Colorectal

Front 1

HALs Left hemicolectomy for splenic flexure cancer

Back 1

General surveillance of abd for mets

1.Create Gelport extraction site. Typically 6 cm pfanenstiel incision.

2. Insufflate

3. Placement of other ports. 5 mm umbilical camera port, 5 mm right upper quadrant working port, 12 mm regular quadrant working port. Consider llQ 5mm working port instead?

4. Transection of IMV and High ligation of the left colic artery, at the origin of the IMA.

5. Complete medial to lateral mobilization of the splenic flexure. Dissection of the white line of toldt, Removal of all ligamentous attachments ( splenocolic/gastrocolic etc)

7.Intracorporeal transaction of the colon, extraction.

8. Intracorporeal colo-colonic anastomosis without tension.

9. Close mesenteric defect

*Eval spleen prior to closing

Front 2

Extended R colectomy in the presence of complete transverse colon obstruction

Back 2

1.lithotomy positioning

2. Ex-lap, abdominal exploration for metastases.

3. Decompressive enterotomy via the right colon if necessary.

4. Mobilization of the right colon from lateral to medial.mobilize the hepatic flexure.

5. Enter the lesser sac, remove the greater omentum from the stomach.

6. Mobilize the splenic flexure.

7. High ligation of the ileo- colonic, right colic, and the middle colic artery vascular pedicles.

8. Ileo- colonic anastomosis, functional end-to-end.

Front 3

Describe your laparoscopic sigmoidectomy ( diverticulitis)

Back 3

Consideration of ureter stents. After preoperative bowel preparation. Patient supine position.

1. Pneumoperitoneum established ( Gelport extraction site), quadrant method port placement

2. Mobilize the lateral attachments of the sigmoid/descending/splenic flexure colon (toldt)

3. Incise the peritoneum overlying the IMA, identify and protect the left ureter.

4. Ligate the IMA.

5. Thin the rectal mesentery and divide healthy proximal rectum with a laparoscopic stapler.

6. Identify healthy uninflamed sigmoid colon or distal left colon for proximal division.

7. Extract specimen through extraction site (typically lower midline- makes it easier to sew in the anvil extracorporeally)

8. Perform anastomosis with eea stapler, anvil placed in proximal colon.

9. Perform a leak test, with flexible sigmoidoscopy and proximal lumen occlusion in saline filled pelvis.check donuts

**Consider ligating the imv for further mobilization of the splenic flexure and creation of tension free anastomosis

Front 4

Elective, staged surgery for medically refractory ulcerative colitis. Describe the stages

Back 4

1. Laparoscopic Subtotal colectomy, with end ileostomy

2. Completion proctectomy, Ileal pouch anal anastomosis IPAA, creation with diverting loop ileostomy.

3. Reversal of loop ileostomy

Front 5

Complications/postop expectations associated with ileal pouch anal anastomosis ( J pouch creation) and their treatment

Back 5

1. Diarrhea- if causing significant morbidity revise to end ileostomy.

2. Pouchitis- treat with flagyl

3. Pouch failure- revise to end ileostomy

4. infertility in women

5. Late diagnosis of Crohn's disease- revise with APR and end ileostomy.

Front 6

IPAA op steps (robotic)

Back 6

1. Lithotomy position

2. Completion proctectomy, staple The anorectal junction at the level of the levator muscles

3. Staple and divide the terminal ileum (take down the end ileostomy prior to docking robot- put in Gelport?)

4. Mobilize the small bowel and it's mesentery, mobilize any adhesions to create a tension-free anastomosis.

* If necessary perform lengthening procedures such as dividing the mesenteric peritoneum, selective vascular ligation and consideration of an alternative pouch shape.

5. Create a 15 to 20 cm long J pouch by stapling the distal two limbs of ileum together with a EndoGIA stapler and inserting the anvil into the distal ileum.

6. Create the ileal pouch anal anastomosis using an EEA stapler. Perform leak test, check donuts.

7. Undock robot. Removal of proctectomy specimen.

8. Creation of diverting loop ileostomy.

Front 7

Emergent treatment of refractory toxic megacolon or acute fulminant ulcerative colitis

Back 7

Subtotal colectomy ( total abdominal colectomy) with end ileostomy

Front 8

Laparoscopic Ileocolonic resection (Crohn's)

Back 8

1. Laparoscopic Port placement

2. Evaluation of the entire small bowel

3. Lateral to medial mobilization of the ascending colon and hepatic flexure. identification of the duodenum and the right ureter.

4. Ligation of the ileocolonic vascular pedicle ( Vascular stapler)

5. Division of healthy proximal and distal bowel with stapler.

6. Creation of tension free ileo- colonic anastomosis.

7. Extraction of specimen via extraction site.

Front 9

Robotic LAR

Back 9

Pre-op bowel prep and bilateral ureter stent placement.

Lithotomy position.

1.create pfanenstiel extraction site, place gel port and instaflate.

2. Mobilize the left colon, sigmoid colon, and splenic flexure if nec.

3. Identify the IMA and the left ureter.

4. Divide and ligate the sigmoidal and superior rectal aa

5. Divide the proximal bowel mesocolon.

6. Perform a total mesorectal excision ( by entering the endo-pelvic fascia)

7. Perform an En-bloc resection of any adherent structures.

8. Staple and divide the distal rectum

9. Staple and divide the proximal colon. Insert the anvil.

10. Perform colorectal anastomosis with eea stapler. Leak test with rigid proctoscopy. Check donuts. Check spleen

Front 10

Crohn's disease: indications for surgery

Back 10

Medically refractory disease, medication related complication, massive hemorrhage, perforation, obstruction, neoplasia, abscess not amenable to percutaneous drainage, and fistulas.

Front 11

Crohn's disease with small bowel stricture, presenting with obstruction. What are your surgical options?

Back 11

Surgical options are dependent on nutritional status, any immunosuppression status, history of previous bowel resections and the number of strictures, the severity of inflammation.

In patients with a single long isolated strictured segment of the terminal ileum, ileo- colonic resection is the treatment of choice.

Other options include resection, structural plasty and bypass techniques.

Front 12

Laparoscopic ileocolonic resection ( for Crohn's stricture)

Back 12

1. Umbilical camera port, three working ports: epigastric pubic and left lower quadrant.

2. Evaluation of the entire small bowel

3. Medial to lateral mobilization of the ace and colon and mesentery

4. Identification of the duodenum and right ureter

5. Ligation and division of the ileocolonic vessels

6. Division of the proximal and distal bowel

7. Ilequonic anastomosis

A midline incision can also be made afterwards for extraction of the specimen

Front 13

Medical treatment of Crohn's disease

Back 13

Acute flares ( in order of increasing severity):

-Steroids and 5 ASA (Amino salicylates e.g. mesalamine)

-Biologic treatment including anti tnf alpha monoclonal antibodies. E.g. infliximab

-Immunomodulators, EG is a diaprine, 6 mercaptopurine.

Remission/maintenance tx- slowly taper off steroids, continue on 5 ASA derivatives long term.

Front 14

Appendiceal NETs, how to treat?

1cm, 1.5cm, >2cm?

Mesoappendiceal or vascular invasion, mitotic activity >2cells/mm, +Ki 67 (proliferative marker), location at the base of the appendix, and positive margins.

Positive goblet cell histology

Back 14

1cm- appendectomy

1.5cm- appendectomy (without high risk features)

>2cm- right hemicollectomyHigh risk features= Mesoappendiceal or vascular invasion, mitotic activity >2cells/mm, +Ki 67 (proliferative marker), location at the base of the appendix, and positive margins. >>> NEEDS A RIGHT HEMICOLECTOMYPositive goblet cell histology>>>ALWAYS RIGHT HEMICOLLECTOMY

Front 15

How to treat:

Benign mucinous neoplasms of appendix? aka: cystadenomas, mucinous tumor of uncertain potential, adenomeucinosis and malignant mucocele.

Mucinous adenocarcinomas

Any of these have the potential to rupture and spread throughout the peritoneum causing pseudomyxoma peritonei and peritoneal carcinomatosis. How to treat if this happens?

Back 15

Treatment based on degree of cellular atypia.

Lesions can find the appendix with benign histology should be treated with appendectomy.

Involvement of the base of the appendix requires cecectomy with en bloc resection of the mesoappendix.

Benign mucinous neoplasms of appendix> Appendectomy aloneMucinous adenocarcinomas> right colectomy

Pseudomyxoma peritonei- cytoreductive surgery with HIPEC

Front 16

Appendiceal NET work up

Back 16

If>2cm, incomplete resection, locally advanced disease, metastatic disease or goblet cell histology require:

Stage and surveillance-with serial Chromogranin A levels,

CT chest abdomen pelvis.

Suspicious for mets: Otreotide scintigraphy or PET CT

Distant disease with carcinoid syndrome- treat with somatostatin analogs. In some cases liver- directed ablation or debulking surgery may provide symptomatic relief.

Front 17

Anal canal cancer fu

Back 17

After the first treatment of the nigro protocol allow 8 weeks before the first follow-up and up to 6 months from the start of chemo radiation to assess for regression of the lesion prior to proceeding with surgical resection.

Every 6 months for 5 years. DRE and anoscopy for the first 3 years. For higher stage lesions annual CT chest/ab/ pelvis for 3 years.

Check the inguinal lymph node basin

Front 18

Apr

Back 18

pre-op bowel prep and pre-op stomach marking, bilateral ureters stents.

If female may need to take posterior while the vagina

1. Lithotomy, DRE palp mass, eval for mets

2. Robotic or laparoscopic mobilization of the distal recto sigmoid

3. Identification of the superior rectal artery, the left ureter, and high ligation.

4. Division of the approximal retro sigmoid junction.

4. Mobilize the colon to the splenic flexure

5. Total meso rectal excision ( maintains the animatonic plains and preserves the peritoneal envelope around the meso rectum)

Avoiding the hypogastric nerves

6. Dissection continues until the pelvic floor is identified. Watch out for both ureters.

7. Perineal dissection is completed- elliptical incision is made( from coccyx to perineal body and ischial spine to ischial spine marks boundaries) and dissection continued cephlad to meet the intra-abdominal portion of the dissection through the levator ani muscles.

8. Specimen extraction, hemostasis, drain placement, consideration of a myocutaneous flap ( after XRT) with the assistance of plastic surgery.

8. End colostomy

The perineal defect is closed in several layers with absorbable suture including absorbable suture in the skin to avoid uncomfortable suture or staple removal postoperatively.