirpation
• Documentation of hepatic or nodal involvement
• Confirmation of imaging studies
• Therapeutic decision making for Hodgkin lymphoma
• Full assessment of ascitic fluid
--- Techniques utilized during diagnostic or staging laparoscopy: (1.75 marks)
• Full abdominal and pelvic evaluation
12
• Division of gastrohepatic omentum
• Biopsy using cupped forceps or core needle
• Abdominal lavage for cytologic study
• Retrieval of ascitic fluid for cytology and culture
• Identification and removal of enlarged lymph nodes
• Laparoscopic ultrasound
D/ answer all (13 marks)
1.mention anatomical variation of cystic artery (2 marks)
Classical single cystic artery
Double cystic artery
Cystic artery originating from gastroduodenal artery
Cystic artery originating from the variant right hepatic artery
Cystic artery originating directly from the liver parenchyma
Cystic artery originating from the left hepatic artery
2. Indications and techniques of selective intraoperative cholangiography (3
marks)
clinical history of jaundice
pancreatitis
elevated bilirubin level
abnormal liver function test results
increased amylase levels
high lipase level
Dilated common bile duct on preoperative ultrasonography or intra operative
3. Red flags during laparoscopic cholecystectomy (2 marks)
Bleeding
Bleeding can occur during or after your operation.
If it does occur intraoperative, you may need to convert to open
cholecystectomy.
If it does occur pos operative, you may require a further operation to stop it.
Bile leakage
When the gallbladder is removed, special clips are used to seal the tube that
connects the gallbladder to the main bile duct.
Bile fluid can occasionally leak out into the tummy (abdomen) after the
gallbladder is removed.
Bile leakage not from the gall bladder is an alarming sign.
Injury to the bile duct
The bile duct can be damaged during a gallbladder removal.
If this happens during surgery, it may be possible to repair it straight away.
Injury to the intestine, bowel and blood vessels
13
The surgical instruments used to remove the gallbladder can also injure
surrounding structures, such as the intestine, bowel and blood vessels.
4. Enumerate approaches to reduce the risk of laparoscopic port site tumor
implantation. (3 marks)
Place trocars perpendicular to the peritoneum
Prevent carbon dioxide leakage around trocars
Minimize handling of tumor tissue
Protect extraction sites
Bag specimens intra-abdominally to avoid spillage
Remove entire lesion rather than an excisional biopsy if possible
Drain the peritoneal cavity before deflating
Deflate the abdomen with trocars in place
Close the fascia of the trocar port site while avoiding liquid spillage into the wound
5.Mesh fixation techniques during laparoscopic ventral hernia repair
(3marks)
I-Double Crown technique: In this technique, the mesh is fixed to the abdominal wall with two rows of tacks. The first row is placed right at the fascial defect and the second row is placed at the edge of mesh approximately 6–10 mm from the edge. We now use the absorbable tacks that will dissolve in less than 6 month
II. Transfacial sutures: In this technique, four nonabsorbable sutures are
placed at each corner of the mesh. These sutures are tied twice and then
cut long enough to be passed through the abdominal wall. The length of
overlap is added to each side of the hernia mark on the skin and a new
marking that corresponds to the mesh size is drawn on the skin. The exit
site of these sutures is then marked on the skin.
After the mesh is introduced into the abdominal cavity, these four sutures
are passed through the abdominal wall. The suture passer is introduced
through the abdominal wall through a stab wound . The mesh should be
flat, but not under too much tension
E/ Discuss : Answer One only (6 marks) 1.Discuss medial dissection of Lt colon and names instrument used and name possible complications Model answer
Medial dissection of colon ;
• it starts by creating pneumoperitoneum and introduction of trocars as shown in
pictures above
• Then the patient must be put on anti trendenlenberg position with right tilt
• Internally the small bowels must be arranged in upper abdomen to give space for
identification of aortic bifurcation and ileal vessels.
• In female the uterus has to be retracted upwards
14
• the sigmoid must be put under tension so the dissection starts between the ileal
vessels and arching sigmoid, this is the easiest way to identify loose areolar tissue
and enter the holy plane of mesorectum from above
• The dissection goes lateral and upwards to identify the ureter
• after that identification of IMA, ureter must be protected before ligation of the IMA
( sparing the ascending left colic)
• Dissection is going upwards till the lower border of pancreas where the IMV is cut
• Then the colon is dissection from the lateral side through Told fascia till liberating
the splenic flexure
• After complete mobilization of the left side then the surgeon is directed downwards
to the mesorectum
• The same rules of open surgery applied here, we start with posterior dissection as
far as possible in the holy plane of rectum , then we progress laterally and anterior
• Caution must be taken anterior as the mesorectal fat is so deficient , so injury of
related organs is easier
• The rectum is dissected down wards till the level of plevic floor, at this level the
upper end anal canal can be dissected from the musculare complex
• Pfennestiel incision is done to deliver the resected rectum and sigmoid , the anvil of
circular stapler is introduced inside the proximal colon
• The abdomen is reclosed and the anastomosis is done mechanically
• Proximal stoma is done to protect the anastomosis
2/ Discuss Management options of leak following laparoscopic sleeve
gastrectomy.
Classification:
Gastric leak was defined as “the leak of luminal contents from a surgical join between two
hollow viscera”. It can also be an effluent of gastrointestinal content through a suture line,
which may collect near the anastomosis, or exit through the wall or the drain.
Leaks can be classified based either on the time of onset, clinical presentation, site of leak,
radiological appearance, or mixed factors.
Csendes et al defined early, intermediate and late leaks as those appearing 1 to 4, 5 to 9 and
10 or more days following surgery respectively. By clinical relevance and extent of
dissemination, they defined typeⅠor subclinical leaks as those that are well localized without
dissemination into the pleural or abdominal cavity, nor inducement of systemic clinical
manifestations, usually they are easy to treat medically. Type Ⅱ are leaks with dissemination
into abdominal or pleural cavity, or the drains with consequent severe and systemic clinical
manifestations.
Based on both clinical and radiological findings, type A are microperforations without clinical
or radiographic evidence of leak, while type B are leaks detected by radiological studies but
without any clinical finding, and finally, type C are leaks presenting with both radiological
and clinical evidence.
Clinical presentation vary widely between totally asymptomatic patients diagnosed with routine imaging studies
(upper gastrointrstinal series…) post op, that are considered type A , to the signs and
15
symptoms of a septic shock including fever, abdominal pain, peritonitis, leucocytosis,
tachycardia, hypotension
Unexplained fever and tachycardia post op should raise the index of suspicion of a possible
complication and push the surgeon to perform further radiological investigations to R/O the
presence of leak
Early leaks usually present with sudden abdominal pain, accompanied with fever and
tachycardia in most cases, while late leaks tend to present with insidious abdominal pain
commonly associated with fever
Investigations
Computed tomography (CT) of the abdomen with IV and PO water soluble contrast is
considered as a part of the diagnostic workup of patients with suspected leak, with the
presence of abdominal collection or free fluid, extravasation of contrast into the abdominal
cavity or the drain tube, or persistent pneumoperitoneum as diagnostic findings of leak or
fistula.
CT is considered to be the best non-invasive modality for detection and confirmation of a
gastric leak.
These results are also supported in another multicenter experience showing that CT had the
highest detection rate of gastric leaks in up to 86% of patients
Even in the setting of positive diagnosis with CT scan of a leak, an upper gastrointestinal
gastrografin swallow is of great importance to identify the magnitude and the level of the leak
Management
The treatment may include:
1. early oversewing,
2. drainage (open or laparoscopic),
3. endoscopic clipping, stenting or using fibrin glue,
4. sometimes the use of a Roux limb or total gastrectomy as the last resort
Treatment is based on 3 characteristics:
1. Time of appearance (early, intermediate and late);
2. Location (proximal, mid or distal gastric);
3. Severity or magnitude (type Ⅰ and Ⅱ).
16
Endoscopic modalities
Closure techniques: (1) Endoclips were used initially for hemostasis, later on trials to treat esophageal, colonic and
duodenal mucosal defects and perforations were extrapolated to be used in post sleeve
gastrectomy leakage, now the new over the scope clips (OTSC) have more promising results,
but they are limited for very small mucosal defects and microperforations, and are
inefficacious in inflammatory or edematous mucosa, demanding technical skills; and
(2) Sealant materials including fibrin glue and cyanoacrylates. Fibrin glue acts by dual effect,
as a plug directly occluding the defect and as a fibroblast promoter to enhance wound healing,
thus it is absorbed after 4 wk and replaced by connective scar tissue.
Exclusion techniques - endoprosthesis (stents):
Initially stents were used to treat stenosis, it was shown that they decrease the intraluminal
pressure, which may be part of the pathophysiology of the gastric leak post sleeve as
mentioned above, so its use gained a widespread in the management of proximal and middle
gastric leak due to the advantage of the ability to resume per os feeding and discharge the
patient home, but the migration index is high, reaching 30%, with the same rate when
comparing self-expanding metallic stents (SEMS) and self-expanding polyester stents (SEPS)