1. Feeding jejunostomy
   • Indications and contraindications
   • Relevant anatomy and physiology
   • Types and techniques: Witzel, needle catheter, Stamm-type variants, laparoscopic approach
   • Operative steps and key technical precautions
   • Postoperative feeding protocol and nutritional calculations
   • Complications: tube-related, intestinal, metabolic, infective
   • Troubleshooting common viva scenarios
   • Short cases and rapid-fire questions
2. Haemorrhoids
   • Definition, anatomy, cushions, and pathogenesis
   • Classification: internal, external, grade I-IV, special forms
   • History, examination, proctoscopy, and differential diagnosis
   • Conservative and office-based management
   • Operative options: open and closed haemorrhoidectomy, stapled haemorrhoidopexy, Doppler-guided ligation, etc.
   • Complications and their management
   • Emergency presentations: thrombosis, bleeding, strangulation
   • Viva cases, instruments, operative steps, and rapid-fire questions

PG General Surgery Viva Guide

Feeding Jejunostomy and Haemorrhoids

PART A: FEEDING JEJUNOSTOMY

1. Definition

2. Why use the jejunum for feeding?

• Preserves gut mucosal integrity and reduces bacterial translocation compared with exclusive parenteral nutrition.
• Delivers nutrition beyond the stomach and duodenum.
• Useful when gastric feeding is contraindicated or poorly tolerated.
• Reduces risk of aspiration compared with gastric feeding, although aspiration is not completely eliminated.
• Allows early enteral nutrition after major upper gastrointestinal surgery.

3. Indications

A. At the time of major upper GI surgery

• Oesophagectomy
• Total gastrectomy
• Pancreaticoduodenectomy, selectively depending on institutional practice
• Major gastric surgery where delayed oral intake is expected
• Complex reoperative upper GI surgery
• Severe upper GI trauma

B. When gastric feeding is unsuitable

• Gastric outlet obstruction
• Severe gastroparesis
• Persistent vomiting with an intact distal small bowel
• High aspiration risk from gastric feeding
• Proximal enterocutaneous fistula
• Severe reflux or recurrent aspiration despite gastric feeding
• Following oesophageal or gastric perforation repair, where gastric feeding should be avoided temporarily

C. Long-term enteral access

• Head and neck malignancy when gastric access is not possible or is inappropriate
• Neurological dysphagia with gastric feeding intolerance
• Short period of expected upper GI dysfunction when access beyond the pylorus is needed

D. Therapeutic use

• Feeding distal to a proximal GI fistula or leak
• Decompression plus feeding in selected situations using separate gastric and jejunal access

4. Contraindications

Absolute

• Distal small-bowel obstruction
• Bowel ischaemia or nonviable jejunum
• Diffuse peritonitis not being addressed surgically
• Uncorrectable coagulopathy
• Haemodynamic instability in which the procedure adds unacceptable risk

Relative

• Massive ascites
• Severe adhesions or hostile abdomen
• Inflammatory bowel disease involving the jejunum
• Severe malnutrition or immunosuppression, due to wound and infective risk
• Peritoneal carcinomatosis
• Very short remaining small bowel
• Inability to safely appose bowel to the abdominal wall

5. Relevant anatomy

Duodenojejunal flexure

• Located to the left of L2.
• Suspended by the ligament of Treitz.
• Jejunum begins here.

Features of jejunum

• More vascular, thicker wall, larger diameter than ileum.
• Prominent plicae circulares.
• Fewer arterial arcades and longer vasa recta compared with ileum.
• Usually select a proximal jejunal loop, approximately 20-40 cm distal to the duodenojejunal flexure, provided it reaches the abdominal wall without tension.

Blood supply

• Jejunal branches of the superior mesenteric artery.
• Venous drainage through the superior mesenteric vein to the portal vein.

Important practical principle

6. Types of jejunal access

1. Open surgical feeding jejunostomy
   • Witzel tunnel technique
   • Stamm-type jejunostomy
   • Needle catheter jejunostomy
2. Laparoscopic feeding jejunostomy
3. Radiologically inserted jejunostomy
   • Percutaneous puncture of jejunum under image guidance, guidewire placement, tract dilatation, and fluoroscopic confirmation.
4. Direct percutaneous endoscopic jejunostomy (DPEJ)
5. Gastrojejunostomy tube
   • A jejunal extension through a gastrostomy, useful if simultaneous gastric decompression is required.

7. Witzel feeding jejunostomy

Principle

Instruments

• Feeding catheter, commonly 10-14 Fr depending on patient and system
• Fine atraumatic bowel graspers
• Absorbable sutures, for example 3-0 or 4-0 polyglactin/polydioxanone
• Nonabsorbable sutures for skin fixation if desired
• Suction, electrocautery, standard laparotomy set

8. Steps of open Witzel jejunostomy

Model operative answer

1. Confirm indication and optimise the patient
   • Correct fluid and electrolyte deficits.
   • Give perioperative antibiotics where indicated.
   • Check coagulation status.
   • Confirm that distal small bowel is patent and viable.
2. Access the abdomen
   • Usually performed during the primary operation or through a small upper/mid abdominal incision.
3. Identify jejunum
   • Identify the duodenojejunal flexure.
   • Select a mobile proximal jejunal loop, often around 20-40 cm distal to the flexure.
   • Ensure the selected loop reaches the anterior abdominal wall without tension.
4. Select an abdominal wall exit site
   • Usually in the left upper abdomen.
   • Avoid scars, skin folds, costal margin, belt line, and stoma sites.
   • Make a small stab incision.
5. Place a purse-string suture
   • On the antimesenteric border of the jejunum.
   • Avoid the mesenteric vessels.
6. Create a small enterotomy
   • At the centre of the purse string.
   • Insert the feeding tube into the lumen and advance it distally.
7. Secure the entry site
   • Tie the purse string snugly around the catheter without occluding its lumen.
8. Create the Witzel tunnel
   • Place serial interrupted seromuscular sutures over the tube.
   • Bury approximately 5-7 cm of tube along the bowel wall.
   • Do not take full-thickness bites.
9. Fix jejunum to the parietal peritoneum
   • Use two or more seromuscular sutures around the tube exit site.
   • This decreases leakage and helps prevent tube traction from pulling bowel away from the abdominal wall.
10. Bring tube through the abdominal wall
    • Deliver it through the stab incision without tension or kinking.
    • Secure externally.
11. Confirm patency
    • Flush gently with sterile saline.
    • Confirm no leak, no kink, and no torsion of bowel.
12. Document
    • Technique, site, tube size, fixation method, and instructions for feeding.

9. Key technical precautions

• Use a tension-free jejunal loop.
• Avoid bowel or mesenteric twisting before fixation.
• Keep the tube directed distally.
• Avoid excessive tightening of purse-string sutures.
• Ensure a sufficient serosal tunnel.
• Fix bowel to parietal peritoneum to reduce intraperitoneal leak.
• Do not place the jejunostomy through grossly unhealthy, oedematous, irradiated, or ischaemic bowel.
• Keep tube external length documented at the skin to detect migration.
• Avoid forceful flushing of an obstructed tube.

10. Needle catheter jejunostomy

Principle

Advantages

• Smaller enterotomy
• Less operative time
• Can be useful during upper GI surgery

Disadvantages

• Smaller lumen leads to a higher risk of blockage
• Less suitable for thick feeds or crushed medications
• Tube displacement and bowel obstruction can occur

11. Laparoscopic jejunostomy

Basic steps

• Establish laparoscopic access.
• Identify the duodenojejunal flexure and choose proximal jejunum.
• Select an appropriate abdominal wall exit site.
• Fix jejunum to abdominal wall using intracorporeal sutures.
• Insert catheter through a trocar or stab wound.
• Introduce tube into bowel and secure with purse-string and serosal tunnel, or use a T-fastener/Seldinger approach depending on technique.
• Confirm distal direction, lack of tension, absence of torsion, and tube patency.

Advantages

• Smaller incision
• Less wound morbidity
• Useful when performed with laparoscopic oesophagogastric procedures

12. Postoperative feeding protocol

Before feeding

• Confirm haemodynamic stability.
• Check abdominal examination.
• Ensure tube position and external length are unchanged.
• Check patency with sterile water flush.
• Correct major electrolyte abnormalities.
• Assess for refeeding risk.

Starting feeds

• Begin with sterile water flushes, then isotonic polymeric enteral feed.
• Continuous pump feeding is preferred initially because the jejunum has limited reservoir capacity.
• Start slowly, commonly around 10-25 mL/hour, then increase according to tolerance and nutritional plan.
• Bolus feeding is generally less well tolerated in jejunal feeding.

Monitoring

• Abdominal pain or distension
• Nausea, vomiting, diarrhoea
• Tube site leak
• Fluid balance
• Blood glucose
• Sodium, potassium, magnesium, phosphate
• Weight and nutritional targets
• Evidence of sepsis or peritonitis

Nutritional targets

• Energy: 25-30 kcal/kg/day
• Protein: 1.2-2 g/kg/day, depending on illness and catabolic state

13. Refeeding syndrome

Definition

High-risk patients

• Prolonged minimal intake
• Major weight loss
• Alcohol dependence
• Malignancy
• Chronic malabsorption
• Elderly frail patients
• Very low BMI
• Low phosphate, potassium, or magnesium before feeding

Biochemical hallmark

Prevention

• Identify risk before feeding.
• Give thiamine where indicated.
• Correct electrolytes.
• Start feeds slowly.
• Monitor phosphate, potassium, magnesium, glucose, and fluid balance closely.

14. Complications of feeding jejunostomy

A. Early procedural complications

• Haemorrhage
• Bowel perforation
• Intraperitoneal leak
• Peritonitis
• Tube misplacement
• Tube kinking or blockage
• Tube dislodgement
• Wound infection
• Injury to mesenteric vessels
• Bowel ischaemia, rare

B. Mechanical complications

• Tube obstruction
• Tube migration
• Tube dislodgement
• Kinking
• Knotting
• Intussusception around the tube
• Volvulus or small-bowel obstruction due to fixation, adhesions, or internal herniation
• Buried tube or erosion into bowel wall

C. Infective and local complications

• Cellulitis
• Peristomal abscess
• Granulation tissue
• Skin excoriation from feed leakage
• Persistent enterocutaneous fistula after removal, especially after prolonged placement

D. Feed-related complications

• Diarrhoea
• Cramping
• Bloating
• Dehydration
• Hyperglycaemia
• Electrolyte disturbance
• Refeeding syndrome
• Aspiration is less likely than with gastric feeding but may still occur

15. Management of common jejunostomy problems

16. Common FJ viva questions and model answers

“When would you choose a feeding jejunostomy over a PEG?”

“Why is a Witzel tunnel made?”

“What is the most feared early complication?”

“What will you do if the tube falls out on postoperative day 3?”

“When is the tract mature?”

PART B: HAEMORRHOIDS

1. Definition

2. Anal canal anatomy relevant to haemorrhoids

Anal cushions

• Left lateral: 3 o’clock
• Right anterior: 11 o’clock
• Right posterior: 7 o’clock

Pectinate line

Why is this important?

• Internal haemorrhoids are usually painless unless prolapsed, thrombosed, strangulated, or associated with another lesion.
• Procedures such as rubber-band ligation must be performed above the dentate line to avoid severe pain.

3. Function of anal cushions

• Contribute to fine continence.
• Help seal the anal canal at rest.
• Augment the action of the internal anal sphincter.
• Allow discrimination of gas, liquid, and solid stool.

4. Pathogenesis

Current mechanism

• Degeneration and fragmentation of the fibroelastic supporting tissue and Treitz muscle.
• Sliding downward of anal cushions.
• Venous engorgement and impaired drainage.
• Repeated straining and shearing trauma.
• Mucosal prolapse and bleeding.

Risk factors

• Constipation and straining
• Prolonged toilet sitting
• Low dietary fibre
• Pregnancy
• Obesity
• Chronic diarrhoea
• Heavy lifting, possibly through raised intra-abdominal pressure
• Age-related connective-tissue degeneration
• Pelvic floor dysfunction
• Family predisposition

5. Classification

A. Internal haemorrhoids: Goligher classification

B. External haemorrhoids

C. Mixed haemorrhoids

6. Clinical presentation

Typical symptoms

• Bright-red rectal bleeding, usually painless, during or after defecation
• Prolapse
• Mucous discharge
• Pruritus ani
• Soiling
• Sensation of incomplete evacuation
• Discomfort from prolapse
• Acute severe pain if thrombosed or strangulated

Important statement in viva

7. History in a haemorrhoid patient

Bleeding

• Colour: bright red or dark
• On paper, dripping into bowl, coating stool, or mixed with stool
• Quantity and frequency
• Anaemia symptoms

Prolapse

• During defecation only or at rest
• Spontaneous reduction, manual reduction, irreducibility
• Pain, oedema, discharge

Bowel habit

• Constipation
• Straining
• Stool consistency
• Diarrhoea
• Change in bowel habit
• Tenesmus

Red flags

• Weight loss
• Iron-deficiency anaemia
• Abdominal mass
• Family history of colorectal cancer/polyposis
• New symptoms in older age
• Bleeding mixed with stool
• Persistent altered bowel habit

Risk factors and comorbidities

• Pregnancy
• Anticoagulants, antiplatelet drugs
• Bleeding disorder
• Liver disease/portal hypertension
• Immunosuppression
• Inflammatory bowel disease
• Previous anal surgery
• Continence status

8. Examination

Position

• Left lateral/Sims position is convenient in clinic.
• Lithotomy is often used in theatre.

Steps

1. Inspect the perianal region.
2. Ask patient to strain.
3. Look for prolapse, skin tags, fissure, fistula opening, dermatitis, thrombosed external haemorrhoid, malignancy, or rectal prolapse.
4. Digital rectal examination.
5. Anoscopy/proctoscopy.
6. Assess the remainder of colon when indicated.

Why perform digital rectal examination?

• Detect mass, tenderness, sphincter tone, impacted stool.
• Exclude low rectal tumour.
• However, internal haemorrhoids are often soft and may not be felt well on DRE.

Proctoscopic findings

• Enlarged vascular cushions above dentate line.
• Bleeding points.
• Degree of prolapse.
• Associated proctitis, mass, fissure, or other pathology.

9. Differential diagnosis of rectal bleeding/prolapse

Bleeding

• Anal fissure
• Colorectal cancer
• Polyps
• Inflammatory bowel disease
• Diverticular disease
• Angiodysplasia
• Proctitis
• Solitary rectal ulcer syndrome
• Rectal varices
• Anticoagulant-associated bleeding

Prolapse

• Rectal prolapse
• Mucosal prolapse
• Prolapsing rectal polyp
• Hypertrophied anal papilla
• Prolapsed thrombosed haemorrhoid

Painful anal swelling

• Thrombosed external haemorrhoid
• Perianal abscess
• Anal fissure with sentinel tag
• Strangulated internal haemorrhoid
• Anal malignancy, rarely

10. Investigations

Basic evaluation

• Full blood count if significant or recurrent bleeding.
• Coagulation profile if on anticoagulants, liver disease, or suspected coagulopathy.
• Proctoscopy/anoscopy.

Colonoscopy or flexible sigmoidoscopy

• Age and screening eligibility
• Anaemia
• Red-flag symptoms
• Family history
• Change in bowel habit
• Persistent bleeding despite treatment
• Uncertain diagnosis

11. Conservative treatment

Components

• Increase dietary fibre.
• Adequate oral fluids.
• Avoid straining and prolonged toilet sitting.
• Treat constipation with fibre supplementation and stool softeners where appropriate.
• Regular exercise and weight management.
• Avoid unnecessary topical agents used for prolonged periods.
• Sitz baths may improve comfort, although evidence is limited.
• Short-term topical local anaesthetic or steroid preparations may help symptoms but do not cure haemorrhoids.
• Consider phlebotonic medication where locally used, recognising that practice varies.

12. Office procedures

A. Rubber-band ligation (RBL)

Principle

Best indications

• Grade I and II internal haemorrhoids
• Selected grade III haemorrhoids
• Persistent bleeding/prolapse despite conservative therapy

Technique

1. Proctoscopy.
2. Identify the haemorrhoidal cushion.
3. Ensure application is above the dentate line.
4. Suction or grasp tissue into ligator.
5. Deploy band at base.
6. Ask about immediate severe pain. If pain occurs, remove the band and reapply higher.

Complications

• Pain due to low placement
• Bleeding, often delayed at 7-14 days when slough separates
• Urinary retention
• Vasovagal symptoms
• Thrombosed external haemorrhoid
• Pelvic sepsis, rare but life-threatening
• Recurrence

Contraindications or cautions

• Active anorectal sepsis
• Significant coagulopathy
• Anticoagulation/antiplatelet therapy, after individualised assessment
• Immunosuppression, relative caution
• Significant inflammatory bowel disease, especially active proctitis
• Pregnancy is not an absolute contraindication, but conservative treatment is usually preferred unless compelling symptoms occur

B. Injection sclerotherapy

Principle

Indications

• Mainly bleeding grade I-II haemorrhoids
• Frail patients
• Patients in whom banding is unsuitable

Complications

• Pain if injection is too low
• Ulceration
• Bleeding
• Infection
• Rare prostate, bladder, vaginal, or rectal injury from incorrect placement

C. Infrared coagulation

Principle

Indications

• Small grade I-II bleeding internal haemorrhoids

Limitations

• Often requires repeated sessions.
• Less useful for large prolapsing grade III-IV disease.

D. Doppler-guided haemorrhoidal artery ligation (HAL/THD)

Principle

Advantages

• Less postoperative pain than excisional haemorrhoidectomy in some patients.
• No tissue excision.

Disadvantages

• Recurrence, particularly with advanced prolapse.
• Requires equipment and expertise.

E. Stapled haemorrhoidopexy

Principle

Indications

• Selected circumferential grade III prolapse
• Some grade IV prolapse in experienced hands, though results require careful selection

Advantages

• Less early postoperative pain than conventional excisional haemorrhoidectomy.
• Faster recovery in some patients.

Disadvantages and concerns

• Does not remove external haemorrhoidal component.
• Higher recurrence/prolapse rates than excisional surgery in many comparisons.
• Rare but severe complications: rectal perforation, pelvic sepsis, rectovaginal fistula, severe bleeding, and chronic pain.

13. Indications for surgery

• Grade III haemorrhoids with significant symptoms, especially if recurrent after office procedures
• Grade IV haemorrhoids
• Large external component or mixed internal-external disease
• Recurrent disease after banding/sclerotherapy
• Strangulated or irreducible prolapsed haemorrhoids, after initial assessment and stabilisation
• Patient preference after appropriate counselling
• Diagnostic uncertainty requiring examination under anaesthesia and biopsy where malignancy is possible

14. Excisional haemorrhoidectomy

A. Open haemorrhoidectomy: Milligan-Morgan

Principle

Basic steps

1. Anaesthesia and appropriate position.
2. Anal dilation is usually avoided or minimised because excessive dilation may injure sphincters.
3. Examine anus and rectum.
4. Identify major haemorrhoidal columns.
5. Grasp the haemorrhoid.
6. Make a V-shaped incision in anoderm around the external component.
7. Dissect in the submucosal plane, preserving internal sphincter.
8. Ligate/transfix the vascular pedicle at its apex.
9. Excise the haemorrhoidal tissue.
10. Leave adequate skin and mucosal bridges between excision sites.
11. Haemostasis, local dressing, analgesia plan.

Key principle

B. Closed haemorrhoidectomy: Ferguson

Principle

Potential advantages

• May reduce postoperative wound care burden.
• Some surgeons report earlier wound healing.

Potential disadvantages

• Wound dehiscence
• Infection
• Possible discomfort due to closure under tension

C. Energy-device haemorrhoidectomy

• LigaSure
• Harmonic scalpel
• Other vessel-sealing devices

Potential advantages

• Reduced operative time
• Better haemostasis
• May reduce early pain in some studies

Caveat

15. Complications after haemorrhoidectomy

Early

• Severe pain
• Primary/reactionary bleeding
• Urinary retention
• Constipation due to pain and opioid use
• Faecal impaction
• Wound infection
• Perianal abscess
• Urinary tract infection
• Thrombosis of residual external haemorrhoids

Delayed

• Secondary haemorrhage, often around 7-14 days
• Anal stenosis
• Skin tags
• Nonhealing wound
• Fissure
• Chronic pain
• Recurrence
• Faecal urgency
• Incontinence, usually due to sphincter injury or excessive dilation
• Rare rectovaginal fistula or deep pelvic sepsis

Prevention

• Meticulous haemostasis
• Preserve mucocutaneous bridges
• Avoid sphincter injury
• Multimodal analgesia
• Stool-softening regimen and high-fibre diet
• Clear written advice about delayed bleeding and return precautions

16. Acute thrombosed external haemorrhoid

Presentation

• Sudden onset severe anal pain.
• Tender bluish-purple perianal lump.
• Often follows constipation, straining, exercise, pregnancy, or diarrhoea.

Management

• Analgesia
• Stool softeners/fibre
• Sitz baths
• Local care
• Excision under local anaesthesia can be considered in selected patients with severe pain presenting early, often within approximately 48-72 hours.
• Late presentation is generally managed conservatively unless symptoms are severe or diagnosis is uncertain.

17. Strangulated prolapsed internal haemorrhoids

Features

• Irreducible prolapse
• Oedema
• Severe pain
• Congestion, thrombosis, or ulceration
• Possible necrosis

Management

• Assess urgently.
• Exclude other pathology and sepsis.
• Analgesia, fluid resuscitation where needed, bowel regulation.
• Manual reduction may occasionally be possible after analgesia and oedema reduction.
• Urgent operative management may be required in selected patients with strangulation, necrosis, uncontrolled bleeding, or failed conservative management.

18. Haemorrhoids in pregnancy

Key points

• Common due to constipation, increased pelvic venous pressure, and hormonal changes.
• Most improve after delivery.
• First-line management is conservative: fibre, fluids, stool softeners, local symptom control.
• Avoid elective operative treatment unless there is major complication such as severe thrombosis, strangulation, or uncontrolled bleeding.

19. Haemorrhoids in anticoagulated patients

• Assess thrombotic risk before interrupting antithrombotic therapy.
• Liaise with the prescribing physician/cardiology/haematology team where needed.
• Correct significant coagulopathy.
• Office procedures and surgery may carry increased bleeding risk.
• Do not stop anticoagulants reflexively without assessing indication, such as mechanical heart valve, recent venous thromboembolism, or recent coronary stenting.

20. Rapid-fire haemorrhoid viva questions

“At what positions do primary internal haemorrhoids occur?”

“Why are internal haemorrhoids painless?”

“Why is rubber-band ligation done above the dentate line?”

“What is Goligher grade III disease?”

“What is the definitive operation for grade IV mixed haemorrhoids?”

“What is the major technical cause of anal stenosis after haemorrhoidectomy?”

“What is the commonest immediate complication after haemorrhoidectomy?”

“When does secondary haemorrhage occur?”

“How do you distinguish rectal prolapse from prolapsed haemorrhoids?”

Final 60-second viva summary

Feeding jejunostomy

Haemorrhoids