Gastrointestinal Surgery

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Gastrointestin Surgery al

Laparotomy

Moclern inragine technicltresand lzrparoscopl have reduced the need {irl cliagnosticlaparotomr'. Hol'ever, the ability to assess atr abdonren caletr.rllv ancl thoroughlv is essential in certain clrcull)stances, palticularlv abdrininal tralrma, laparotomy fbr tuudiasnosed abclonrinal pain, ar-rcl the staging o{'tumours. It in is trsefirl experience fol the trainee to perfbrm a corrplete lapar-otonry Ii'equentlv as possible in orcler to obtain a feel for as nortual variatiorrs,ancl to develop a svstematic routine firr the exauritrationo{'the entire abdorrinal cality. Thoroug}r laparotonry is inaclvisablein casesof localized abclorlinal sepsis, n'ith the possible exception of perfbratecl tunrours, because it mav dissenrinate inf'ection. The orcler ol examination is a ntatter of pet'sonal prel'elence; one techniqtre is clescribed belor,v ancl s h o w t ri n F i g . 5 . l . T h e e s s e n t i a lf e a t u r e i s t h a t n o t h i n g s h o u l d be overltxlked anrl nrost of the assessment is b1' palpation reqtririne'erlucated' sur-gicalhancls.

full assessmentis needed, a rnidline incision is usually'employed because it can be extencled to expose anl of the fbur quadrants of the abdomen. It has the additional aclvantagesof speed in accesslvhen dealine rvitl-rabdonrinal trauma, and sound rvound closure. In young children a transverse incision sitedjust above the urnbilicus provides eood exposure and heals rvell.

Operative technique 1. It is logical to start bl examining tl're small bowel because once this has been eviscer-ated,visibilitv is improved lbr the rernainclel ol the exanrination. Thelefirre, deliver the o[lentlrln and trzrnsversecolon into the rvound and ask the assistant to hold them uprvarcls (Fig. 5.2). Starting at the duorlenojejunal flextrle, inspect the paraduodenal lbssaand examine the entire small bol'el. Paloate the root of the

PREOPERATIVE ASSESSMENT
1. This is lalselv cleternrined bv the nature ofthe problem, but in all casesthe patient nrtrst be suitabll' prepared fbr sureery with atlequate resuscitation and cor-rectionof haematological ancl birichenricalabnornralities. 2. Any investisations l'hich uright have a bearing on the probleur nrust be available in the theatr-e and relevant X-ravs displa_vecl.

S e q u e n co f e x a m i n a t i o n e

RELEVANT ANATOMY
-I'he abdorninal cavitv exten<ls fi-on the ler,el of the nipples to the sluteal cLeaseand eren the rnost sensitive examining l'rzrnd cirtronly get a lirnitecl alt]ount of infitrtnation preoperativelv. 'I'he l:rpar-orrml plovicles the opportunity to exanrine the -l'he nxlst inacr:essible reaches of the peritoneal cavity. amount of infil-mati<ln olrtainecl is ploportional to the time and care taken <lur-ins' surgical explolation.

OPERATION Preparation
The anaesthetizerlpatienr is generallv positioned supine, althtiugh iu the presence o1' pelvic patholoey the t-loycl-Davies position urav be nrore applopriate. The patient is cleansecl and clrapecl to expose the abrlomen, and the chest in cases of
traulllil.

Incision Abdonrinal iucisitins are covered in the Introduction. Routine lapat'otonrv lareh alters ntallaqelnent. The length and siting of'the incision slrould be sover-ned by the natlrre of the operation beins per-Iil'nred rather than to allorv ideal conditions lbr thortltrgh :lssessnrent the entire abdominal contents. When a of

Fig.5.l

LAPAROTOMY

nlesclltel'\'. araveltebral retroper-itoneunr, a()rta ar)(l p t-nesente ressels,arrrl <lisplacetl're snrall bot'el to the lefi ol lic the n'or,rnrl. Inspect the bkrorl vesselsirl the rnesenter)'. 2. Retract the ab<krurinal incision to the r-isht, alkxvins visualization an(l ltalltirtion ol the cilecutn, a1>penrlix, ascen<ling colon, hepatir: flextu'e :rnrl lisht kirlner. llxarnine the tr-ansverse col<ln t:irlelirllr', then rlisplace the srnall bou'el to the lisht an(l retnrct the incision to the leli. 3. [,xarnine the splenic llexur-e ol the cokrn and spleen; particulal car-eis neerlerl here because i1' arlhesions are Dl.esent t h e c a p s r r l e l t h e s l t l e e n i s e a s i l v t o r n . P a s sa h a n c l t i v c r . t h e o s p l e e n o p a l p a t e t h e l e l t h e n r i r l i a p h r a e r n ,s u b p h r e n i c s p a c e , t auclasscsshe size an<l conrlition ol the spleen. In deept chestetlol oltese ltaticrrts it is eusr to uriss a snrall carcinonra o 1 ' t h es p l e n i <f'l e x u l e o 1 ' t h e c o l o n . 4. Palpatethe left kidney, descending colon, sigmoid colon and rectum in turn. The hand is then turned over to palpate the rectovesical recto-Llterine pouch and the pelvic contents. or Havingcompleted the examinarion of the infracolic con.rpartment, return the small borvel and transverse colon to the abdomen. 5. Inselt a Nlon'is or l)e:rver- retractor into the upper en<l <ll' t h e i n c i s i o na n r l l i l i i t u p u a r c l s . P a s st h e h a n < l t o t h e s i r l e o l ' t h e l i r l c i l i n ' r rlri g a r r r e n r a n c l p a l p a r e r h e l e l t k r b e < l l ' t t r e l i v e r . 'l'lte bet$'een ingeI anrl thtrnrb (Fig. 5.3). [ a s s i s t a n rr e t r - a c [ s the right costalrrrargin to alkxv bimanual palpation ol'the l i s h t k r l l eo l t h e l i v e l a n r l p a l p a t i o n o l ' r h e r i e h t s u b p h r e n i c a n r ls u b h e l t a t i c l l r c e s( F i g . 5 . { ) . s

P a l p a t i oo f l i v e r n

.--.-Y----\/

,F i g . . 3 5

R e t r a crti g h tc o s t am a r g i no e x a m i n r i g h t o b eo f l i v e r l t e l L i f t t r a n s v e r s e 0 n o e x a m i n ie f r a - c o l ic o m p a r t m e n t col t n c

-.,----\\

Fis. 5.2

Fig. 5.4

5.3

OPERATIVE SURGERY

6. Assess the oesophagealhiatus with the index finger, and then passthe hand down over the fundus and body of the stomach. Using the examining hand, stretch out the stomach to look for puckering of the serosalsurface that might indicatean ulcer or small tumour, and examine the upper part of the aorta and body and tail of the pancreasby palpation through the lesseromentum. 7. The assistant draws the sromachto the lef t and displacesthe transverse colon inferiorly to expose the pylorus and first part of the duodenum. Feel the head of the pancreasin the concavityof the duodenum. 8. Palpatethe common bile duct, hepatic artery and portal vein through the foramen of Winslow, and examine the gall bladder for stones;an anomalous hepatic arterial supply is common.

exposure of the great vessels below the duodenum, displace the small bowel to the right, and divide rhe peritoneum in the midline, avoiding injury to rhe mesentericvessels. 5. For a full assessment the right hemidiaphragm and bare of area of the liver, together with accessto rhe suprahepatic inferior vena cava, incise the right triangular ligament and upper leaf of the coronary ligament.

Wound closure and dressing Close the wound with monofilament nylon and the skin by the method of choice. No dr-ain is required for an explorarory laparotomyalone.A waterproof dressingis applied.

Additional manoeuvres l. For a full assessment the first and second parts of the of duodenum, head of the pancreas and disral common bile duct, mobilize the duodenum by incising the peritoneum between the duodenum and inferior vena cava. lnsert a finger behind the duodenum, which is then lifted forwards (Kocher'smanoeuvre). 2. If access the lessersac,posterior nall of the stomach and to pancreasis required, divide the avascular porrion of the transverse mesocolonor the gastrocolicomentum.

POSTOPERATIVE CARE This will be largely determined by the operation which has been undertaken. If there has been no additional procedure,a nasogastrictube is advisableuntil any ileus from handling the bowel has subsided.Fluids and diet are then reintroduced.Skin suturesare removed after 8-10 davs.

SPECIAL OPERATIVE HAZARDS l. Poor siting of the incision. the entire abdominal cavity, particularly 2. Failure to assess if there are multiple adhesions. 3, Damage to the capsule of the spleen which usually responds to packing. Rarely, a splenectomy may be needed.

3. Exposure of the kidney, urerer and iliac vesselsis obtained
by mobilizing the ascendingcolon, or descending colon and the spleen, by division of the perironeum along its antimesentericborder. When combined with Kocher's manoeuvre,the inferior venacavaand the right kidney are exposed. COMPLICATIONS l. Paralyticileus. 2. Wound problems, such as haematoma, infection and dehiscence.

4. During staging laparotomy for Hodgkin's disease (less
frequentlyindicated with the advenr of CT scannine),or for

7

Nissen Fundoplication

This operation is indicated for a minority of casesof' reflux associatedwith a sliding hiatus hernia, in which 1 oesophagitis i there are either intracrable symproms of gastro-oesophageal i reflux or complicationsof gastro-oesophageal reflux (e.g. stricture formation with or without aspiration pneumonitis, ulceration i ! and haemorrhage).The aim of the operarion is ro restore a I length of intra-abdominal oesophagus and create a valvular i

associated stricture must be treated on its own merits. Once other causes, especially malignancy, have been excluded the stricture can be endoscopically dilated.

RELEVANT ANATOMY The oesophagus passes through the diaphragmat the levelof the tenth thoracic vertebra(Fig.5.5).The oesophageal hiatus is more verticalthan horizontal and the fibresof the right crusof
the diaphragm loop around the oesophagusat this level; the action of this muscular loop, together with the effect of intraabdominal pressure on the intra-abdominal oesophagusand the weak intrinsic cardiac sphincter all act to prevent reflux of food, acid and bile from the stomach.In a sliding hiatushernia, the gastro-oesophagealjunction slidesup into the chestthrough the hiatus, Ieavingthe cardiac sphincter alone to prevent gastrooesophagealreflux. Gastro-oesophageal reflux can occur without a hiatus hernia and reflux need not accompanya hiatus hernia. The normal intra-abdominal oesophagusis approximately I cm long, and on its surface lie the anterior and posteriorvagal trunks. lt is enveloped between two leavesof peritoneum which fuse on its right as the uppermost part of the lesseromentum and on its left as the upper extremity of the greater omentum; both omenta are firmly attached to the diaphragm. Lying in front of the gastro-oesophageal junction is the lateral segment of the left lobe of the liver; this is attachedto the diaphragm by the left triangular ligament. The oesophagus enters the stomach at the cardiac orifice. The fundus of the stomach is that part which extends above the level of the cardiac orifice and which is in contactwith the Ieft hemidiaphragm. It is closely related to the spleen,being attached by two folds of peritoneum called the gastrosplenic omentum which contains the short gastricarreries(vasa brevia); these arise from the splenic artery (Fig. 5.6).

OPERATION ABDOMINAL APPROACH Preparation The patient is placed supine on the operating table and a crossbar inserted into the table to allow the third blade of a Balfour retractor to be hooked under it, to provide sternal retraction. A wide-bore, for example 40Fr, orogastric tube is passedby the anaesthetistto prevent undue narrowing of the lower oesophaguswhen performing the fundoplication. The skin is cleansed and drapes are applied to expose the lower chest and upper abdomen.

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Incision The abdomen is entered through an upper midline incision, starting at the level of the xiphisternum (seethe Introduction).

OPERATIVE SURGERY

Operative technique l. Following a thor-ough laparotonrt,, expose the gastrooesophaeeal junction bl division of' the lef't triar.rgular'fhis lisament (Fig. 5.7). allou,s the lateral segrnenr ol'the lelt lobe of tl.reliver to be sently retracted lirnvard ancl t<l the right. 2. (lentle tractior) on the upper part o1' the storrrach reduces the hiatus hernia. Divicle the peritoneunl ()\'el' the Ixrnt ol the abclonrinal oes<lphaeus ancl nrobilize the krrver- oesophaer-rs, taking care not to claruage the vagi. 3 . E x t e n < l h i s i n c i s i o nt o t h e u p p e l p a r t o l ' t h e l e s s e ro n r e n t u n r . t Av<licl <larnage to an accessorv leli hepatic ar-tcry ulisin{ lirrnr the lelt sastric arter-\'; this occur-sh 237r of'parients.

4 . Nlobilize the I'undtrs ol the stomach bv division of its peritoneal attachrnent to tl-recliapl.rraem; ligation and division ol the upper short gastricarteries nral'be necessar)'(Fig. .8). 5
5 . With the finSlels of'the risht hand, pusl.r tl.reanterior- u'all of'

tl.relunclus of'the stonrach behincl the oes<lphagus o the t patient's risht and erasp it n ith a Ilabcock's lilrceps (Fig. 5.9). Inselt non-absorbable slrtlrres (e.g. (X) silk) into the sastlic lirndus to the right of the oesophaeus, through the anterior u ' a l l o f ' t h e o e s o p h a g t r sa n r l i n t o t h e u p p e r s t ( ) r r ) a c ho t h e t leli o1' the oesophagus, tl)us rvr-appine the I'undus arouncl the klrver oesopha{trs (Iig. 5.10). (ienerallv onl,v three ur lirtrr strttrres are recluir-erl.

Anatomy the cardia of

D i v i s i oo f l e f tt r i a n g u l a irg a m e n o e x p o s e b d o m i n a l n l tt a o e s o p h a g u s dh i a t u s an

left triangular lrgament

Fig. 5.6

Fis. 5.7

5.6

NISSENFUNDOPLICATION

m I n c i s i oo f p e r i t o n e uo v e ro e s o p h a g u s dd i v i s i o o f s h o r tg a s t r i c e s s e l s n an n v

nerve vagus shortgastflc artenes

relraclor over le{tlobeof liver

:r,#,'Jrll,,t.
, t l , l , ll' ,l t , t l t
" r t \ , ,t \ L I \ I 1 -/a

a.'

Fig. 5.8

Wrappinq fundus around oesophagus the

C o m p l e t i o nf u n d o p l i c a t i o n of

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f
Fig. 5.9

I n c o r p o r a oe s o p h a g u s te the in sutures prevent to w r a ps l i p p i n g

Fig5.10 .
3.1

OPERATIVE SURGERY

Posterior repair hiatus of

7, With eentle tracti()n on a sling placecl axrund the oesophaeus, the nrarsins of' the hiatus are delined posteriorlv and tl-retr\'()crura opposed rvith interrr-rpted non-absorbable 'fhe s u t L l r e s( l ' i g . 5 . 1 l ) . r e s u l t i n s l ' r i a t u ss h o u l d b e s n u g b u t rx)t tight.

Wound closure and dressing 1. (iheck that there is no bleeclins l.nrrn the spleen and close the t'ound. A drain is not necessarr'. 2. Replace the u'ide-bor-etube u'ith a standard nasogastrictube. A rlrl <h'essingis appliecl.

APPROACH Preparation '['he patient is anaesthetized ancl then intubated rvith a rkrubleIunren er)(lotracheal ttrbe and placecl in the Iull lateral position.

.fHORACIC

F i g5 . 1 1 .

F i x a t i oo f f u n d o p l i c a t i t o m a r g i n f h i a t u s n on o

Insertion sutures narrow 0f to hiatus

Fig.5.12 ,,$

Fis.5.13

N I S S EF U N D O P L I C A T I O N N

Incision Perform a left posterolateral thoracoromy (see page 2.20) above the seventh rib.

C o m p l e t eh o r a c i cu n d o p l i c a t i o n td f

Operative technique l. Open the pleura and ask the anaesthetist to deflate the left lung. The inf'erior pulmonarv ligament is divided as f'ar as the inferior pulmonary vein and the lung retracted upward and anteriorly. 2. Divide the parietal pleura over rhe lower third of the oesophaeusand mobilize this segment, passing a linen tape around it. A nasogastric tube helps idenrification of the oesophagus and can now be r.vithdran'n. Throushout the operation care is taken to preser-\,ethe vagus nerves which are clearly felt as cord like structures beneath the fingers, and are often visible. 3. Continue the mobilization caudally, separating rhe oesophagus and hiatus hernia from rhe crura of the diaphragm. This is achieved by dividing the condensation of connecri\re tissue betrveen the oesophagus and diaphragm (phrenooesophageal ligament) and opening the basal pleura and peritoneum in order that a finger may be passed int<t the abdomen and srvept completely around the gastroj oesophaueal uncl ion. 4. Deliver the gastric fundus into the chest and ligate the upper short gastric vessels. Reduce the stomach into the abdomen (see ig. 5.12). F 5. Define the crura and insert three non-absorbable sutures (e.g. Ethibond) between them posteriorly. These are left untied at this stage, but are later tied to repair the hiatus so that it will just admit two fingers (Fig. 5.12). 6. Draw the stomach into the chesr, clear the fat pad fiom the gastro-oesophagealjunction, and ask the anaesthetist to introduce a size 50 cir 55 Hurst-Nlaloney bougie to pr-evenr undue narrowing of the lumen of the oesophagus. 7. Wrap the f'undtrs of the stornach 360' around the lower 3-4cm of oesophaeus fi'orn behind and secure it rvith three non-absorbable sutures (e.g. Ethibond), passed from one side of the fundus to the orher via the encircled oesophaeus. W i t l r d r ' : n v l r c l r o t rg i e . t 8. Insert two or three non-absorbable sutures horizontally through oesophagus, fundus and crus so rhat when tightened the wrap is reduced into the abdomen (Fig. 5.13). 9. Tie the cr-ural suttu-es, lvhich rvere inserted earlier, to narrolv t h e h i a l t r s F i s .5 . 1 4 1 . t

Fig.5.14

returns; oral fluids can then be reintroduced. The skin sutures are removed after 8 davs. Follorving the thoracic approach, the chest drain is removed on the first postoperative day unless there is an air leak fiorn the lune.

SPECIAL OPERATIVE HAZARDS
l. Damage to the spleen.This may be treated by conservative measures,but generally a splenectomyis necessary. 2. Damage to the vagi can cause functional gastric outlet , obstruction, requiring a pyloroplasty or gastroenterostomy. 3. lnability to bring the gastro-oesophagealjunction into the abdomen.This is usuallydue to scarringand consequent shortening of the oesophagus. There are two alternatives to overcome this problem: (i) perform a Nissen fundoplication in the left chest; (ii) create a 'neo-oesophagus' performing a Collis by gastroplasty with a linear stapler(Fig.5.l5). 4. A tight peptic stricture rvhich cannot be dilated, even when operated under direct vision. In such cases Thal a fundic patch can be performed by incising the stricturein the line of the oesophagus and suturing the fundusof the stomach to the margins of the incision. Then a fundoplication is perf-o;med.

Wound closure and dressing Inselt a chest rlrain, reinflate the lefi lung and close the chest.

POSTOPERATIVE CARE Thenasogastr-ic shouldremainin place tube until gastric motiliry

COMPLICATIONS l. 'Gasbloat' is a term used to describethe unpleasant gaseous

5.9

al
OPERATIVE SURGERY

i
Principles ofgastroplasty
distention experienced by some patients following a fundoplication. It occurs particularly after fizzy drinks, which should be avoided. The valvular wrap created by this operation cannot relax and consequently the patient frequently cannot belch or vomit. Dysphagia is usually transient and due to oedema around the lower oesophagus. However, in caseswhere a wide orogastric tube is not inserted at the start of the operation, the wrap can be made too tight in which case the dysphagia will not be transient.
l

,

Fig.5.l5

a

Oesophagogastrectomy

T'his operation is indicated for the treatment of carcinoma of the distal oesophaeus and gastro-oesophageal junction. With any further involvement of the stomach a total gastrectomy should be considered, or an Ivor-Lervis oesophagectomy if rhe involvententis more proximal.

PREOPERATIVE ASSESSMENT l. Establishthe diagnosis and exrent of the disease with a barium meal,endoscopywith biopsy, chest X-ray, liver ultrasoundand CT scanning. 2 . M a l n o u r i s h e dp a t i e n t s m a y b e n e f i t f r o m p r e c i p e r a r i \ . e parenteral nutrition. 3. In patientswith poor respiratory f'unction, particularly n'ith aspiration from oesophageal obstr-uction, consider a procedure which does nor require a thoracoromy (e.g. a purely abdominal an abdominocer-r'ical or approach). 4, Arrangea pr-eoperati\,e to the intensivecare unit. visit

ting or ligating any small arteries running into the oesophagus directly from the aorta. Nlobilize the oesophagus, keeping with it as much surrounding lymphatic and connective tissue as possible, to allorv transection at least 5cm above the upper extr-emity of the tumour; this may require mobilization up to the level of the aortic arch. Free the peritoneal attachments at the hiatus, excising any muscle adherent to the tumour en bloc,and divide the left triansular ligament if it will improve access(Fig. 5.16).

gea E x p o s u r0 f g a s t r o - o e s o p h a lj u n c t i o n e

RELEVANT ANATOMY Thisis covered pages2.I I and 5.2 3 in Oesophagectomy on and PartialGastrectomy. After the opel-ation gastricremnanr will rely on rhe risht the gastric and right gastro-epiploicarreries (both derived from the hepatic artery)fbl its blood supply.

cutedge ot diaphragm

OPERATION Preparation
The anaesthetized patient is intubated and ventilated n,ith a double-lumen endotrachealtube (to allon selectivedeflation of the left lung), and positionedfor a thoraco-abdominal incision ( s e e a g e5 . 3 0 ) . p

lncision Make an oblique, Ieft-sided abdominal incision and, having confirmed resectability,exrend it as a left thoraco-abdominal incision described page 5.30. as on

Operative technique l. With the left lung drawn npwards, divide the inferior p u l n r o n a l y i g a m e n tr r s i n g <s s o r s . l si
2. Divide the diaphragm radially down to the hiatus and insert stay slltures at intervals to allow retraction of the diaphragm and reopposition afterwards. If the tumour is adherent to the nrargins of the hiatus plan to remove tli'is en bloc. 3. Open the pleura overlying the thoracic aorta with scissors and Iree the thoracic oesophagus fiom the aorta, coagula-

Fig.5.l6

I 5.1

OPEHATIVE SURGERY

4 . l l n t e l t h e l e s s e l s : r cl r r r l i r i r l i n e t h e g a s t l o c o l i c o n t e r r t u r t t
b e n l e e u l i g a t u l c s u n t [ < l i v i < l ea n v a < l h e s i o n sb e t u ' e e n t h e s t o u r a c ha r r t l p a r r c r e a s .K e e p i n g -l e l l c l e a l o 1 ' t h e s t o n r a c l r s o l l s t o l ) r e s e r \ e t h e U a s t | 0 - e P i P l o i c | c a < l e ,u o r ' k u l ) t ( ) t h e a l i r n < l t r sr.l i v i c l i n g t h e s h o r t q : r s t r i c a r - t e l i e s; r n r l l c l t g a s t r ( ) e p i l l k r i ca l t e l i c s c l o s e t o t h e i l o l i g i n ( F i g - .i r . l 7 ) .

lrelrinrl lhe stonurclr.l)issect the vesselll-ce as it closses t l r e f l o o r - o I t l r e l e s s e r - a c w i t h i t s s u r r - o u n r l i n ul v r n p h a t i c s t i s s u e u n t i l t h e u p p e l s t o u r a c h a n < l l o l e r o e s o p h a { u sa r e ( c o n r p l e t e l r1 r ' e e F i g . 5 . I 8 ) . ' l 6 . l ) i r i < l e t h e t h o l a c i c o e s o p h u u t r s a t t l l e s e l e c t e cs i t e a n d t r a n s e c t t h e s t o n r a c h o l l l i c l t r e l r ' . j r r s te k r v a c r u s h i n u c l a n r p b b e k r n t h e c i r l r l i a . u ' i t h a r r o r r - c n r s h i n g c l u n r p a c r o s st h e 'l'he stornuch. l e l t s u s t r i c p e c l i c l el i t h i t s a t t a c h e c l v r n p h i r t i c sl i r r u r s p a l t o l t h c s p e t i n r e n . ( . h e c k t h a t t h c n r o b i l i z e d s t o r t t : r c hc a r r c o r t t l i r r t u l r l v r - e a c l tt l r e c t r t e n r l o l t h e o e s o p h i r e u s . I I i t u i l l n o t , r l i l i < l e t h c g l e a t e l a n < ll e s s e r ' o n l e n t a I r r r t h c l l x r t e r r s r r l et l r u t t h e l i g l r t g a s t r i ca n c le a s t l o - e p i p k r i c lultelies lu'e r)ot <larrurge<I.

5 . l ' u l l v n r o b i l i z e( K o c l r e l i z e )t h e r l u o c l e n u n r .l ) i v i c l e t h e l e s s e r
o n l e l l t u n rr : l o s e o t h e s t o n r a c h ,u i t l t l i g a t i o n a n d < l i v i s i o no [ ' t a n l a b e r n r n t a l t e l i a l i n p r . r tt o t h e l e l t k r b e o I t h e l i v e r h - o n r t h e l e { i g : r s t r i cu r t e r \ ' . a n < l e x p o s e t h e o l i g i n o 1 ' t h e l e [ ' t gastrit urtelr llonr the coeliacaltelr'.jr.rsabove the ul)l)er t lxn'rlcr'ol the llrncr-eas. \'ith the stoutach lilte<l Iirnvaxls \ r k r u l l l v l i g a t e a l l ( l < l i v i r l et h e l e l t s a s t r i c a r r e r y u t i t s o l i q i n ; t h i s i s o l i c n u r o r e e : r s i l r p e r l i r l r n e c l I r ' o r t rt h e l e l i , u ' o l k i n g '

g r M o b i l i z a t io fn r e a t ec u r v a t u ra n df u n d u s e

C o m o l e t e do b i l i z a t i o n m

chnrt n:ctr a

vesse is

Fig.5.l7

Fig.5.18

t2

OESO PHAGOGASTRECTOMY

Close the lesser curve defect completely rvith either two layers of continlrous absorbable sutlrres, such as Vicryl or Polydioxamone (Fig. 5.19), or a linear stapling device.

8. Using diathermy make an incision in the anterior wall of
the fundus of the stomach to match in size the cut end of the oesophagus and fashion an anastomosis between them using either one or two concentric layers of interrupted sutures (Fig. 5.20). It is easiest ro inserr all the posterior layer of sutures first, then tie them r,vith the knots on the inside. Include the oesophageal mucosa in each srirch as it tends to retract, and if a second layer is used umbricate the outer layer of the anastomosis in an ink-well fashion (see the inset on Fig. 5.20). Alternatively, this anastomosis can be

made with a stapling device, introduced through a pyloroplasty incision in the stomach in a similar fashion to that described for total gastrectomy (see page 5.31). If stapling devices are used to both close the stomach and for the anastomosis, it is important not to leave a narrow potentially devascularized area between these two staple lines; the anastomosis must either include part of the staple line or be well separated from it.

H a n d e w no e s o p h a g o g a s arnc s t o m o s i s s t ia

Closurecardia of

l
l

I l I I i I i

l

I I
Fi9.5.19

Fig. 5.20

I I
I

5 . 1 i3

I

OPERATIVE SURGERY 9. Perform a pyloromyotomyrvith diathermy (Fig. 5.21) or a (seepage 5.21) since the vagi will have been pyloroplasty divided.

COMPLICATIONS
l. Anastomotic leakage should be treated conservatively with a nasogastric tube and parenteral nutrition until radiobgically healed. 2. Anastomotic strictures may be benign or malignant and are treated by dilatation or palliative intubation. 3. Chest inf'ection. Physiotherapy should be used in all patients af ter extr-rbation. 4. Post-thoracotomy pain.

10. Ensure haemostasis, particularly around the spleen, and check the position of a nasogastric tube which is passed through the anastomosis.

Wound closure and dressing Insert apicaland basal chest drains and close and dress the thoraco-abdominal wound as describedon page 5.33 POSTOPERATIVE CARE The patient is nursed in an intensive care unit Ibr the first 24-48 hoursand electively venrilared overnight.Good analgesia withoutrespiratory depression be achieved administering can by opiates a thoracicepidural cannula.The patient is kept nilvia by-mouthwith a nasogastric tube unril the sixth day, when a Gastrografin(nreglumine diatrizoate) swallow is performed t<r visualize anastomosis. the During this period parenteral nutrition is administered. the anastomosis intact the nasogasrric If is tube is removedand oral fluids are reintroduced. The apical drain is removed if the lung is fully expanded after 24-48 hours,and if there is no air leak.The basaldrain remainsuntil the seventh day.Suturesare rernovedafter 8-10 days.
I

Pyloromyotomy

SPECIAL OPERATIVE HAZARDS l. Disseminatedtumour, in which case palliative resection might bejustified particularly for cases wirh dysphagia.If not, considerbypassingrhe tumour with a loop of bowel, or palliativeintubation. 2. There may be an accessoryleft hepatic artery, which generallyarisesfrom the left gastric arrery and must be sacrificedif present. 3. Damage to the spleen, which requires a splenectomy if this doesnot respond to packing with moist swabs. 4. Damage to the inferior pulmonary vein when dividing the inferior pulmonary ligament. 5. Damageto the rhoracicduct leading to a chylous elTusion or ascites. noted at the time of surgery, ligate the duct If with a non-absorbabletie.

Fig. 5.21

Highly SelectiveVagotomy

fiighly selective vagoromy (parietal cell vagotomy) is an acid [educing operation fbr patients with duodenal ulcerarion Fefractoryto adequare medical therapy. This procedure aims ro denervatethe gastric parietal cells whilst preserving the hepatic, boeliacand antral branches of the vagus nerves. Intact antral innervation ensures adequate gastric emptying, obviating the need for a gastric drainage procedure. This operadon carries a [ower morbidity than truncal vagotomy and drainage (see page 5. I 8), but there is concern about the increasing long-term recurfence rate. Highly selective vagoromy is contra-indicated in pbesepatients because of the technical difficulties. It is eenerally ponsidered that this procedure is too time-consuming to be appropriate as part of an emergency operation for complications of duodenal ulc'eration (e.g. bleeding).

2. Exclude pyloric stenosis this is usually considereda contraas indication to highly selectivevagotomy, although rhere are techniques duodenal dilation and duodenoplasty. of 3. Exclude, if suspected, a gastrinoma by the fasting serum gastrinestimationmethod, and duodenal Crohn'sdisease by biopsy.

ASSESSMENT PREOPERATIVE
l. Confirm the presence of persistent or recurrent duodenal ulceration using endoscopy or a barium meal.

RELEVANT ANATOMY (Fig. 5.22) The anterior vagus nerve lies on the anterior surface of the abdominal oesophagus,and the posterior vagusliesbehind and to the right of the oesophagus. Both give rise to multiple small branches which run onto the stomach. The vagal trunks also give rise to the hepatic and coeliac branches, and continue adjacent to the lessercurve of the stomach as the anterior and posterior nerves of Latarjet; these supply multiple secretory branches to the stomach, each accompaniedby branchesof the left and right gastric vessels. The nerves of Latarjet give off a leash of branches to the gastric antrum, and the watershed

Relevant anatomV
antefl0r vagus nerve

. \t:\ irl17>)a
3r r'

\utt, [\]

I(i,

(fi

l j

t,ll
nerve Latariet of

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Fig. 5.22

I I
5.15

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I

I

I

OPERATIVE SURGERY

between these motor branches and the secretory branches to the body of the stomach is usually clearly seen at the proximal 'crows's extremity of the foot', 5-6cm proximal to the pylorus.

Digital assessment gastric 0f outlet

OPERATION Preparation The patientis placedsupine,and the mid and upper abdomen and lower chest is cleansedand draped. A crossbar is fitted to the table. A nasogastrictube is passed, and a single dose of broad-spectrum intravenous antibiotics are given at induction.

' 1'

Incision Make an upper midline incision (see the Introduction) and carry it up into the notch betweenthe xiphoid and costalmargin to achievethe best exposlrreof the oesophagealhiatus. Insert a self-retaininsretractor and retract the sternum with the third blade of a Balfour retractor, hooked under the crossbar.

:,','ffi, NN ru[-_....],ll,,rr,
tttr

= -1, l'l --= . i

./ --

{\'.-

='

\ =\\

ffi$..'$.,:
\=E/z
-*4'tA,/

7W

illl
,,i1

iiiiriii,\

Wi[il:.tfu'
Fis. 5.23

Operative technique l. Confirm thb diagnosisof chronic duodenal ulceration, assess the gastricoutlet using a finger and thumb (Fig. 5.23) and per{brm a thorough laparotomy.
2. Open the lesser sac by opening the gastrocolic omentum, taking care to preserve the gastro-epiploic arcade. Free adhesions between the posterior wall of the stomach and pancreas and check that there is no unsuspected gastric ulcer. 3. Identify the anterior nerve of Lararjet. Make a hole in the lesser omentum close to the stomach u'all just to the left of 'crow's the foot', and pass a rubber sling through this hole and out through the hole in the gastrocolic omentum (Fig. 5.24). lncise the peritoneum over the anterior surface of the stomach along the lesser curve. 4. Starting at the hole in the lesser omentum and working towards the gastro-oesophageal junction, ligate and divide all the branches of the anterior nerve of Latarjet to the stomach with their accompanying vessels (Fig. 5.25). The dissection begins no further than 6cm from the pylorus. Use the rubber sling to draw the nerve of Latarjet taut. 5. Roll the stomach clockwise to expose the branches of the posterior nerve of Latarjet (Fig. 5.26). lt is not necessary ro identif y the posterior nerve itself, as it should not be damased if the dissection is kept close to the wall of rhe stomach. Alternatively, rotate the greater curve of the stomach superiorly and to the right so the posterior nerve of Latarjet can be directly seen through the hole in the gastrocolic omentum, and then divide the branches of the posterior vagus and the accompanying vesselsfrom behind (Fig. 5.27). 6. Ligate and divide the remaining neurovascular bundles on the lesser curve of the stcmach; it may be easier to use ciips rather than ligatures in the upper part of the dissection. The lessercurve is thus completely denuded.

W
:
I

p g Sling assed round astric ntrum a a

Fig. 5.24
l6 7. Incise the serosa over the gastro-oesophagealjunction from

I
HIGHLY SELECTIVE VAGOTOMY Division branches anterior of of nerve0f Latariet the lesser curve r() the oesophagogastric angle, dividing all the branchesof-the anrelior vagus nerve to the upper stomach. Car-ef'ully preser\/e vagaltrunk itself'and the retract it to the right. It is useful to place a sling around rhe oesophagus to draw it dou'nn'ardsar this stage,taking care to excludethe posterior vasal rrunk litm the sling (Fig.5.28). Meticulously' clear tl'relon'er 6cm of'the oesophagus circumf-erentially of'all vagal libres running dou'n f rom ab<lve (Fig.

nerve Latarjet of

Posterior approached trunk through lesser the sac

\\

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Fig. 5.25

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Division posterior of branches

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Fi1.5.27

j eal D i s s e c t i o n t e n d eo v e rg a s t r o - o e s o p h a gu n c t i o n ex d

,'rilArlrml
Fig. 5.26 Fig. 5.28

5.r7

OPERATIVE SURGERY

L o w e6 c mo f o e s o p h a g u se a r e d r cl

sling may be neces5.29);some traction on the oesophageal sary to obtain adequate exposure. From this Ievel down, completely separate the back of the oesophagusfrom the posteriorvagal trunk (Fig. 5.30). 9. Check haemostasis.

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:--/,'..

--,': //

Wound closure and dressing l. A drain is not generally needed. Close the wound by a mass closure technique with a monofilament suture, and useinterrupted nylon for the skin. Apply a dry dressing. 2. The nasogastrictube can be retained or removed according to preference; it is probably not needed postoPeratively.

POSTOPERATIVE CARE Oral fluids may be commenced on the first postoperative day, but intravenous fluids are continued until oral intake is adequate. To confirm parietal cell denervation an insulin test meal can be performed, observing the acid output in the nasogastricaspiratein responseto insulin-inducedhypoglycaemia. Removethe skin sutureson the eighth day.

Fis. 5.29

P o s t e r i o a g u s o m p l e t eflr e e d r o ml o w e r0 e s o p h a g u s vr c y f

SPECIAL OPERATIVE HAZARDS 1. Tearing of the spleen due to traction on the stomach during dissection.Small tears may be repaired, but more splenectomy. extensivedamage will necessitate 2. Division of the vagal trunk. If this is recognized intraoperatively a pyloroplasty is advisable,otherwise gastric stasisis likely to follow. 3. Bleeding from a vesselwhich retracts between the leaves of the lesseromentum. Great care must be taken to avoid damage to the nerve of Latarjet so the blind application of clips must be avoided. If bleeding persistsdespitesustained pressure the vesselrequires exposure by incising the peritoneum and ligation.

Fig. 5.30

5 .l 8

COMPLICATIONS l. Dysphagiadue to oedemaor haematomaof the distaloesophagus. This usually settles within a f'ew days, and always within a month. 2. Lessercurve necrosisis a rare but seriouscomplicationwhich leads to leakageof gastric content due to necrosisof'the wall of the stomach in the region of the incisura. lt is probably due to inclusion of part of the gastric wall in ligatures.lf suction and anticonservativemanagement with nasogastric biotics does not bring about rapid resolution, laparotomy and suture repair will be necessary. 3. Recurrent duodenal or pyloric ulceration may be due to inadequate vagotomy. This is not uncommon, and results andior from incomplete clearanceof the lower oesophagus dissection commenced too far proximal to the pylorus. If medical treatment is unsuccessful,truncal vagotomy and drainage or autrectomy are necessary. 4. Gastric stasisis uncommon, and is due to damage to the vagal trunk.s or nerves of Latarjet, or division of branches will settle with a period too closeto the pylorus. Many cases of intravenous fluids and nasogastricsuction, but some will require reoperation and a drainage procedure.

Truncal Vagotomy and Pyloroplasty

The aim of truncal vagotomy is to reduce the gastric acid secretion patients with peptic ulcerarion of the duodenum of whichis resistantto medical therapy. Delayed gasrric emptying is a fiequent result of truncal vagotomy, and a drainage procedure is therefore necessary. The drainage operation described here is pyloroplastv, but alternatively the pylorus may be bypassed a gastrojejunosromy by (see page 5.35), and this is appropriate cases severepyloric scarring or srenosis. in of Highly selective vagotomy (see page 5.15) obviates rhe need for a drainage procedureby preserving the innervation ofthe gastric antrum,but is more time-consuming,difficult in obesepatients, andresults a higher ulcer recurrence rate. Truncal vagotomy in andpyloroplasty also the procedure of choice when surgery is is requiredfor a bleeding dr-rodenal ulcer (seepage 5.41).

carry it up into the notch benveen the xiphoid and costalmargin in order to achieve adequate exposure ofthe oesophagealhiatus.

Operative technique l. Insert a self-retaining retractor and retract the sternum rvith the third blade of a Balfour retractor hooked under the crossbar. Confirm the diagnosis of chronic duodenal ulceration and perform a thorough laparotomy. 2. Divide the left triangular ligament with scissorsand reflect the left lobe of the liver to the patient's right (see Fig. 5.7 on page 5.6). 3. Confirm the position of the nasogastric tube and, with the fingers of the left hand on either side of the tube, mobilize the phreno-oesophageal ligament lr,ith scissors whilst grasping it with Roberts' forceps (Fig. 5.3 I ) and push the perito-

PREOPERATIVE ASSESSMENT l. Conlirm the presenceof persistentor recurrent duodenal ulceration endoscopl'or a barium meal. by 2. Exclude, suspected. gastrinomacausingZollinger,Ellison if a syndrome fastingserum gasrrinestimarion. by Crohn's disease of the duodenumis vcrr, rare.

M o b i l i z a t i o nh i a t u s of RELEVANT ANATOMY The left triangular ligament of the liver often overlies the oesophaeeal hiatus,and the oesophagus firmly atrachedro is the diaphragmb,va fold of reflected perironeum (the phrenooesophageal lieament). The distributionof the vasal rrunks is quite variable. The posteriorvagal trunk is usually single and lies behind the oesophagus little to the right, either closelyapplied ro the a oesophaeus in the soft tissues or more posteriorly.The anterior vagushas often divided into two or more branches before entering abdomen,and theserun dou,nthe anterior surface the of tl.re oesophagus onto the stomach,the largest usually lying somewhat the left. Small blood vessels to frequently accompany thenervetrunks. The pylorus is identified by the prepyloric vein crossingit anteriorly, and confirmed by palpating the pyloric sphincter betlveen flneer and thumb. the

OPERATION Preparation The patient is placed supine on the operaring table and a crossbar attached.The mid and r-rpperabdomen and lower chestare cleansed and dr-apedand a 16Fr nasogasrric tube is passed.

us 0es0pnag
gdJLr ru

tundus
phreno-oesophagea I Iigament

Incision Make an upper midline incision (see the lntroduction) and

Fig. 5.31

5 .l 9

O P E R A TSV E G E B Y I UR

neal lellecti<ll) on the anter-ior-surlhce ol'the oesophaeus usins a pledget. super-ior-lv 4. (lentlv nrobilize the oesophaeus trsing the fingers, and pass a soli rtrbber slins or a length o{' Paul's tubing around it (seel'ig. 5.1i2). 5. With tracti()n or) the sling, pasi the lir.rqers of' the light hand behincl the oesophaeus. I{'tl-re p<lsterior vasal trunk is in the sline it l'ill be f'elt as a tight band behind the oesopl.ragus. I['it is not. it will be lirund posteriorlr', trsuallf in the sulcus benveen the vertebral column and the aorta. Push the posterior vagus fonvard on the tip of the right middle finger to the right of the oesophagus (Fig. 5.32). 6. (ilasp the posterior vAglrs u'ith three pairs of' R<lberts' lirrceps and divirle the tr-unk above and belorv the nricldle pair (F'ig.o.3ii). l-igate or Llsediathernrr' on the upper and Iorver cut ends, ancl send the exciserl segnrent fil- histological analvsis. Look firr a seconcl posterior- tnrnk antl, if' present, cleal rvith it in tl-resanre 1\'zl\'. 7. l-ifi the anterior la{rus llerve rr'ith a nerve hook (Fig. 5.i},1), excisea segnlent in a sinrilar lnzlllller to the p()ster-iorvarltts nen'e; the sesnlent is also sent fi)r histological analvsis. Sear-ch carelirllr' lor nrultiple anteriol nerves rvl.ricl.r I'elt are

v n D i v i s i oo f p o s t e r i o ra g u s e r v e n

Fig. 5.33

Visualizationposterior of vagusnerve n f L i f t i n g n t e r i ov a g u s e r v e r e ef r o mo e s o p h a g u s a r
antorinr vanrtc nonro

nerve n00K

-/

Z-S ==i
\

postenor vagus nerve

rubber sling

.20

Fig. 5.32

Fig. 5.34

TRUNCAL VAGOTOMY PYLOROPLASTY AND

Incision Heineke-Mikulicz for pyloroplasty

as cord-like structures on the surface of the oesophagus. Lift these smaller nerves from the oesophagus with a nerve hook and diathermize and divide them. 8. Steadythe pylorus with superior and inferior sraysutures and perform a pyloroplasty. This is made easier if the duodenum is mobilized (Kocherized) by division of the peritoneum along its lateral side.Tlvo techniques pyloroof plasty are described in this chapter:

, , t - '
o-.-'i'/ 4

N N>
Fig. 5.35
l n n ea l l - c o a tls y e r r a

F or a H einehe-Mikulicz lryloroplasty 9. Open the pylorus longitudinally for 3-4cm usinga curring diathermy point (Fig. 5.35). 10. With traction applied to the stay sutures,bring the proximal and distalends of the incisioninto appositionand close the incisiontransversely two layers;an over-and-over, in inner continuous layer (Fig. 5.36) and an outer layer of interrupted seromuscular(Lembert) stitchesusing an absorbable suture (e.g.2/0 Vicryl) (Fig. 5.37). For a Finnel pyloroplastl 9. Prior to opening the stomach,opposethe adjacent wallsof the antrum and descendingduodenum with a continuous seromuscular stitch,although somesurgeon's consider this (Fie. 5.38). Make a curved, invertedUstep unnecessary

ttt

Interrupted seromuscular laver 0uter

i( ,,(t(((fril

4,/,2=-E t!,,'tii7:r.?,

Fig. 5.36

Fig. 5.37

5.2

(]PERATIVE SURGERY

shaped sastroduodenotomy r'r,ith cutting diathermy from the gastric antrum to the descending duodenum (see Fig.

SPECIAL OPERATIVE HAZARDS
l. Tearing the spleen due to traction on the stomach during vagotomy. Small tears may be repaired, but more extensive damage will necessitate splenectomy. 2. Perforation of the oesophagus during mobilization; this is usually due to inadequate mobilization of the phrenooesophageal ligament. 3. Failure to identify all the vagal nerves, leading to incomplete vagotomy.

5.38).
'U', 10. Starting at the apex of the serv the cut edges of the stomach and descending duodenum together with a continuous over-and.over suture until the ends of the gastroduodenotomv are reached. Complete the anterior layer with an over--and-over sutllre inverting the mucosa with each stitch and bur,v it lvith a layer of interrupted serornuscularLer.nber-t stitches (Fig. 5.39). I l. Check the completed pvloroplastv to ensure that it is widely patent by invaginating the thumb and index finger through the lumen. Also check the hiatus fbr haemostasisand adjust the position of the nasogastric tube so that it lies in the gastric antrum.

COMPLICATIONS 1. Leakage frorn the pyloroplasty may occasionally occur where sutures have cut out in the presence ofoedema and scarring. If gross scarring or oedema is present, a gastroenterostomy is a wiser choice of drainage procedure. 2. Delayed gastric emptying. If this is due to postoperative oedema it will settle with a felv days of nasosastric suction. lf the pyloroplasty is too narrow, surgical revision will be necessary. 3. Diarrhoea is due to rapid gastric emptying, and usually settles spontaneously. 4. Bilious vomiting results f rom reflux of bile into the stomach through the pyloroplastv, especially if this has been made too wide. Treatment rvith metoclopramide and a bile-binding asent such as aluminium hvdroxide or hydrotalcite will help. No revisional surgerv for diarrhoea or bilious vomiting should be undertaken within a year of'the operation. 5. Recurrent ulceration is usuall,vdue to incomplete vagotomy. 'fhis may heal rvith H2 blockers, but revisional surgery with re\ragotomy or Partial gastrectomy ma,v be necessary.

l

l

Wound closure and dressing The use of a drain is a rnatter of personal preference. Close the wound by a rnassclosnre technique lvith a monofilament suture, and use intermpted nylon sutures for the skin. Apply a dry dressing.

POSTOPERATIVE CARE
lntravenous fluids and nasogastric suction are continued until gastric emptying is established, usually on the second or third postoperative day. I'he drain, if used, is removed after 2 3 days and the skin sutur-esafter 8-10 days.

p 0 p t i o n a lo s t e r i o r r 0 m u s c u l a r e r o r F i n n e p y l o r o p l a s t y y f y se

C l o s u ro f F i n n e p y l o r o p l a s t y e y

line f incision o

t,2

Fig. 5.38

Fi9.5.39

Partial Gastrectomy

There are trvo principle indications fbr this procedure. 'fhe first is benign pepric ulceration in lvhich there has been either failure of medical treatment, or cor.nplicationssuch as perfirration or haenorr-hage; particlrlarlv i1'r'agotonr,vand drainage is inappropriateor has been perfirrn.red previousll,. fhe second is either a benien (e.g. leionrvoma) or rnalignant lesion of' the distal two-thirds of' the sromach. In cases of' rnalignar-rcy,as much lymphatic tissue as possible is resected rvith the specir.nen and the vessels ligated close to their rlrigins. Following resection of-the distal sromach, reconstnrcrion can be perfbrmed by either fashioning a nerv lesser curve and creatinga gastroduodenal anast<lmosis (Billroth l) or by anastonrosis the gastric remnant to a loop of' jejunum, rvith of' closureof the duodenal str-rnrp(Billroth II or P<ilyagastrectomy).

PREOPERATIVE ASSESSMENT
l . A d e q u a t e r e s u s c i t a t i o n p r i o r t o s u r c e r y i s e s s e n t i a l{ o r patients with either haentorlhase rtr perlirration. 2. Preoperative end<lscopy should be perlirrrned in caseso1' haemorrhage to establish the site of'bleeding and t<lbi<-rpsy a gastric ulcer.

RELEVANT ANATOMY The stomach in the epigastriunr leli l.rlpochondrium, lies and
and fbrms part of'the anterior t'all ol'the lesser sac (Fig. 5.40). It comprises lbur regions: the firndr-rs (the region ab<lvethe cardiac orifice) rvhich is closelv related to the spleen; rhe body which is separated liom the pancreas bl the lesser sac; the

Relevant anatomv

leftgastric artery artery coeliac hepatrc artery vasa brevta

gastric right \\ artery

anery splenlc

Fig. 5.40

5.23

OPERATIVE SURGERY

antrunl which is the propulsive clistal portion o1'the stonrach: and the pylorus, u'hich is the rnuscular valve contl-()lling eastric emptying into the cluoclenum, the lirst part t>f'u'hich is intraperitoneal and overlies the conrnton ltile duct. The two leavesof'peritonetrm firrnring the lesser ()mentlllll extend f}om the liver t<l the lesser curvature ol' the stonrach, where they then separate to enclose the stonrach and f'use once again akrnu the greatel cllrvatrlre ol'the stornach to lirrnr the greater onlentum. 'I'his overlies and is aclher-ent the transverse t() colon and nresocolon. The stomach derives its blood supplv fionr the coeliac axis as firllows. l. The leli eastric ar-tery arises directlv I'rt>nrthe coeliac axis and runs acr-oss the floor- of'the lesser sac tou'ar-cls the oesophageal hiatr-rs.It then passes betn'een the leaves ol' the lesser <lt-ttenttrrrt ancl rtrns aklng the lesser cur\,2ltllre to anastonloservith the rigl-rt gastric arter\'. 2. The r-ight uastlic arterv arises filrrn the hepatic aftefv an(l similarly runs betu'een the leaves of'the lesser onlentuul. 3. The sastro(luodenal arterr', a brirnch of' the hepatic arter1,, runs behind the first part ()l the cluoclenurn and gives rise to the rieht gastr'o-epipkric arter\'rvhich passeslnrnr the pvkrr-trs along the greater crlr\':ltul-e tou'ards tl're firnclus to ureet the leIt eastro-epiploicar-ten'. It gir es o1'l'sastric blanches t<l the

stomirch and epiploic arteries to the greater ()nlentunl. 4. The lef t gastro-epiploic artery arises f ronr the splenic ar-terv and similarll'runs benveen the leavesol'the greater onlenttlrlr towards the pllorrrs. -I'he vasa br-evia,rlr short sastric arteries, o1'rvhich ther-eare 5. llve or- six, arise lkrrn the splenic arterv and rtrn in the uastrosplenic ()mentrlrn to reach the firndtrs of'the stourach. The lymphatic drainage of the stomach follows the arterial supply and drains to the pre-aortic nodes around the coeliac axis. Venous blood drains into the splenic and portal veins.

OPERATION Preparation
'l'he operation is pellirr-nrecl uncler seneral anaesthesia r\'ith a nasogastric tube introclucecl bv the anaesthetist. A crossbar 'l'he stritable Iirl a sternal retractor is fixe<l to tl.retable. patient is placecl supine, the skin is prepared ancl clrapes are placed.

Incision N I a k e a r r r i c l l i n e b r l o r n i n a l i n c i s i o n ( s e et h e I n t n r d u c t i o n ) . a

I

r O e v e l op l a n e e t w e e g r e a t eo m e n t u mn dt r a n s v e r s e p b n a mesoc0l0n

Division rightgastric of artery
gastric right artery

I'i'I SS
\\

divided gastro-epiploic right artery

,.4

Fig. 5.41

Fig. 5.42

PARTIAL GASTRECTOMY

Operative technique l. Perform a laparotomy and insert a self-retaining retractor. In casesof haemorrhage the bleeding site must be located and haemostasis secured (see page 5.41 in Management of Gastroduodenal Bleedine). 2. Commence mobilization of the stomach. ln benign conditions, divide the gastrocolic omentum with ligation and division of the gastro-epiploic vessels to gain access to the lessersac. In casesof malignancy, lift the omentum up and dissectit off the trans\/erse colon and mesocolon (Fig. 5.al) in the so-called bloodless plane, taking care to identify and avoid the niddle colic artery n,hich runs in the transverse mesocolonclose to the pylorus. 3. Divide any adhesions in the lesser sac between the pancreas and the stomach. 4. lf present, a posterior gastric ulcer eroding into the pancreasshould be pinched offleaving the excluded ulcer base stuck to the pancreas. The resulting hole in the stomach m u s t b e c l o s e dt o p r e v e n l c o n t a m i n a t i o n . 5. Mobilization of'the greater cur\.arure is completed by ligation and division of the lower short gastric vessels, the lef t gastro-epiploic ar-terv and also the right gastro-epiploic pedicle, rvhich is divided belor,v the duodenum (see Fie.

6. Divide the right gastric pedicle on the lesser curvature (Fig. 5.42). 7. Divide and ligate the lesser omentum from the pylorus proximally until the left gastric pedicle is reached. This is then doubly lisated and divided, with care being taken to preserve an aberrant left hepatic artery if it is present. 8. Place a crushing clamp just distal to the pylorus and a soft clamp across the duodenum before dividing the duodenum between the nvo clamps (Fig. 5.a3). To perform a gastroduodenal anastomosis 9. Ensure that the nasogastric tube is withdrawn into the fundus and place a long non-crushing clamp across the stomach from the greater curvature for-a distance that will be suitable to anastomose to the duodenal stump. Apply a crushing clamp aloneside and distal to it and divide the stomach between the clamps. 10. Apply a second pair of clamps at an angle to the first pair from the apex of the previous incision to the lesser curvature ensuring that the ulcer will be included in the resected specimen. Divide the remaining stomach (Fig. 5.44) and remove the resected soecimen. tl. Fashion a new lesser curve by suturing over-and-over the upper non-crushing clamp with a 2/0 absorbable suture

5.42).

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OPERATIVE SURGERY

(Fig. 5.a5).Tighten the suturesafrer removing rhe clamp and bury the suture line with a continuous seromuscular stitch(Fig.5.46). 12. The gastrodtrodenal anasrornosis should be performed in two layers,n'ith an inner all-coatslayer and an outer seromuscularsuture (Fig. 5.a7).The weakestpoint of'the anastomosis at the Y-junction fbrmed with the newly is Iashioned lessercurve. This should be reinfbrced with a horizontal mattress suture (Fig. 5.47, inset).

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Fig. 5.47

t d U s eo f s t a p l i n d e v i c eo c l o s e u o d e n u m g

Fig. 5.45
Hand-sewn chnioue te

Two-layer closure lesser of curve

Fig. 5.46

Fig. 5.48

PARTIAL GASTRECTOMY

To perform a gastrojejunal anastontosis 9. Close the duodenal stump b,v inserting an over-and-over, conlinllous absorbable suture rvhich is drau'n tight as the clamp is eased off. Insert a second layer of continuous, or lnterrupted sutures to invert the previous suture line (see rnset to Fig. 5.a8). Alternatively a linear srapler may be used to close the duodenum prior ro dividing it (Fig. 5.48). 10. Choose the level of' resection of the sromach, aimine ro remove the distal two-thirds in peptic ulceration and at leasta 5cm margin rvith a malignancy. Place a non-crushins clamp across the stomach, 2cm proximal to the chosen level of resection. ll. Bring a loop of proximal jejunum, taken from as close to the duodenojejunal flexure as possible, in front of or through the rransverse mesocolon to the left of the middle colic artery and place it in an isoperistalsic position (afferent end to the greater cun'e) (Fig. 5.a9). The afferent loop should be kept short.

15. Anastomose the adjacent edges of the gastric and jejunal incisions with an over-and-over, all-layer, continuous absorbable suture (Fig. 5.51) to complete the posterior wall of the anastomosis.

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12. Pull the stomach remnanr over ro the left and allow it to hang over the costal margin. Place a non-crushing clamp acrossthe jejunal loop, or alternarively use a pair of inter. locking Lane's twin gastroenterostomy clamps, and insert a posterior continuous 2/0 absorbable seromuscular suture to unite the jejunum ro rhe sromach beyond the clamp. 13. Place crushins clamps across the stomach from the lesser and greater curves and open the posterior wall of the stomach remnant with diathermy (Fig. 5.50). 14. Using a diathermy point, open the jejunum adjacent to the gastric stoma with a longitudinal incision which should match the divided stomach (see Fig. 5.51).

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5.27

OPERATIVE SURGERY

16. Now rernove the stomach remnant by division of the anterior stomach wall u,ith diathermy (Fig. 5.52) and continue the all-layers suture around the incision to complete the

inner layer of the anastomosis. An over-and-over stitch should be used to ensure haemostatic closure (Fie. 5.53). Remove the clamps.

t7.

Complete the anterior seromuscular layer (Fig. 5.54) and check the stoma fbr adequate patency by invaginating a finger and thumb throush the anastomosis. partial width stoma is preferred to reduce bile reflux into the stomach, a Hofmeister valve can be fashioned, reducing the storna length to around 5cm. This is achieved by resecting the stomach remnant rvith cutting diathermy af ter completion ofthe posterior serclsalla,ver.Fashionthe valve by suturing together the anterior and posterior cut edges of the stomach from the lesser curve towards the greater curve until 5cm of gastric stoma remains. Then open the jejunum o\/er this length and complete the anastomosis as above including the valve segment in the anterior seromuscularlayer (Fig. 5.55).

D i v i d i na n t e r i o r a l lo f s t o m a c h g w

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Wound closure and dressing Place a drain and close the abdomen ruith loop nylon and interrupted skin sutures.Apply a dry dressing.

Fig. 5.52

POSTOPERATIVE CARE The patient should be managed rvith intravenousfluids and nasogastric tube on free drainage. ()nce borvelsoundshave returned and the drainage from the nasogastric tube has diminished, oral intake can be increasedand the nasogastric tube can be remor,ed.

A l l c o a t s u t u r e f a n t e r i ow a l l s o r

C o m p l e t i o ng a s t r o j e j u n a l a s t o m o s i s an of

5.28

Fig. 5.53

Fis. 5.54

PARTIAL GASTRECTOMY

The drain should be left for 24-48 hours unless,in a Billroth II gastrectomy, closure of the duodenal stump was difficult, the in which case the drain is left for l0 days unril a tracr has formed.

Postgastrectomy complications may occur as fbllows: (i) Vasomotor dumping; if symptoms do not settle with medical treatment, various operative techniques are available to interpose a loop of jejunum between the stomach and the duodenum, either isoperistalsic or antiperistalsic to slow down gastric emptying. Late dumping; the patient is advised to eat small amounts of food frequently. (iii) Small stomach and dumping; several procedures have been described to form a reservoir (e.9. the Poth pouch and the Hunt Larvrence pouch). (iv) Reflux gastritis; this is best treated by a Roux-en-Y diversion. 4. The risk of gastric malignancy in the stomach remnant is increased. Anaemia fiom iron or B yr deficiency. (ii)

SPECIAL OPERATIVE HAZARDS l. The comrnon bile duct may be damaged when mobilizing the first part of the duodenum. It should be repaired around a T-tube in these circumstances. 2. Damage to the middle colic artery in the transverse mesocolon, which can lead to ischaemiaof the colon and necessitate resection. 3. With an ulcer high on the lesser curve, Pauchet'sprocedure can be employed in which a tongue of lessercurve (includingthe ulcer) is taken prior to making a new lesser curve. With a high ulcer that is not on the lesser curve, the stomachcan be rotated to allow the ulcer to be resected as though it was on the lesser curve (Tanner's rotation). Alternatively the ulcer can be locally excised and the defectclosedprior to distal gastrecromy. 4. It may be impossibleto closethe duodenal stump securely. In such casesthe stump is closed around a 30Fr Foley catheter hich is broughr out rhrough rhe anrerior w -abdominal wall and removed on the fourteenth postoperativeday. By this time a tract will have formed, creating a controlled fistula which should close spontaneously. 5. Occasionallyrvhen a large posterior duodenal ulcer is present, full mobilization of the duodenum is not possible. Nissen'smethod of closure can then be performed by suturing the anterior edge of the duodenum to the lateral edge of the ulcer crater, thus excluding the ulcer {iom the gastrointestinaltract. 6. Damageto the spleen when mobilizing rhe stomach.

Hofmeister valve

{w
Fig. 5.55

COMPLICATIONS l. Haemorrhage occur either from an inadequately can undermn arter-yin the base of the ulcer or from the cut edges of stomach and smallborvelparticularlvif a continuoushaemostaticover-and-overstitch is not used. Haemorrhage may alsoresultlrom a splenictear that was overlooked. mav occllr from either the duodenal stump or from 2. Leakage the anastonrosis. there are no signs of peritonitis and If drainage satisfactorv, is parenteralnutrition should be instituted and the patient placed 'nil-by-mouth'. lf there are signsof peritonitis, laparotomy should be performed and the leak repaired if it is from the anastomosis. it is from lf the duodenal stump, the stump should be closedaround a largeFolevcatheter(seeSpecialOperative Hazards).

5.29

Total Gastrectomy for Gastric Malignancy

To offer a potential cure from gastric cancer, radical resection of the stomach and its surrounding lymph nodes is indicated in selected patients with gastric malignancy. Continuity is restored by oesophagojejunal anastomosis. The extent of the lymphadenectomy forms the basis by which radical gastrectomy is classifiedas Rl, R2 or R3 types. An Rl resection includes the immediate lymph nodes along the stomach wall, an R2 resection (described below) also includes the nodes around the splenic hilum and along the coeliac artery and its branches, and in an R3 resection the nodes from the porta hepatis, the front of the aorta, behind the head of the pancreas and in the base of the mesentery and transverse mesocolon are also removed. There remains some debate as to whether a more radical operation is necessarily going to benefit the patient. The operation can be performed through a long midline incision, but in large indivi- duals a thoraco-abdominal approach gives better access to the lower oesophagus.

the peritoneum. After a preliminary laparotomy to confirm suitability for resection, extend the skin incision laterally along the line of the eighth or ninth rib to the lateral border of erector spinae, and deepen it onto the rib with cutting diathermy. Incise the periosteum and strip it upwards and off the upper border of the rib as far as its neck using a periosteal elevator. Excise a 2-3cm portion of the rib posteriorly with a costatome, and the costal cartilage anteriorly where it crosses the relevant interspace with a knife. Open the pleura, insert a Finochietto retractor, and crank the retractor open. The diaphragm is then divided radially down to the oesophageal hiatus after stay sutures have been inserted at intervals to allow its accurate reopposition afterwards (see Fig. 5.16). If the tumour is adherent to the margins of the hiatus plan to remove this en bloc. For an abdominal approach make a long midline incision (see the Introduction) with division of the xiphisternum.

PREOPERATIVE ASSESSMENT 1. Establish diagnosis the and exrent of the disease using a bariummeal, endoscopy biopsy, with chest X-ray,liver ultrasound and CT scanning. 2. Consider preoperative total parenteral nutrition in severely wastedpatients. 3. Perform gastriclavagein cases gastric obstruction. of 4. Arrange for an intensivecare bed postoperatively. 5. Prescribe prophylactic antibiotics. P o s i t i o f o r t h o r a c o - a b d o m iin a li s i o n n nc

RELEVANT ANATOMY This is coveredon page 5.23 in PartialGastrectomy.

OPERATION Preparation If a thoraco-abdominal incision is to be used, the anaesthetized patient is intubated and ventilated with a double-lumen endotrachealtube to allow selectivedeflation of the left lung. They are supported on the operating table on their right side but tilted backward to lie midway between a full lateral and semilateral position, The left leg is flexed at rhe knee and the hip and right leg extended with a pillow between rhe knees. The left arm is bandaged to a supporr in the position shown in Fig.
5.5r).

For an abdominal approach the patient is placed supine. Incision If a thoraco-abdominalapproach is to be used, make an oblique abdominalincisionfrom the midline to the costalmargin. Divide the underlying muscles in the line of the skin incision with cutting diathermy, Iigate and divide the superior epigastric vessels which lie deep to the rectus abdominus muscleand open

Fig. 5.56

[.30

TOTAL GASTRECTOMY FOR GASTRIC MALIGNANCY

Operative technique l. Divide the left triangular ligamenr and the perironeum over the gastro-oesophageal junction with scissors for a as truncalvagotomy(seepage 5.19). 2. Divide and fiee the oesophagusfrom the margins of the diaphragmatic hiatus unlesstumour is adherent. 3. Mobilizethe lower oesophagus and placea sling around it; divisionof the vagi will provide extra length. lf a rhoracoabdominalapproach is used the thoracic oesophagus can be more easily mobilized after division of' the in{'erior pulmonaryligamentand upward retracrionof'the left lung. 4. Divide the peritoneal attachments of the spleen ro the diaphragmand posterior abdominal wall wirh scissors and draw the spleen and attached fundus of the stomach medially, li{ting the rail of the pancreasforward. 5. Divide the peritoneal fbld attaching the splenic Ilexure t<r the spleen;this often conrainsa blood vessel which requires ligation or diathermy. Lift up the omenrum and with scissors develop the bloodlessplane berween it and the transverse mesocolonfiom the hepatic to the splenicflexure .so that it remainsattachedonly to the stomach.

6. Mobilize the duodenum by division of rhe lateral reflection of peritoneum, and continue to incisethe peritoneumasit crosses bile duct and hepatic artery ro becomethe leSser the omentum. Keep close to the liver and continue until the cardio-oesophagealjunction reached(see is Fig. 5.57), sacrificing an accessory left hepatic artery arising from the left gastricartery if present.This compleres rhe divisionof the peritonealattachmentof the stomach. Divide the right gastric and right gastro-epiploic arteries closeto their origin from the hepatic and gastroduodenal (Fig.5.57). arteriesaboveand belowthe pylorus respectively Clamp and divide the first part of the duodenum and close the distal end, using either a linear staplingdeviceor two layers of sutures with an inner continuous and an outer interrupted or continuouslayer,as for a P<ilya gastrectomy (seepage 5.27). 8 . Lifi the spleenforward and dissect fiee fiom the pancreas its posteriorattachments until the coeliac artery is reached. Dissect out and divide the splenicand lelt gastricar-teries. Clear the coeliac artery of surrounding lymphatic tissue keeping this tissuewith the specimen. 9 . Ligate and divide the splenicvein and divide the pancreas

Mobilization totalgastrectomy for

sling round a oesophag us

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Fig. 5.57

5.31

OPERATIVE SURGERY

just to the left of the aorta fiom any bleeding points Carefully transfrx the cut oversew the cut end of sutlrres(Fig. 5.58).

rvith a knife. Secure haemostasis r,vith fine sutures or diathermy. end of the pancreatic duct and the gland u.ith non-absorbable

jejunum through this hole and up to the hiatus (Fig. 5.59). The oesophagojejunal anastomosis is norv f ashioned, either 'fo suture the anastomosis, make a by suturing or stapling. hole in the antimesenteric border of the bolvel with diathermv to match the lumen of' the oesophaeus, 3-4cnr from the cut end of the jejunal loop. Oversew the cut end of thejejunum rvith trvo lavers of an absorbable suture such as Vicryl. Fashion the oesophaeojejunal anastomosis u'ith a sinsle layer of interrupted non-absorbable sutures; if preferred, this suture line can be buried r.vitha second layer of interrupted sutlrres (Fig. 5.60), picking up the diaphragm rvith a couple of these to keep the anastomosis in the 'fhere must be good vascularity and no tension abdomen. on this anastomosis. To staple the oesophagojejunal anastomosis insert a purse-string sllture into the distal end of the oesophagtrs and introduce a circular stapling gun into the cLlt end of the jejunal loop with the upper stapling head removed. Push the central post of the delice through the antirnesenteric wall of the bou'el 3-4cm from the end, screrv on the upper stapling head and slide the end of the oesophagus over it (see the inset on Fig. 5.60), tightening the purse

10. Place a right-angled non-crushing clamp across the oesophagus and divide it distally above the gastro-oesophageal .junction, ensuring at least 5cm clearance from the tumour margin, and remove the specimen. When completed the oesophagojejunal anastomosis should lie within the abdomen. ll. To lashion the Roux loop, take a mobile loop ol'jejunum just distal to the duodenojejunal flexure and holding it by the apex of the loop, divide the proximal bowel at the base of the loop betrveen non-crushing clamps, and partially divide its mesenterv rvith ligation of its contained blood vessels that the cut end of the loop will reach the cut end so of the oesophagus. 12. Nlake a hole in the transverse mesocolon and take the

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.32

TOTAL FOR GASTRECTOMYGASTRIC MALIGNANCY

go 0 e s o p h a l e j u n a ln a s t o m o s i s a

string. Scren up the stapling gun, fire it, and unscrew and remove the sun before closing the open end of the jejunum either with a linear stapler or by suturing in tu'o layers. Suture the jejunum to the edges of the opening in the mesocolon.

1 3 . Perfbrm

an end-to-side anastomosis between the divided proximal jejunum and a convenientl,v sited enterotoml in one or two lavers according to preference. Use catgut sutures to close any holes in the mesenrerv rhrough which a loop of bowel could herniate (Fie. 5.61).

14. Ask the anaesthetist to pass a nasogastric tube which should
be positioned in the efferent limb of'the jejunum.

W
Fig. 5.60 C o m p l e t ee c o n s t r u c t i o n rd

Wound closure and dressing Insert abdominal drains to the anastomosis and duodenal stump. For- a thoraco-abdomir-ral approach insert chest drains into the left pleural space and repair the diaphraun wirh interrupted non-absorbable sLltllres using the stav sutures to realign the cut edges. Leave the last f'el' sutures untied until the chest is ckrsed and tie thenr from belorv. Inser-r a rib approximator and close the chest as fbr a thoracotomr. (see page 2.23). The abdomen is closed rvith rnonofilament nvlon and the skin r,r'ith slltures or staples. Suture the drains in position, place a silk purse string around each chest drain, and connect to an underlvater seal. Dress the wound l'ith a light non-occlusive dressing.

POSTOPERATIVE CARE
If facilities are available the patient should be ventilated until the follou'ing da,v and nursed in an intensive care or high dependency unit. Give parenteral nutrition. lf the lung is fulll' expanded and rvhen there is minimal drainage, the chest drains are removed and the surrounding purse-strines tied. The nasogastric tube should remain for 6 days and the patient kept strictll' nil-by-rnouth during this period. On the sixth dav a barium or Gastrografin (meglumine diatrizoate) sn allorv is performed and if there is no anastomotic leakage the nasogastric tube is removed and the patient is allowed to drink and then eat. Skin sutllres or staples are removed after 8-10 days. The patient should be encouraged to eat normally. Long-term, vitamin B12 injections lvill be required each month.

SPECIAL OPERATIVE HAZARDS 1. Unresectability. at the preliminarylaparotomy If thereis localinvasion, may be possible extendthe resection it to
margins (e.g. to include the transverse colon and mesocolon) to allow en b/oc excision of the rumour. If local extension is unresectable (e.g. involvement of the superior mesenteric vessels) or if there is distant spread (e.g. peritoneal seedings or multiple liver metastases), it may be more appropriate to perform a simpler palliative operafion such as a gastroenterostomy or partial gastrectomy, although a total gastrecromy can give good palliation. 2. Damage to to the bile duct. 3. Damage to the hepaticarrery. 4. Damage to the middle colic artery, which may compromise the blood supply of the colon.

Fis. 5.61

5.33

ru
COMPLICATIONS l. Major leakage from the oesophagojejunal anastomosis is often fatal from mediastinitis.Most leaks,however, are minor and only demonstrated radiologically. Continue parenteral nutrition in such casesand keep nil-by-mouth until healing is radiologically confi rmed. 2. Leakagefrom the duodenal stump.

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3. Pancreaticfistula from the pancreatic remnant. 4. Dysphagia, which may be due to a benign anastomotic stricture or tumour recurrence. Perform endoscopy with biopsy to establishthe diagnosis.Tumour recurrenceis rarely amenable to resection but the patient may benefit from endoscopicdilation or occasionallyendoscopicintubation. A benign stricture should be dilated.

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Gastroenterostomy

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A gastroenterosromy performed to bypassan obsrructionto is t h e g a s t r i c u r l e ro r d u o d e n u m b y s u c h c a u s e s s c a r c i n o m a o a of the distal stomach or pancreatic head (see page 4.32 in Triple Bypass)and pyloric srenosis following scarring from duodenal ulcerarion.It can be combined with a rruncal vagotomyasan akernarive pyloroplasry(seepage 5.19). ro Whilst popularfor many years,rhe posreriorretrocolicgasrroenterostomy (where the small bowel is taken through the transverse mesocolonand anastomosedto the posterior wall of the stomach) offers little advantage over the simpler anrerior a n a s t o m o s i s . a n r e r i o rg a s t r o e n r e r o s t o ms d e s c r i b e d e l o w . An iy b

unfit patients. In patients with tumours of the pancreatic head, gastroenterostomy is combined with a biliary diversion ( s e ep a g e 4 . 3 2 ) . 2. Confirm the position of the nasogastric tube and aspirate the stomach contents before the stomach is opened. 3. Select the site for the anastomosis on the anterior wall of the stomach; this should be placed distally (in the antrum if possible) to allorv the anasromosis to be dependanr, although in cases of malignancy it is essenrial to adjust rhe site in order to prevent malignant involvement and early obstruction of the stoma. 4. Pick up the anterior u,all of the stomach with two pairs of' Babcock's tissue forceps placed at either end of the proposed site fbr the stoma. Identify the duodenojejunal flexure under the transr,'erse mesocolon and follow it to the first loop of proximal jejunum rvhich is similarly picked up with Babcock's forceps and laid alongside the stomach (Fig. 5.62), in front of the transverse colon. Ensure that the

] t I PREOPERATIVE ASSESSMENT l. Confirmthediagnosis usinga barium mealand/or endoscopy I with biopsy. I fluid and electrolyte disrurbances. I 2. Correct 3. Perform a gastric lavage with a wide-bore tube if there is J f o o dr e s i d u en r h e i r s r o m a c h . i I 4 . P r e s c r i b e o p h v l a c r ia n t i b i o r i c s . pr c J

I

l J nnnvnNT ANAToMv

fne greateromentum is attachedto the greater curvature of I I the stomachand su'eepsdown over the transverse mesocolon andcolon. Thejejunum arisesunder the root of the transverse I mesocolon the duodenojejunalflexure. To perform a sastroat J enterostomy proximal loop ofjejunum is selecred a which will J comfortably reach the anterior surface of the body/antrum of I lying in front of the transverse colon, mesocolon t thestomach, I andomenrum.

S m a l lb o w e l a p p o s e d o s t o m a c h t

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I Preparation Place patient the supine and cleanse drapethe abdomen. and J

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lnt., the abdomen through a midline or right paramedian incision(seethe Introducrion). The fbrmer is preferable if a truncal vagoromy anricipared. is

t I
Operative technique I l. Perform a thorough laparoromy.In cases benign ulcerof J ation perform a rruncal vagotomy because of the high f incidenceof stomal ulceration if acid secrerion is allowed I ,o continue(seepage5.19).For patientswith gastricmalig[ nancy assrssthe position and extent of the tumour, the I regional lymphatics and the liver; the best palliation in J gastriccancer (and the only chance of a cure) comes from ! resection,although this may be inappropriare in elderly I

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transverse colon

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Fig. 5.62

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O P E R A TSV E G E R Y I UR

snrall bou'el lies l'ithor.rt tension n'ith the pr<lximal end of tl-reklop on the gt'eater cllrvatllr-e side ol the stomach (i.e. isoperistalticrather than antiperistaltic).

5. Ask the anaesthetist to l'ithdrarv the nasogastric tr-rbeil necessarv (to avoid it being picked up by the clamp), belirre applying a Lane's sastroenterostonty tn'in-clamp to the

layer Posterior seromuscular

stitch over-and-over Posterior all-coats

Fig. 5.63

Fig5.65 .

Gastrotomy enterotomy and

a A n t e r i oa l l - c o a tls y e r r

t6

Fig. 5.64

Fig. 5.66

GASTROENTEROSTOMY

stomachand small bowel and interlockins the two halves of the clamp (see Fig. 5.63;. Close rhe clamp firmly ro preventvenous congestion and bleeding. 6. Remove the Babcock's forceps and insert a running seromuscularsuture (e.g. 2/0 Polydioxamone) between the stomach and bowel (Fig. 5.63). ln cases benign disease of aim to makethe sroma5-6cm long, but for a malignancyit shouldbe longer (up to l0cm). Cut the proximal end of this seromuscularstitch long and mark it with a clip, then lock the sutllre at the distal end and place a clip onto the needle; this will be used later for the anterior seromuscular layer. Using cutting diathermy, open the stomach and antimesenteric border of the bowel about 0.75cm from the seromuscular stitch, along a length which is I cm shorter thanthe seromuscular surure ar eachend (Fig. 5.64).lnsert an all-coats, over-and-over, absorbable continuous suture (e.g.2/0 Polydioxamone)to complere rhe posterior layer of the anastomosis (Fig. 5.65). The proximal end is left long and clipped with an artery forceps. Continue this suture around as the anrerior layer (Fig. 5.66) until the srarting point is reached, when the suture is tied to its clipped proximal end. A Connellstitchwill allow the edgesto invert, but is not haemostatic and fbr this reasonnot recommended.

8. Remove the clamps and then complete the anastomosis by coming back using the first suture to complete the anterior seromuscular layer (Fig. 5.67). 9. Confirm the patency of the stoma by invaginating the thumb and index finger through the anastomosis. 10. Ensure that the bowel lies without kinks, and draw the transverse colon to the right to check that it is not dragging down on the anastomosis.

Wound closure Insert a silicone tube, and close interrupted skin

and dressing drain, check the position of the nasogastric the abdomen with monofllament nylon and sutures. Apply a waterproof wound dressing.

POSTOPERATIVE CARE
The patient is nursed with a nasogastric tube and intravenous fluids until the stomach starts to empty. This may take several days and if slow, regular metoclopramide may help; if persistent a barium meal is advisable. The drain is removed after 48 hours unless drainage is excessive,or there is ascitesin which caseit should remain longer. Sutures are removed after 8-10 days.

SPECIAL OPERATIVE HAZARDS
l. Extensive gastric malignancy, in which case a palliative total gastrectomymay be appropriate in occasional cases. Alternatively, consider anatomosing a jejunal loop onto the upper body or fundus of the stomach,with or without exclusion of the tumour. 2. Difficulty in bringing the stomach and jejunum together without tension. This may require opening the gastrocolic omentum and performing a retrocolic posterior gastroenterostomy, bringing the jejunum through the mesocolon to the left of the middle colic vessels it and anastomosing to the posterior wall of the stomach.Oppose the edgesof the defect in the mesocolonto the anastomosis prevent to a n i n t e r n a lh e r n i a .

Anterior seromuscular withclamps layer removed

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\, .: lirt,
COMPLICATIONS 1. Haemorrhage,which is usually from the gastricsideof the anastomosis. the bleeding is into the lumen of the gut it If may not be apparent at operation sinceit only startswhen the clamps are released, by which time the lumen is not visible. It occasionallyrequires exploration.
Leakage, possibly as a result of tension on the anastomosis. Sepsis, either as a wound inf'ection or an intra-abdominal abscess. 4. Recurrent obstruction. Early obstruction follows oedema around the stoma or kinking, but later is probably due to
J.

I

progression of a malignancy. Reduce the risk by making the stoma as wide as is practical and well clear of the tumour in casesof malignancy. 5 . Stomal ulceratio4, which can be prevented by a vagotomy in casesof peptic ulceration, or H2 blockers. 6 . Pancreatitis due to afferent loop obstruction.

Fig. 5.67

5.3

Perforated Peptic Ulcer

Improved r.nedicalmanagelnent of peptic ulr:eration has reduced the incidence of per-fbration, although this remains a common cause of peritonitis. ln the majority of casessurgery rs advisable, but in ven unflt Patients, consen'atire treatment with antibiotics, intravenous fluids and nasogastlic aspiration can be emplo,ved.

4. The saf'estprocedure, Particularh' n'hen either the patient is unfit or the surgeon is inexperienced in gastroduodenal sur-gerv, or both, is simple closure of the perforation \\'ith postoperative medical tl-eatment to heal the ulcer.

RELEVANT ANATOMY PREOPERATIVEASSESSMENT
1. Ensttre that there is adequate resuscitation \vith intravenotls fluids and antibiotics. 2. A history of chronic dyspepsia, previous pePtic ulceration or perforation rvhilst on H2 blockers indicates that it may be advisable to perform a definitive anti-ulcer procedure rather than simple closure of the perforation, provided that the patient is fit and that there is little peritoneal contamin a t i o n ( s e ep a g e s 5 . 1 9 a n d 5 . 2 3 ) . 3. A history of previous peptic ulcer sllrgerv ma,v indicate a perfbrated stomal ulcer (e.g. after a P6l,va gastrectomy or gastroenterostom|). Again a definitive anti-ulcer procedure mav be advisable. The majority of perforations are through the anterior rvall ol the first part of the duodenum; this is easily located just belol' the lower border of the liver, immediatelv to the right of the midline. The fir-st part of the duodenum (2'5cm long) is sttspended in continuit,v rvith the stomach fiom the liver-bv the lesser omentum, the duodenum becoming retroperitoneal in its second part. The position of the p1'lorus at the junction of the stomach and duodenum is shorvn bl' the presence of the plepyloric vein (Nlay'o'svein), a prominent vessel that crossesthe anterior gastric surface immediatell' proximal to the pllorus' The prominent circular muscle of the pylorus is easy to I'eel ln the case ofa perforated gastric ulcer, accessmay be required to the anterior and Posterior aspects of the stomach; for the relevant anatomy of this see page 5.23 in Partial Gastrectomy' In the case of a perforated stomal ulcer, the usual anatourl will be distorted by the presence of either an antecolic or retrocolic gastroenterostomv. An antecolic gastroentel-ostonrf is relatively easy to find as there rvill be a loop of small bolvel passing anterior to the transverse colon to the stoma' A retrocolic gastroenterostomv may not be immediatell' apparent as tt lies deep to lhe transverse colon and omentum.

wall 0f firstpartof duodenum Perforation anterior 0n
OPERATION Preparation The operation is performed under general anaesthesia and the anaesthetist inserts a nasogastric tube. The Patient is then placed supine and the skin prepared from the nipples to the groin; this degree of preparation is important as the initial incision may have to be extended (e.g. to exPose oesophageal hiatus {br a vagotom}'). Suction should be read,v and u'orking b e f o re t h e s t a l t o l t h e o p e r a t i o n .

Incision The abdomen is usuall,vopened u'ith an upper midline incision (see the lntroduction). When the peritoneum is flrst opened there may be a pufl'of escaping gas n'hich should be odourless in peptic perfbration.

5.68 Fig.

Operative techpique 1. Clear the peritoneum with suction and swabs. Peritoneal Iluid from a gastroduodenal perforation is characteristic, containing food residue and bile; it is not purulent or fheculent with a recent perforation.

5.38

PERFORATED PEPTIC ULCER

Per-lil'nr a lapar'<tt<trrtr (see page 5.2) to identily the site oI the perlilration. 1-he c()nlntonest site is the anterior wall ol the li-st part o1'the du<ldenum (Fig. 5.69) and such a sire can usualh be treated br simple clostrre. Pack o1'1'the ar-ea anrund the duodenum abdonrinal packs. with moistened

perforation Insertion closure 0f sutures transversely across

Pick up the pvlorus beru'een the linger and thumb (Fig. 5.69) or rrith Babcock's firrceps, and insert a series of'f'ull thicknesssutures of'a hear,r',slorvlt,absor-bablematerial (e.g. 00 Viclvl) in a lir.retransverselv across the duodenum spann i n s t h e a r e a o f ' t h e t r l c e r ( F i g . 5 . 7 0 ) ; l e a v et h e m u n t i e d w i t h arter-\'lol'ceps attachecl until thev are all inserted. Between three and llve strttrres rvill be required depending upon the sizeof'the trlcer. Tie the sutr.lresto ckrse the trlcer, taking care to avoid overtightenine as rhel u'ill cr-rt()Lrr.The ends are lefi long (Fig. 5.71).

P e r f o r a td u o d e n a ll c e r ed u

Fig. 5.70

=\ -.-: \ =

S u t u r ets e dt o c l o s e e r f o r a t i o n i o

Fig. 5.69

Fig.5.7l

ur

O P E R A T IU R G E R Y S VE

6. Find a pieceof greater omentum that will easily reach to the site of perforation and thread a tongue of this omentum overthe line of sutures(Fie. 5.72). 7. With the omentum covering the repair, secureit in position by gently tying the sutures over it (Fig. 5.73). Avoid overtighteningthe sutures u'hich will strangulate the omentum. 8. Thoroughly wash out the peritoneal cavity with warm sterile solid debris, particularly from the saline,removing all visible. and the pelvis. and hepatorenalspaces, subphrenic

weeks, as up to 25% of patients will have further complications from an acute ulcer, and up to 80% from a chronic ulcer (see below).

SPECIAL OPERATIVE HAZARDS l. If no perforation site is evident on initial laparotomy, in of expose posteriorsurface the stomach the lesser the
sac(seeadditional manoeuvreson page 5.4). 2. If accessto the duodenum is poor, perform Kocher's manoeuvre to mobilize it (seepage 5.4). 3. If the duodenal ulcer is too large and/or the tissuesare too friable to perform a simple closure, a partial gastrectomy may be required (seepage 5.23). A 4. A perforated gastric ulcer needs careful assessment. proportion (8%) will be malignant and gastric ulcers are more likely to reperforate after simple closure. Therefore, if the expertise is available,a resection is advisable (either partial gastrectomyor ulcer excision with a vagotomy). If it is not available it is reasonable to perform simple closure but biopsies must be taken from all four quadrants of the ulcer and medical therapy started.

Wound closure and dressing a 1. Place largesiliconedrain into the subhepaticspace. 2. Closethe incision lvith a mass closure technique using loop nylon and the skin n'ith interrupted sutures. Apply a wound dressing.

POSTOPERATIVE CARE This involves good analgesiawithout excessivesedation (e.g. intercostal blocks)and regular chest physiotherapy.The nasogastrictube is removed and oral fluids introduced when flatus has been passed.Antibiotics should be prescribed fbr a full 5 daysunlessthere is minimal peritoneal contamination.The drain can be rernovedlvhen less than 50ml per day of clear fluid is drained, provided that the patient is afebrile. seror-rs medicaltherapv involvesuse of an H2 antagoPostoperative nist to heal the ulcer. Outpatient follolr'-up is essentialafter 6

COMPLICATIONS 1. Intraperitoneal abscess,fbr instance, in the subphrenic spaceor pelvis. or 2. Persistence recurrenceof ulcer symptoms. 3. Leakage fiom oversewn perforation and reperforation. 4. Gastricoutlet obstructionfrom scarrins of the duodenum.

p p 0 m e n t a l a t c h l a c e d v e rr e p a i r o

g t 0 m e n t u m e n t l yi e di n t op l a c e

l

5.40

Fig.5.72

Fig. 5.73

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SURGEBY OPERATIVE

(Fig. 5.75). Avoid extending the incision across the pylorus into tl.reduodenum at this stage since it rvill make a subsequent partial gastrectorny more difficult. Evacuate the blood clot with a sucker and locate a bleeding gastric ulcer or bleeding erosiorrsif present. If the site was unknown and is still not apparent, blood mav be seen welling up from the proximal stomach or from the duodenum. lf the bleeding is coming fi'om l-righer up insert a narrow-bladed Deaver retractof into the lumen of the stomach to allow visualization of tl-re|undus and cardia; this mav require the gastrotomy [o be extendecl.The mttcosa can then be brought into vierv by digitall,v invaginating it into the gastrotomy (Fig. 5.77)' Examine the entire lining of the stomach. If the blood is coming f rom distalh, extend the gastrotomy incision across the pvlorus into the first part of the duodenum. 4. Establish temporarv control of a bleeding ulcer with digital pressrlre for 5 minutes. lf unexpected bleeding varices are found consider either ir-rsertinga James', Linton or Sengstaken tube or-, if the slrr-geon has sufficient experience and the patient's condition is reasonable, perform suture ligation or of the var-ices, oesophageal transection shunt or a shunt ( s e ep a g e , 1 . l 4 ) . 5. A spurting vessel such as the gastroduodenal artery or a bleeding point l'ill usuallv be visible in the base of the ulcer; underrun the vesselor bleeding point with interrupted nonabsorbable slrtures such as 00 linen or silk in a figure-of-8 lashion (f-ig. 5.77), placing the slrtures under the vessel on either side of the bleecling point. Avoid biting too deeply

into the posterior n'all of the duodenum rvhere the bile duct can be damaged and do not overtighten the stitch or it will cut out of the friable ulcer. Ensure complete haemostasis befbre proceeding; it is norv necessary to perform a definitive operation to prevent rebleeding. 6. For a duodenal ulcer perform a vagotomy and pvloroplasty (see page 5.19). With an extensive gastroduodenotomy perform a Finney-type pyloroplasty, and if, in an obese Patient the vagi are inaccessible, a P6lya-type partial gastrectomy should be performed (see page 5'27). For a bleeding gastric ulcer perform a partial gastrectomy to include the ulcer; \'agotomy and pyloroplasty carries a higher risk of rebleeding and an unsuspected malignant gastric ulcer will be allou'ed to remain. The rim of an eroding posterior ulcer, once underrttn, should be pinched o{f the pancreas, leaving its base excluded from the gut Iumen. If the ulcer is high up in the stomach, rotate the stomach so that the ulcer comes to lie on the lesser curvature and then excise and oversew the lesser curve and fashion a gastroduodenal anastomosis (Billroth I, see page 5.25). Erosions can be treated bv underrunning alone but if extensive perform a vagotomv rvith p,vloroplasty (see page 5.19) or, preferablv, a gastrectoml' (see page 5.23). Ensure an,vbleeding points in the remaining proximal gastric remnant are c a r e [ u l l vu n d e r r u n . A bleedins carcinoma can be resected bv lvhatever operation would have been chosen if the case were elective' Alternatively bleeding can be controlled with sutures if resectionis inappropriate.

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a Making gastrotomY

m I n s p e c t i oo f g a s t r i c u c o s a n

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Fig. 5.75

Fig. 5.76

M A N A G E M E O TG A S T R O D U O D E N E E D I N G NF BL AL

Wound closure and dressing Ask the anaesthetist to insert a nasogastric tribe and cl-reckits position in the stomach. Insert a drain and close the wound with monofilament nvlon and the skin n.ith interrupted slltures. A p p l r a r ra t c r p r o , f d r e s s i r r g . r

POSTOPERATIVE CARE
Careful correction and maintenance of fluid and electrolrtte balanceis nrost important, rvith under- and over-transfusion both being potential hazards. The need for oneoing monirorins and in sone casesposroperative ventilation often demands that these patients are managed in an intensive care unit after the opelation. Carefullr cibserve the patient for bleeding but remember that sor.ne rlelaena is inevitable. The nasogastric tube is allorved to dr-ain but should nor be aspirated; continue intravenousflr"rids and nasogastric drainage until borvel sounds retum and flatus is passed. If doubt exists regardinu completenessoi vagotomv prescribe Hq antagonists or omeprazole until the histologvof the r,agi is available. Remor,e the drain after 48 hoursif ther-e no significant drainase. Snrures can be removed is after'8-10 days.

operate, reopenine the anterior gastlic suture line and securing haemostasis. , Discoverv of'an unsuspected gastric cancer following partial gastrectomv. In a ,voung fit patient, or if'the excision margins appear to be involved u'ith tumour, consider electively performing a more radical resection. Incomplete vagotomv, in rvhich casecontinue H2 antagonists rather than considering another operation. 4. Leakage fiom a suture line or duodenal stump.

Under-running of bleeding vessel

SPECIALOPERATIVE HAZARDS l. Damage the bile duct; the retroduodenalportion of to thebiledr-rct vulnerable surures hurriedlyinserted is if are
to underrun a bleeding gastroduodenal artery. If a duodenalulcer has causedmuch distortion of the tissues open the supr-aduodenalportion of the bile duct and insert a rubber Jacques carherer to aid its identification. Closethe duct over a T-tube. 2. No gastroduodenal causefound for the bleeding, in which case perform a complete small bowel laparotomy and carefully examine the pancreas, gall bladder and bile duct, and the aorta \rhere it is crossedby the fourth part of rhe duodenum.If the site is srill not apparenr and the bieeding hasstopped,closethe abdomen.

f inr rp-nf-oinht

c r r i rr r o

COMPLICATIONS See alsothe complications page 5.19 in Truncal \,ragotomv on andPyloroplastv, page 5.23 in PartialGastrectomv. and 1. Rebleeding, r,hich nav be I}om a sasrricsurureline or fiom theoligirralbleedinssite.If it persists, despiteH2 antauonists and correction of anv clotting abnormalities,elect to re-

Fig. 5.77

c.aJ

Ramstedt'sPyloromyotomy

This idiopathic condition occurs in neonates at around 4 weeks of age. It is more common in first born male infants and there is a familial tendency towards it.

and overlapped by the inferior margin of the liver. The more mobile pylorus in the neonate can be delivered through an abdominal incision without difficultv.

PREOPERATIVE ASSESSMENT 1. To confirm the diagnosis,the hypertrophied pyloric muscle is palpated during a 'test feed' with glucose water; this may be followed by projectile vomiting. On rare occasionsconfirmation may require the use of ultrasonography or barium studies. 2. Correct any dehydration and acid-basedisturbances. 3. Empty the stomach nasogastric by aspiration,combinedwith gastriclavage to remove milk curd and, if present, barium from the stomach.

OPERATION Preparation The anaesthetist should be skilled and experiencedin paediatric is anaesthesia, and care should be taken to ensure that heatloss minimized by placing the baby on a heated mattress.The skinis prepared and drapes placed. At the cephalic end it is usefulto use a clear, sterile, plastic sheet spread over a wire cageso that the patient's head remains visible,while the abdomenis covered by a transparentadhesivedrape.

RELEVANT ANATOMY While the pylorus Iies midway between the umbilicus and the xiphoid in the adult, in the infant it is slightly more caudal and

Incision 1. Incise the skin with a transverse incisionin the right upper quadrant, above the palpable liver edge and extend it towards the midline for 2.5cm (Fig. 5.78).

Positionincision of

Incision pyloric into tum0ur using back knife of

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Fig. 5.78

Fig. 5.79

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RAMSTEDT'S PYLOROMYOTOMY

2. Enter the peritoneal cavity by dividing the right rectus abdominusmuscle and the perironeum in the Iine of the skin incision,paying meticulous attention to haemostasis.

Postoperative vomiting is rarely due to inadequate myotomy, and is usually due to gastro-oesophageal reflux which can be reduced by nursing the baby in a chair inclined at 60o to the horizontal.

Operative technique l. Gently retracr the liver upwards and grasp the gastric antrum, this is then delivered into the wound followed by the thickenedpylorus which can be held with a pair of Denis Browneforceps. 2. Usingthe backof a scalpel blade make a longitudinalincision through an avascularportion of the serosaalong the length of the hypertrophied segmenr (Fig. 5.79), extending onto the antrium. 3. Introducea Denis Brorvne spreaderor small artery forceps into this incision and open rhem transverselyto split the hypertrophied muscle down ro the mucosa, which then bulges into the incision (Figs 5.80 and 5.81). Check that all the muscle fibres are divided. 4. Ensurethat the mucosahas not been opened by squeezing air from the stomach into the duodenum; a leak in the mucosa can be detected by a tell-tale bubble and should be repaired with 4/0 cargut. Slight oozing from the pyloromyotomyis usually due to venous engorgement and will stop when the pylorus is rerurned to the abdomen. Avoid usingdiathermyon the mucosa.

P r i n c i p lo f p y l o r o m y o t o m y e

Wound closure l. Close the abdomenin trvo layers,first the peritoneum with the posterior rectlrs sheath and then the anrerior rectus sheath,using a slolr,ly absorbable 3/0 suture such as Poly(PDS). dioxamone the 2. Close skin lvith 3/0 subcuticularsrirches.

Fi9.5.80

0pening tumour Denis the with Browne spreader

POSTOPERATIVE CARE Oral feedingr,vithan electrolyre/dexrrose solurion (10mI kg=t bodyweight)is commenced4 hours postoperatively and given every2 hours for the subsequent12 hours. If tolerated, half strength milk (l5mlkg-r body.weight) is given 2-hourly, convertingto full strength after 6 hours with normal feeding being resumedwithin 24 hours. If vomiting occurs, return to the previous phaseof the regime. The patient can be discharged homewhen toleratingfeeds,this usuallyoccursby day 2-3.

/o

SPECIAL OPERATIVE HAZARDS l. Opening the mucosa; this is most likely to occur at the duodenal fornix. 2. lncorrectdiagnosis.

COMPLICATIONS l. Unrecognizedmucosalperforation can be avoided by checking for air leaks(seeabove).

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Laparotomy for Adhesions

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After abdominal surgery, blood and inflammatory exudate in the peritoneal cavity can become organized to form fibrous adhesions, which is one of the commonest causes of small bowel obstruction. A laparotomy is indicated if conservative treatment fails, if there are recurrent obstructive symptoms. or if there are signs of ischaemic bowel as indicated by signs of toxicity or peritonitis.

supply via the mesentery from branches of the superior mesenteric artery. Adhesions can affect any or all of the small bolvel, binding the loops to each other and to the abdominal u'all, particularly to the back of wounds and to sites of previous sepsis. A volvulus around a band compromises the blood supply to the bowel and if vascular occlusion is complete it will lead to gangrene and perforatron.

PREOPERATIVE ASSESSMENT
l. Rehydrate and resuscitatethe patient with intravenous fluids. 2. Correct any electrolyteor acid/base disorders. 3. lnitiate nasogastric aspiration.

OPERATION Preparation
Under general anaesthesia, place the patient supine on the operating table. Expose, cleanse,and drape the entire abdomen.

RELEVANT ANATOMY The small bowel loopsusually in the infracoliccompartment lie of the abdomen and in the pelvis.They receivetheir blood

Incision
Either reopen the old scar and extend the incision to allorv good exposure or make a fresh midline incision (see the Introduction). 'false The fresh incision is frequently a economy' since the bowel which is adherent to the old incision will have to be is encountered and dealt with at some point, and better access afforded by the old incision. Very careful dissection is needed at this stage since bowel may be adherent to the scar. It is saf'est to begin the incision on fresh tissue,just beyond the end of the old incision. Enter the peritoneal cavity initially at this point, and dissect the bowel off the inside of the scar before reopening it.

A d h e s o n s t w e e b o w e l o o p s n da b d o m i n wla l l be n a a Operative technique 1. Separate. loops of bowel by a combination of sharp and blunt dissection clear the wound edges (Fig. 5.82). to

,

Insert a self-retaining retractor, or apply Kocher's tissueholding forceps to the deeper layers of the wound edge and have an assistant lift them vertically. Separate the adhesions using gentle traction and sharp dissection (Fig. 5.83). If the seromuscular coat is divided during the mobilization of the bowel, repair it with a 2/0 continuous catgut stitch. Continue until the whole length of the small bowel is mobilized.

3.

ril''
adhesi ons

4. Decompress the small bowel by milking the contents into
the stomach, from where they are aspirated via the nasogastric tube.
5.

Resect anv loops of bowel that have been rendered ischaemic by obstrrrciiue bands or have been damaged during mobilization (see page 5.50 in Small Bowel Resection).

Fig. 5.82
6. Adhesions are likely to reform and may cause further small

a
LAPABOTOMY ADHESIONS FOR

D i v i da d h e s i o n si t h s h a r p i s s e c t i o n e w d

bowel obstruction. A number of procedures are described to reduce the risks of subsequent obstruction and these procedures have the common objective of tethering the bowel loops in a concertina form. Insertion of aJones'tube is one way to achieve this goal (Fig. 5.8a). The tube is a 3m long, l8Fr gauge balloon carherer with side holes in the distal half to allow decompression of the bowel. The tube is insertedjust beyond the duodenojejunal flexure and passed to the caecum. It acts as an internal splint, so that when adhesions reform they do so with the bowel positioned in gentle loops without sharp kinks. To insert the Jones' tube, make a stab incision in the anterior abdominal wall to the left of the wound at a ooint overlying the duodenojejunal flexure. Pull the Jones' tube through the abdominal wall with Roberts' forceps (Fig.

5.85).
8 . Make a small enterotomy near the duodenojejunal flexure
with a knife and place a catgur purse-srring suture around it. Insert theJones'tube through the enterotomy and inflate the balloon with 5ml of saline. Tie the purse-string loosely around the tube.

Fig. 5.83

Jones'tube

I n t r o d u cJ o n e s ' t u b t h r o u g h n t e r i oa b d o m i n wla l l e e a r a

side holes

Fig. 5.84

Fis. 5.85

5.47

OPERATIVE SURGERY

9. Milk the tip of theJones' tube along the small bowel distally
by applying gentle traction on the balloon (Fig. 5.86). When the balloon reaches the ileocaecal valve, deflate it, pass the tip into the caecum (Fig. 5.87) and then reinflate the balloon with l0ml of saline, to retain it beyond the ileocaecal valve.

oxide mixture. Apply a gauze dressing to the enterotomv site until the flstula closes spontaneously.

10. Insert

a second purse-string stitch around the enterotomy site which is tightened and then tacked to the abdominal wall close to the point of entry of the Jones' tube to prevent intra-abdominal leakage of small bowel contents when the Jones'tube is removed.

SPECIAL OPERATIVE HAZARDS Damage to the bowel whilst opening the abdomen and dividing the adhesions.Any damaged bowel is either repaired or resected.

t l . Lay the small bowel in gentle curves (Fig. 5.88) and cover it
with the greater omentum.

r s B a l l o o ne t a i n t i o i n t h e c a e c u m
l

Wound closure and dressing The wound is closedwith a monofilament nylon and interrupted and theJones'tube securedto this skin atthe exit skin stitches, is site.A light dressing applied.

l

POSTOPERATIVE CARE Nasogastricaspiration and intravenous fluid replacement should be continued until bowel function returns. Adequate postoperativeanalgesiais essential because the patient may suffer intestinalcolic from the Jones' tube. The Jones' tube should be allowed to drain freely initially, but it is spigottedwhen bowel function returns with twice-daily flushing with salineto prevent the tube from blocking. Remove the tube after 14 days; this can be done on the ward with analgesiasupplemented if necessarywith an oxygen/nitrous

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Fig.5.87 t n m t W i t ht h eb a l l o oin f l a t e d , i l k h eJ o n e st' u b ea l o n g h e b o w e l

curves fashion with gentle Layout bowelin orderly

48

Fig. 5.86

Fig. 5.88

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LAPAROTOMY FOR AOHESIONS

plication the smallintestine Noble's of

COMPLICATIONS l. Recurrence of bowel obstruction. 2. Leakagefrom the site oftheJones'tube.

ALTERNATIVE METHODS OF BOWEL PLICATION An alternative to Jones' intubation is Noble's plication. Once the small bowel has been freed from adhesions,it is sutured together with interrupted seromuscular sutures (e.g. 310 catgut) so that the plicated bowel lies in regular folds (Fig. 5.89). The procedure is very time-consuming and carries the risk of small intestinal fistula formation. As with Jones' intubation, it reducesbut does not completely prevent recurr.entsmall bowel obstruction. A s-econd alternative is to passnon-absorbable sutures through the mesentery to prevent sharp angulation of the bowel. This carries the risk of bleeding as the result of damage to a mesenteric vesseland again does not guarantee the obstruction will not occur again.

Fig. 5.89

Small Bowel Resection

of Smallbowelresection indicated for: cases obstruction where is the bowel is judged to be non-viable once the cause of the obstructionis released;irreducible small bowel intussusception; ischaemiasecondary to arterial embolus; traumatic damage; a Meckel'sdiverticulum causing symptoms, such as intussusceptionand bleeding;strictures,asoccur for example in Crohn's disease; and tumours of the small bowel. Primary small bowel tumours,both benign (e.g. hamartoma and lipoma) and malignant (e.g.lymphoma, adenocarcinomaand carcinoid), are uncommon but a loop of small bowel is frequently adherent to large bowel tumours and needs to be resected.

PREOPERATIVE ASSESSMENT l. Barium follow-through in casesof Crohn's diseaseand primary small bowel tumours. 2. Nasogastricaspiration, rehydration with intravenous fluids and correction of any electrolyte disturbance in casesof small bowel obstruction.

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l

1

RELEVANT ANATOMY from the posterior The small bowel (Fig. 5.90) is suspended It abdominalwall by the mesentery. has a rich blood supply

Relevant anatomy

m I n c i s i o o f p e r i t o n e uc o v e r i n m e s e n t e r y n g

superior mesenteric artery

Fig. 5.90

Fig. 5.91

SMALL BOWEL RESECTION

Division mesenteric of vessels

fiom branches of the superior mesenteric artery, which pierce the mesenteric border of the bowel wall. Venous drainage is to the superior mesenteric vein and thence to the portal vein and the liver. The lymphatic vessels run with rhe arreries and drain into pre-aortic nodes around the origin of the superior mesenteric artery. The small bowel is intraperitoneal throughout its length. Approximately 60cm proximal to the ileocaecalvalve,a diverticulum (Meckel's) arises fiom the anrimesenteric border in approximately 2% of the population. Since the small borvel lies fiee in the peritoneal cavity and is fieely mobile, it is prone to kinking, compression and obstruction by adhesions, which can be either congenital or acquired (e.9. after previous surgery or sepsis). Its mobility also allows it to enter the sac of an abdominal wall hernia, purting it at risk of ischaemic damage by pressure at the neck of the hernia (strangulation), which is generally the narron'est point.

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OPERATION Preparation
Place the patient supine, and cleanse and drape in the usual manner. Ask the anaesthetist to pass a nasogastric tube.

*:.^'
Incision

Fig. 5.92

Make a midline incision, unless there is a conveniently sited previous incision which can be reopened. In casesof strangulated external hernia, an incision will have been made to approach it. If it is found that a resection is necessarr',either extend this incision (e.g. through the posterior wall of the inguinal canal) if it is possible, or make a separate laparotomy incision.

Ligation mesenteric of vessels
Operative technique

l. Perform a thorough laparotomy (see page 5.2).

,

In casesof obstruction, locate the cause and deal with it, for example by dividing an obstructing fibrous band. Carefully inspect both the segmenr of small bowel requiring resection and also the remaining bowel, and choose the resection margins. In cases of malignancy, a 5cm margin should be taken on each side. This is not necessary in benign disease, such as ischaemia and Crohn's disease, where the amount resected is kept to a minimum, ensuring however that the marsins are viable and healthy.

3.

4. Using scissorsdivide the peritoneum covering one side of
the mesentery betu'een the margins of resection (Fig. 5.91). In benign disease keep close to the bowel wall, but for malignant disease, take a generous V-shaped wedge of mesentery rvith the bon'el segment to remove the local lymphatic tissue which runs with the arreries.
5.

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Fig. 5.93

With scissors, divide the mesenrery between clips along the line of this incision (Fig. 5.92). By shining a light through the mesentery Ii-om behind the vessels can be seen more clearly. Ligate the vessels with absorbable (e.g. 00 Vicryl) ties (Fig. 5.93). fake as little fat and connecrive tissue with the vessel as possible since when tied, the vessels may slip back into the mesentery and bleed.

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OPERATIVE SURGERY

6 . Clear the nlesenterl'up to the bou,elu'all (Fig. 5.94) and apply cmshing clamps to the bowel immediately beyond the point of'section.Then, after the bowel contentshave beenmilkedfrorn the inter-vening segment, apply soft (noncrushing) clamps proximal and distalto the crushingclamps ( F i e .5 . 9 4 ) . Using a knife divide the borvel flush with the crushing ( c l a n r p F i g .5 . 9 5 ) .
8. Anastonose the t$'o cut ends in one or two layers (see the lnt|oduction) according to preference. 9. Close the defect in the mesentery with a continuous 00 chronic catgut stitch on a round-bodied needle (Fig. 5.96). Only the peritoneum covering the mesentery should be picked up rvith this stitch to avoid damaging the blood supply to the anastomosis (Fig. 5.97). Alternatively leave the ties lieating the vessels long and tie them rogerher in pairs to close the l-rolein the mesentery.

Application intestinalamps of c

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10. Lay the omentum around the anastomosis.

i

Wound closure and dressing Drainageis not usuallvnecessarv. Close the wound with loop nylon,catgutand 00 nylon for the skin.

n o n - c r u s hc na m p il g

crusnrng ctamp

POSTOPERATIVE CARE Nasogastric aspiration and intravenous fluids should be continued until gut motilitv returns, as indicated by decreasing volumesof aspirate, normal bor.vel soundsand the passage of flatus.

Fig. 5.94

D i v i d e o w e f l u s h i t hc r u s h i n c l a m p b l w g SPECIAL OPERATIVE HAZARDS 1. Damageto the main trunk of the superior mesenteric artery can only occur if the dissectionextends too deep into the root of the mesentery.If must be repaired. 2. Gross disparity between the sizesof the cut ends. This can occur with long-standing obstruction, in which case either perform an end-to-side anastomosisor divide the narrower bowel obliquely. 3. With extensive adhesions and obstruction, consider either a Noble'splicationor insertionof aJones' tube (seepage 5.46). 4. Extensiveinfarction and difficulty in deciding where the bowel becomesviable. This is seen in casesof superior mesentericartery thrombosis and embolus of the main trunk. It may be necessaryto resect what is definitely non-viableand either exteriorize the ends or anastomose and perform a second-looklaparotomy 24 hours later.

52

COMPLICATIONS l. Anastomaticleakagewill lead to either an abscess, fistula, or both. The rich blood supply to the small bowel makes this uncommon,but it is particularly seen in casesof Crohn's disease and in irradiated bowel. A fistula may close spontaneously if the patient is kept nil-by-mouth and fed intravenously; abscess an needsto be drained.

Fig. 5.95

SMALL BOWEL RESECTION

2. Stricture formation; because of the fluid nature of the small bowelcontent, this has to be quite severe to cause symptoms. It generallyrequires resection if symptomatic. 3. 'Shortgut syndrome', in which massivesmall bowel resection

will lead to malabsorption and intractable diarrhoea. It can be managed with either an enteral elemental diet or parenteral nutrition. Surgical reversal of a segment of the bowel can be performed to slow down intestinal transit.

Closuremesentery running of peritoneal with suture

Closure mesentery suture of with drawn tight

Fig. 5.97

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Intussusception

Au irttussuscel)tion arr invaginati()n,ol telescoping,ol the is p l o x i r n a l b o l e l i n t o t h e r l i s t a l b o w e l . I n t u s s u s c e l ) t i o ni n : r r l u l t s s h o t r l db e t r e a t e ( la s a s v l ) l l ) t ( ) l ro l ' a n u n < l e l l v i n g c o n r l i t i o n a n r l r t h e p l e c i p i t a t i n s c o n c l i t i o n s l r o t r k l b e s o u s h l . I < l i o l t i r t h i ci n t u s ( s u s c e p t i o n ) c c r l r s n i n l i r n t s a r o r r n c lt h e t i n r e o l l e a n i n g : r n r l i s i attributerl to enlar-genrentoI l)ever''s Patches, rlue eithel to a chatrqe in gut llol-a or to a viral inl'ection.

4. Irr the inl'ant, a rliagnostic l;aritrnr enenla rnay achieve l e < l t r c t i o r ro l t h e i n t t r s s u s c e p t i o nl r v h v d r - t ) s t a t i c r c s s r . r r e . p ()1>enrtive re<[uction is inrlicatecl il' hvrlr'ostatic reductiorr I u i l s , o l i l t h e r e a l e l e a t u l e s s u l l e e s t i n gP e r - f i l - a t i o n .

RELEVANT ANATOMY
At the apex ol the invaginating lro\\'el,oL irtttrssusceptunl,there i s u s u a l l y ' a l e s i o n l ' h i c h i s p r ' o u r l o l ' t h e n r u c o s as u c h a s a p o l r p , hanrartonrzr. an invertecl Nleckel's cliverticulutn ()r a carcurollt:l 'l'his (Fig. ir.98). is ptrlled distallr bv per-istalsis,draling the -I-he bou'el akrnq with it. inner (entering) tube and nridclle (returning) tube ol'brll'el lirrnr the inttrssusceptunl, uhile the o u t e r -s h e l t e l i s k n o t n a s t h e i n t u s s u s c i p i e n s . -l'he intussuscepti()n is alrnost alu'avs antegrade, single, and lusuallv involves telnrinal ileunr as the inttrssusceptunr, l'ith 'l-his three-rlalled sesnrent colon lirrnring the intussuscipiens. ol borvel is trstrallv easilv palpable akrng the line o1'the colon.

PREOPERATIVEASSESSMENT
|. lntusstrscel)ti()nlllu\ c:ruse u strarrgulation obstnrction anrl h e n c e r r r r r s ltr e t l e a t e r l r s i t l r t r l g e n c r ' . 2 . l n a c h i k l , c a l e l i r l r l i e i t a l e x a n r i n a t i o n s h o t r l < lc l i s t i n s u i s h a rectal prolapse, nhere the rectal rlluc()s:l is continr-rotrsrvitlr skin Il'onr the altex ol'an intusstrscel)ti()n resenting at tlte l) altus. 3. (lircuntolal piuurentation suggests Peutz-.feehers svn<lronre r v h i c hn r a t l ) r ' e s e l llt' i t h n r u l t i p l e i n t r r s s u s c e p t i o n lsl ' o u r s n r a l l b<xlel harnartolllas.

I n t u s s u s c e p tdo nt o p o l y p i ue

R e d u c f r o md i s t ae n d e l

p rea0 o r n l

intussuscepiu m

lntussuscrprens

proximai

Fis. 5.98

Fig. 5.99

INTUSSUSCEPTION

OPERATION Preparation The patient should be adequately resuscitatedbefore surgery and have a nasogastric tube. The abdomen is cleansed and drapedin the normal way.

POSTOPERATIVE CARE
After simple reduction, oral fluids can be introduced after 24-48 hours. If the bowel has been opened or resected, the management will be similar to that described for small bowel r e s e c t i o no n p a e e 5 . 5 2 .

Incision A midline laparotomy incision is most suitable in the adult, but a transverse high gridiron incision is better in the infant. or

SPECIAL OPERATIVE HAZARDS Damage to the intussusceptumwith perforation by traction on the proximal bowel.

Operative technique 1. Locate intussusception the and attempt to reduce it by gently squeezing distal bowel over the apex, trying to milk the the proximal bowel back (Figs 5.99 and 5.100), rather like squeezing toothpastefrom a tube. The intussusceptummay be friable and should not be pulled out proximally. 2. Once the bowel has been fully reduced, palpate it for any intraluminal lesions which may have acted as the apex. If there is any doubt an enterotomy should be made and the lumen assessed directly.
3. If there is no lesion present, as is common in the infant, the bowel can be left as postoperative adhesions make the likelihood of recurrent intussusception very low. 4. If there is a lesion present. excise it as appropriate. Hence a Meckel's diverticulum is resected, and a neoplasm requires the appropriate bowel resection (e.g. a right hemicolectomy) together with a laparotomy. An enterotomy and polypectomy are performed for a simple polyp. 5. If the intussusception cannot be reduced or it is of dubious viability once reduced, resect the bowel. 6. In casesof PeutzJeghers syndrome, multiple intussusceptions may be present and all should be reduced. Remove the hamartomatous polyps which are responsible for the intussusceptionsthrough a minimum number of enterotomies by intraluminal resection.

COMPLICATIONS Recurrence is rare, providing an underlying causehasnot been overlooked.

T e c h n i q uo f r e d u c t i o n e

Wound closure and dressing The abdomenis closedin routine fashion with loop nylon and nylonskin suturesin the adult. For an infant, slowly absorbable sutures suchas PDS should be used for the deeper layers.A dry dressing applied. is

Fi9.5.100
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Appendicectomy

PREOPERATIVE ASSESSMENT
l. Exclude an intrascrotal pathology (e.g. testicular torsion) and infection or calculusdisease the renal tract which can of mimic appendicitis. 2. Perform a rectal examination in the presence of urinary symptoms excludea pelvicappendix lying in contactwith to the bladder. 3. The very young and very old have a low tolerancet<-, peritonitis and immediate exploration is recommended i{' the historyis suggestive. 4. If the historyis not conclusive a young rvomanwith pelvic in pain,laparoscopy may be more appropriate. 5 . G i v ea m e t r o n i d a z o ls u p p o s i r o r y . e

RELEVANT ANATOMY The vermilbrm appendixarisesfrom the posteromedial wall of

Relevant anatomy

the caecum, 2cm below the end of the ileum (Fig. 5.101). Its base is located deep to a point one-third of the distance between the right anterior superior iliac spine and the umbilicus (McBurney's point). The position of the caecum should be verifled in the anaesthetized patient prior to making an incision, as pregnancy and arrested caecal descent result in a more cranial position in the right upper quadrant. Malrotation places the appendix in the left iliac fossa (Fig. 5.102). The appendix varies from 2 to 20cm in length, and arises n,here the three taeniae coli converge on the caecum; this provides a valuable guide to its position. As the appendix is relatively free it may point in anv direction, but it usually lies in a pelvic or retrocaecal position. Occasionally, subcaecal and paracaecal positions may cause diagnostic and surgical difllculties. The mesoappendix carries the appendicular artery, which is a terminal branch of the ileocolic artery, rvhich lies in its free border. The overlying abdominal wall consists of skin, subcutaneous connective tissue, Scarpa's f'ascia and deep connective tissue. Beneath lie, in order, the external oblique aponeurosis running obliquely, parallel to the inguinal ligament to become the rectus sheath; the internal oblique muscle running uprvard and medial with its fibres at right angles to those of the external oblique; the transversus abdominis muscle running horizontally across the abdomen and the transversalis fascia and extraperitoneal fat which covers the parietal peritoneum overlying the caecum, The ilio-insuinal nerve and accompanying vesselspassthrough the abdominal muscles to lie on the internal oblique muscles c l o s et o M c B u r n e l ' s p o i n t .

OPERATION Preparation the Under generalanaesthesia patientis placedsupine, the
the abdomen is cleanedand drapesare applied to expose right lower quadrant. Ensure that the proposedincisioncan be extended medially or laterally should it becomenecessary.

Incision A skin crease (Lanz) or a gridiron oblique incision is centred over McBurney's point and extended laterally to within a finger'sbreadth of the anterior superioriliac spine(f-ig.5.103). The Lanz incision provides a more cosmeticscar,but the gridiron affords better and swifter access. is also extended more It easily.
position retrocaecal

F i g5 . 1 0 1 .

,56

Operative technique l. Incise the fat and fascia to reveal the external oblique (Fig. 5.104),which is opened with a knife and aponeurosis then scissors the line of its fibres for the full length of the in wound.

APPENDICECTOMY

2. Split

t h e i r r t e l r r : r lo b l i r l t r e i t t t c I t l a n s v e r s t r s a b < k r r r r r n u s 'l-ltis nruscles betrveen theil lll;res. i s s t : r l l e r lr r i t l r t l r e l l o i n t s

o l u p a i l o l N I a r o s c i s s o l st h a t a r - eo p e n e < la t r i g h t a n s l e st o t h e { i b l e s ( l i i g . 5 . 1 0 5 ) . a n c l e n l a r s e < lr r ' i t h t l t e l i n s e l ' .

Possible forappendix sites

lncision f externalblique poneurosis o o a

Fig.5.l02

Fig5.1 4 . 0

Skin incision

S e p a r a t i n ig r e s f i n t e r n a l b l i q u e n dt r a n s v e r s u s d o m i n i s f b o o a ab muscles

Fig.5.103

Fig.5.l05

5.5?

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(]PERATIVE SURGERY

T e n t i nu p a n do p e n i ntg e p e r i t o n e u m g h

Sweep aside the preperitoneal fat and tent the peritoneum between two artery forceps, before incising it lvith a scalpel (Fig. 5.106) and enlarging the incision transversely using scissors.A foul smell or the presence of pus at this stage indicates advanced appendicitis. If greater exposure is required, incise the rectus sheath and retract the rectus muscle medially, or divide the muscles laterallv in the line of the skin incision.
5 . After locating the appendix b,v pursuing the caecal taeniae

distally, take a su,ab of any fi-ee lluid present fbr bacteriological assessment. Delir,er the appendix, together-rvith the caecum, into the wound and hold it u'ith a Babcock tissue forceps. Alternatively, an artery for-ceps mal be placed on the distal mesoappendix. If the appendix is rellrctant to appear, it can sometines be su'ept into the $'ound rvith the surgeon's right index finger; this procedure rnay be facilitated by

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Fi9.5.106

C r u s h i ntg e a p p e n d is t u m p h x C l a m p i nh ea p p e n d i c u la rrt e r yn t h e m e s o a p p e n d i x tg a i

Fis.5.107

Fis. 5.108

APPENDICECTOMY

gentle traction on the caecum which is held with a small gauge swabin the left hand. 7. Divide the mesoappendix with the conrained appendicular arterybetrveen arrery fbrceps (Fig. 5.107)and ligate it with 2/0 chromic catgut ligatures. 8. Using the Babcock forceps, hold the appendix up and crushits basewith heavy artery forceps, e.g. Spencer Wells (Fig.5.108). The artery forceps is then opened, moved up the appendix and closed again. 9. Tie a strong 00 catgut ligature around the base of the appendix where it lvas crushed, leaving a cuff of about 3mm betweenthe heavy arrery forceps and the tie (Fig. 5.109). |.0. Placea srnall arrery forceps adjacent to the knot of the stumptie, and cut the ends.

l l . Divide the appendix with a scalpelblade by running it along the undersideof the forceps(Fig. 5.1l0).

12. Insert a purse-stringsuture around the stump using 2/0
chromic catgut, picking up the seromuscular wall of the caecum.The stump is then invaginatedinto the caecum using the artery forceps and the purse string is tied (Fig. 5.lll). 13. Check the ligated mesoappendix for haemosrasis. 14. In cases with perforation aspirateany collectionof pus with a sucker and ensure that all particulate matter is removed.

Wound closure and dressing 1. Close the peritoneum with a continuouscargursuture (Fig. 5 . 1l 2 ) .

Ligation appendix of base

E x c i s i oo f a p p e n d i x n

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5.59

OPERATIVE SURGERY

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Purse-string technique burial appendix for 0f stump

3.

Close each of the remaining layers with interrupted chromic catgut. Use interrupted nylon sutures to close the skin. If the wound has been contaminated, either a corrugated wound drain is inserted into the wound or the skin closure may be deferred with delayed primary suturing 3 to 5 days later.

POSTOPERATIVE CARE
Metronidazole is continued for two dosesto reduce the incidence of wound infection. Oral fluids can usually be started the following morning, and the patient should be eating and fully mobile by the third postoperative day.

U/f----- .[--:

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Closure peritoneum of

SPECIAL OPERATIVE HAZARDS 1. Poor access,which can be improved by converting the muscle-splitting incision into a muscle-cuttingincisionby dividing the internal oblique laterally and the rectus sheath medially. , Incorrect diagnosis. A normal appendix should be removed and a search made for alternative pathology; the small bowel mesenteryshould be inspectedfor mesenteric adenitis, the bowel for Crohn's ileitis and a Meckel'sdiverticulum, and the female pelvis should be examined for ovarian cysts or tubal pathology. A swab on spongeholding forceps should be passedinto the pelvis to discover whether free blood or pus is present. 3. Retrocaecalappendix, in which casethe caecumis mobilized by dividing its lateral peritoneal attachment and, if by necessary, extending the skin incision laterally. 4 . If the appendix cannot be found, it will be revealedby following the taeniaecoli caudally. 5 . A gangrenous appendix base.To avoid the risk ofleakage from the caecumthrough the gangrenousportion a purse wall string suture should be inserted in the healthy caecal before mobilizing the appendix, which can be tightened to control leakageif it occurs. 6 . Appendix mass. If, by the time of presentation, the appendicitis has progressed to an inflammatory mass,it Mark its contour should be initially treated conservatively. on the skin surface to observe for any change in its size and plan an interval appendicectomy 2-3 months after resolution. If there is worsening pain or the size of the mass increaies, or if signs of systemictoxicity or peritonitis develop, surgical exploration should be undertaken has since these are indications that an appendix abscess formed.

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COMPLICATIONS
l. Wound infection and intra-abdominal abscess. 2. Paralyticileus. 3. Incorrect diagnosis, for example serositisdue to pus from elsewheremay be misinterpreted as the primary infection. 4. Leakage from the appendix stump; difficult closuresshould be oversewnwith catgut and drained, and the stump covered with omentum." 5. Haemorrhage from the mesoappendix.

60

F i g5 . 1 1 2 .

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Right Hemicolectomy and Extended Right Hemicolectomy

The most frequent indications for right hemicolectomy are malignant disease of the caecum and ascending colon, Crohn's disease and angiodysplasia.

PREOPERATIVEASSESSMENT l. The diagnosis must be confirmedand synchronous pathology in the rest of the colon excluded by barium enema or colonoscopy,with or without biopsy. 2. In cases of malignancy, chest X-ray, liver scanning, liver function tests and assays for tumour markers (e.g. carcinoembryonic antigen) should be carried out. 3. Ifthe patient has angiodysplasia, carry our angiography and red cell scanning. 4. Commence antibiotic cover, and prophylaxis for deep vein thrombosis. 5. Ensure adequate fluid replacement and correct any electrolyte disturbances in the presence of an intestinal obstruction.

medial wall of the large intestine at the junction of the caecum and ascending colon. The caecum is covered on three sides by peritoneum, its posterior aspect is applied to the posterior abdominal wall. The appendix arises from the lower pole of the caecum. The ascending colon, which is l5-l8cm long, runs from the caecum to the hepatic flexure. Lateral to the ascending colon is the right paracolic gutter, and medially is the right infracolic compartment. The ascending colon turns medially at the hepatic flexure to become the transverse colon. The right side of the colon and its blood supply overlie the right ureter, genitofemoral nerve and the right gonadal vessels. The hepatic flexure overlies the lower pole of the right kidney, and may be covered by the inf'erior surface of the liver. The second part of the duodenum is medially related to the hepatic flexure. The transverse colon hangs down in the peritoneal cavity, and within its concavity lies the greater curvature of the stomach; the gastrocolic omentum stretches between the two and continues as the greater omentum below the transverse colon. The blood supply to the right side of the colon comes from arteries which arise from the right side of the superior mesenteric artery. This runs in the root of the small bowel mesentery,

RELEVANT ANATOMY
The right side of the colon extends from the caecum to the hepatic flexure (Fig. 5.1l3); the rerminal ileum opens into the

Relevant anatomy

jtt,
mesenlenc anery supen0r

middle colic artery

rightcolicartery

ileocolic artery
line f incision peritoneum o i

Fis. l3 5.1

5.61

OPERATIVE SURGERY

gives rise to the rriddle and r-ight colic arteries, and the ileocolic artery. The right colic and ileocolic arteries r-Lrnto the right, beneath the peritoneurn on the posterior abdominal rvall. The middle colic arter-v luns in the transr,erse mesocolon. Each vesseldivides into ascendins and descending branches close to the bowel rvall, l'hich form a single mar-ginal artery (of Drunrmond); this mns I'rom the caecunl to the rectuln, being supplieclon the left siclebl the branches of the inf'erior rnesenteric artery. Venous drainage {bllol's the arterial supply, with the veins drainir.rginto the strperior-rnesenter-ic vein, and from there to the liver via the portal vein. The lynphatic drainage is to epicolic nodes lying on the mesentet-ic bolder o1'the borr'ell'all, and then throush paracolic nodes located along the arterial tr-unks to pre-aor-tic nodes around the origin of the super-ior-nesenter-ic artery. Nlalignancies of'this legion of the bou'el are spread through these path\,vays.

c R i g hp a r a c o l ig u t t e r t

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OPERATIONS RIGHT HEN,I ICOT,EC]TONIY Incision
1. Place the patient supine and enter the abdomen through a midline, trzlnsverse or right paramedian incision (see the Introclui:tion) accolcling to pref'erence or any previorrs incisions. 2. Occasionally,a caecalcarcinona mav present as appendicitis and is discoverecl cluring the operation. In such cases,extend the sridiron incision obliquelv as a muscle-cutting incision ttr allolv adequate access.

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gonadaessels ureter vl

reflected mesocolon

0u00enu m

F i s5 . 1 4 .
Operative technique l. ln casesof' nralignancl', confir-m the site of the lesion and assess nrobility. Perfilrnr a thoror.rsh laparotomy (see page its 5.2), paying particular attention to the draining lymph nodes and the liver'.In Cr-ohn'sdisease,carefully examine the entire sastrointestinal tract fbr evidence of active disease. For angiodysplasia,the colon freqtrentlv looks normal althoush an abnornral vascular patter-n may be apparent. Mobilize the light side cif'the colon b1,division of the peritoneluu on its lzrteral side from ttre terminal ileum to the hepatic llexure (Fig. 5.I l3). Lift the colon off the posterior abd<lminal rvall and swing it torvar'ds the midline on its primitive mesenter]-.Take care to identify and preserve the right uleter, the second part of'the duodenum and the right gonaclal vessels(Fig. 5.ll.1). The caeclrm and distal ileum ale firrther nrobilized b1'dividing the peritoneal attachments between the l'oot of the mesentely and the abdorninal wall r r r r d e lt l r e i l e o c a e a l r e g i o n . . t

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3 . Choose the

level of'borvel secti()n; fcrr malignant disease of the caecum rvhich appears curable r-esect30cm <,rf the distal ileunr, together-lvith the colon as far as the proximal transverse colon. Resection can be lnol-e conservative for benign disease.

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4. Divide the gastrocolic omentum and greater omentum between clips up to the point chosen fbr sectioning of the colon.

F i g5 . 1 5 .

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RIGHT HEMICOLECTOMY EXTENDED AND RIGHT HEMICOLECTOMY

5 . If the mesentery is held up to the light, the vesselsrunning

L i g a t i o n dd i v i s i o o f b l o o d e s s e l s an n v

in it can be clearly seen, provided there is not too much fat. The intervening mesentery is relatively avascular and can be divided with scissors(Fig. 5.1 l5). Ligate and divide the ileocolic and right colic arteries, and the right branch of the middle colic artery (Fig. 5.116). In cases of malignancy, divide the vessels close to their origin from the superior mesenteric or middle colic artery in order to remove as much lymphatic tissue as possible. In benign disorders, divide the mesentery close to the bowel u'all. Once the mesentery and omentum have been divided, exclude the bowel frorn the operative field with large acriflavine-soaked srvabsand apply crushing clamps to the bowel at the site chosen for resection. Apply non-crushing clamps to the bowel on either side of the specimen 5cm from the crushing clamps, having rnilked any borvel contents out of the intervening segment (Fig. 5.1 l7). Ensure the clamps are applied firmly or venous engorgement will occur. Using a knif'e, divide the bowel flush rvith the crushing clamp so that this clamp remains rvith the specimen. Hold the borvel lumen open u'ith Babcock's tissue-holding fbrceps (Fig.5.l18) and dab it clean with aqueousiodinesoaked dental swabs; coagulate anl' bleedins points with diathermy or fine catgut ligatures. Unite the bowel ends in

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non-crushi ng clamp

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O P E R A TSV E G E R Y I UR

one or two layers (see the Introduction) according to preference. Any disparity in size between the ileum and colon can be overcome by a more oblique division of the ileum, resecting more tissue from the antimesenteric border so as not to compromise the blood supply, or by performing an end-toside or side-to-end anastomosis and oversewing the other end with two layers of absorbable sutures. On completion, remove the non-crushing clamps and discard the acriflavinesoaked swabs. Suture the cut edge of the mesocolon to the cut edge of mesentery with 2/0 catgut in order to avoid leaving a hole through which bowel could herniate (Fig. 5.1 l9). Pick up only the peritoneum with the suture, as there is a risk of damage to the blood supply of the anastomosis if vesselsrunning in the edge of mesentery or mesocolon are sutured. 8. Make a careful check for haemostasis, and wrap the remaining omentum around the anastomosis.

EXTENDED RIGHT HEMICOLECTOMY
Lesions of the transverse colon, splenic flexure, and even the descending colon can be treated by extended right hemicolectomy; this prevents a colo-colic anastomosiswith its more precarious blood supply, and can be safely performed in unprepared bowel (e.g.in the presence obstruction). of

Operative technique l. In addition to the mobilizarion as describedabove,the transverse colon and splenic flexure are mobilized with ligation and division of the middle colic artery and if need be the upper left colic vessels. colon. the ileum to the descending 2. Anastomose 3. Oppose the mesentery and mesocolonin front of the proximaljejunum.

Wound closure and dressing Place a silicone drain in the right paracolic gutter. Close the wound with loop nylon; if a midline incision was made it is closed in one layer, if the incision was paramedian or transverse, close in two layers. Use catgut to the fascia and 210 nylon for the skin.

POSTOPERATIVE CARE A nasogastrictube is left in situ until gastric emptying recovers. Oral fluids should be increased as bowel sounds return and flatus is passed.Prophylactic antibiotics are usually continued for 24*48 hours and the drain is removed when drainageis less than l00ml per day. The skin suturesremain fbr 8-10 days.

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SPECIAL OPERATIVE HAZARDS l. Damage to the duodenum. 2. Damage to the right ureter. 3. Damage to the middle colic artery in a right hemicolectomy, which may compromise the blood supply to the and the remaining colon. anastomosis a 4. D a m a g et o t h e s u p e r i o rm e s e n t e r i c r t e r y . 5 . Occluded inferior mesenteric artery in patients underthe going extended right hemicolectomy. ln such cases descendingand sigmoid colon rely on the marginal artery and superior mesenteric artery for their blood supply and a more extensiveresectionis necessary. 6. A tumour involving the abdominal wall may be resectable en bloc. In an elderly patient with an incurable fixed tumour, a pallative side-to-sideileocolic bypass may be more appropriate. This procedure may also be indicated in the presenceof obstruction in an unfit patient, prior to definitive operative treatment.

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COMPLICATIONS 1. Haemorrhage from a poorly applied ligature; double ligation will help to prevent this. of large vessels Abscess fistula formation from an anastomoticleak. or 2. of 3. Stricture formation is rarely a problem because the fluid composition of the bowel content in this region. It generally follows either ischaemia or tumour recurrence at the anastomosis.

F i g 5 . 19 . l

64

Sigmoid Colectomy

Segmental resection of the sigmoid colon is performed for cases of limited diverticular disease, sigmoid volvulus, benign colonic polyps not amenable to endoscopic removal and some cases of carcinoma of the sigmoid colon. Cases of carcinoma fiequently require a more radical resection, but this is not appropriate in all cases,for example in the presence of liver metastases.

OPERATION Preparation
Under a general anaesthetic the patient is catheterizedand placed in Lloyd-Davies position (seepage 6.49).This allowsthe distal bowel to be washed out prior to anastomosisand, if necessary, stapling device can be inserted through rhe anus. a

PREOPERATIVEASSESSMENT
l. Confirm the diagnosis with barium enema and/or colonoscopy with biopsy. 2. Prepare the bowel and administer prophylactic antibiotics. 3. Ascertain whether a resrorative operation is safe. In the emergency situation such as obstruction, perforation or with abscess formation, exteriorization of the proximal end may be preferable as a temporary measure (see page 6.36).

Incision Enter the abdomen through a lower midline or left paramedian incision (seethe Introduction).

Operative technique 1. Perform a thorough laparotomy. If the operation is for diverticulitis the rectum is spared from the disease, the but proximal limit of severediseasemust be confirmed. 2. With the patient in a head-down tilt, pack the small bowel away into the upper abdomen with a large damp abdominal swab. 3. Frequently there are some fibrous adhesionsbetweenthe sigmoid colon and the parietal peritoneum in the left iliac fossa.These are divided, followed by the peritoneum over the lateral side of the sigmoid mesocolon(Fig. 5. 120).Free the sigmoid colon from any adherent viscussuchasbladder or small bowel, repairing any defect that this creates.

RELEVANT ANATOMY For a full description page 6.22 in Abdominoperineal see Excision the Rectum. of

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Incision lateral of reflecti0n peritoneum of 4. Extend the peritoneal incision down into the pelvis alongside the upper rectum, while the sigmoid loop is retracted to the patient's right by the assistant. Identify and preserve the left ureter as it crossesthe bifurcation of the common iliac artery. 5. Draw the colon to the left and similarly divide the peritoneum on the other side of the sigmoid mesocolon(Fig. 5.121);a finger is insinuatedunder the inferior mesenteric vessels the root of the mesocolon.Identify and lift up the in inferior mesenteric artery and vein, and continue the dissection in the plane behind thesevessels down as far as the upper rectum. Unlike an anterior resection, the lateral ligaments of the rectum are not divided. 6. Selectthe proximal level of bowel sectionwhich is usuallyat the junction of the descending and sigmoid colon. The distal level of resection is also selected,generally in the upper rectum. iliac artery 7. Locate the sigm<iidarreries which can be seenin the mesocolon, and decide whether one or more of the sigmoid vessels to be preserved,or if the proximal bowel is to rely is on the lower left colic arrery for its blood supply. Ligate

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O P E R A TSV E G E R Y I UR

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and divide the inferior mesenteric vesselsbeyond the lowest branch to be preserved and divide the mesocolon between clips up to the point of proximal bowel section. Distally the mesorectum is divided betrveen clips and ligated up to the bowel wall at the level of proposed transection. 8. Apply a Hayes clamp to the upper rectum, and crushing and non-crushing clamps to the proximal bowel as shown in Fig.5.122.'fhe distal bowel beyond the Hayes clamp is washed out with saline using a rvide bore tube introduced through the anus, and sucked dry via a proctoscope. Support the distal bou'el with Babcock's forceps and divide it flush with the underside of the Hayes clamp (Fig. 5.123). Insert stay slrtllres into each corner of the distal bowel. 9. Divide the proximal colon between the clamps and anastomose the bowel end-to-end with either one or two layers of sutures according to preference (a single layer anastomosis is shown in Figs 5.124 and 5.125).It is generally unnecessary to use a stapling device since the anastomosis is at the level of sacral promontory and therefore easily hand-sewn. To ensure the anastomosis is lying without tension, the lateral peritoneum alongside the descending colon can be divided and, if necessary, the splenic flexure is mobilized by division of the peritoneal attachment betu'een the colon and the spleen (Fig. 5.126). This must be done with sharp dissection; if done bluntly the splenic capsule will tear and bleed. There is frequently a moderate sized vessel in the peritoneal reflection which is ligated or cauterized. 10. Test the anastomosis to ensure that it is watertight. This is performed by inflating the rectum with air via a sigmoido-

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S I G M OCD L E C T O M Y IO

Posterior of single-layer layer anastomosis completed

scope rvtrile pelvisis firll of'sterile the salineand the proximal non-crushingclamp is still applied. Additional suturesare insertedif'required.

Wound closure and dressing Insert a siliconedrain and closethe n'ound u'ith loop nylon and interrupted skin sutures.Appll' a \\'aterproofdressing.

POSTOPERATIVE CARE 'fl-re patier-rt retlrr-ns the ward u'ith a nasogastric to tube and an 'I'he intravenous clrip. nasogastric tube is removed and oral fltrids are reintroduced as boruelfunction recovers. further A 24 hours of intravenous antibiotics given.The drain remains are Iirr 7 days, and the urinary catheter is removed when the patient is mobile. Suturesare removed on rhe eighth day.

SPECIAL OPERATIVE HAZARDS 1. Damageto the ureter. 2. Damage to the hypogastric nerves as they crossthe pelvic brim; this causes retrograde ejaculationin the male but is of little consequence the female. in

Fig.5.l24

F u r t h em o b i l i z a t i o nl e f tc o l o n r f Completed anastomosis

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COMPLICATIONS l. Anastomoticleakageand fistula formation; these are unlikely if there is no tension on the anastomosis. A fistula can be treated conservatively but if a leak leads to a generalized peritonitis, a laparotomy and defunctioning colostomy is required.

2. Anastomotic stricture is also likely to follow tension on the
anastomosis. This can sometimes be treated by peranal dilatation, but further resection is often required. 3. Recurrence of original disease(e.g. diverticulitis in persisting diverticuli in the proximal colon).

i

()PERATIVE SURGERY

lifiing the greater omentum upwards, 6. With an assistant dissect transverse coloncaudallyand using scissors drawthe in the bloodless plane between omentum and transverse the omentum. mesocolon preserve and 7. Divideany adhesions benveenthe sigmoid colon and pariand using scissors mobilizethe left side of etalperitoner-rm, colon by dividing the lateral peritoneal reflection upthe wards lionr the pelvic brim towards the splenic flexure. Draw the cokrn mediall,vand identify and preserve the lef t ureterand gonadalvessels. tl-re llexure b,vdivisionof the fbld of'perito8. Mobilize splenic whilst neum betweenthe spleen and colon with scissors and distal gently drawing both the proximal (transverse) (descending) rvith the other hand (Fig. colon dorvnrvards 5.128).This lbld often contains a blood vesselwhich is coagulatedwith diathermy or ligated. Avoid excessive traction to the colon rvhich can strip the splenic capsule causing spleento bleed. the 9. Divide and ligate the middle colic, upper and lower left ckrset<l the bowel wall, dividing colicand sigmoidvessels the mobilized For convenience the interveningmesocolon. bowelcan nou'be placedinto a sterilepolythenebag. 10. With an assistant betu'eenthe patient'slegs displayingthe

sutures with 3 p0int fixation mucocutaneous

Kiili

Fig. .129 5

Evertion spout of Mobilizationsplenic of flexure

70

Fig. 5.128

Fig. 30 5.1

a

PROCTOCOLECTOMY AND ILEOSTOMY

rectum by downward traction on a St Mark's retractor, incise the pelvic peritoneum along each side of the rectum and continue these two incisions across the front of the rectum to meet each other. Keep both ureters in sight, placing a sling around them if necessary. 11. With the rectum dran'n forward, divide the inf'erior nlesenteric vessels at the pelvic brim, and the posterior fascial attachments of the rectum to the sacrum. Keep close to the rectum, lieating or diathermizing an1' vessels as rhey are encountered. 12. Mobilize the rectum anteriorly from the seminal vesicles and prostate in the male and from the uterus and cervix in the female. 13. With traction up and to the lefr, clamp (using Lloyd-Davies clamps), divide and ligate the right lateral lisament and its enclosedmiddle rectal arrerv close to the bowel wall. Repeat this fbr the left side. The remainder of the mobilization will have been performed from below (see later in this chapter) and the entire large bowel can non' be removed fiom the patlent. 14. Closethe pelvic peritoneum with a running 00 catgut stitch. 15. Grasp the cenrre of the proposed sroma sire with Lane's tissue-holding forceps and, lvhilst renring it up, excise a disc of skin rvith a knif'e. Similarly excise a disc of underlying fat and incise the anterior rectus sheath in cruciate fashion with a knife. Insinuate nvo fingers between the fibres of the rectus abdominis muscle and either create an extraperitoneal tunnel to the original incision in the peritoneum lareral to the right side of the colon (for an extraperitoneal ileostomy), or open the posterior rectus sheath and peritoneum at this point with scissors(for an intraperitoneal ileostomy). 16. Bring the terminal ileum to the surface by f'eeding the de Martell clamp through the tunnel or the posterior rectus sheath and allow 8-l0cm of ileum to prorrude. 17. For an intraperitoneal ileostomy secure the ileum to the peritoneum and close off the lateral space with catgut to prevent parastomal and lateral space herniae (see page

3. Using a pair of non-toothedforceps(e.9.Canadianpattern) inserted at the 6 o'clock position, gently push the ileum throush the stoma from rvithin so as to evert the ileum (Fig. 5.130).Insert interrupted circumf'erential chromiccatgut sutures,picking up the skin, the deep serosal surface of t h e i l e u m a n d t h e c u t e n d o I ' t h e i l e u m ( F i g .5 . 1 3 1 ) . 4. Apply a transparentileostomyappliance.

PERINEAI- OPERATION In the presenceof rectal malignancyor severesepsis such as may occur in Crohn'sdisease, proceedasfor Abdominoperineal Excisionof the Rectum (seepage 6.27).Widespread sepsis with ulceration and fistula formation may make closureof the wound unsafeand it shouldbe packedand allowedto healby secondary intention. In other casesan intersphinctericdissection the of rectum is used as desci'ibedbelorv.

Preparation This has been describedfor the Abdominal Ooeration.

Incision By careful palpation a gr-oove can be felt around the anus betweenthe internal and external sphincters. Make a circular

Completed ileostomy

6.30).

Abdominal wound closure and dressing lnsert a silicone drain, close the wound u'ith loop nylon and use interrupted sutures or staples for the skin. Apply a waterproof dressing to the wound. Once the lvound is covered create the spout ileostomy as described below.

Formation of ileostomy 1. Secure the ileostomy to the anterior rectus sheath with a few non-absorbable suturcs. 2. Cut the ileum flush with the undersurface of the clamp and insert three mucocutaneous sutures at the 3, 9 and l2 o'clock positions using 00 chromic catgut mounted on a cutting needle as shown in Fie. 5.129.

Fig5.131 .
3.1

OPERATIVE SURGEBY

incision over this groove and identify the lower borders of the internal and external sphincters. The intersphincteric plane lies between them.

3. Once the large bowel has been withdrawn ensurehaemostasis.

Operative technique 1. Grasp the anus with a Lane's tissue holding forceps, insert a self-retaining retractor and using sharp dissection with develop the intersphincteric plane (Fig. 5.132). lnjecscissors tion of dilute adrenaline solution (l:300,000) will aid identification of the plane. 2. Posteriorly and laterally stay in this plane until the abdominal dissection is reached. Anteriorly, as the dissection proceeds, divide the anterior fibres of the external sphincter to enter the plane behind the prostate in the male and behind the vagina in the female to meet the abdominal operator.

Perineal wound closure and dressing with Insert a fine suctiondrain, opposethe external sphincters (e.g.Vicryl), and closethe skin sutures interrupted absorbable with a subcuticular suture. Cover with a gauze pad and Tbandage.

POSTOPERATIVE CARE Maintain nasogastric aspirationand intravenousfluids until gas and fluid appear in the ileostomy bag, then reintroduce fluids and food. Continue to use the epidural catheter for analgesia for the first 2-3 days. Remove the drain when drainagehas ceased, usually after 2-3 days,and talie out the catheterwhen the patient is mobile. Removethe suturesafter 8 days.

Plane intersphincteric dissection of

SPECIAL OPERATIVE HAZARDS l. Damage to the ureters when mobilizing the colon. 2. Damage to the spleenwhen mobilizing the splenicflexure. In which case, pack the area for l0 minutes with warm packsto control bleeding; haemostaticgauze(e.g.oxidized cellulose)may also help. It is uncommon to have to resort to splenectomy to control the bleeding. 3. Bleeding from the pelvic dissection,which also will generally stop if packed.

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Fig. 5.132

COMPLICATIONS 1. lschaemia,retraction, or stenosisof the ileostomyusually reflects that the ileostomy was created under tension. revision. 2. Ileostomy prolapse which may necessitate 3 . P e l v i cf l o o r h e r n i a t i o n . 4. Parastomaland lateral spaceherniation are usually complications of an intraperitoneal ileostomy and may require surgery and resiting of the stoma. 5. Impotence in males from damage to the hypogastricnerves, which should not occur if the surgeon keeps in the right plane, close to the rectal wall. 6. Failure of the perineal wound to heal with sinus fbrmation. must any sepsis This is usually a feature of Crohn's disease; if need be, and cavities be drained, excising the coccyx saucerized and allowed to heal by secondary intention. Ensure that no foreign material (including non-absorbable sutures) remains. In selectedcasesa gracilis or gluteal flap can be raised and used to pack the defect. 7. Dehydration and salt depletion following high output from the ileostomy. When bowel function returns postoperatively the output is often high initially and treated by adequate intravenous hydration. Later, if the problem persists,prescribecodeine phosphate or loperamide. in of 8. Recurrence Crohn's disease the smallbowel.

72

TransverseLoop Colostomy

A loop colostomy defunctions the distal colon and rectum and is intended as a temporary measure either to relieve a distal obstruction prior to a definitive procedure, or to allow a distal anastomosis heal. In some circumstances it may be performed to as a palliative procedure and remain permanently.

resections of the left colon and rectum, or because,in many elderly patients, the vesselis no longer patent. The left colon is then supplied by the marginal vesselextending fiom the left branch of the middle colic artery. To avoid impeding this blood supply a transverseloop colostomy is formed to the right of the middle colic artery.

PREOPERATIVE ASSESSMENT I. Forewarn patientundergoing distalcolonicresecrion the a
thata temporarycolostomymay be necessar'y. 2. A stomatherapist should mark the position of rhe colostomy on the patient's abdomen preoperarively, either in the right upperquadrantor right iliac {bssafor a transverseloop colostomy or in the left iliac fossafor a sigmoid loop colostomy.

OPERATION Preparation The patient is either placed supine, or in the Lloyd-Davies position if a low colonic anastomosis has been performed.

RELEVANT ANATOMY A loop colostomyis usually placed in the proximal transverse colon, althoughit can be sited in the sigmoid colon. The colon and upper rectum receiveblood from the superior and inferior mesenteric arteries,with major branches feeding the marginal arteryalongits length (Fig. 5. 133).A proportion of patientsdo not have an inferior mesenteric artery blood supply. This is either becauseit has been ligated flush to rhe aorta during

Incision Make a midline or left paramedian incision in the abdomen(see the Introduction). A separaterransverse incisionwill be required for the colostomy after the colon has been mobilized.

Operative technique l. Identify the transverse colon and middle colicvessels, and selectand manipulate a point to the right of thesevessels to

Relevant anatomy

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margrnal artery

right artery colic

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supenor mesentefl c artery leftcolic artery sigmoid artery

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Fig.5.l33

5.73

()PERATIVE SURGERY

ensure the colon can lie without site.

tension at the intended

w t a B o w e l r a w n h r o u g h b d o m i n a la l l d

, If the transversecolon is to be used, clear the omentum
from a short length, and open the mesocolon adjacent to the serosato allow the passageof a glass rod which is attachedto a rubber colostomy tube (Fig. 5.134). Avoid the marginal artery if possible.

3. Make a transverse skin incision 5cm long at the site marked
for the colostomy.If no site is marked, it should be on the right side, midway from umbilicus to costal margin or, if the transversecolon can be brought down, a right iliac fossa colostomyis more manageable.In either caseit should not be in the line of skin creasesor near the laparotomy incision. 4. Deepenthe transverseskin incision through the connective tissueand anterior and posterior rectus sheaths, dividing the lateral half of rectus abdominis. 5. Open the peritoneum and draw the loop of bowel through by traction on the rubber tube so it lies without tension or twistingon the abdominalwall (Fig. 5.135).

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6. Having closedand dressedthe laparotomy wound, open the colon longitudinallyusing a 3cm linear incision along one of the taeniae;a transverse cruciateincisionmay be or usedwith a dilated obstructed colon. Start the incision with a scalpel,sinceif the bowel has been obstructed diathermy may ignite the intraluminal gases.

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Mucocutaneous t0 secure sutures colostomV

G l a s r o dp a s s etd r o u g h e s o c o l o n s h m

Fis.5.134

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74

--.1
LOOP TRANSVERSECOLOSTOMY

,

loop Completed colostomy

Suture the full thicknessof the edge of the colon wall to the skin edge using interrupted 2/0 chromic catgut on a cutting n e e d l e( F i g .5 . 1 3 6 ) . n s u r i n gm u c o c u t a n e o u sp p o s i t i o n . e a 8 . Insert a finger down both proximal and distal lumina to ensure patency. 9 . Cut off surplus rubber tube and secure it to the skin, transfixing it \l'ith 2/0 silk sutures (Fig. 5.137).Alternatively thread the glassrod back under the colon, keeping its ends linked with the rubber tube (Fig. 5.138).

10. Spray the surrounding skin with tincture of benzoinand fit
a colostomybag.

POSTOPERATIVE CARE fluids tube Nursethe patientwith a nasogastric andintravenous
until wind is seen in the bag. Remove the colostomy bridge on the tenth day. Once distal contrast X-ray studies have proved patency and no leaks close the loop colostomy at any time (see page 5.77). A delay of 4 to 6 weeks reduces oedema and facilitates the procedure.

rubber cutshort tube

Fig. 37 5.1 .
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SPECIAL OPERATIVE HAZARDS 1. Damage to the left branch of the middle colic artery impairs the blood supply to the distal colon and any
Bag pplied a
anastomosis. 2. Ischaemia of the colostomy due to tension or twisting.

COMPLICATIONS l. Colostomy retraction as a result of tensioh on the loop can be avoided by adequate mobilization. 2. Parastomal hernia. 3. Colostomy prolapse.

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Closure of Loop Colostomy (and lleosto-y)

RELEVANT ANATOMY
Once the requirementfor a loop colostomyhas passed(e.g.an anastomosis healed),the colostomycan be closedand the has distalbowelput back into intestinalcircuit. The colon as the result of a loop colostomyhas been opened and sutured to the skin, most commonly in the right upper quadrant. Both the proximal and the distal colon passthrough the abdominal wall, where the serosabecomes adherentto the abdominal wall muscles The and connectivetissue(Fig. 5.139). transverseloop is placed to the right-hand side of the middle colic vessels, that, should the marginal artery be damaged, so the blood supply to the distalcolon is not compromised(see Fig. 5 . 1 3 3o n p a g e5 . 7 3 ) .

PREOPERATIVE ASSESSMENT l. A distalloop barium enemaand/or endoscopic examinarion (sigmoidoscopy colonoscopy) required prior to closure. or are This will confirm that the colon distal ro rhe colosromyis healthyand that any anastomosis healed. has 2. Preparation both the proximal and distalcolon is required, of usingboth an oral purgativeand a distal loop wash-outwith saline.

OPERATION CLOSUREOF A LOOP COLOSTOMY Preparation
The operation is perforrned under a general anaesthetic with muscle relaxation. The patient is placed supine and the colostomy bag is removed.

Loop colostomy

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76

Fig.5.140

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C L O S UO F O OC O L O S T O M Y RE L P

M o b i l i z a t i o f b o w e f r o ma b d o m i n a la l l n l w

Incision Make an elliptical incision through rhe skin around the colost()my,lr'ith the long axis lying transverselr'.

Operative technique 1. PlaceAllis tissueforcepson rhe skin, one ar eachend of the e l l i p s e( F i g . 5 . 1 4 0 ) , n d i n s e r ra s e l f r e t a i n i n gr e t r a c r o irn r o a the incision.
9

Using dissecting scissorsseparate the subcutaneous {'atfiom t h e s e r o s ao f ' t h e c o l < l n ( F i g . 5 . 1 , 1 ) ; i t i s i m p o r r a n t r o s r a yi n l this plane. Dissection pr<lceeds until the borvel is completely fieed ro the level of'the perironetrm (Fig. 5.142). A finger in the lumen may {acilitate this dissection and help deline the anatomical plane.

3.

4. I1'the stoma is oedematous, excise the edges to reveal the
two lumina of'the proxinral and distal colon. II'the edgesare not oedenratolrs, the skin ellipse is excised at the mucocutan e o u sj u n c t i o n . Anastomose the tn'o er.rds of'the c<llon using a single laver of interrr-rpted absrlrbable sLrrures (i.e. 3/0 Polydioxamone). T h i s i n ' , ' o l v e s l a c i n g s r a v s l r r u r e sa t e a c h e n d ( F i g . 5 . 1 4 3 ) .I f p

F i g5 . 1 4 1 .

ge_ntle Applying tra.cti0n stomauntilfreedto levelof on C l o s u ro f s t o m a i t hb r i d g e e t a i n e d e w r

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Fig5.143 .

Fig.5.142

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SURGERY OPERATIVE

tl.re posterior lall has Ilot been excised, place the first of' these sutures at the nrargins of' tl.ris posterior bridge. Il, however, it u'asnecessarvto completell excise the stoma (see step 4), the back rr'all is anast<lmosedat this Point rvith interr u p t e d , a l l - l a r e rs u t u r e s( F i g . 5 . l a a ) . 6. Oppose the enclsthat u'ill lirrnr the anterior rvall with a layer of intelrupted l,ernbert stttlrr-esuhich are supported and checked bv passing a fir.rger beneath the slrttlre line. This pre\ ents inaclvertent apposition of'the anterior and posterior rvalls. 7. Verilr, the patencv of'the anastomosis b,v gently invaginating tl.reindex lir.rgerancl thumb through it. When complete, the stay sutures are divided and the borvel is allowed to {all back t inttl tlre pet'itoneal :tr itr.

R e c o n s t r u c t io fn a c kw a l l ob

Wound closure and dressing dlain dorvn to the anastomosis (Fig. 5.145). l. Placea cor-r'ugated 2. Oppose the incised tnttscle u'ith a continuous nyltln suture and use atr intet-rupted nvlon suture ttl close the skin around the cort-ttgateddrain. clressins. 3. Appl;' an absot-batrt

Fi9.5.144

OF CLOSURE A LOOP ILEOSTONIY
A kxlp ileostontv nrav be closed in a similar manner, if' the Iilll<lrvir.rg points ar-ebortre in mind: to l. It is nrore str-aiglttfirnlar-cl excise the stoma and perfirrm a especiallv u'here the ileostandarclencl-to-encl:rrlastonx)sis, stonry is lonnecl uith a spottt. in 2. Fashion the atrastotntlsis either olle or $vo layers (see the lntroduction). 3. The ar-terialsupph is better and there is less risk of-jeopardizing the supplv to the distal borvel.

l n s e r t i oo f d r a i n n

CARE POSTOPERATIVE as by fbllon'ed solids' bowel reintroduced, are Fluids gradually
sounds return and anf ileus resolves. The drain is rem<>ved when the bowels have opened.

SPECIAL OPERATIVE HAZARDS l. Failure to excise non-viable or oedematous bowel ends will predisposeto anastomoticbreak down. sited to 2. Damageto the marginal artery in loop colostomies the blood the le{i of the middle colic artery may prejudice supply of the distal colon as f'ar as the uPper rectum.

78

COMPLICATIONS is l. Wound inl'ectitln a risk, but signilicantlylessso lirllowing tll'a ckrsut-e l<xrpileostomy. anastomaticleakage. or 2. Abscess fisttrla firrmation f<rllou's A flstula uill resolve spontaneouslyif' there is no distal obstrttctiott. filmration at the siteof the anastomosis. 3. Strictur-e

Fig. 5.145

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