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Position This is supine and the patient is prepared from the nipples to the groin. Any abnormalities should be dealt with accordingly. These also depend upon what procedure is required. There are four anatomical narrowings to the oesophagus, these are listed proximal to distally. The endoscope is passed into the oesophagus, the stricture is visualised and a wire passed through the stricture.

The endoscope is then removed and increasing sized plastic dilators passed over the wire through the stricture until satisfactory clearance is achieved. Rockwall scoring system.

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It is a widely used diagnostic and therapeutic tool and tolerated well. It may be either diagnostic or therapeutic as mentioned below. A small cannula is inserted into the bile duct and pancreatic duct. Contrast solution usually iodine is then injected into the biliary tract with a subsequent radiograph taken.

Operative Surgery Vivas for the MRCS

The two approaches for performing an orchidectomy are the scrotal or inguinal approaches. A routine preparation and draping of the groin is performed. It is important to clamp the cord prior to mobilising the testes to prevent squeezing tumour cells into the circulation. The cord is cut and the two ends ligated. The testis is then delivered through the inguinal canal by traction on the cord stump. The testis is released from its attachment to the scrotum and sent to histology.

Closure Haemostasis is ensured. Note: A biopsy of the contralateral testis may also be performed. Orchidectomy 6 What adjuvant treatment modalities can be undertaken? The superior margin can be marked on the side of the face by a curved line starting at the tragus of the ear running to the middle of the cheek, just below the zygomatic arch. From here a curved line drawn down to the angle of mandible marks the anterior border. The inferior border is between the angle of the mandible and the mastoid process.

When are they performed? A parotidectomy is performed to excise a tumour of the parotid gland.

This refers to the excision of the entire gland with conservation of the facial nerve. Routine preparation is applied.

It is important that draping leaves the face exposed to allow assessment of facial nerve function by visualising fascial muscle twitching. Incision A pre-auricular incision is made see diagram curving behind the ear and to the mastoid process. From here the incision is curved again down the neck along the anterior border of the sternocleidomastoid muscle.

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It is important to identify and protect the facial nerve and its branches. The position of the nerve can be further ascertained by using a nerve stimulator. If the deep lobe is to be excised the facial nerve is carefully mobilised prior to its excision. Closure The wound is closed in layers after absolute haemostasis is ensured and a suction drain is positioned. The nerve lies about 1 cm medial and inferior to the tip of this pointer. The stylomastoid foramen point of exit of the facial nerve is just medial to this suture. How can it be treated? The treatment involves reassurance and conservative measures in most instances, however local Botox injection or surgical division of the petrosal nerve tympanic neurectomy can be performed in severe cases.

Position This is supine the patient is prepared and draped as for a laparotomy. Incision Upper midline through linea alba see Chapter 24, Laparotomy.

A patch of omentum is oversawn across the perforation using Vicryl sutures. The abdomen is irrigated with copious amounts of warm saline. A drain may be placed prior to closure. Closure The abdomen is closed using mass closure technique as for a laparotomy. This will only be evident at operation and the treatment is the same as for DU. This is a congenital condition that presents in infants at around 6 weeks of age.

Hypochloraemic metabolic alkalosis. The serum potassium and sodium may also be decreased. There may even be a paradoxical acid urine as the kidneys excrete hydrogen ions in order to preserve potassium. Classically there is a history of non-bilious projectile vomiting, dehydration and failure to thrive.

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The child remains hungry after each vomiting. Clinically the thickened pylorus can be palpated in the epigastrium as an olive-sized mass. Incision Usually a right upper quadrant cutting or muscle splitting incision is used upper midline, umbilical and laparoscopic approaches may also be used. A small transverse incision is made 2 cm below the right costal margin. If this is found it should be repaired in a similar manner to duodenal perforations by using an omental patch. Closure A mass abdominal closure is undertaken. Incision The abdomen is draped and prepared as for a laparotomy and a midline laparotomy incision is made see Chapter 24, Laparotomy.

Clamps are placed on either side of the tumour to prevent intraluminal spread. The ileum is then anastomised with the transverse colon see Chapter 6, Principles of bowel anastomosis. Intraperitoneal lavage is carried out. Closure The peritoneum and the anterior abdominal wall are closed as for a laparotomy see Chapter 24, Laparotomy. What are the advantages and disadvantages of each? The two main types are full or partial thickness skin graft.

Partial-thickness grafts are available in larger sizes and can be used to cover large defects, as the donor site does not require closure. In the long Operative surgery vivas for the MRCS term however they have a poorer cosmetic outcome. There may also be problems with the donor site during the healing process. Full-thickness grafts have a better cosmetic outcome and match the surrounding skin better. There are fewer problems with the donor site as they are closed directly.

Full-thickness grafts are available in small sizes however and cannot be used to cover very large defects. These grafts are taken from the volar forearm skin. If the bed is suspected to be infected grafting must be delayed whilst the infection is treated. Friable small capillaries grow from the graft bed to supply the graft by around the 3rd day.

Sheering and movement will lead to their disruption and graft failure. Grafts are therefore secured to the bed using peripheral sutures or clips. A haematoma or a seroma in between the graft and its bed can disrupt the blood supply leading to failure. Meticulous haemostasis prior to grafting, and meshing or slitting the graft to allow escape of any collection will therefore improve graft survival. Exposed tendons, bone and neuro-vascular structures can lead to graft failure. Alternative reconstructive methods may be required. The vascular pedicle is anastomised to the host blood supply. Posterior approaches These can be midline approaches over the spinous processes with retraction of the paraspinal muscles from the lamina using a cobb retractor.

This gives good access to the posterior elements of the cervical, thoracic and lumbar spine. It is commonly used for lumbar discectomy, laminectomy and for posterior spinal instrumentation as it gives an easy route to the lamina and the pedicles. A costotransversctomy approach provides a posterolateral approach to the thoracic spine through which the lateral aspect of the vertebral body and the anterior aspect of the spinal cannal are reached without the need for a thoracotomy. A transpedicular approach refers to creating a tunnel within the pedicle to allow access to the anterior elements.

This allows access to far lateral disc herniations without the need to resect joints. Anterior approaches Anterior cervical approach, medial to sternocleidomastoid muscle, retracting the carotid sheath laterally and the trachea and the oesophagus medially, allows good access to the cervical spine as well as the T1 verteral body. A transdiaphragmatic thoracolumbar approach is used to access the anterior aspect of the thoracolumbar junction T10—L2. The anterior aspect of the lumbar spine is accessed through abdominal incisions.

This can be extra- or transperitoneal. What is the surface marking of this level? The anatomical landmark for this point is the supracristal plane, which is a plane that transects the L4 spinous process and corresponds to the highest points of the iliac crests. The skin is cleaned and the area prepared and draped. Procedure An appropriate size spinal needle is used.

The needle is entered in the midline and in the space between the L4 and L5 spinous processes see above with the needle directed caudally.

A manometer is attached; the pressure is recorded and up to 40 ml of CSF may normally be withdrawn safely. This is sent for protein, glucose, microscopy and culture. Erythromycin is given in cases of penicillin allergy.