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SURGERY UNIVERSITY EXAM - 10 MARK ANSWERS

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Q1. Various Pancreatic Function Tests and Their Interpretation

A. Direct (Invasive) Tests

• Gold standard for exocrine function
• IV secretin (stimulates HCO3- secretion) + CCK (stimulates enzyme secretion) are administered
• A triple-lumen tube is passed into the duodenum; gastric juice and duodenal juice are separately aspirated using a non-absorbable marker (polyethylene glycol) to assess completeness
• Normal: Volume >2 mL/kg/hr, HCO3- >80 mEq/L, enzyme output normal
• Reduced HCO3- and enzyme output = exocrine insufficiency (chronic pancreatitis, pancreatic cancer)

• Physiological stimulus: a standardized liquid meal (fat + protein + carbohydrate) is given orally
• Duodenal aspiration over 2 hours; measures trypsin concentration
• Normal trypsin: >6 IU/L
• Low trypsin = exocrine insufficiency
• Less sensitive than secretin-CCK test; affected by gastric emptying

B. Indirect (Non-Invasive) Tests

• Nitroblue tetrazolium-para-aminobenzoic acid (NBT-PABA) is taken orally
• Pancreatic chymotrypsin cleaves the compound → free PABA is absorbed by intestine and excreted in urine
• Urinary PABA measured at 6 hours
• Normal: >50% recovery; <50% suggests exocrine insufficiency
• Non-specific: falsely low in gastric resection, celiac disease, renal impairment

• Fluorescein dilaurate taken orally; cleaved by arylesterase from pancreatic juice
• Free fluorescein absorbed, excreted in urine
• Day 1: with a high-fat breakfast (test); Day 2: free fluorescein given (control)
• Ratio <30% = exocrine insufficiency

• Most widely used non-invasive test in clinical practice
• Elastase is stable in stool (not degraded by colonic bacteria)
• Normal: >200 μg/g stool
• Mild insufficiency: 100-200 μg/g
• Severe insufficiency: <100 μg/g
• Advantages: simple, cheap, specific, unaffected by enzyme replacement therapy

• Patients on a standard 100g fat/day diet; stool collected for 72 hours
• Normal: <7g fat/day
• Steatorrhea (>7g/day) indicates severe exocrine insufficiency
• Requires fat malabsorption >90% to become abnormal - insensitive early marker

• Stable isotope labelled substrate taken orally; pancreatic enzymes cleave it → 13CO2 exhaled
• Non-invasive, safe, can be done in outpatient setting

C. Endocrine Function Tests

• Assess beta-cell (insulin) function
• Impaired glucose tolerance or overt diabetes in chronic pancreatitis

• C-peptide reflects endogenous insulin secretion
• Low in pancreatogenic (type 3c) diabetes

• Assesses residual beta-cell reserve

Interpretation Summary

• Bailey and Love's Short Practice of Surgery 28th Ed, p. 1284

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Q2. Pancreatic Stones (Pancreatic Calculi) and Management

Definition

Pathogenesis

• Chronic inflammation → protein plugs form in ducts → calcification → obstruction → ductal hypertension → pain and parenchymal damage
• Alcohol is the most common cause (70-80%); tropical pancreatitis (nutritional), hereditary, idiopathic, hyperparathyroidism also cause stones

Clinical Features

• Recurrent severe epigastric pain radiating to back, often post-prandial
• Steatorrhoea (fat malabsorption)
• Diabetes mellitus (endocrine failure)
• Jaundice (common bile duct obstruction by stricture or stone)
• Weight loss

Investigations

• Plain X-ray abdomen: calcifications along pancreatic axis ("chain of lakes")
• CT abdomen (gold standard): unenhanced phase best for calcifications; shows ductal dilatation, parenchymal changes, complications
• MRI/MRCP: non-invasive ductal anatomy, stricture assessment
• Endoscopic Ultrasound (EUS): sensitive, early detection
• ERCP: gold standard for duct anatomy, therapeutic access

Management

1. Conservative / Medical

• Abstinence from alcohol and smoking (essential)
• Low-fat diet
• Pancreatic enzyme replacement (PERT) for malabsorption
• Analgesics: NSAIDs, tramadol, pregabalin; opioids if severe
• Antioxidants (some evidence in tropical pancreatitis)
• Insulin for diabetes

2. Endoscopic Management

• ESWL (Extracorporeal Shock Wave Lithotripsy): fragmentation of stones >5 mm; 1-3 sessions needed; followed by ERCP for stone extraction
• ERCP + Sphincterotomy + Stone Extraction: for smaller stones, stones at the ampullary end; balloon or basket extraction
• Pancreatic Duct Stenting: for dominant strictures; improves drainage; temporary stenting or multiple stents
• EUS-guided procedures: drainage, rendezvous techniques

3. Surgical Management

• Partington-Rochelle (Modified Puestow) Procedure: lateral pancreaticojejunostomy; main pancreatic duct opened along its full length, anastomosed side-to-side with a Roux-en-Y loop of jejunum; stones removed; 80% pain relief
• Original Puestow-Gillesby: caudal pancreatectomy + pancreaticojejunostomy (now rarely done)

• Whipple Procedure (PD): for head-predominant disease, suspected malignancy
• Frey Procedure: local resection of head + lateral pancreaticojejunostomy; preserves more parenchyma; good for head-dominant disease
• Beger Procedure: duodenum-preserving pancreatic head resection
• Distal pancreatectomy: tail/body stones with distal duct obstruction

Algorithm

• Small stones, dilated duct → ERCP + stone extraction ± stenting
• Large/multiple stones → ESWL → ERCP
• Failed endotherapy, dilated duct → Partington-Rochelle
• Head-predominant disease → Frey/Whipple
• Suspected malignancy → Whipple

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Q3. Different Methods of Cholecystectomy

1. Open Cholecystectomy (Conventional)

• Access peritoneal cavity
• Expose hepatoduodenal ligament
• Identify and dissect Calot's triangle: CVS (Critical View of Safety) - two structures (cystic duct + cystic artery) entering gallbladder
• Ligate and divide cystic artery and cystic duct
• Retrograde or fundus-first dissection of gallbladder from liver bed
• Haemostasis of liver bed

2. Laparoscopic Cholecystectomy (Gold Standard)

• 10mm umbilical port (camera)
• 5mm epigastric port (liver retractor)
• 5mm right hypochondrium (dissecting instrument)
• 5mm right iliac fossa (fundus grasper)

1. Pneumoperitoneum with Veress needle (or Hasson open technique)
2. 30° telescope inserted at umbilicus
3. Fundus of gallbladder retracted superiorly; Hartmann's pouch retracted laterally
4. Dissection of peritoneum at hepatocystic triangle - achieve Critical View of Safety (CVS):
   • Lower third of gallbladder separated from liver
   • Hepatocystic triangle free of fat/fibrotic tissue
   • Only two structures entering gallbladder
5. Clip (titanium × 2 proximal, × 1 distal on cystic duct and artery) and divide
6. Gallbladder dissected from liver bed using electrocautery
7. Extraction via 10mm umbilical port (endobag if stones spilled or thick wall)
8. Port closure

3. Mini-Laparotomy (Mini-Lap) Cholecystectomy

• 3-4 cm right subcostal incision
• Uses a specifically designed retractor (Cuschieri mini-retractor) with a rod lens illumination system
• Similar steps to open cholecystectomy
• Advantages: Avoids laparoscopic equipment, good cosmesis, less pain than standard open
• Used in developing countries; useful when laparoscopy unavailable

4. Single Incision Laparoscopic Surgery (SILS / SILC)

• All ports placed through a single multi-channel access device at the umbilicus
• Articulating instruments required
• Advantages: Better cosmesis (scarless)
• Disadvantages: Technically demanding, loss of triangulation, higher conversion rate, longer operating time

5. Robotic Cholecystectomy (Da Vinci System)

• Robotic arms replace laparoscopic instruments
• 3D visualization, wristed instruments, tremor filtration
• Advantages: Better dexterity, 3D vision
• Disadvantages: Expensive, longer setup time, no tactile feedback, no proven benefit over standard laparoscopy for routine cholecystectomy
• Role primarily in training and complex cases

6. Natural Orifice Transluminal Endoscopic Surgery (NOTES)

• Transgastric (through stomach) or transvaginal approach
• No abdominal incisions
• Mainly experimental; transvaginal NOTES cholecystectomy has been performed clinically in some centers
• Issues: access, closure, infection risk, limitation of instrumentation

7. Subtotal (Partial) Cholecystectomy

• Performed when safe dissection of Calot's triangle is impossible (Mirizzi syndrome, "frozen Calot's", severe inflammation)
• Types:
  • Fenestrating: gallbladder opened, stones removed, posterior wall left in situ on liver, cystic duct controlled from inside
  • Reconstituting: fundus to safety zone; stump closed; leaves no open fundus
• Reduces bile duct injury risk in difficult cholecystectomy

Comparison Summary

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Q4. Various Procedures for Rectopexy

Classification of Surgical Approaches

• Perineal approaches (for high-risk/elderly patients)
• Abdominal approaches (definitive treatment, lower recurrence)

A. Abdominal Rectopexy (Open / Laparoscopic)

• Rectum fully mobilized down to levator ani (posterior and lateral mobilization)
• Rectum pulled cephalad (upward) and fixed to the presacral fascia at S3 level using non-absorbable sutures (polypropylene) on both lateral sides
• No mesh used
• Recurrence ~10%; good for constipated patients (no anterior mobilization)

• Mesh sling placed anteriorly around the rectum
• Mesh anchored to sacral promontory
• Complication: obstructive defecation due to anterior constriction (sling syndrome), infection; less popular now

• Mesh (Ivalon sponge - now Prolene/Gore-Tex) placed posterior to rectum
• Mesh sutured to sacrum and lateral walls of rectum
• Rectum pulled up and fixed
• Recurrence <5%
• Disadvantage: mesh infection, sepsis; constipation in 50%

• Two strips of mesh from lateral sides of rectum to the sacral promontory
• Good results; mesh used bilaterally

• Rectopexy (suture or mesh) + sigmoid colectomy
• Addresses redundant sigmoid colon and constipation
• Reduces recurrence rate and improves constipation
• Preferred when patient has preoperative constipation or redundant sigmoid

• Currently the most popular laparoscopic technique
• Anterior dissection of rectum and posterior vaginal wall only (avoids posterior mobilization - preserves autonomic nerves)
• Mesh sutured to anterior aspect of rectum at the puborectalis level, then fixed to sacral promontory
• Addresses both rectal prolapse and rectocele/enterocele simultaneously
• Lower constipation rate, preserves nerve function, good for women with ODS (Obstructed Defecation Syndrome)
• Recurrence ~3-5%

B. Laparoscopic Rectopexy

• 4-5 port technique
• 30° scope, patient in Lloyd-Davis position
• Same principles as open; better visualization of presacral space
• Advantages: less blood loss, faster recovery, shorter hospital stay
• Robotic-assisted rectopexy also described

C. Perineal Approaches (for High-Risk Patients)

• Rectal mucosal sleeve resection: mucosa stripped from the prolapsed segment
• Underlying muscle wall plicated with sutures (plication of muscularis)
• Mucosa reapproximated
• Lower recurrence vs. Thiersch wire; higher than abdominal approaches (~10-25%)
• Suitable for elderly/high-risk patients, smaller prolapses

• Full-thickness resection of prolapsed bowel through the perineal route
• Redundant rectosigmoid excised; coloanal anastomosis performed
• Levatoroplasty often added (reduces incontinence)
• Suitable for large prolapse, high-risk patients
• Recurrence ~15-20% (higher than abdominal)

• Silver wire or nylon encircles the anus to reduce the opening
• Largely abandoned due to high complication rate (wire breakage, fecal impaction, incontinence, infection)

Choice of Procedure

• Fit patient, first time: Laparoscopic ventral (mesh) rectopexy or laparoscopic resection rectopexy
• Constipation predominant: Resection rectopexy
• Elderly/frail: Delorme or Altemeier
• Internal intussusception: Ventral rectopexy
• Concomitant rectocele/enterocele in women: Ventral rectopexy (D'Hoore)
• Schwartz's Principles of Surgery 11th Ed, p. 1333

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Q5. TAR (Transversus Abdominis Release) Technique

Definition

Concept

Indications

• Large and complex ventral/incisional hernias (fascial defect >10 cm or >25% of abdominal wall)
• Loss of domain hernias
• Cases requiring medial myofascial advancement for tension-free midline closure
• Lateral hernias (lumbar, flank)
• Recurrent hernias with multiple previous repairs
• Hernias with significant comorbidities

Anatomy

• Posterior rectus sheath is incised at its lateral edge
• Retromuscular space dissected laterally
• Transversus abdominis (TA) muscle identified and incised at its medial aspect along its length
• This releases the TA and enters the preperitoneal space (between TA and transversalis fascia/peritoneum)
• Dissection is extended laterally to the retroperitoneal space (reaching the psoas muscle)
• This space is devoid of neurovascular bundles (which travel between TA and internal oblique), preserving them

Surgical Steps

1. Midline laparotomy or re-entry through previous incision
2. Reduction of hernia contents
3. Development of retromuscular (Rives-Stoppa) space bilaterally by incising the posterior rectus sheath
4. Lateral dissection reaches the lateral edge of the posterior rectus sheath
5. Incision of the posterior rectus sheath at its lateral attachment
6. Identification and incision of the transversus abdominis muscle medially in a longitudinal direction
7. Entry into the preperitoneal plane (between TA and transversalis fascia)
8. Blunt dissection extends this plane laterally to the retroperitoneum, superiorly to the diaphragm, inferiorly to the retropubic space (Retzius)
9. This creates a large space for mesh placement
10. Peritoneal/posterior fascial closure: The posterior fascial layer is closed in the midline (often with barbed suture), separating the mesh from bowel
11. Mesh placement: A very large prosthetic mesh (polypropylene or biologic) placed in the preperitoneal/retromuscular space - extends well beyond hernia defect on all sides
12. Anterior fascial closure: Midline fascia closed primarily, tension-free
13. Drains placed

Advantages

• Creates the largest mesh space of any technique
• Mesh in ideal biologic position (retromuscular/preperitoneal) - lower infection rate vs. onlay
• Preserves neurovascular supply to rectus (vs. anterior component separation which may denervate)
• Allows tension-free closure of large defects
• Suitable for contaminated fields (biologic mesh option)

Disadvantages / Complications

• Technically complex; steep learning curve
• Risk of peritoneal/visceral injury
• Seroma (most common - managed by drains/aspiration)
• Mesh infection, hernia recurrence
• Abdominal compartment syndrome (if closure too tight)
• Requires preoperative assessment of loss of domain (LOD)

Outcomes

• Recurrence rate: 5-10% for complex hernias (superior to traditional repairs)
• Wound complication rate: ~15-20%
• Pneumoperitoneum (botulinum toxin injection) used preoperatively in LOD cases to expand abdominal cavity

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Q6. Laparoscopic Anterior Resection

Definition

Indications

• Carcinoma of rectosigmoid junction, upper/mid rectum
• Some lower rectal cancers (with adequate distal margin)
• Diverticular disease (sigmoid)
• Inflammatory bowel disease

Preoperative Preparation

• Bowel preparation (oral polyethylene glycol) + antibiotics
• Stoma marking if temporary ileostomy anticipated
• Cross-match, DVT prophylaxis
• MRI pelvis for staging and TME plane assessment (R0 resection planning)
• Ureteric stents in complex cases

Patient Position

• Lloyd-Davis (modified lithotomy): legs in stirrups, slight Trendelenburg, right lateral tilt
• Surgeon stands to patient's right; camera assistant to the right; assistant to the left

Port Placement (Standard 4-5 Port)

• 10/12 mm umbilical port (camera)
• 12 mm right iliac fossa (dominant hand)
• 5 mm right hypochondrium (retractor)
• 5 mm left iliac fossa (assistant)
• Optional 5 mm suprapubic

Key Operative Steps

• 30° laparoscope; survey abdominal cavity, confirm resectability

• Sigmoid mesentery elevated; IMA (inferior mesenteric artery) identified at its origin
• IMA divided just distal to its origin (high tie) or between LCA and first sigmoid artery (low tie) depending on cancer level and need for splenic flexure mobilization
• Inferior mesenteric vein (IMV) divided at inferior border of pancreas
• Embryological avascular plane developed medially to laterally (lifting mesentery off retroperitoneum)

• Left lateral peritoneal attachments divided (white line of Toldt)
• Splenic flexure mobilized when needed for tension-free anastomosis

• Peritoneal incision at sacral promontory → enter avascular presacral holy plane
• Sharp dissection follows mesorectal fascia propria all around rectum
• Posterior: presacral space; lateral: lateral ligaments (autonomic nerves preserved)
• Anterior: Denonvilliers' fascia (seminal vesicles and prostate in men; vagina in women)
• TME extends to the level of the pelvic floor (levator ani)

• Distal margin confirmed (minimum 1 cm distal to palpable tumour, 2 cm ideal)
• Transected with laparoscopic linear stapler (endo GIA) - may require 2-3 firings
• ICG fluorescence angiography - increasingly used to confirm adequate perfusion at anastomotic site

• Pfannenstiel or left iliac fossa extraction incision
• Specimen delivered; proximal bowel transected with adequate proximal margin (5 cm minimum for cancer)
• Anvil of circular stapler inserted into proximal bowel end; purse-string suture placed

• Pneumoperitoneum re-established
• Transanal end-to-end anastomosis using circular stapler (EEA)
• Colorectal anastomosis created under laparoscopic vision
• Doughnuts inspected for completeness; air-leak test performed

• Loop ileostomy fashioned if:
  • Anastomosis <5 cm from anal verge
  • Tension on anastomosis
  • Incomplete doughnuts
  • Male patient, irradiated pelvis, prolonged surgery, steroid use

Oncological Principles

• High ligation of IMA for lymph node clearance (D3 dissection in Japanese classification)
• En bloc resection within mesorectal fascial envelope (R0 resection)
• No-touch technique: vascular ligation before tumour mobilization
• Lateral lymph node dissection in selected cases

Conversion Indications

• Bulky tumour, narrow pelvis, obesity (BMI >35), bleeding, adhesions, inability to identify safe planes

Advantages over Open

• Less blood loss (median 100 vs. 300 mL)
• Faster return of bowel function
• Shorter hospital stay
• Less wound complications
• Equivalent oncological outcomes (CLASICC, COLOR II trials)

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Q7. Loss of Domain for Hernia

Definition

Pathophysiology

• Herniated bowel occupies the sac for years/decades
• Peritoneal cavity shrinks due to lack of contents
• Diaphragm rises; lung bases collapse
• Return of contents would cause:
  • Abdominal compartment syndrome (intraabdominal pressure >20 mmHg)
  • Respiratory failure (diaphragm pushed up)
  • Inferior vena cava compression → reduced venous return → cardiovascular compromise

Assessment

• Long-standing hernia (>5-10 years)
• Irreducible large hernia occupying significant portion of abdomen
• Respiratory distress/limitation

• CT abdomen + pelvis with contrast
• Measure hernia sac volume and peritoneal cavity volume
• LOD ratio = hernia sac volume / (hernia sac + peritoneal cavity volume)
• LOD >20-25%: clinically significant loss of domain
• LOD >40%: extreme risk; often requires staged repair with preoperative preparation

Preoperative Optimization (Prehabilitation)

• Incremental daily insufflation of CO2 or air into the peritoneal cavity via a Veress needle or Tenckhoff catheter
• Stretches the peritoneal cavity over 1-3 weeks
• Allows gradual accommodation of hernia contents
• Increases abdominal domain before surgery
• Requires daily monitoring, patient hospitalization or outpatient if well-trained
• Volumes: start 500 mL/day, increase to 2000 mL/day

• Currently the most widely used preoperative technique
• CT/ultrasound-guided injection into bilateral lateral abdominal wall muscles (external oblique, internal oblique, transversus abdominis)
• Causes muscle relaxation → increases abdominal wall compliance → allows return of hernia contents
• Dose: 300-500 IU total (distributed in 3 muscles each side)
• Effect appears in 2-3 weeks, peaks at 4-6 weeks, lasts 3-4 months
• Increases abdominal wall surface area, facilitates myofascial advancement at repair
• Often combined with PPP for very large LOD

• Anaesthesiologist (CPET - cardiopulmonary exercise testing)
• Pulmonologist (PFTs, chest X-ray)
• Nutritionist
• Radiologist (CT volumetry)

Surgical Management

• Achieve tension-free closure of fascia
• Use component separation technique (TAR, ACS) to advance myofascial flaps
• Large mesh reinforcement (synthetic or biologic based on contamination)

1. Open repair with component separation + TAR - most common approach
2. Biologic mesh if contaminated field (Class II-III wounds)
3. Staged repair: initial hernia reduction without mesh; second-stage definitive repair after abdominal compliance achieved

• Intra-abdominal pressure (Foley catheter intraperitoneal measurement)
• Peak airway pressure
• Target: IAP <15 mmHg, PIP <30 cmH2O after repair

• ICU monitoring mandatory
• Ventilatory support may be needed
• Abdominal binder
• DVT prophylaxis
• Early physiotherapy
• Watch for abdominal compartment syndrome

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Q8. Various Secretion Cells of the Stomach and Physiology of Stomach and Duodenum

A. Secretory Cells of the Stomach

B. HCl Secretion by Parietal Cells

• H+/K+ ATPase (proton pump) on apical membrane pumps H+ into lumen in exchange for K+
• Carbonic anhydrase: CO2 + H2O → H2CO3 → H+ + HCO3-
• HCO3- exits basolaterally (Cl-/HCO3- exchanger) → "alkaline tide" in blood postprandially
• Cl- enters lumen via apical Cl- channel

1. Vagal (ACh): via M3 muscarinic receptors on parietal cells AND via GRP → G cell → gastrin → ECL → histamine
2. Hormonal: Gastrin → CCK2 receptor on ECL (predominantly) and parietal cell
3. Paracrine: Histamine from ECL cells → H2 receptor on parietal cells (most important amplification pathway)

• Somatostatin from D cells (inhibits G cells and ECL cells and directly inhibits parietal cells)
• Secretin (from S cells of duodenum in response to low pH): inhibits gastrin, stimulates pancreatic HCO3-
• GIP (from K cells): inhibits acid
• PGE2: cytoprotective, inhibits acid via cAMP

C. Phases of Gastric Secretion

• Triggered by sight, smell, taste, chewing, swallowing
• Mediated by vagus nerve (ACh): directly stimulates parietal cells + G cells via GRP
• Can be abolished by vagotomy

• Food enters stomach → gastric distension → G cell stimulation
• Proteins/amino acids → G cell stimulation
• Gastrin released → parietal cells → HCl

• Chyme in duodenum → small amount of gastrin from duodenal G cells
• Amino acids continue to stimulate small amounts of secretion

• Fat, acid (pH<2 in duodenum), hypertonic solution → secretin, GIP, CCK → inhibit gastric acid + motility

D. Gastric Motility and Emptying

• Reservoir function: fundus relaxes (receptive relaxation via VIP and NO) to accommodate food without pressure rise
• Mixing/Grinding: peristaltic contractions from gastric pacemaker (set at 3 contractions/min) in greater curvature
• Pyloric gatekeeper: liquids empty rapidly; solids held until triturated to <2mm particles
• Rate: liquids 20 min; mixed meal 2-4 hours; fatty meals delayed

E. Duodenal Physiology

• Secrete alkaline mucus + HCO3-
• Neutralize gastric acid entering duodenum

• Interdigestive motor pattern: occurs every 90-120 min in fasting state
• Phase I (rest), Phase II (irregular activity), Phase III (burst activity - "housekeeper" - clears residue)
• Regulated by motilin; erythromycin (motilin agonist) used clinically
• Mulholland and Greenfield's Surgery 7e; Costanzo Physiology 7e

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Q9. No-Scalpel Vasectomy (NSV)

Introduction

Advantages over Conventional Vasectomy

• Single midline skin puncture (vs. 1-2 incisions)
• Shorter operating time (~15 min)
• Less bleeding, haematoma, and infection
• Less pain and swelling
• Faster return to work/activity
• No sutures needed for skin closure
• Equivalent contraceptive efficacy

Instruments

1. Ring-tipped (vas fixation) clamp (Vas Ring Forceps): extracutaneous clamp that fixes the vas beneath the skin without piercing
2. Sharpened dissecting forceps (Helly or Li forceps): pointed, curved dissecting forceps used to puncture and spread the scrotal skin

Anaesthesia

• Vasal Block: 1% lignocaine without adrenaline (1-2 mL) injected at the base of the vas through the scrotal skin using a 27-gauge needle
• No-needle technique: high-pressure jet injector (MadaJet) delivering 0.3 mL lignocaine through intact skin - increasingly used
• Bilateral block performed before starting

Technique (Step-by-Step)

• Patient supine; scrotum shaved and cleaned
• 3-finger technique to trap the vas beneath the scrotal skin (middle finger posterior, index and thumb anteriorly)
• Vas positioned under taut skin at median raphe

• Ring clamp applied to trap the vas (sheath and skin) subcutaneously at mid-scrotum
• Clamp closed and locked perpendicular to the vas

• Sharpened dissecting forceps used to puncture through the skin at the apex of the trapped skin
• Forced into the vasal sheath with a single puncture (no scalpel used)

• Forceps opened and withdrawn to spread the skin incision (~2 mm)
• Vasal sheath incised with the sharp tips
• Vas delivered through this small incision - a 1-2 cm segment looped out

• Adventitia and vasal vessels stripped from 2-3 cm of vas
• Both ends prepared for occlusion

• Multiple methods available:
  • Ligation and excision: most common - ligate both ends with absorbable suture; excise 1-2 cm segment; separate stumps by fascial interposition
  • Fascial interposition: prostatic stump placed within fascial sheath, testicular stump outside - reduces recanalization rate
  • Mucosal fulguration (intraluminal cautery): electrocautery destroys vas mucosal lining
  • Clips: titanium clips applied to both ends
  • Open-ended vasectomy: only prostatic end occluded; theoretically reduces post-vasectomy pain syndrome

• Second vas identified and delivered through the same puncture site (single puncture technique) or a second puncture at the median raphe

• Skin puncture closes spontaneously (no sutures needed)
• Small dressing applied

Post-Procedure

• Scrotal support/jockstrap for 48-72 hours
• Ice pack, analgesics (NSAIDs)
• Avoid heavy lifting for 48 hours
• Sexual activity after 5-7 days
• Alternative contraception until semen analysis at 8-12 weeks or after 20 ejaculations confirms azoospermia (success)
• Success rate: >99.5%

Complications

• Early: Haematoma (1-2%), wound infection (<1%), epididymitis (<1%)
• Late: Sperm granuloma (3%), chronic scrotal pain/Post-Vasectomy Pain Syndrome (2-5%), recanalization (<1%)
• Failure: Spontaneous recanalization (1 in 2000)

Contraindications

• Local anaesthetic allergy
• Active scrotal skin infection
• Previous scrotal surgery (relative - proceed with caution)
• Bleeding diathesis
• Single testis (counsel carefully)

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Q10. Laparoscopic Adrenalectomy

Introduction

Indications

• Phaeochromocytoma (up to 6-8 cm; bilateral in MEN-2/NF-1)
• Conn's syndrome (aldosterone-secreting adenoma - APA)
• Cushing's syndrome (adrenocortical adenoma, ACTH-independent)
• Adrenal virilism (androgen-secreting tumour)

• Adrenal incidentaloma >4 cm (or growing on serial imaging)
• Myelolipoma (if symptomatic or >5-6 cm)
• Adrenal cysts
• Metastasis (isolated, for tissue diagnosis or palliation)

• Adrenocortical carcinoma (ACC) > 6-8 cm (risk of capsule breach, positive margins)
• Bilateral tumours (managed laparoscopically with experience)
• Invasion of adjacent structures

Preoperative Preparation

• Full hormonal workup: urinary/plasma catecholamines, aldosterone:renin ratio, overnight dexamethasone suppression test, DHEA-S
• CT adrenal protocol: thin-slice, Hounsfield units (HU), washout characteristics
• Adrenal vein sampling (AVS) for bilateral disease or unilateral lateralization in Conn's

1. Alpha-blockade first: Phenoxybenzamine (non-selective, irreversible) for 10-14 days minimum, titrate to postural hypotension; or Doxazosin/Prazosin
2. Then beta-blockade: Only after adequate alpha-blockade (to prevent unopposed alpha crisis); propranolol or atenolol
3. Volume expansion: High salt diet + liberal fluid intake after alpha blockade
4. Ensure preoperative BP <130/80 with postural drop
5. Glucocorticoid supplementation perioperatively if bilateral adrenalectomy planned

Approaches

• 10-12 mm camera port subcostal mid-clavicular line
• 5 mm port subcostal anterior axillary line
• 5 mm or 10 mm port subcostal posterior axillary line
• Optional 5 mm epigastric (fan retractor for liver)

1. Mobilize right lobe of liver medially (incise right triangular ligament)
2. Expose retroperitoneum; identify inferior vena cava (IVC) and right adrenal vein
3. Early identification and control of right adrenal vein (short, drains directly into IVC) - clip and divide early (especially for phaeo to prevent catecholamine surge)
4. Dissect adrenal from surrounding fat in medial-to-lateral direction
5. Small feeding vessels from aorta, inferior phrenic artery clipped or coagulated
6. Adrenal extracted in endobag through enlarged port or Pfannenstiel incision

1. Take down splenic flexure of colon (lateral mobilization)
2. Reflect spleen and pancreatic tail medially (medial visceral rotation)
3. Expose retroperitoneum and left adrenal
4. Left adrenal vein (longer, drains into left renal vein) identified, clipped, divided
5. Adrenal dissected from surrounding structures

• Used when bilateral disease; easy conversion to open
• Patient supine; bilateral subcostal ports

Intraoperative Points

• Haemodynamic instability expected with phaeo: anaesthetist must be prepared with phentolamine, sodium nitroprusside, magnesium infusion for hypertensive crisis; noradrenaline for hypotension post-ligation
• Gentle handling to avoid catecholamine release
• Argon beam coagulator or bipolar for haemostasis
• Adrenal must be removed intact (avoid tumour rupture)

Postoperative Care

• ICU monitoring for 24-48 hours (phaeo cases)
• Hydrocortisone replacement if bilateral adrenalectomy
• Monitor for Addisonian crisis post bilateral adrenalectomy
• BP monitoring; antihypertensive wean (Conn's - usually resolves in weeks)
• 24-hr urinary catecholamines at 6 weeks (phaeo - biochemical cure)

Advantages of Laparoscopic over Open

• Less blood loss
• Shorter hospital stay
• Less pain
• Faster recovery
• Fewer wound complications
• Equivalent oncological outcome for benign pathology

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Q11. Laparoscopy and Endoscopy Unit Setup

Introduction

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A. Physical Space and Infrastructure

• Ideally adjacent to the main operation theatre complex
• Independent access for patients, staff, and equipment
• Proximity to recovery/PACU and ICU

1. Endoscopy Suite (minimum 20-25 m²):
   • Examination/procedure rooms
   • Patient holding bay
   • Recovery area (1 recovery bay per procedure room recommended)
2. Laparoscopy Theatre (minimum 35-40 m²):
   • Full operating room standards (positive pressure ventilation, HEPA filters)
   • Booms/ceiling-mounted equipment to reduce floor clutter
3. Decontamination/Cleaning Room: separate clean and dirty zones for scope reprocessing
4. Equipment Storage: laminar flow optional for clean scope storage
5. Reporting Room: workstation for image review/reporting

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B. Endoscopy Unit Setup

• Single most critical aspect for infection control
• Steps: Pre-clean at bedside → Leak test → Manual cleaning (detergent) → Automated endoscope reprocessor (AER) with glutaraldehyde or peracetic acid → Drying → Storage
• Must follow SGNA/BSG/ASGE guidelines; Hepatitis B/C, HIV risk from inadequate reprocessing
• Automated Endoscope Reprocessors (AER): automated, standardized, timed, documented cycle

• Endoscopy nurses (procedure nursing, recovery nursing)
• Endoscopy technicians (equipment handling, reprocessing)
• Medical staff: endoscopists (gastroenterologist or surgeon)
• Administrative: booking, consent, reporting

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C. Laparoscopy Theatre Setup

• 5mm, 10mm, 12mm trocars (Hasson cannula for open entry)
• Graspers, dissectors, clip appliers, scissors, needle drivers
• Endo-GIA stapler, circular staplers
• Reducers, thread catchers

• Standard anaesthesia machine + GA capability
• Capnography (CO2 monitoring) essential during pneumoperitoneum
• Trendelenburg and reverse Trendelenburg table
• Pressure-cycled ventilation (IAP raises diaphragm)

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D. Safety Standards

• Isolated power supply for ESU
• Earth leakage circuit breakers
• No flammable anaesthetic agents with diathermy

• Ceiling-mounted booms reduce cable clutter and risk of tripping
• Monitor height adjusted for surgeon's eye level (reduce neck strain)
• Antifatigue mats for surgeon

• Separate dirty/clean corridors if possible
• HEPA filtered ventilation
• Regular ATP surface testing in endoscopy unit

• Endoscopy reporting software (e.g. Endosoft, ProVation)
• Image capture, procedure notes, pathology tracking
• Integration with hospital HIS/PACS

• Adenoma Detection Rate (ADR) >25% for colonoscopy
• Caecal intubation rate >95%
• Complication tracking (perforation, bleeding rates)
• Scope reprocessing audit

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E. Personnel and Training

• Core Staff: Laparoscopic surgeon, scrub nurse, circulating nurse, anaesthetist
• Subspecialty: endoscopist (GI/surgeon), radiologist (for ERCP fluoroscopy)
• Laparoscopic skills lab: box trainer, virtual reality simulators (LAP Mentor, LapSim) for resident training
• Credentialing: Institutions should have structured proctorship programs before independent practice

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Summary Table

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Note: All answers are written at the senior surgery resident / FRCS examination level and draw from Bailey & Love's Surgery 28th Ed, Schwartz's Principles of Surgery 11th Ed, Mulholland & Greenfield's Surgery 7th Ed, and current surgical guidelines (2024-2026).All 11 university exam answers are complete above. Here's a quick reference guide for what each answer covers:

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Quick Reference - What Each Answer Covers

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SURGERY UNIVERSITY EXAM - 10 MARK ANSWERS (Part 2)

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Q1. Impotence in Male: Management and Recent Advances

Definition

Classification / Aetiology

• Performance anxiety, depression, relationship problems, stress
• Characterised by normal nocturnal penile tumescence (NPT)

Investigations

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Management

A. First Line: Lifestyle Modification + PDE5 Inhibitors

• Mechanism: Nitric oxide (NO) → cGMP → smooth muscle relaxation → arterial dilation and tumescence. PDE5 degrades cGMP; inhibition prolongs erection
• Drugs:
  • Sildenafil (Viagra): 25-100 mg, on-demand, 1 hr before; duration 4-6 hrs; fatty food reduces absorption
  • Tadalafil (Cialis): 10-20 mg on-demand OR 2.5-5 mg daily (continuous use); duration 36 hrs ("weekend pill")
  • Vardenafil (Levitra): 10-20 mg on-demand
  • Avanafil (Stendra): Fastest onset (15-30 min), highly selective, fewer visual side effects
• Contraindications: Nitrate use (risk of life-threatening hypotension), severe hypotension, recent MI/stroke

B. Second Line

• Cylinder placed over penis; vacuum created by pump → blood drawn in → constriction ring applied at base to maintain erection
• Safe, effective in ~90%; suitable for patients on anticoagulants, cardiac patients
• Erection may feel unnatural (pivoting)

• Alprostadil (Prostaglandin E1): 2.5-40 mcg injected into corpus cavernosum; erection within 5-20 min; duration 30-60 min
• Bimix: Papaverine + phentolamine; Trimix: Papaverine + phentolamine + alprostadil (most potent)
• Complications: Priapism, pain, fibrosis, haematoma
• Success rate: 70-80%

• Alprostadil pellet inserted into urethra via applicator
• Absorbed through urethral mucosa into corpora cavernosa
• Less effective than ICI; compliance issues (burning sensation)

C. Third Line: Surgical

1. Semi-rigid (Malleable) Prosthesis:
   • Two bendable rods inserted into corpora cavernosa
   • Always semi-rigid; bent up for intercourse, down for concealment
   • Simple, durable, low complication rate
   • Suitable for elderly, neurological ED, manual dexterity issues
2. Inflatable Penile Prosthesis (IPP):
   • Two-piece (AMS Ambicor): cylinders + scrotal pump; no separate reservoir
   • Three-piece (AMS 700 CX / Coloplast Titan): Cylinders + pump (scrotum) + reservoir (retropubic space); most natural erection quality
   • Inflated for intercourse, deflated at rest
   • Patient satisfaction >90%; partner satisfaction >80%
   • Complications: Infection (1-3%), mechanical failure, auto-inflation, erosion

• Penile arterial revascularization (Michal-Brindley procedure): For focal arterial stenosis in young men with pelvic trauma; inferior epigastric artery anastomosed to dorsal penile artery
• Venous ligation surgery: Ligates venous leak sites; long-term results disappointing; largely abandoned

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Recent Advances

• Low-energy acoustic shockwaves applied to penile shaft
• Induces neovascularization (angiogenesis), promotes NO synthesis, regenerates cavernous tissue
• 6-12 sessions; effective for mild-moderate vasculogenic ED
• Can restore responsiveness to PDE5 inhibitors in prior non-responders
• Non-invasive, no anaesthesia; evidence base growing (ISSM guidelines 2021)

• Autologous PRP injected intracavernously
• Growth factors (PDGF, VEGF, TGF-β) promote tissue repair and angiogenesis
• Early studies promising; still investigational

• Mesenchymal stem cells (adipose or bone marrow-derived) injected intracavernously
• Aim: regenerate smooth muscle cells, endothelium, nerves destroyed by diabetes/prostatectomy
• Phase I/II trials ongoing; not yet standard of care

• Maxi-K gene therapy (hSlo) for smooth muscle relaxation: Phase I trial showed benefit at 6-month follow-up
• VEGF gene therapy for angiogenesis

• Topical alprostadil (Vitaros): 300 mcg applied to urethral meatus; approved in Europe
• MED3000 (ScopeAim): Topical GT3 formulation (glyceryl trinitrate + pentoxifylline)

• Bremelanotide (PT-141 / Vyleesi): Centrally-acting melanocortin 4 receptor agonist; acts via hypothalamic pathway, not vascular; works in patients who fail PDE5 inhibitors; SC injection

• Improved nerve identification and sparing; ED rates after RARP significantly lower than open prostatectomy

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Q2. Etiopathogenesis, Investigation and Management of Psoas Abscess

Anatomy

Classification

• No identifiable adjacent source
• Hematogenous spread to psoas muscle
• Common in immunocompromised, IV drug users, diabetes
• Organism: Staphylococcus aureus (most common worldwide; including MRSA)
• More common in developing countries

• Direct extension from adjacent infected structure
• More common in developed countries
• Sources:
  • Vertebral (Pott's disease): Mycobacterium tuberculosis - historically most common; still prevalent in developing countries
  • Crohn's disease: most common cause in developed world
  • Appendicitis/perforated appendix
  • Diverticulitis
  • Renal pathology: Perinephric abscess, renal tuberculosis
  • Infected aortic aneurysm / graft
  • Septic arthritis of hip/sacroiliac joint
  • Pelvic inflammatory disease
  • Vertebral osteomyelitis (non-TB): S. aureus, Streptococcus, gram-negatives

Pathogenesis

• Is a closed space, promoting anaerobic conditions for abscess development
• Communicates superiorly with the mediastinum (diaphragmatic hiatus) and inferiorly with the femoral triangle (below inguinal ligament)
• Thus, abscess can track to the groin/thigh (presenting as a mass or "pointing abscess" in upper thigh)

Clinical Features - Classic Triad (present in only 30%)

1. Fever
2. Back/flank pain
3. Limp / limitation of hip movement (psoas sign)

• Groin pain or mass
• Hip flexion deformity (psoas spasm)
• Referred pain to anterior thigh
• Weight loss, night sweats (TB)
• Hip held in flexion, external rotation

Investigations

• FBC: Leukocytosis (neutrophilia in bacterial; lymphocytosis in TB)
• ESR, CRP: Elevated
• Blood cultures (50% positive in hematogenous cases)
• Mantoux/Tuberculin skin test, IGRA (Quantiferon Gold) for TB
• Serum calcium (TB - hypercalcemia)

1. Ultrasound: First-line; shows hypoechoic collection in psoas region; may miss deep/small abscesses; guides drainage
2. CT Abdomen/Pelvis (Gold Standard):
   • Hypodense collection with ring enhancement within/around psoas muscle
   • Identifies source (vertebral, bowel, renal)
   • Shows extent; guides drainage approach
   • Gas within collection = pyogenic abscess
3. MRI:
   • Superior soft tissue resolution; preferred for vertebral involvement (Pott's disease)
   • T1: Low signal; T2: High signal; gadolinium enhancement of rim
   • No radiation; preferred in young/pregnant
4. X-ray spine/hip: May show vertebral collapse, disc space narrowing (Pott's), loss of psoas shadow
5. Bone scan/PET-CT: For occult source identification

• Aspirate from drainage: Gram stain, culture (aerobic, anaerobic, AFB, fungal)
• AFB smear and culture (Lowenstein-Jensen medium) for TB; takes 6-8 weeks
• PCR/GeneXpert for rapid TB identification
• Histopathology of tissue: Granulomas = TB

Management

A. Medical Treatment

• IV antibiotics empirically covering S. aureus and gram-negatives:
  • Primary: Flucloxacillin + gentamicin (or piperacillin-tazobactam in severe sepsis)
  • MRSA cover: Vancomycin
  • TB psoas abscess: Standard RHEZ regime (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide) for 2 months, then RH for 4-7 months
• Nutritional support, analgesia

B. Drainage (Most Important)

• Treatment of choice for most psoas abscesses
• Real-time imaging guidance; posterior or posterolateral approach
• Pigtail catheter left in situ for continuous drainage (7-14 days)
• Aspiration alone sufficient for <3 cm well-loculated abscesses
• Success rate: 85-90%
• Preferred in: medically unfit patients, loculated collections, TB abscesses (after anti-TB therapy initiated)

• Retroperitoneal (posterior flank) approach (preferred): Patient in lateral decubitus; incision over 12th rib; extraperitoneal access to psoas; thorough drainage, debridement, wash-out
• Anterior transperitoneal approach: For abscesses extending into pelvis or when laparotomy needed for source control
• Medial (lumbar) approach: For vertebral TB with paravertebral abscess

• Crohn's disease: Resection or strictureplasty + drainage
• Appendiceal source: Appendicectomy
• Vertebral TB: Anti-TB drugs; surgery for spinal instability
• Perinephric abscess: Nephrostomy ± nephrectomy

C. Postoperative Care

• Continue antibiotics (IV → oral) for minimum 4-6 weeks (6-12 months for TB)
• Monitor WBC, CRP, ESR for resolution
• Repeat CT at 4-6 weeks to confirm resolution
• Source treatment as appropriate

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Q3. Urinary Diversion: Indications, Methods and Complications

Definition

Indications

• Radical cystectomy: Muscle-invasive bladder cancer (T2-T4), high-grade non-muscle-invasive bladder cancer refractory to BCG
• Neurogenic bladder: Refractory to conservative management
• Pelvic exenteration: For advanced pelvic malignancy
• Radiation cystitis: Refractory with reduced capacity/fistula
• Interstitial cystitis: Refractory bladder pain syndrome
• Trauma with irreparable bladder/urethra
• Congenital anomalies: Bladder exstrophy, cloacal anomalies

Classification

Urinary Diversion
├── Incontinent (Non-Continent)
│   └── Ileal Conduit (Bricker)
│   └── Colon Conduit
├── Continent Cutaneous
│   └── Kock Pouch (ileal reservoir)
│   └── Indiana Pouch (ileocaecal)
│   └── Mitrofanoff (appendicovesicostomy)
└── Orthotopic (Continent, voiding via urethra)
    └── Ileal Neobladder (Studer / Hautmann)
    └── Sigmoid neobladder

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A. Ileal Conduit (Bricker, 1950) - Most Common

1. Resect 15-20 cm distal ileum (preserving mesentery and blood supply)
2. Restore ileal continuity with end-to-end anastomosis
3. Reimplant ureters into proximal end of conduit (Wallace or Bricker technique - refluxing or non-refluxing)
4. Distal ileum brought through right abdominal wall; stoma fashioned (spout/rosebud) flush above skin

• Technically simpler; shorter operative time
• Most reliable; widely applicable regardless of comorbidity
• No reservoir complications

• External bag worn permanently (body image, QoL issues)
• Continuous urine leakage if bag fails

• Early: Urine leak, wound infection, ileus, DVT
• Late (most significant):
  • Stomal stenosis (15-20%)
  • Parastomal hernia (20-30%)
  • Ureteroileal stricture/obstruction (5-10%)
  • Pyelonephritis, urolithiasis
  • Upper tract deterioration (reflux nephropathy): 30% at 10 years
  • Hyperchloraemic metabolic acidosis (chloride reabsorption from ileum)

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B. Orthotopic Ileal Neobladder (Studer / Hautmann)

• Negative urethral margins on frozen section
• Intact urethral sphincter mechanism (external sphincter)
• Good renal function (creatinine <150 μmol/L - able to compensate metabolic acidosis)
• Motivated, compliant patient
• Suitable anatomy

1. Isolate 54-60 cm of ileum; restore intestinal continuity
2. Detubularize all but proximal 10-12 cm (proximal tubular chimney for ureteral implantation in a non-refluxing or refluxing manner)
3. Fold and anastomose opened ileum into a U/W/M shaped reservoir
4. Close the neobladder leaving a dependent pouch
5. Anastomose to the urethra (vesicourethral anastomosis)
6. Left ureter brought through mesentery (Studer afferent limb preserves anti-reflux)

• Urinary incontinence: Daytime 10-20%; Nocturnal (enuresis) 20-40% (loss of nocturnal cortical control)
• Urinary retention requiring CIC (clean intermittent catheterisation): 10-25%
• Metabolic: Hyperchloraemic metabolic acidosis (ileum reabsorbs Cl-; monitor regularly)
• Vitamin B12 deficiency (if terminal ileum used; lifelong supplementation)
• Nocturnal enuresis (absent sphincter tone during sleep)
• Pouch stone formation
• Ureteroenteric strictures

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C. Continent Cutaneous Diversion (Indiana Pouch)

• Low-pressure reservoir (detubularized bowel)
• Continence valve: narrowed terminal ileum (plicated/tapered) or appendix (Mitrofanoff)

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D. Other Methods

Summary Table

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Q4. Surgical Anatomy of the Prostate

Overview

Dimensions and Relations

• Weight: 20g (normal adult)
• Shape: Inverted cone/chestnut
• Above: Bladder neck
• Below: Urogenital diaphragm (external sphincter)
• Anterior: Puboprostatic ligaments, Santorini's venous plexus (dorsal venous complex), pubic symphysis
• Posterior: Denonvilliers' fascia → seminal vesicles and vas deferens above; rectum posterior (separated by fascia)
• Lateral: Levator ani (pelvic floor), neurovascular bundles (NVB)

Zonal Anatomy (McNeal, 1981)

Fascia and Planes

• Between posterior prostate/seminal vesicles and anterior rectal wall
• Two layers (anterior + posterior) with potential space
• Important in radical prostatectomy: dissecting anterior to posterior layer (prostatic side) protects rectum; dissecting posterior to anterior layer (rectal side) may improve oncological clearance but risk rectal injury

Blood Supply

• Inferior vesical artery (branch of internal iliac) → main supply
• Middle rectal artery (contributes)
• Prostatic arteries enter at 5 and 7 o'clock positions on DRE (posterolateral)

• Dorsal Venous Complex (DVC) of Santorini: Major venous plexus anterior to prostate between puboprostatic ligaments; communicates with deep dorsal vein of penis and pelvic veins; major source of haemorrhage in radical prostatectomy → controlled by suture ligation (Bunce stitch) before division

Lymphatic Drainage

• Obturator nodes (most important/first echelon)
• Internal iliac nodes
• Presacral nodes
• External iliac nodes
• Pelvic lymphadenectomy (PLND) removes obturator and iliac nodes for staging

Nerve Supply and Neurovascular Bundles (NVBs)

• Autonomic nerves from pelvic plexus (T10-L1 sympathetic + S2-S4 parasympathetic via inferior hypogastric plexus)
• Travel in the posterolateral "neurovascular bundles" at 5 and 7 o'clock positions
• Provide cavernous nerve innervation to corpora cavernosa → responsible for erection
• Run in the groove between prostate and rectum, then behind the membranous urethra
• Nerve-sparing prostatectomy: preserves NVBs → preserves erectile function (bilateral nerve-sparing: 70-80% potency; unilateral: 50%)

• External urethral sphincter: Striated muscle; inferior to prostate; at membranous urethra; voluntary control; most important for post-prostatectomy continence
• Bladder neck (internal sphincter): Smooth muscle; often deliberately divided in TURP/prostatectomy
• Rhabdosphincter: horseshoe-shaped at membranous urethra; preserved during radical prostatectomy

Urethra in Relation to Prostate

• Proximal prostatic urethra: Crista urethralis, colliculus seminalis (verumontanum) at posterior wall
• Verumontanum: Most important landmark in TURP; at junction of prostatic and membranous urethra; 1-1.5 cm distal to external sphincter; resection must stop proximal to verumontanum
• Ejaculatory Ducts: Open at verumontanum; arise from fusion of vas deferens and seminal vesicle ducts

Surgical Relevance

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Q5. Recent Modalities in Management of Benign Prostatic Hyperplasia (BPH)

Overview

Indications for Active Treatment

• Moderate-severe LUTS (IPSS >7)
• Failed medical therapy (alpha blockers ± 5-alpha reductase inhibitors ± PDE5i)
• Complications: AUR, recurrent UTI, bladder stones, renal impairment, haematuria

Traditional Surgical Standard: TURP

• Transurethral resection of the prostate remains the benchmark
• Bipolar TURP (saline irrigation) has replaced monopolar TURP
• Reduces TUR syndrome risk

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Recent / Minimally Invasive Surgical Therapies (MISTs)

1. HoLEP - Holmium Laser Enucleation of the Prostate

• Laser: Holmium:YAG laser (2140 nm wavelength)
• Principle: Anatomical enucleation of prostatic adenoma from surgical capsule (same plane as open simple prostatectomy), then morcellated in the bladder
• Suitable for any prostate size (30 g - >200 g)
• Advantages: Size-independent; bloodless (haemostatic); suitable for anticoagulated patients; hospital stay 1-2 days; durable results equivalent to open prostatectomy; preserves tissue for histology (unlike vaporization)
• Considered the new gold standard for surgical BPH management (EAU Guidelines 2024)
• Learning curve: 50-100 cases

2. GreenLight PVP - Photoselective Vaporization of the Prostate

• Laser: KTP (potassium-titanyl-phosphate) 532 nm or XPS 180W GreenLight
• Principle: Laser energy absorbed by oxyhemoglobin → vaporizes prostatic tissue without morcellation
• Bloodless, suitable for anticoagulated patients
• Disadvantage: No tissue for histology; limited to moderate-size prostates

3. Thulium Laser (ThuLEP / ThuVAP)

• Thulium:YAG (2013 nm) or Thulium fiber laser (TFL - 1940 nm)
• Similar to HoLEP; some data suggest better haemostasis
• TFL (Thulium Fiber Laser) is newest; continuous-wave; efficient vaporization and enucleation

4. Aquablation (AquaBeam - Robotic Waterjet)

• Principle: Real-time ultrasound imaging + robotically controlled high-velocity waterjet that ablates prostatic tissue with heat-free precision
• AQUABEAM robotic system
• Pre-operative MRI/ultrasound mapping; robotically executes customized resection plan
• Avoids ejaculatory duct zone → preserves ejaculatory function (major advantage vs. TURP/HoLEP)
• Suitable for 30-150 g prostates
• WATER/WATER II trials: Non-inferior to TURP; lower retrograde ejaculation rate
• FDA approved 2017

5. Rezum (Steam Therapy / Water Vapor Thermal Therapy)

• Principle: Radiofrequency energy converts water to steam (103°C); steam injected into prostatic transition zone → convective thermal damage → cell death → tissue resorption over weeks
• Office procedure under local anaesthesia
• 10-minute procedure; catheter for 3-7 days
• Best for small-moderate prostates (30-80 g)
• Preserves sexual function (ejaculatory and erectile)
• IPSS improvement: 50%; Qmax improvement: 50%
• Durable results at 5 years; FDA approved 2015

6. Urolift (Prostatic Urethral Lift)

• Principle: Small permanent implants (nitinol clips + suture) retract and hold the lateral prostatic lobes away from the urethra under cystoscopic guidance
• No tissue removal or heat; preserves ejaculatory and erectile function
• Office procedure; immediate improvement
• Not suitable for: obstructive median lobe, >80 g prostate
• L.I.F.T. trial: Significant IPSS and Qmax improvement; 5-year durable results
• Ideal for sexually active men with lateral lobe obstruction

7. iTind (Temporarily Implanted Nitinol Device)

• Nitinol device inserted and left in urethra for 5-7 days; reshapes urethra; then removed
• Single outpatient visit essentially; preserves ejaculation
• Early data encouraging

8. Prostate Artery Embolization (PAE)

• Interventional radiology procedure
• Super-selective catheterization of prostatic arteries (bilateral); microembolic particles (polyvinyl alcohol / bead embolics)
• Reduces prostatic blood supply → infarction → volume reduction (25-40%)
• ROPE registry; IMPACT trial (non-inferior to TURP in selected patients)
• Advantages: No anaesthesia; preserves ejaculatory function; suitable for large prostates, anticoagulated, frail patients
• Disadvantages: Technically demanding; post-embolization syndrome; less durable than TURP; non-target embolization risk

9. Convective RF Ablation (Optilume BPH Balloon)

• Drug-coated balloon delivering paclitaxel to urethra + mechanical dilation
• Investigational

10. Focal Laser Ablation / HIFU for BPH

• Emerging; limited evidence currently

Medical Management (for completeness)

• Alpha blockers (tamsulosin, silodosin): First-line; rapid symptom relief
• 5-ARI (finasteride, dutasteride): Reduce prostate volume over 6 months; best for large prostates (>40 mL); combination therapy superior
• PDE5 inhibitors (tadalafil 5 mg daily): Improves both LUTS and ED
• Beta-3 agonist (mirabegron): For OAB/storage symptoms
• Anticholinergics: Storage symptoms (caution - AUR risk)

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Q6. Recent Advances and Modalities in Prostate Cancer

Staging and Risk Stratification

• TNM staging; Gleason grading (now Grade Groups 1-5 by ISUP 2016)
• Risk groups: Low (PSA<10, GG1, T1-2a), Intermediate (GG2-3 or PSA 10-20 or T2b-c), High (GG4-5 or PSA>20 or T3)

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Recent Diagnostic Advances

1. MRI-Targeted Biopsy (Fusion Biopsy)

• mpMRI (Multi-parametric MRI): T2W + DWI + DCE sequences; PI-RADS v2.1 scoring (1-5)
• PI-RADS 3-5 lesions targeted with biopsy; reduces over-diagnosis of low-grade cancer
• MRI-TRUS Fusion Biopsy: Real-time MRI-TRUS fusion overlay; targeted cores from PI-RADS ≥3 lesions + systematic biopsies
• In-Bore MRI-guided biopsy: Highest accuracy; expensive/time-consuming
• PROMIS, PRECISION trials: mpMRI-targeted biopsy superior to systematic TRUS biopsy for clinically significant cancer detection

2. PSMA PET-CT (Prostate-Specific Membrane Antigen)

• Gallium-68 PSMA PET-CT: Supersedes conventional staging (CT + bone scan)
• PSMA overexpressed on prostate cancer cells; radiolabeled ligand binds with high specificity
• Superior sensitivity for: nodal metastases, bone metastases, biochemical recurrence (PSA >0.2 post-prostatectomy)
• OSPREY, CONDOR, proPSMA trials established superiority
• Lu-177 PSMA (Theranostics): Same PSMA ligand; radiolabeled with lutetium-177 (beta emitter) → targeted radiotherapy to PSMA-expressing metastases; VISION trial: significant rPFS/OS benefit in mCRPC

3. Liquid Biopsy

• ctDNA (Circulating tumour DNA): Detected in plasma; mutation profiling; treatment selection
• AR-V7 splice variant: Detected in CTCs; predicts resistance to enzalutamide/abiraterone → direct to taxane chemotherapy

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Treatment: Recent Advances

A. Radical Prostatectomy

• Da Vinci system (Xi/SP); most radical prostatectomies now robotic
• 3D visualization, wristed instruments, tremor filtration
• SP (Single Port) robotic prostatectomy: Single incision; improved cosmesis; reduced port-site complications
• Outcomes equivalent to open; lower blood loss, shorter catheterization

B. Radiation Therapy

• 5 fractions (1 week) vs. conventional 40 fractions
• PACE-B trial: Non-inferior to IMRT at 5 years; fewer patient visits
• MRI-guided radiotherapy (MR-Linac): Real-time MRI during radiotherapy; adapts plan to organ motion; spares bladder/rectum

• LDR (low dose rate): Iodine-125 seeds permanently implanted; for low/intermediate risk
• HDR (high dose rate): Temporary Iridium-192 catheters; single/few fractions; combined with EBRT for high-risk

C. Focal Therapy (for Localized, Low-Intermediate Risk)

• Focused ultrasound waves → focal thermal necrosis of prostate
• Ablatherm (EDAP), Sonablate (SonaCare) systems
• Whole-gland or focal (hemi-ablation) treatment
• Preserves continence and erectile function (vs. radical treatment)

• Laser fiber placed in lesion under MRI guidance; thermal ablation of focal lesion
• Minimal tissue loss; preserve function

• Argon gas probes freeze prostate tissue to -40°C → ice ball formation → cell death
• Primary or salvage after radiotherapy failure
• Side effects: ED (50-60%), sphincter injury, urethral sloughing

• Non-thermal electrical pulses create permanent pores in cell membranes → apoptosis
• Spares collagen, vessels, nerves → low risk to urethra and NVB
• True "nerve-sparing" focal therapy; results awaited

D. Systemic Therapy - Recent Advances

• Next-generation androgen receptor pathway inhibitors
• ARCHES, TITAN, ARAMIS trials: Significant OS benefit in mHSPC and nmCRPC
• Apalutamide + ADT: standard of care for mHSPC (TITAN trial)
• Darolutamide: Fewer CNS side effects (does not cross BBB)

• CYP17A1 inhibitor → blocks androgen synthesis from adrenal/tumor
• LATITUDE, STAMPEDE trials: OS benefit in mHSPC
• Combined with enzalutamide: ENZAMET, ARASENS trials

• Olaparib, Rucaparib, Niraparib, Talazoparib
• For mCRPC with BRCA1/2, ATM mutations (Homologous Recombination Repair - HRR gene defects)
• PROfound trial (olaparib): Significant rPFS benefit in HRR-mutant mCRPC
• BRCA testing now standard before second-line mCRPC treatment

• Sipuleucel-T (Provenge): Autologous dendritic cell vaccine; FDA approved for asymptomatic/minimally symptomatic mCRPC; modest OS benefit (IMPACT trial)
• Pembrolizumab: For MSI-H / dMMR prostate cancer (tumour-agnostic approval)
• PD-1/PD-L1 inhibitors generally have low activity in prostate cancer (immunologically "cold" tumor)

• 177Lu-PSMA-617 (Lutetium Vipivotide Tetraxetan / Pluvicto): VISION trial; FDA/EMA approved 2022; for PSMA-positive mCRPC post-ARSI and taxane
• Actinium-225 PSMA: Alpha emitter; early trials very promising; higher cell kill

• AMG 160 (PSMA × CD3 bispecific): Redirects T-cells to kill PSMA+ prostate cancer cells
• Phase II trials ongoing

• ADT + Docetaxel + Darolutamide (ARASENS): mHSPC; significant OS improvement
• ADT + Abiraterone + Enzalutamide: Combinations under investigation

• BRCA1/2 germline/somatic testing for all mCRPC
• Decipher, Oncotype DX Prostate, Prolaris: Genomic risk classifiers for adjuvant therapy decisions

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Q7. Laser Ablation of the Prostate

Introduction

Physics of Laser-Tissue Interaction

• Absorption: Tissue absorbs laser energy → heat → vaporization/coagulation
• Vaporization: >100°C → explosive steam; tissue destruction
• Coagulation: 60-100°C → protein denaturation without vaporization
• Wavelength determines absorption coefficient by tissue chromophores (water, hemoglobin, melanin)

Types of Lasers Used

1. Holmium:YAG Laser (Ho:YAG) - 2140 nm

• Gold standard laser procedure; equivalent to open simple prostatectomy
• Anatomical enucleation at surgical capsule plane
• Three-lobe technique or two-lobe
• Morcellation required (Karl Storz/Wolf morcellator)
• Suitable for any prostate size; anticoagulated patients
• Disadvantage: Learning curve; dedicated morcellator required

• Pure vaporization of smaller prostates
• No morcellator needed; no tissue for histology

• Resection in chips (like TURP); antiquated

2. Potassium-Titanyl-Phosphate (KTP) / GreenLight Laser - 532 nm

• 80W KTP → 120W HPS → 180W XPS systems (progressive evolution)
• Tissue vaporized instantly with laser fiber in non-contact mode
• Excellent haemostasis (can be used on anticoagulated patients)
• Coagulation zone 1-2 mm deep
• Limitation: No tissue for histology (vaporized); retrograde ejaculation still common; limited to moderate prostate sizes

3. Thulium:YAG Laser (Tm:YAG) - 2013 nm

• Newest generation; diode-pumped fiber laser
• Continuous-wave or pulse-modulated
• Efficient at lower powers; delivered through thin flexible fibers (180 μm)
• Suitable for flexible ureteroscopy AND prostate
• TFL-HoLEP equivalent outcomes; potentially less thermal spread

4. Diode Laser - 940/980/1470 nm

• Compact, portable, low-cost
• Vaporization and coagulation modes
• InterStim, Biolitec systems
• Adequate for smaller prostates
• Less established than HoLEP or GreenLight

5. Nd:YAG Laser - 1064 nm

• Poor absorption (deep penetration 10 mm); primarily coagulative
• VLAP (Visual Laser Ablation of Prostate): Lateral firing fiber; coagulative necrosis of prostatic tissue; significant post-treatment retention period (weeks of sloughing); historically important; now largely replaced by above

Comparison Summary

Advantages of Laser over TURP

• Lower blood loss; reduced transfusion rate
• Shorter catheterization time
• Day surgery feasible
• Safe in anticoagulated patients
• Lower TUR syndrome risk (saline irrigation in HoLEP)

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Q8. Cystoscopy

Definition

Types of Cystoscopes

• Stainless steel; available in 17-30 Fr; 0°, 30°, 70° lens systems
• 30° lens: most used (general inspection, most of bladder)
• 70° lens: bladder base, trigone, dome inspection
• Superior optics; requires lithotomy position under anaesthesia

• Fibre-optic or digital chip-on-tip (Karl Storz FLEX-XC)
• Deflectable tip (210° range)
• Performed under local anaesthesia (intraurethral lignocaine gel)
• Outpatient, no stirrups
• Smaller working channel (2 mm); less therapeutic capability

Indications

• Haematuria (painless frank haematuria - MUST exclude bladder cancer)
• Recurrent UTIs
• LUTS - assess bladder outlet, trigone, trabeculation, diverticula
• Follow-up surveillance: Bladder cancer, urethral stricture
• Ureteric orifice assessment (duplication, reflux workup)
• Suspicious urine cytology with negative imaging
• Fistula assessment (vesicovaginal, vesicoenteric)
• Foreign body
• Interstitial cystitis (Hunner's ulcer)
• Failed ureteral catheterization under fluoroscopy

• Bladder tumour biopsy and TURBT (transurethral resection of bladder tumour)
• Bladder stone fragmentation (litholapaxy, laser)
• Dilatation of ureteral stricture / ureteroscopy
• Ureteral stent (JJ stent) insertion/removal
• Haematuria management (diathermy of bleeding vessels)
• Bladder neck incision (BNI)
• Urethral stricture dilatation / internal urethrotomy (Otis urethrotome, Cold knife)
• Botulinum toxin injection (OAB, neurogenic bladder)
• Hydrodistension (interstitial cystitis)
• Retrograde pyelogram
• Placement of suprapubic catheter (Trocar cystostomy)

Procedure (Flexible Outpatient)

1. Patient supine; intraurethral lignocaine gel (2%) instilled; 3-5 minutes wait
2. Flexible cystoscope inserted with gentle irrigation of normal saline
3. Urethra inspected: Strictures, false passages
4. Bladder neck and prostate (in males) inspected
5. Bladder distended with 200-300 mL saline
6. Systematic inspection: trigone, both ureteral orifices, lateral walls, dome, anterior wall (tilt head down)
7. Document findings; biopsies/interventions as needed

Findings and Significance

Complications

• UTI (most common; antibiotic prophylaxis: trimethoprim or nitrofurantoin)
• Haematuria
• Urethral trauma/false passage
• Perforation (rare)
• TUR syndrome (with monopolar electrocautery + glycine irrigation)
• Failure to complete/poor visualisation

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Q9. Endoscopy (General Principles and Types)

Definition

Classification

Endoscopy
├── Upper GI (UGI)
│   ├── OGD / Gastroscopy (diagnostic + therapeutic)
│   ├── ERCP (biliary + pancreatic)
│   └── Enteroscopy (small bowel)
│       ├── Push enteroscopy
│       ├── Double-balloon enteroscopy (DBE)
│       └── Capsule endoscopy
├── Lower GI
│   ├── Colonoscopy
│   ├── Flexible sigmoidoscopy
│   └── Anoscopy/Proctoscopy (rigid)
├── Respiratory
│   └── Bronchoscopy (rigid or flexible)
├── Urological
│   ├── Cystoscopy
│   ├── Ureteroscopy (flexible/semi-rigid)
│   └── Nephroscopy (PCNL)
└── Other
    ├── Laparoscopy (surgical endoscopy)
    ├── Thoracoscopy / VATS
    ├── Arthroscopy
    └── Hysteroscopy

Components of an Endoscope

1. Control head: Angulation controls (up/down, left/right), suction, air/water buttons, working channel port
2. Insertion tube: Flexible; contains light bundles (fibre-optic or LED light guide), image transmission (CCD chip or fibre-optic bundle), air/water channels, suction/working channel
3. Light source: LED (modern) or Xenon; 300W
4. Video processor: Image processing, enhancement (NBI, BLI, LCI)
5. Monitor: Full HD or 4K
6. Universal cord: Connects scope to processor and light source

Image Enhancement Technologies

• NBI (Narrow Band Imaging, Olympus): Uses 415nm + 540nm wavelengths; enhances mucosal vascular pattern; improves polyp/early cancer detection
• BLI (Blue Light Imaging, Fujifilm): Similar principle; enhanced vascular contrast
• LCI (Linked Colour Imaging): Enhanced colour differentiation for flat lesions, H. pylori gastritis
• Chromoendoscopy: Dye spray (indigo carmine, methylene blue) for pit pattern assessment
• Magnification endoscopy: 100-150x; combined with NBI for early cancer characterization
• AI-assisted colonoscopy (CADe - Computer-Aided Detection): Real-time AI polyp detection; reduces adenoma miss rate by 30%

Endoscopic Hemostasis Methods

• Injection: Diluted adrenaline (1:10,000) + fibrin glue/thrombin
• Thermal: Argon plasma coagulation (APC), heater probe, bipolar electrocautery
• Mechanical: Endoclips (Resolution 360, Instinct), over-the-scope clips (OTSC/"bear claw"), endoloops
• Combination (most effective): Injection + thermal/clip

Endoscopic Resection Techniques

• Polypectomy: Hot/cold snare; <10 mm → cold snare; >10 mm → hot snare
• EMR (Endoscopic Mucosal Resection): Submucosal injection → lift → snare; for flat/sessile lesions <20 mm
• ESD (Endoscopic Submucosal Dissection): En-bloc resection of any size flat lesion using needle knife; Japanese origin; allows R0 resection of early GI cancer without surgery; steep learning curve
• EFTR (Endoscopic Full-Thickness Resection): Full-thickness excision using OTSC + snare; for subepithelial tumours, non-lifting polyps

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Q10. Oesophagogastroduodenoscopy (OGD): Diagnostic and Therapeutic Uses (20 marks)

Introduction

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Instrument

• Flexible videoendoscope: 8-11 mm diameter; 100-125 cm working length
• 2° angulation (up/down 210°; left/right 100°)
• Working channel 2.8-3.7 mm
• Suction, air/water irrigation
• Standard gastroscope / therapeutic gastroscope (wider channel) / ultra-thin (transnasal)

Patient Preparation

• Nil-by-mouth: 6 hours food, 2 hours clear liquids (elective)
• IV access; pulse oximetry monitoring
• Sedation: IV midazolam ± fentanyl (conscious sedation) or propofol (deep sedation with anaesthesia); OR topical pharyngeal lignocaine spray only
• Antispasmodic (IV hyoscine butylbromide / glucagon) if needed to reduce peristalsis
• Patient left lateral decubitus position; bite guard inserted

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Diagnostic Uses

1. Oesophagus

• Reflux oesophagitis / GERD: LA classification (A-D); Barrett's oesophagus surveillance (Prague classification - C+M criteria); biopsies
• Barrett's Oesophagus: Metaplastic columnar epithelium; dysplasia grading; risk of adenocarcinoma; surveillance every 3-5 years (non-dysplastic), annual (LGD), 3-monthly or ablation (HGD)
• Oesophageal cancer: Squamous or adenocarcinoma; staging, biopsy, assessment of involvement
• Achalasia / Dysmotility: Dilated oesophagus, food residue, "puckered" gastro-oesophageal junction (GOJ)
• Strictures: Peptic, malignant, post-caustic; can be dilated
• Varices: Grading (Grade I-IV); treatment with band ligation
• Webs and rings: Schatzki ring, Plummer-Vinson web
• Hiatus hernia: Type assessment
• Diverticula: Zenker's, epiphrenic

2. Stomach

• Peptic ulcer disease: Gastric/duodenal ulcers; Johnson classification (GU); biopsy from ulcer edge (4-6 quadrant) to exclude malignancy; H. pylori testing (RUT - rapid urease test)
• Gastric cancer: Early gastric cancer (EGC) vs. advanced; Paris classification; biopsy for histology; staging for ESD eligibility
• Polyps: Hyperplastic, fundic gland, adenomatous; resect or biopsy depending on type
• MALT lymphoma: Associated with H. pylori; biopsy + RUT
• Gastritis: H. pylori gastritis (Sydney classification); Atrophic gastritis; autoimmune gastritis (corpus-restricted, anti-IF antibodies)
• Subepithelial tumours: GIST (gastrointestinal stromal tumour), leiomyoma, carcinoid; EUS assessment
• Bezoar: Trichobezoar, phytobezoar; fragmentation and removal
• Foreign body: Ingested objects; extraction if in oesophagus/stomach

3. Duodenum

• Duodenal ulcers: D1 most common; H. pylori biopsy (CLO test)
• Coeliac disease (Sprue): D2 biopsies (4-6 samples); villous atrophy (Marsh classification); scalloping, mosaic pattern
• Ampullary lesions: Adenoma, carcinoma; biopsy; may block biliary/pancreatic drainage
• Duodenal cancer: Rare; biopsy and staging
• Crohn's disease: Cobblestone mucosa, aphthous ulcers

4. Post-Surgical Assessment

• Anastomotic leaks, strictures, marginal ulceration after gastrectomy, gastric sleeve, Roux-en-Y
• Stent patency assessment
• Feeding jejunostomy assessment

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Therapeutic Uses

A. Haemostasis (Upper GI Bleeding)

• Ia: Spurting - urgent endoscopic + surgical standby
• Ib: Oozing - endoscopic treatment
• IIa: Non-bleeding visible vessel - treat (re-bleeding 50%)
• IIb: Adherent clot - treat or wash
• IIc: Flat spot - no treatment needed
• III: Clean base - discharge possible

1. Injection therapy: Dilute adrenaline 1:10,000 (4 quadrant injection, 1mL each) for tamponade + vasoconstriction; alone insufficient - combine with thermal or mechanical
2. Thermal coagulation: Heater probe (15-30J); bipolar BICAP electrode; APC (500-750 kHz argon gas coagulation; 40-60W)
3. Mechanical - Endoclips: Quickclip (Olympus), Resolution (Boston Scientific), Instinct (Cook); apply to visible vessel or ulcer base; gold standard for visible vessel haemorrhage
4. Over-The-Scope Clip (OTSC/"Bear Claw"): For difficult-to-clip lesions, full-thickness closure, fistula closure, recurrent bleeding
5. Haemostatic Powder (TC-325 / Hemospray): Spray applied to bleeding point; forms physical barrier; used as bridge therapy; acute severe haemorrhage
6. SEMS (Self-Expanding Metal Stent): For malignant bleeding or Dieulafoy's if other methods fail

• Band Ligation (EVL): Standard of care for oesophageal varices; rubber bands applied to each varix above GOJ; repeat every 2-3 weeks until eradicated
• Injection Sclerotherapy: Ethanolamine oleate or sodium tetradecyl sulfate; largely replaced by band ligation but still used for gastric varices inaccessible to banding
• Histoacryl (Cyanoacrylate) Injection: For gastric varices (fundal); glue injection obliterates varices; risk of embolism
• TIPSS (Transjugular Intrahepatic Portosystemic Shunt): Radiological procedure for refractory/recurrent variceal bleeding

B. Dilatation

• Balloon Dilatation (TTS - Through-the-Scope): For peptic, anastomotic, or post-caustic strictures; water-filled balloon; Graded up to target diameter
• Bougie Dilatation (Savary-Gilliard): Tapered wire-guided polyvinyl dilators; over guidewire; for fibrotic strictures
• Pneumatic Dilatation: 30-35-40 mm balloon across cardia; for achalasia; 70-80% remission; risk of perforation 2%

C. Foreign Body and Bezoar Management

• Foreign bodies: Coins, bones, dentures, button batteries (URGENT - alkali leakage), magnets
• Devices: Rat-tooth forceps, Roth net, polypectomy snare, overtubes, protector hoods
• Button batteries: EMERGENCY; hydroxide injury within 2 hours; remove immediately
• Bezoars: Fragmentation with snare/forceps + irrigation; enzymes (cellulase for phytobezoars)

D. Enteral Access

• PEG (Percutaneous Endoscopic Gastrostomy):
  • Endoscope-guided placement of feeding tube through abdominal wall into stomach
  • Techniques: Pull technique (Gauderer-Ponsky), push technique, introducer (Russell) technique
  • Indications: Dysphagia (stroke, head/neck cancer, motor neurone disease), nutritional support
  • Complications: Buried bumper syndrome, leakage, bleeding, aspiration, tumour seeding (with PEG through pharyngeal cancer)
• PEJ (Percutaneous Endoscopic Jejunostomy): Extension tube through PEG into jejunum; for gastroparesis, aspiration risk
• Nasojejunal tube placement: Under endoscopic guidance into jejunum

E. Tumour-Related Procedures

• Stenting (SEMS):
  • Palliative treatment for inoperable oesophageal/gastric cancer
  • Self-expanding metal stents (uncovered, partially-covered, fully-covered)
  • Relieves dysphagia within 24 hours
  • Complications: Migration (FC > UC), ingrowth (UC), pain, perforation, fistula
  • SEMS also for colonic obstruction (bridge to surgery or palliative)
• APC (Argon Plasma Coagulation): Ablation of tumour tissue, Barrett's metaplasia, radiation telangiectasia, watermelon stomach (GAVE)
• PDT (Photodynamic Therapy): Photosensitizer + laser light → reactive oxygen species → tumour necrosis; for Barrett's HGD, early oesophageal cancer; largely replaced by RFA
• RFA (Radiofrequency Ablation - HALO system):
  • Circumferential (360°) or focal (90°) electrode balloon
  • For Barrett's oesophagus with HGD or LGD
  • AIM Dysplasia trial: 80-90% complete eradication of dysplasia; 75-80% complete eradication of intestinal metaplasia
  • Combined with EMR for nodular Barrett's

F. Endoscopic Resection

• EMR: Oesophageal/gastric lesions; inject → lift → snare; piecemeal for large lesions; for early cancer staging
• ESD: En bloc resection; larger lesions; early oesophageal squamous cell carcinoma (SCC), early gastric cancer; suitable for lesions not amenable to EMR
• EFTR: Full-thickness resection (subepithelial tumours)
• Endoscopic submucosal tunneling resection (STER): For submucosal tumours arising from muscularis propria (cardia, oesophagus)

G. Biliary and Pancreatic (ERCP via Duodenoscope)

• Sphincterotomy: Opening of ampulla of Vater for stone extraction
• CBD Stone Extraction: Balloon/basket retrieval; Cholangioscopy-guided laser/ESWL for large stones
• Biliary Stenting: Plastic stents (short-term); SEMS (malignant strictures); for benign strictures (multiple plastic stents sequentially)
• Pancreatic duct stenting: Chronic pancreatitis, stone, stricture
• Cholangioscopy (SpyGlass): Direct visualization of bile duct; biopsy of biliary strictures; laser lithotripsy of large stones

H. Anti-Reflux and Bariatric Endoscopy

• TIF (Transoral Incisionless Fundoplication): Creates gastroesophageal valve using EsophyX device; for GERD refractory to PPIs
• Stretta Procedure: RF energy to LOS; improves competence
• Endoscopic sleeve gastroplasty (ESG, Overstitch): Suturing stomach wall to reduce gastric volume; BMI reduction ~10%; less invasive than surgical sleeve
• Intragastric balloon: Orbera, Spatz; temporary volume-occupying device; 6-12 months; ~10-15% weight loss

I. Other Therapeutic Uses

• Dilation/treatment of Zenker's diverticulum: Endoscopic septotomy (ZD stapler / Draf / harmonic)
• Peroral Endoscopic Myotomy (POEM): Submucosal tunnel → myotomy; for achalasia; covered in Q15
• G-POEM (Gastric-POEM): Submucosal pyloromyotomy for gastroparesis
• Closure of perforations: Endoclips, OTSC, suturing systems (OverStitch)
• EUS-guided drainage: Pancreatic pseudocyst drainage, walled-off necrosis (WON), hepaticogastrostomy

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Q11. Etiology and Management of Male Infertility

Definition

Etiology

A. Pre-testicular (Endocrine/Hypothalamic-Pituitary) - 2%

• Hypogonadotropic hypogonadism: Low FSH, LH, testosterone
  • Kallmann syndrome (GnRH deficiency + anosmia; KAL1 gene)
  • Pituitary tumours (prolactinoma most common - hyperprolactinaemia inhibits GnRH)
  • Cushing's syndrome, hypothyroidism
• Androgen resistance syndromes

B. Testicular (Primary) - 75%

• Varicocele: Most common correctable cause of male infertility (35-40% of primary, 75-80% of secondary infertility); Left > bilateral > right
• Cryptorchidism (undescended testis): Impaired spermatogenesis from heat exposure
• Orchitis: Mumps orchitis (post-pubertal) - 30% bilateral atrophy; bacterial; granulomatous
• Klinefelter's syndrome (47,XXY): Azoospermia, small firm testes, gynaecomastia; most common genetic cause of azoospermia
• Y-chromosome microdeletion: AZFa, AZFb, AZFc regions; azoospermia or severe oligospermia
• Idiopathic oligoasthenoteratozoospermia (OAT): Most common diagnosis
• Chemotherapy/radiotherapy: Alkylating agents particularly gonadotoxic
• Testicular torsion: Bilateral if contralateral ischemia
• Medications: Sulphasalazine, testosterone supplementation (suppresses endogenous spermatogenesis - "anabolic steroid infertility")

C. Post-testicular (Obstructive) - 20%

• Vasectomy (deliberate obstruction)
• Vas deferens obstruction: Congenital bilateral absence of vas deferens (CBAVD) - associated with CFTR mutation (cystic fibrosis gene); Young's syndrome (sinopulmonary disease)
• Epididymal obstruction: Post-gonococcal/chlamydial infection
• Ejaculatory duct obstruction: Congenital (Mullerian duct cyst) or acquired; transrectal US shows dilated seminal vesicles; treated by transurethral resection of ejaculatory ducts (TURED)
• Retrograde ejaculation: Diabetic autonomic neuropathy, post-TURP, post-retroperitoneal lymph node dissection, alpha blocker use; sperm in post-ejaculate urine (>15 sperm/HPF)

Investigation

• Azoospermia: No sperm in ejaculate (post-centrifuge pellet)
• Oligospermia: <16 million/mL; Severe <5 million/mL
• Asthenospermia: Low motility; Teratospermia: Low morphology
• OAT: Combined deficiency (most common)

• High FSH + small testes = primary testicular failure
• Low FSH + low T = hypogonadotropic hypogonadism

• Karyotype (47,XXY for Klinefelter's)
• Y-chromosome microdeletion (AZF regions): For non-obstructive azoospermia (NOA)
• CFTR mutation: If CBAVD suspected

Management

A. Medical Treatment

• hCG (LH analogue): Restores testosterone; 2000 IU SC 3x/week for 3-6 months
• FSH (hMG or recombinant FSH): Added after adequate testosterone; stimulates spermatogenesis
• Prolactinoma: Dopamine agonist (cabergoline/bromocriptine) → normalizes prolactin → restores spermatogenesis

• Sympathomimetics: Pseudoephedrine, imipramine - increases internal sphincter tone → antegrade ejaculation
• If fails: Alkalinization of urine (sodium bicarbonate) → collect sperm from urine → IUI/IVF

• Antioxidants (CoQ10, vitamin E, vitamin C, selenium): Some evidence for sperm parameter improvement

B. Surgical Treatment

• Most commonly performed procedure for male infertility
• Indications: Clinical varicocele (Grade II-III) + abnormal semen analysis + female partner normal or with treatable infertility + couple failed to conceive ≥2 years
• Approaches:
  • Microsurgical subinguinal varicocelectomy (Goldstein): Gold standard; lowest recurrence (1-2%), lowest hydrocele rate (<1%); uses operating microscope
  • Inguinal (Ivanissevich): Common, reliable
  • Retroperitoneal (Palomo): High ligation of internal spermatic vein at L4; high recurrence; rarely done
  • Laparoscopic: Similar to Palomo; general anaesthesia; rarely used
  • Percutaneous embolization (radiological): Retrograde catheterization of internal spermatic vein; occlusion with coils; outpatient; no incision; suitable for recurrence
• Outcomes: 50-70% improvement in semen parameters; 30-40% spontaneous pregnancy rates

• Vasovasostomy: Reanastomosis of vas deferens; indicated if no epididymal obstruction; success 90% if <3 years, 60-70% if 3-9 years, 30-50% >9 years
• Vasoepididymostomy: Anastomosis of vas to epididymal tubule; indicated if intravasal fluid on intraoperative inspection contains no sperm or sperm heads only (suggests secondary epididymal blockage)
• Both done under operating microscope (microsurgery)

C. Assisted Reproductive Techniques (ART)

• IUI (Intrauterine Insemination): For mild OAT, cervical factors; 10-15% success/cycle
• IVF (In Vitro Fertilisation): Moderate OAT; <5 million sperm/mL
• ICSI (Intracytoplasmic Sperm Injection): Single sperm injected directly into oocyte; for severe OAT, azoospermia with retrieved sperm; 40-50% fertilization rate per injected egg; revolutionized treatment of male factor infertility

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Q12. Fracture of Penis and Management

Definition

Anatomy

• Tunica albuginea: Dense fibro-elastic sheath surrounding each corpus cavernosum; 2 mm thick when erect (thinned from 2 mm flaccid); Type I collagen (outer longitudinal) + Type II collagen (inner circular); resists intracavernosal pressure up to 1500 mmHg normally but vulnerable to acute bending
• Corpus spongiosum + urethra: Separate from corpora cavernosa; spared in 80% of cases but may be injured

Mechanism

• Sudden buckling of erect penis (forced bending)
• Most common during: sexual intercourse (female superior position most common), masturbation, rolling over in bed on an erect penis ("Fajr fracture" in Middle East)
• Fracture typically occurs at the point of maximal stress (usually ventrolateral mid-shaft; proximal shaft 30%)

Clinical Features

• Sudden cracking/popping sound ("crack sound") at time of injury
• Immediate detumescence (penis loses erection)
• Rapid swelling, bruising, deformity - "Eggplant deformity" (diffuse haematoma + ecchymosis)
• "Rolling sign": Penile haematoma lateralizes to side of tear when patient stands (contained by Buck's fascia)
• Marked pain (usually moderate; less than expected - tunica tears rapidly)
• If Buck's fascia also torn: Haematoma extends to perineum, scrotum, inner thighs ("butterfly haematoma" - Colles' fascia distribution)
• Urethral injury (20%): Urethral tear/complete urethral disruption; features: frank haematuria, blood at meatus, inability to void, urinary retention

Investigations

• Clinical diagnosis in most cases (history + examination is pathognomonic)
• If diagnosis uncertain: MRI penis (gold standard; identifies exact tear location and extent); rarely needed
• Retrograde urethrogram: If urethral injury suspected; MUST be done before catheterization if blood at meatus
• Ultrasound (Doppler): Can show haematoma + flow disruption; less sensitive than MRI

Management

Immediate First Aid

• Ice packs (reduce swelling)
• Analgesia
• Urethral catheterization ONLY if no blood at meatus; otherwise RUG first

A. Surgical (Immediate) - Treatment of Choice

• Subcoronal degloving incision (most versatile): Circumferential skin incision just below corona; degloving of entire penile skin to base; allows access to all potential sites of injury; preferred
• Direct incision over haematoma: For definitive single-side injury; quicker; risk of missing contralateral or urethral injury
• Penoscrotal or infrapubic approach: For proximal injuries

1. Penile/regional block + GA or spinal
2. Circumferential subcoronal degloving incision through Buck's fascia
3. Evacuate haematoma; identify tunica albuginea tear (usually 1-2 cm transverse tear)
4. Irrigation
5. Primary repair with 2-0 or 3-0 absorbable suture (Vicryl or PDS) using horizontal mattress or interrupted stitches; ensure watertight closure
6. Inspect urethra (urethral sound/Foley catheter manipulation); if urethral injury found → primary repair over Foley catheter 14 Fr or suprapubic cystostomy + staged repair
7. Skin closure

• Incomplete (contusion): Suprapubic catheter for 2-3 weeks
• Complete tear: Primary urethral repair in same setting OR suprapubic diversion + delayed urethroplasty (3-6 months)

B. Conservative Management (Rarely Used)

• Ice packs, pressure dressing, anti-inflammatory medication, anti-erectile agents (diazepam, estrogen patch)
• Higher complication rates: ED (29% vs. 3% surgical), penile curvature/Peyronie's (50% vs. 5%), fibrous plaque formation, abscess, urethrocutaneous fistula
• Only considered if patient refuses surgery or fitness precludes GA

Complications

• Penile curvature: Fibrotic scarring → Peyronie's-like deformity (5-10% surgical, 50% conservative)
• Erectile dysfunction: More common with delayed repair
• Urethrocutaneous fistula (if urethral injury missed)
• Urethral stricture (at site of urethral repair)

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Q13. Ectopic Testis

Definition

Embryology of Normal Testicular Descent

1. Testis arises from genital ridge (7th week)
2. Gubernaculum forms; testis attached via cranial suspensory ligament
3. Transabdominal phase (8-15 weeks): INSL3 + testosterone → gubernaculum swells → testis moves from posterior abdominal wall to internal inguinal ring
4. Inguinoscrotal phase (25-35 weeks): Gubernaculum shrinks; testis passes through inguinal canal into scrotum
5. Complete by birth in 97% term males; 3% born with undescended testis; 80% descend by 3 months; at 6 months only 0.8% remain undescended (hormonal surge)

Sites of Ectopic Testis (after passing through external ring)

Difference: Ectopic vs. Undescended (Cryptorchid) Testis

Clinical Features

• Empty scrotum on affected side (unilateral or bilateral)
• Palpable lump in perineum, inguinal region, or base of penis
• NOT palpable in scrotum
• Indirect inguinal hernia: 90% of undescended/ectopic testes associated with patent processus vaginalis
• May have testicular torsion (rare; more common in undescended than ectopic)
• Puberty: Normal hormonal axis but spermatogenesis affected

Diagnosis

• Clinical examination: Key; in infant/child; both testes examined
• Ultrasound: Palpable or superficial ectopic testis location confirmation
• MRI / Laparoscopy: For impalpable testis (true cryptorchid in intra-abdominal position)
• If bilateral and not palpable: Hormonal profile (FSH/LH/testosterone); hCG stimulation test; karyotype (46,XX DSD?)

Complications

• Infertility: Spermatogenesis impaired by heat; bilateral > unilateral
• Malignancy: Risk of testicular cancer 3-14x higher than normal; risk reduced but NOT eliminated by orchidopexy; tumour surveillance important
• Torsion: Increased risk (especially if undescended)
• Hernia: 90% have associated patent processus vaginalis
• Psychological: Cosmetic concerns; testicular self-examination education

Management

Timing

• Current recommendation: Surgery at 6-12 months of age (no later than 18 months)
• Early surgery: Maximizes fertility preservation; reduces but does not eliminate cancer risk
• hCG or GnRH therapy (to stimulate descent): Limited role; 20% short-term success; high relapse; not recommended as primary therapy (EAU/ESPU guidelines)

Surgery: Orchidopexy

• Standard approach for ectopic and inguinal undescended testis
• Incision: Small inguinal crease incision (2-3 cm)
• Open external oblique aponeurosis along its fibres
• Isolate spermatic cord; identify and ligate patent processus vaginalis (indirect hernia sac) at internal ring (herniotomy)
• Free cord (vessels and vas) from surrounding tissues; careful not to injure vas
• Create dartos pouch in hemiscrotum (subdartos pouch technique)
• Place testis in pouch under no tension; close Scarpa's fascia over cord
• Critical: Adequate length must be gained - if short, lateral release behind inferior epigastric vessels (Fowler-Stephens maneuver)

• For intra-abdominal testis or when not palpable
• Diagnostic laparoscopy first: confirms testis location
• Laparoscopic single-stage orchidopexy: Mobilize vessels/vas + bring testis to scrotum
• Two-stage Fowler-Stephens (for high intra-abdominal testis with short vessels): Stage 1 - clip internal spermatic vessels laparoscopically; wait 6 months (collateral circulation via vasal and cremasteric vessels develops); Stage 2 - orchidopexy

Orchiectomy

• For atrophic or post-pubertal undiscovered testis (puberty onwards; risk vs. benefit of surgical preservation)
• Prosthetic testis insertion at time of orchiectomy for cosmesis

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Q14. Preperitoneal Anatomy of Inguinal Hernia in Relation to Laparoscopic Surgery (20 Marks)

Introduction

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Anatomy of the Inguinal Region

Bony Landmarks

• Pubic symphysis: Midline anterior
• Pubic tubercle: 1 cm lateral to symphysis; insertion of inguinal ligament medially; key landmark
• Anterior Superior Iliac Spine (ASIS): Lateral landmark
• Iliopubic tract: Thickening of transversalis fascia from ASIS to pubic tubercle; parallel to inguinal ligament but posterior; critical landmark in laparoscopic surgery

Myopectineal Orifice (Fruchaud's Orifice)

• Single large opening in the posterior abdominal wall through which all groin hernias pass
• Bounded by: rectus muscle medially, iliopsoas laterally, Cooper's ligament below, inguinal ligament inferiorly, transversus abdominis above
• Contains: indirect inguinal hernia (lateral to IEV), direct inguinal hernia (medial to IEV), femoral hernia (below iliopubic tract)
• All groin hernias can be repaired by covering this entire orifice with mesh - principle of laparoscopic repair

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The Preperitoneal Space

• Between pubic symphysis/bladder and peritoneum
• Avascular (with careful dissection); entry point for TEP

• Lateral extension of Retzius space; between psoas/iliac vessels and peritoneum
• Site of lateral dissection in TEP/TAPP

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Anatomical Structures in the Preperitoneal Space (Surgeon's View from Behind)

1. Cooper's (Pectineal) Ligament

• Dense fibrous structure on the superior pubic ramus (pectineal line)
• MUST be identified; mesh is stapled/tacked here medially in laparoscopic repair
• Continuous with transversalis fascia and lacunar ligament

2. Iliopubic Tract

• Condensation of transversalis fascia; runs from ASIS to pubic tubercle
• Parallel to inguinal ligament but 1-2 cm posterior
• Inferior boundary of the "safety zone"
• Critical: Tacks must NOT be placed below the iliopubic tract laterally → risk of injuring lateral cutaneous femoral nerve and femoral branch of genitofemoral nerve → lateral thigh numbness/pain

3. Inferior Epigastric Vessels (IEV)

• Arise from external iliac vessels; run medially and superiorly within the posterior rectus sheath
• Key landmark: Divide direct (medial) from indirect (lateral) inguinal hernias
• Must be identified and preserved; damage → haematoma

4. "Triangle of Doom" (Surgical Danger Zone)

• Bounded by:
  • Medially: Vas deferens
  • Laterally: Spermatic vessels (internal spermatic artery and vein)
  • Inferior apex: At the internal ring / peritoneal fold
• Contains: External iliac artery and vein (life-threatening injury if damaged)
• Rule: NO staples/tacks in the Triangle of Doom

5. "Triangle of Pain" (Lateral Danger Zone)

• Bounded by:
  • Medially: Spermatic vessels
  • Laterally: Iliopubic tract
  • Inferior: Peritoneal fold
• Contains: Lateral cutaneous femoral nerve (LCFN), femoral nerve, and femoral branch of genitofemoral nerve
• Rule: NO staples/tacks lateral to the spermatic vessels and below the iliopubic tract = Triangle of Pain

6. Spermatic Cord Structures

• Vas deferens: Runs inferomedially; crosses over iliac vessels; must be identified and preserved
• Internal spermatic vessels: Run laterally; course through internal ring; must be preserved
• Together they form an inverted "V" frame around the internal ring

7. Internal Inguinal Ring

• Opening in transversalis fascia; site of indirect hernia
• Lateral to IEV; spermatic cord traverses
• In females: Round ligament passes through

8. Femoral Canal / Femoral Ring

• Medial compartment of femoral sheath; below inguinal ligament and iliopubic tract; medial to femoral vein
• Site of femoral hernia; covered by mesh in laparoscopic repair (important - open anterior repairs may miss femoral hernias)

9. Nerve Anatomy (Critical for Pain Avoidance)

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Laparoscopic Approaches

A. TAPP (Transabdominal Preperitoneal Repair)

• 10-12 mm umbilical (camera)
• 5 mm right iliac fossa
• 5 mm left iliac fossa

1. Peritoneum incised 2-3 cm above hernia defect from median umbilical ligament (MUL) to ASIS
2. Preperitoneal space developed by blunt dissection
3. Cooper's ligament, IEV, indirect/direct hernia defect, triangle of doom and pain identified
4. Hernia sac dissected from cord (complete for indirect; just reduced for direct)
5. Mesh (15 x 10 cm minimum) placed flat; covers internal ring, direct space, and femoral ring; medial edge overlapping midline
6. Mesh fixed with staples/tacks: Cooper's ligament medially; above iliopubic tract laterally (NO tacks in triangle of doom or triangle of pain)
7. Alternatively: glue fixation (fibrin glue - Tisseel; cyanoacrylate - ProGrip self-fixating mesh) - reduces chronic pain vs. tacks
8. Peritoneum closed over mesh (prevents adhesion between mesh and bowel/cord)

• Easier learning curve than TEP
• Better visualization initially
• Can simultaneously inspect peritoneal cavity (diagnose contralateral hernia)
• Easier for bilateral simultaneous repair
• Can be done after previous pelvic surgery (relative advantage)

• Peritoneal cavity entered → visceral injury risk
• Peritoneal closure required (if inadequate → mesh-bowel contact)
• Higher port-site hernia risk vs. TEP (umbilical port)

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B. TEP (Totally Extraperitoneal Repair)

• 10-12 mm infra-umbilical (camera; through anterior rectus sheath; dissection between posterior rectus sheath and rectus muscle)
• 5 mm 5 cm below umbilicus (midline)
• 5 mm 5 cm further down (midline/pubic area)
• OR: 2 pararectal ports

• Inflated in preperitoneal space (under direct vision) → creates space by blunt dissection
• Balloon path: behind rectus, then caudally into Retzius space
• Alternatively: blunt fingertip or 10 mm scope head used to develop space

1. Posterior rectus sheath incised; balloon dissector inserted; inflated (800-1200 mL)
2. Ports placed under vision in preperitoneal space
3. Cooper's ligament, pubic symphysis, IEV identified
4. Hernia sac dissected (complete parietalization of spermatic cord - 5 cm from ring)
5. Mesh placed (same size); fixed with Cooper's ligament tack ± glue; no peritoneal closure needed
6. Deflate CO2 → mesh held by intraperitoneal pressure

• Peritoneal cavity NOT entered → less risk of visceral injury, adhesions, bowel obstruction
• No peritoneal closure needed
• Lower port-site hernia rate
• Faster recovery (less postoperative ileus)
• Preferred for previous lower abdominal/inguinal surgery (relative)

• Steeper learning curve
• Limited working space (balloon space)
• Risk of peritoneal tear (enters TAPP territory if peritoneum breaches)
• Cannot evaluate contralateral side easily
• Not suitable after previous Retzius space surgery (radical prostatectomy, pelvic fracture repair)

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C. ONSTEP (One-stage Needlescopic Extraperitoneal Patch)

• Single 2 cm skin incision; two mini-ports; partial peritoneal fixation of mesh
• Newer technique; limited adoption

D. Robotic Inguinal Hernia Repair (rTAPP)

• Robotic-assisted TAPP; increased precision of dissection and mesh placement
• Particularly advantageous for bilateral repair in single position
• Da Vinci; emerging evidence comparable to laparoscopic TAPP

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Mesh in Laparoscopic Inguinal Hernia Repair

• Size: Minimum 10x15 cm (EHS guidelines) to cover entire myopectineal orifice with 2-3 cm overlap
• Type: Polypropylene (standard); partially absorbable; lightweight mesh (reduce chronic pain and foreign body reaction)
• Fixation: Fibrin glue / cyanoacrylate (reduced nerve entrapment vs. staples); self-gripping mesh (ProGrip); tacks/staples only on Cooper's and above iliopubic tract
• Non-fixation: For medium-small defects; intraperitoneal pressure holds mesh; comparable recurrence

Comparison: TAPP vs. TEP vs. Open (Lichtenstein)

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Q15. Technique and Complications of Laparoscopic Heller Myotomy

Introduction

• Failure of LOS (Lower Oesophageal Sphincter) to relax with swallowing
• Loss of peristalsis in the oesophageal body
• Pathology: Degeneration of inhibitory neurons (VIP + NO) in Auerbach's myenteric plexus
• Consequence: Functional obstruction → progressive dysphagia, regurgitation, weight loss

Investigations Before Surgery

• OGD/Barium swallow: Confirm diagnosis; "rat-tail" tapering at GOJ; dilated oesophagus
• High-Resolution Manometry (HRM): Gold standard diagnosis; Chicago Classification (Types I, II, III)
  • Type I: Classic (aperistalsis + IRP >15 mmHg)
  • Type II: Pan-oesophageal pressurization (best surgical outcome)
  • Type III: Spastic (worst surgical outcome; consider POEM)
• Timed Barium Swallow: Baseline; follow-up
• CT chest: Rule out pseudoachalasia (malignant infiltration of cardia)
• Endo-FLIP (Endoluminal Functional Lumen Imaging Probe): Measures distensibility index of GOJ; increasingly used

Patient Selection

• All fit patients with confirmed achalasia
• Type II best outcomes with Heller myotomy
• Type III: POEM preferred (longer myotomy on oesophageal body)
• Recurrent/failed pneumatic dilatation: Myotomy indicated

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Laparoscopic Heller Myotomy - Technique

Position and Setup

• Patient supine, slight reverse Trendelenburg (15-20°)
• Surgeon stands between patient's legs (French position) OR right side
• Monitor at patient's head
• Oro/nasogastric tube decompresses stomach; removed before myotomy

Port Placement (5-port technique)

• 10-12 mm umbilical (camera port; 30° scope)
• 5 mm left hypochondrium (retractor for liver)
• 5 mm right hypochondrium (surgeon's right hand)
• 5 mm left iliac fossa (surgeon's left hand)
• 5 mm epigastric/left flank (assistant retraction)
• Nathanson liver retractor (single-use) often used to retract left lobe of liver without a port

Operative Steps

• Pneumoperitoneum 12-14 mmHg
• Left lobe of liver retracted with fan retractor (5 mm port) or Nathanson hook
• Omentum and stomach retracted inferiorly

• Incise gastrohepatic ligament (lesser omentum); expose right crus
• Identify and open the phrenoesophageal ligament (phreno-oesophageal membrane)
• Mobilize anterior vagus nerve (identify and PROTECT) and posterior vagus nerve
• Mediastinal dissection: Mobilize distal oesophagus 6-8 cm above GOJ to gain adequate myotomy length

• Oesophagus encircled with a Penrose drain or tape for traction
• Crural dissection around the oesophagus
• Identify GOJ anteriorly (fat pad - "epiphrenic fat pad" - excised or swept)

• Extent:
  • Oesophageal portion: 6 cm above GOJ (on oesophageal body musculature)
  • Gastric portion: 1.5-3 cm below GOJ onto gastric cardia (onto stomach)
  • CRITICAL: Adequate gastric extension (≥2 cm) prevents dysphagia recurrence; but excessive extension increases GERD risk
• Technique:
  • Hook electrocautery used to incise outer longitudinal muscle layer first
  • Then circular muscle divided in layers
  • Gentle spreading with closed dissector to complete mucosal dissection
  • Mucosa should bulge through ("fish mouth" appearance of completed myotomy)
  • Low or no energy at mucosal level to prevent delayed perforation
• Intraoperative Endoscopy: Simultaneous flexible gastroscopy strongly recommended:
  • Identifies incomplete myotomy (residual circular fibres visible endoscopically)
  • Identifies mucosal perforation (air leak test with scope; stomach submerged in water)
  • Allows transillumination to identify mucosal exposure

• Dor (Anterior 180° Fundoplication): Most widely used with Heller myotomy
  • Anterior surface of fundus folded anteriorly over the myotomy
  • Sutured to left then right cut edges of myotomy
  • Protects mucosa (especially if mucosal injury occurred), reduces GERD
  • Does not require posterior hiatal dissection
  • Advantage: Covers exposed mucosa; lower risk of dysphagia recurrence
• Toupet (Posterior 270° Fundoplication):
  • Posterior wrap of fundus; sutured to both cut edges of myotomy from behind
  • Keeps myotomy edges apart (prevents scar contracture = less dysphagia)
  • Requires more posterior hiatal dissection
  • Some prefer this for better anti-reflux (270° wrap)
• Nissen (360° Wrap): Generally AVOIDED with Heller myotomy due to high dysphagia recurrence (tight wrap over denervated oesophagus)

• Posterior crural sutures to close crural defect
• Prevent postoperative paraesophageal hernia

• Ports removed under vision; fascia closed at 10-12 mm port sites
• OGD performed before port removal to confirm adequate myotomy (EGJ opens with retroflexion, air insufflation)

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Postoperative Management

• Liquid diet for 24 hours; soft diet for 2 weeks; resume normal diet
• Discharge day 1-2
• PPI therapy (omeprazole 20 mg BD) initiated; continued for 6 months
• Timed barium swallow at 3-6 months: Assess oesophageal emptying; document

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Outcomes

• Symptomatic success: 87-92% at 5 years (Type I), 93-96% (Type II), 70-80% (Type III)
• Superior to pneumatic dilatation at 5 years (RCT: POEM/Heller equivalent at 2 years; long-term POEM data accumulating)

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Complications

Intraoperative

• Incidence: 5-15% (most recognized and repaired intraoperatively)
• Cause: Inadvertent entry during myotomy (especially at GOJ where mucosa adherent)
• Prevention: Intraoperative endoscopy; careful sharp dissection; low energy near mucosa
• Management: Primary repair with 3-0 or 4-0 absorbable sutures; reinforce with Dor fundoplication flap (anterior) over repair; if perforation large/unrecognized → convert to open
• If unrecognized → postoperative mediastinitis, pneumothorax, effusion → high mortality

• DVC of gastric vessels; short gastric artery injury
• Usually controlled laparoscopically; conversion if major vessel injury

• Anterior vagus most at risk; identified and preserved
• Injury → gastroparesis, dumping syndrome

• Pleural entry during mediastinal dissection; CO2 pneumothorax
• Usually resolves spontaneously; may need chest drain intraoperatively

Early Postoperative

• Presents: Fever, chest/epigastric pain, tachycardia day 1-5
• Investigation: CT chest/abdomen with oral contrast (Gastrografin)
• Management: NPO, IV antibiotics, PPI; endoscopic clipping; surgical repair if large; rarely SEMS

• Pre-existing oesophageal retention; risk in massive dilatation
• Peri-operative antibiotics; NGT decompression pre-operatively

• Post-mediastinal dissection; conservative management; drain if large

Late Complications

• Incidence without fundoplication: 30-60%; with Dor/Toupet: 15-30%
• Presents: Heartburn, regurgitation; pH monitoring confirms
• Management: PPIs; POEM for failed Heller; re-do fundoplication
• Long-term consequence of untreated reflux: Peptic stricture, Barrett's, adenocarcinoma

• Causes:
  • Incomplete myotomy (most common): Gastric extension <1.5 cm; residual circular fibres
  • Tight fundoplication (Nissen > Dor)
  • Scarring/fibrosis of myotomy edges
  • End-stage mega-oesophagus (non-responsive)
• Assessment: Manometry, timed barium swallow, EGD
• Management:
  • Repeat pneumatic dilatation (short-term relief)
  • POEM (ideal salvage procedure - can address both oesophageal and gastric components, avoids old scar tissue anteriorly by posterior approach)
  • Repeat Heller (technically difficult; risk of mucosal injury in scarred field)
  • Oesophagectomy (last resort; end-stage mega-oesophagus)

• Peptic stricture: Dilatation ± PPIs
• Barrett's oesophagus: RFA/surveillance

• Hernia (at 10-12 mm ports)
• Wound infection

• Rate: <2% (experienced centres)
• Indications: Uncontrolled bleeding, large perforation, dense adhesions, inability to complete myotomy safely

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POEM vs. Laparoscopic Heller Myotomy

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References: Smith and Tanagho's General Urology 19th Ed; Campbell Walsh Wein Urology; Bailey & Love's Surgery 28th Ed; Harrison's Internal Medicine 22nd Ed; Schwartz's Principles of Surgery 11th Ed; current EAU/SAGES/ESGE guidelines (2024-2026).

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