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Cystic Duct, Common Hepatic Duct, Inferior edge of the Liver.
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Cystic artery is often mistaken for the common hepatic duct, always achieve the critical view of safety before clipping.
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Visualising the cystic artery and cystic duct entering the gallbladder prior to clipping.
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Most important step to prevent bile duct injury.
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Cystic artery – a branch of the hepatic artery.
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Can have double cystic arteries, often runs behind cystic duct.
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Symptomatic cholelithiasis, Acute cholecystitis, Choledocholithiasis, Gallstone pancreatitis, Porcelain gallbladder.
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Asymptomatic stones → no surgery, Early cholecystectomy (<72 hours) reduces complications.
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Grade 1: Bleed only, Grade 2: Prolapsed but can be reduced spontaneously, Grade 3: Prolapse requiring manual reduction, Grade 4: Irreducible.
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Grade 2 office procedures like banding; Grade 3-4 often need surgery.
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Inferior rectal branch of the pudendal nerve somatic nerve below dentate line.
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Internal hemorrhoid treatment is less painful due to visceral innervation above the dentate line.
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Fiber + stool softeners, sitz bath, topical nitro-glycerine, topical calcium channel blockers (diltiazem, nifedipine).
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If refractory lateral internal sphincterotomy is done.
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Incision and Drainage; antibiotics added only if systemic signs of infection.
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Antibiotics alone are never enough; about 30-40% develop a fistula afterward.
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Medial: Rectus Abdominis, Lateral: Inferior Epigastric Vessels, Inferior: Inguinal Ligament.
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Direct hernias protrude through this triangle.
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Ilioinguinal nerve runs on top of the spermatic cord and crosses the medial aspect of the inguinal canal.
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Injury can cause chronic groin pain.
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An anatomic danger zone in laparoscopic hernia repair and contains the external iliac artery, external iliac vein and genital branch of the genitofemoral nerve.
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Injury here can cause catastrophic bleeding. Mesh is laid over it but never stapled.
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Anatomic region which contains: Lateral femoral cutaneous nerve, Femoral branch of Genitofemoral nerve and Femoral nerve.
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Injury to these vessels can cause chronic neuropathic pain (inguinodynia).
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Sleeve gastrectomy can worsen or newly cause GERD due to reduced gastric compliance + increase intragastric pressures + loss of gastric fundus.
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If patient has pre-existing GERD or Barrett’s, then RYGB is preferred. Post sleeve GERD with persistent symptoms usually EGD + possible conversion is done.
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An internal hernia that occurs post RYGB: through the space behind the Roux limb and the transverse mesocolon.
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Most common LATE cause of abdominal pain post RYGB. Can cause a closed loop obstruction surgical emergency.
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Rapid gastric emptying into the small bowel post RYGB can cause cramping or diarrhea within 10-30 minutes OR hypoglycaemia from insulin surge within 1-3 hours.
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Treatment is small and frequent meals and avoiding simple carbs.
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Peptic ulcer that forms at the gastrojejunal anastomosis after RYGB; develops where acidic gastric pouch contents contact the unprotected jejunal mucosa.
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Epigastric pain, nausea vomiting post RYGB. Treat with PPI + sucralfate.
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1 month CTA, 6 month CTA, 12 month CTA, and then yearly.
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Sac growth > 5mm investigate for an endoleak.
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Men 5.5cm+, Women 5cm+, Symptomatic or Rapidly expanding (>0.5cm in 6 months).
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Symptomatic aneurysm emergent repair, regardless of size.
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Rest pain, non-healing ulcers, or gangrene caused by PAD. ABI is usually < 0.4.
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Most common cause is multilevel atherosclerotic disease (inflow + outflow).
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SCI can be caused due to interruption of spinal cord blow flow from: segmental arteries, Artery of adamkiewicz, or hypogastric circulation. Risk increases when long segments of the thoracic or abdominal aorta are covered, especially T8-L2 region.
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Maintain intraoperative MAP > 80-90 mmHg. Can present with anterior cord syndrome.
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Prior radiation to chest region, diffuse disease, persistent positive margins after attempts, pregnancy requiring immediate radiation.
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BRCA mutation is NOT a contraindication.
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Express estrogen or progesterone receptors: treat with tamoxifen in premenopausal women or aromatase inhibitors in postmenopausal women.
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These tumours have the best prognosis. ER+ and PR- suggests an aggressive phenotype. Endocrine therapy is continued for 5-10 years.
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HER2 is a growth factor receptor that drives aggressive tumour proliferation.
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Respond well to Trastuzumab and if treated, outcomes are excellent.
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Defined by pectoralis minor: Level 1 is lateral to pec minor; Level 2 is deep/posterior to pec minor and Level 3 is medial to pec minor.
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Sentinel nodes are usually level 1-2. Level 3 dissection carries the highest risk for lymphedema.