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1) jaboulays operation 2) feeding jejunostomy 3) circumcision 4) thyroidectomy 5) tracheostomy 6)open appendicectomy 7) lap appendicectomy Procedures for table viva

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I now have sufficient detailed content from authoritative surgical textbooks. Let me compile the comprehensive table viva Q&A for all 7 procedures.

Table Viva: Surgical Procedures - Complete Q&A Guide

1. JABOULAY'S OPERATION

What is Jaboulay's operation?

It is a side-to-side gastroduodenostomy (or in the context of hydrocele - the Jaboulay/Winkelman technique for hydrocelectomy). It has two distinct surgical meanings:
(a) Jaboulay Gastroduodenostomy - a drainage procedure for the stomach (b) Jaboulay Technique for Hydrocelectomy - excisional hydrocele repair

(A) Jaboulay Gastroduodenostomy

Q: What is a Jaboulay gastroduodenostomy? A: A side-to-side anastomosis between the stomach and the duodenum that bypasses the pylorus, created without opening the pylorus itself. It is a drainage procedure for the stomach.
Q: How does it differ from Finney pyloroplasty? A: Both create a wide gastroduodenal opening but in Finney pyloroplasty, the pylorus must be included in the anastomosis - it is incised through. In a Jaboulay, the anastomosis is created between stomach and duodenum proximal and distal to the pylorus - the pylorus itself is not opened.
Q: What are the steps? A:
  1. Kocher maneuver to mobilize the duodenum
  2. Corresponding incisions on the stomach (antral gastrotomy) and duodenum proximal and distal to the pylorus
  3. Traction sutures placed between the stomach and duodenum
  4. Side-to-side anastomosis fashioned
Q: What are the indications for Jaboulay gastroduodenostomy? A: Gastric outlet obstruction, peptic ulcer disease with pyloric stenosis, as a drainage procedure after vagotomy when pyloroplasty is not feasible.
Q: What is a Jaboulay strictureplasty? A: A modification of Finney strictureplasty used in Crohn's disease, where side-to-side anastomosis is created between uninvolved healthy bowel proximal and distal to the stricture. It is used when the bowel quality at the stricture is not suitable for suturing.

(B) Jaboulay (Winkelman) Hydrocelectomy

Q: What is the Jaboulay technique in hydrocelectomy? A: An excisional technique for hydrocele repair. Steps:
  1. Incise the scrotum, deliver the testis
  2. Open the hydrocele sac
  3. Resect a portion of the parietal tunica vaginalis
  4. Evert the parietal layer of the tunica behind the testis
  5. Approximate the opposing parietal tunical edges without compressing the spermatic cord
  6. The cut edges are oversewn with 3-0 chromic suture
Q: What are the other excisional techniques for hydrocele? A: Jaboulay technique, Bottleneck procedure, Window operation, Simple excision technique
Q: When do you use Jaboulay vs Lord plication? A: Jaboulay (excisional) - for chronic, large, multiloculated, thick-walled hydroceles (lowest recurrence rates). Lord plication - for thin-walled, smaller volume hydroceles (lowest risk of hematoma).
Q: What is the Bottleneck technique? A: Trimming all but a 2-cm circumferential segment of tunica around the testis and cord structures, then tacking the tunical edges together, leaving the sac open.
Q: What is the Window technique? A: A 4-cm anterior scrotal incision, blunt dissection to the parietal tunica, then a 2.5 x 2.5 cm cruciate "window" incision into the parietal layer of the tunica vaginalis.

2. FEEDING JEJUNOSTOMY

Q: What is a feeding jejunostomy? A: Surgical placement of a feeding tube through the abdominal wall directly into the jejunum (15-20 cm distal to the ligament of Treitz) to allow enteral nutrition when the upper GI tract cannot be used.
Q: What is the Witzel/Weitzel maneuver? A: The jejunostomy tube (14-Fr rubber) is inserted into the jejunum and secured in place with a Weitzel (Witzel) tunnel - the tube is tunneled submucosally for several centimeters to prevent leakage, then brought through the abdominal wall.
Q: What are the indications? A:
  • Esophageal/gastric malignancy requiring nutritional support perioperatively
  • Severe esophageal caustic injury
  • When gastric feeding is not tolerable (gastroparesis, gastric outlet obstruction)
  • After major upper GI surgery (esophagectomy, gastrectomy)
  • Neurological dysphagia
Q: What is the advantage of jejunostomy over nasogastric feeding? A: In several RCTs, jejunostomy tube feeding demonstrated superiority over TPN and long-term nasoenteric tube feeding. Bypasses the stomach, allows feeding even with gastroparesis, lower risk of aspiration.
Q: Feeding jejunostomy vs PEG-J (percutaneous endoscopic gastrojejunostomy)? A: Dual-lumen transgastric jejunal feeding tubes (PEG-J) have lower morbidity compared to surgical jejunostomy, with the benefit of small bowel feeding plus a port for gastric decompression. Surgical jejunostomy is preferred when already operating.
Q: What are the complications? A:
  • Tube blockage/obstruction
  • Jejunal volvulus around the tube
  • Intestinal obstruction from overdistension of catheter balloon
  • Peritonitis from tube displacement
  • Diarrhea
  • Wound infection
Q: How is a laparoscopic feeding jejunostomy placed? A: Currently the standard approach - laparoscopic ports are placed, the proximal jejunum is identified 15-20 cm from the ligament of Treitz, and the tube is secured with a Witzel tunnel and tacked to the anterior abdominal wall (Stamm technique).

3. CIRCUMCISION

Q: What is circumcision? A: Surgical removal of the prepuce (foreskin) - the skin covering the glans penis.
Q: What are the indications? A:
  • Medical: Phimosis (congenital or acquired), paraphimosis, recurrent balanitis/balanoposthitis, BXO (balanitis xerotica obliterans / lichen sclerosus), carcinoma of penis
  • Religious/Cultural: Jewish, Islamic traditions
  • Prophylactic: Reduces risk of HIV, STIs, UTIs, penile cancer
Q: What are the techniques? A:
  1. Dorsal slit method - prepuce slit dorsally then excised circumferentially
  2. Sleeve resection method - two circumferential incisions, skin excised as a sleeve (most common in adults)
  3. Plastibell device - used in neonates; ring placed under prepuce, ligature tied, foreskin falls off
  4. Circumcision clamps (Gomco, Mogen clamp) - used in neonates
Q: What is the procedure (sleeve method)? A:
  1. Mark two circumferential incision lines - inner at coronal sulcus, outer 1-1.5 cm proximal to it
  2. Incise inner mucosa at coronal sulcus
  3. Retract, incise outer skin
  4. Excise the sleeve of prepuce
  5. Achieve hemostasis - ligate frenular artery
  6. Approximate inner mucosa to outer skin with interrupted absorbable (4-0 Vicryl) sutures
Q: What is the frenular artery and why is it important? A: Branch of the internal pudendal artery running along the frenulum. If not ligated during circumcision, it is the most common cause of significant post-circumcision bleeding.
Q: What are complications of circumcision? A:
  • Early: Hemorrhage (frenular artery), infection, urinary retention, meatal injury
  • Late: Meatal stenosis, skin bridge, inclusion cyst, poor cosmesis, rarely: injury to glans or urethra
  • Specific to neonates with Plastibell: Ring retention, ring slipping off
Q: What is phimosis? A: Non-retractile prepuce. Physiological phimosis up to 2-3 years is normal. Pathological phimosis (BXO) requires circumcision.
Q: What is paraphimosis? A: Retracted prepuce that cannot be reduced - forms a constricting band causing edema of glans. Emergency reduction first (manual compression, or dorsal slit), then elective circumcision.

4. THYROIDECTOMY

Q: What are the types of thyroidectomy? A:
  • Hemithyroidectomy/Lobectomy - one lobe + isthmus
  • Subtotal thyroidectomy - most of both lobes left with small remnants bilaterally
  • Near-total thyroidectomy - all thyroid tissue removed except a small remnant (<1g) near the RLN entry
  • Total thyroidectomy - all grossly visible thyroid tissue removed
Q: What are the indications for total thyroidectomy? A:
  • Differentiated thyroid cancer (papillary, follicular)
  • Medullary thyroid cancer
  • Graves' disease / toxic multinodular goiter (when surgery chosen as primary therapy per ATA guidelines - high-volume surgeon required)
  • Large goiter causing compressive symptoms
  • Thyroid lymphoma
Q: What are the indications for lobectomy alone? A: Toxic adenoma (ipsilateral lobectomy), follicular adenoma, indeterminate FNA cytology, small papillary carcinoma <1 cm (microcarcinoma)
Q: Describe the surgical technique of total thyroidectomy. A:
  1. Position: Neck extended (sandbag under shoulders), supine
  2. Incision: Kocher's collar incision - 2 finger-breadths above sternal notch, skin crease incision
  3. Subplatysmal flaps raised superiorly and inferiorly
  4. Strap muscles divided in midline (linea alba colli), or cut transversely if thyroid is very large
  5. Medial mobilization of the lobe - divide isthmus between clamps, ligate superior thyroid vessels close to the gland (to protect superior laryngeal nerve)
  6. Identify and preserve RLN - runs in the tracheoesophageal groove, enters larynx at cricothyroid joint
  7. Identify parathyroids - superior (near upper pole), inferior (near lower pole/thyrothymic ligament) - preserve with blood supply
  8. Berry's ligament - posterior suspensory ligament of thyroid; divide carefully, RLN is at highest risk here
  9. Remove lobe - repeat on other side for total thyroidectomy
  10. Check hemostasis, place drain, close in layers
Q: What nerve is at risk in thyroidectomy and why? A:
  • Recurrent laryngeal nerve (RLN): Runs in tracheoesophageal groove. Right RLN loops around right subclavian artery; left RLN loops around aortic arch (runs longer, deeper). At greatest risk near Berry's ligament. Damage = hoarseness (unilateral), respiratory distress (bilateral).
  • External branch of superior laryngeal nerve (EBSLN): Runs close to superior thyroid vessels. Damage causes loss of high-pitched phonation ("cricothyroid muscle palsy").
Q: What is the non-recurrent laryngeal nerve? A: Present on the right side only (0.5-1% of population), associated with an aberrant right subclavian artery (arteria lusoria). The nerve runs directly from the vagus to the larynx without looping. Surgeons must be aware of this anomaly to avoid injury.
Q: What are the complications of thyroidectomy? A:
ComplicationDetails
HemorrhageMost dangerous if post-op neck hematoma - causes airway compression. Open wound at bedside immediately
HypocalcemiaDue to parathyroid injury/devascularization. Presents as perioral tingling, Chvostek's sign, Trousseau's sign, tetany
RLN injuryHoarseness (unilateral), stridor/respiratory compromise (bilateral)
Thyroid stormRare, if inadequately prepared Graves' patient
HypothyroidismAfter total thyroidectomy - lifelong T4 replacement
Q: What is Chvostek's sign? Trousseau's sign? A:
  • Chvostek's: Tapping over facial nerve at angle of jaw causes ipsilateral facial muscle twitching - sign of hypocalcemia
  • Trousseau's: Inflating BP cuff above systolic for 3 minutes causes carpal spasm (main d'accoucheur) - more sensitive for hypocalcemia
Q: What is a Kocher's incision? A: Transverse neck incision placed in a skin crease 2-3 cm above the sternal notch, extending 6-8 cm. Heals as an excellent cosmetic scar.

5. TRACHEOSTOMY

Q: What is a tracheostomy? A: A surgical opening between cartilaginous rings of the trachea and the skin, with a tracheostomy tube placed into the stoma to facilitate ventilation. Usually performed as an elective/semi-elective procedure.
Q: What are the indications? A:
  • Upper airway obstruction: Head/neck malignancy, angioedema, maxillofacial trauma, upper airway tumors
  • Prolonged mechanical ventilation: Expected ventilation >7-14 days
  • Neurological: Brain injury, spinal cord injury, severe agitation, prolonged altered mental status
Q: What are the contraindications? (all relative) A: Recent anterior neck surgery (<7 days), high ventilator settings (FiO2 >50%, PEEP >10 cmH2O), elevated ICP, hemodynamic instability, significant bleeding risk, local infection/malignancy at proposed site, predicted early mortality
Q: What are the types of tracheostomy? A:
  1. Standard surgical (open) tracheostomy - performed in OT under GA
  2. Percutaneous Dilatational Tracheostomy (PDT) - bedside ICU procedure, first described by Ciaglia (1985)
  3. Emergency surgical airway/cricothyroidotomy - lifesaving when intubation fails
Q: Describe the open surgical tracheostomy technique. A:
  1. Position: Neck extended, sandbag under shoulders
  2. Incision: Horizontal (1 cm below cricoid) OR vertical midline incision between 1st and 3rd tracheal rings
  3. Divide subcutaneous fat and platysma
  4. Separate strap muscles in midline
  5. Identify and retract/divide thyroid isthmus (between sutures)
  6. Identify tracheal rings - confirm level with finger and needle
  7. Stay sutures (Bjork flap): sutures placed in tracheal rings on either side before opening
  8. Enter trachea between 2nd and 3rd rings (or 3rd and 4th) - incise cartilage. Remove an ellipse or create a Bjork flap (inferior-based flap)
  9. Dilate stoma, insert tracheostomy tube
  10. Confirm position with CO2/capnography, bag ventilation
  11. Secure tube with ties and/or suture
Q: What is a Bjork flap? A: An inferiorly based U-shaped cartilaginous flap created when entering the trachea. It is sutured to the skin to make early tube change safer.
Q: What is PDT (Percutaneous Dilatational Tracheostomy)? A: Ciaglia technique (1985). Performed at the bedside under bronchoscopic guidance:
  1. Identify 2nd/3rd tracheal interspace
  2. Needle puncture of trachea
  3. Guidewire insertion (Seldinger technique)
  4. Serial dilatation
  5. Tracheostomy tube placed over dilator
Advantages over surgical tracheostomy: Decreased wound infection, less clinically relevant bleeding, more cost-effective. Periprocedural mortality <0.2%.
Q: Between which rings is the trachea entered? A: Between the 2nd and 3rd tracheal rings (surgical) - never the 1st ring (risk of subglottic stenosis) and never below the 4th ring (risk of innominate artery erosion).
Q: What are complications of tracheostomy? A:
ImmediateEarlyLate
HemorrhageTube displacementTracheal stenosis
False passageWound infectionTracheomalacia
PneumothoraxMucus pluggingTracheo-innominate fistula
Subcutaneous emphysemaSurgical emphysemaTracheoesophageal fistula
Cardiac arrestTube obstructionDecannulation failure
Q: What is the most dangerous late complication? A: Tracheo-innominate artery fistula - life-threatening hemorrhage. Presents as "sentinel bleed" before catastrophic hemorrhage. Occurs when tracheostomy tube erodes into the innominate artery (usually from low-placed tracheostomy or over-inflated cuff).
Q: What are the types of tracheostomy tubes? A: Cuffed (prevent aspiration, used in ventilated patients), uncuffed, fenestrated (allow speech), speaking valves (Passy-Muir), silver (Negus), single-lumen vs double-lumen (inner cannula for cleaning).

6. OPEN APPENDICECTOMY

Q: What is the standard incision for open appendicectomy? A: Gridiron (McBurney's) incision - at right angles to a line joining the anterior superior iliac spine (ASIS) and umbilicus, centered on McBurney's point (junction of lateral 1/3 and medial 2/3 of this line). Alternatively, a Lanz incision (transverse, more cosmetic) may be used.
Q: What is McBurney's point? A: A point on the line from the ASIS to the umbilicus, at the junction of the outer 1/3 and inner 2/3 - corresponds to the base of the appendix on the surface.
Q: Describe the steps of open appendicectomy (gridiron approach). A:
  1. Incision: Gridiron incision at McBurney's point (skin and subcutaneous fat)
  2. External oblique aponeurosis incised in direction of its fibers
  3. Internal oblique and transversus abdominis split (not cut) along the direction of their fibers - grid-iron effect
  4. Peritoneum picked up, incised to enter peritoneal cavity
  5. Identify caecum by following the taeniae coli to the appendix base
  6. Deliver appendix - if retrocaecal, caecum may need to be mobilized
  7. Mesoappendix divided between artery forceps and ligated (appendicular artery ligated)
  8. Base of appendix crushed, ligated with absorbable suture (2-0 Vicryl)
  9. Appendix divided above ligation
  10. Stump treatment: Stump is invaginated using a purse-string then Z-stitch (or figure-of-8) into the caecal wall. (Note: Many surgeons now consider stump inversion unnecessary)
  11. Swab count, check for hemostasis
  12. Closure: Peritoneum, muscles, aponeurosis, subcutaneous fat, skin
Q: What do you do if the appendix base is gangrenous? A: Do NOT attempt ligation. Two stitches are placed through the caecal wall close to the gangrenous base, the appendix is amputated flush with the caecal wall, and these stitches tied. A second layer of interrupted seromuscular sutures closes the defect. Alternatively, resect the appendix with a cuff of healthy caecum using a linear stapler.
Q: What if you open the abdomen and the appendix appears normal? A: Inspect terminal ileum for Meckel's diverticulum, Crohn's disease, mesenteric lymphadenitis. In females, examine pelvic organs. Remove the appendix regardless (negative appendicectomy) to prevent future diagnostic confusion from the scar.
Q: What is the appendicular artery and where does it come from? A: A branch of the ileocolic artery (from superior mesenteric artery), running in the free edge of the mesoappendix. It is an end artery - hence thrombosis causes gangrene quickly.
Q: When do you give antibiotics? A: Single perioperative dose (e.g., metronidazole + cefuroxime/co-amoxiclav) reduces wound infection in uncomplicated appendicitis. Therapeutic antibiotics (covering Gram-negative bacilli + anaerobes) if peritonitis is suspected.

7. LAPAROSCOPIC APPENDICECTOMY

Q: What are the advantages of laparoscopic over open appendicectomy? A:
  • Diagnostic: allows full abdominal survey - especially valuable in women of childbearing age (can exclude ovarian/tubal pathology)
  • Lower wound infection rate
  • Quicker recovery, earlier return to activities
  • Better cosmesis
  • No increase in postoperative pelvic collection (as initially feared)
Q: What are the port positions? A: Variable by operator preference. Standard:
  1. Umbilical port (10-12 mm) - camera port (pneumoperitoneum via open infraumbilical approach)
  2. Suprapubic port (5 mm) - working port
  3. Left lower quadrant port (5 mm) - working port
Q: Describe the laparoscopic technique. A:
  1. Bladder must be empty (patient voids preoperatively, or catheter)
  2. Pneumoperitoneum established (open/Hasson technique at umbilicus)
  3. 30° camera inserted; two working ports under direct vision
  4. Patient positioned: Trendelenburg + right side elevated - shifts small bowel away from RIF
  5. Identify appendix by tracing the taeniae coli to caecum
  6. Elevate appendix with laparoscopic tissue forceps
  7. Display mesoappendix - dissect with diathermy hook/scissors or coagulate with energy device
  8. Ligate/clip appendicular vessels
  9. Base of appendix divided using:
    • Absorbable loop ligature (Roeder loop/Endoloop)
    • OR linear stapling device
  10. Appendix divided and placed in specimen bag - removed through umbilical port
  11. Stump NOT inverted (routine inversion not performed laparoscopically)
  12. Fascia closed at umbilical port (>10 mm) and any port >5 mm
Q: How is the appendix base secured laparoscopically? A: Either with absorbable loop ligatures (Endoloops) placed at the base, or a linear stapling device fired across the base. Stapling preferred when base is edematous or inflamed.
Q: What is the Roeder loop (Endoloop)? A: A pre-tied extracorporeal slip knot (absorbable suture) pushed down with a knot-pusher to ligate the appendix base laparoscopically.
Q: What is the rate of conversion to open and when do you convert? A: Conversion rate approximately 3-10%. Indications for conversion:
  • Dense adhesions preventing safe dissection
  • Retroperitoneal or complex appendix not deliverable
  • Uncontrolled bleeding
  • Uncertainty about diagnosis/anatomy
  • Inadvertent bowel injury
Q: Laparoscopic vs open: which is better for perforated appendicitis? A: Laparoscopic approach is still preferred - allows irrigation of multiple quadrants. However, some evidence suggests slightly higher risk of intraabdominal abscess formation compared to open in perforated cases. Adequate washout is essential.
Q: What is the port closure rule? A: Fascial closure is performed at all port sites >5 mm (typically 10-12 mm ports) to prevent port-site hernia.

Quick Reference: Complications Comparison Table

ProcedureSpecific Key ComplicationNerve at Risk
Jaboulay hydrocelectomyHematoma, recurrence-
Feeding jejunostomyJejunal volvulus, tube migration-
CircumcisionFrenular artery bleed, meatal stenosisDorsal penile nerve
ThyroidectomyHypocalcemia, RLN palsy, neck hematomaRLN, EBSLN
TracheostomyTracheo-innominate fistula, tracheal stenosis-
Open appendicectomyWound infection, pelvic abscess-
Lap appendicectomyPort site hernia, intraabdominal abscess-
Sources: Campbell-Walsh-Wein Urology, Bailey & Love's Short Practice of Surgery (28th ed), Sabiston Textbook of Surgery, Fischer's Mastery of Surgery (8th ed), Cummings Otolaryngology, Current Surgical Therapy (14th ed), Mulholland & Greenfield's Surgery (7th ed)
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