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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)

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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

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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?

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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

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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.

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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.

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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

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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

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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

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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

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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

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• 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

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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

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• 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

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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).

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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)