Atlas of General Surgery [1 ed.] 3131440910, 9783131440914, 9783131496812

Table of contents :
General Aspects 1
General Aspects .................................. 2 8 Venous Access ................................. 21
9 Central Venous Port ............................. 25
1 Preliminary Remarks on the Surgical Intervention .... 2 10 Venous Cutdown ............................... 26
2 Use of Scalpel, Needle Holder, Forceps, and Scissors ... 4 11 ]oint Punctures ................................ 28
3 Ugation and Suture Ugation ...................... 6 12 Pleural Punctures ("Thoracentesis) .................. 31
4 Knots ........................................ 8 13 Urinary Bladder Puncture ........................ 33
5 Skin Suture ................................... 11 14 Ascites Puncture (Paracentesis) . .................. 34
6 Drains ........................................ 14 15 Fine-Needle Aspiration Biopsy .................... 35
7 Urinary Catheter ............................... 17 16 Arterial Puncture and Arterial Catheterization . ...... 36
39
Skin and Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Thoracic Wall and Cavity . . . . . . . . . . . . . . . . . . . . . . . . . 98
17 Excision of Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . . . 40 38 Axillary Lymph-Node Oearance . . . . . . . . . . . . . . . . . . . 98
18 Removal of Soft Tissue 1\unors . . . . . . . . . . . . . . . . . . . . 43 39 Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
19 Removal of Inguinal Lymph Node . . . . . . . . . . . . . . . . . . 45 40 Subcutaneous Mastectomy . . . . . . . . . . . . . . . . . . . . . . . 1 03
20 Wound Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 41 Mastectomy (Auchindos-Patey) . . . . . . . . . . . . . . . . . . . 105
21 Secondary Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 42 Chest Drain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 09
22 Carbuncle of the Neck........................... 51 43 Median Sternotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
23 Bursectomy (Elbow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 44 Posterolateral Thoracotomy . . . . . . . . . . . . . . . . . . . . . . 1 1 6
24 V-Y Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . 55 45 Axillary Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 20
25 Z-plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 46 Atypicallung Resection Open . . . . . . . . . . . . . . . . . . . . 1 23
26 Split-Skin Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 47 Atypical Thoracoscopic Lung Resection . . . . . . . . . . . . . 126
27 Ganglion (Wrist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 48 Right Superior Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . 1 29
28 Panaritium (Felon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 49 Pneumonectomy ............................... 132
29 Paronychia (Run-around) . . . . . . . . . . . . . . . . . . . . . . . . 64 50 Thoracoscopic Pleurectomy . . . . . . . . . . . . . . . . . . . . . . . 135
30 Ingrown Toenail (Unguis lncarnatus; One-third Wedge
Resection) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Abdominal Cavity: Diaphragm.................... 138
Neck ............................................. 69 51 Rupture of the Diaphragm . . . . . . . . . . . . . . . . . . . . . . . 138
31 Removal of Cervical Lymph Node... . . . . . . . . . . . . . . . 69
32 Tracheotomy (Open and Percutaneous Tracheostcma) . 71
Abdominal Cavity: Esophagus . . . . . . . . . . . . . . . . . . . . 140
33 Exposure of the Jugular Vein . . . . . . . . . . . . . . . . . . . . . 76 52 Hiatal Hernia Repair (Lortat-]acob Hiatoplasty)....... 140
34 Subtotal Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . 79 53 Fundoplication (Nissen-Rosetti and Toupet) . . . . . . . . . 144
35 Total Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
36 Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
54 Laparoscopic Fundoplication . . . . . . . . . . . . . . . . . . . . . . 148
55 Cardiomyotomy for Achalasia (Gottstein-Heller) . . . . . . 154
37 Zenker Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Abdominal Cavity: Stomach . . . . . . . . . . . . . . . . . . . . . . 156
56 Percutaneous Endoscopic Gastrostomy (PEG) . . . . . . . . 156
57 Gastrostomy (Witzel) . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
58 Oosure of a Perforated Ulcer . . . . . . . . . . . . . . . . . . . . . 162
59 Oversewing of a Bleeding Peptic Ulcer...... . . . . . . . . 165
60 Gastrojejunostomy.............................. 168
61 Pyloroplasty (Heineke-Mikulicz, Finney, jaboulay) . . . . 172
62 Selective Proximal Vagotomy . . . . . . . . . . . . . . . . . . . . . 175
63 Truncal Vagotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
64 Gastroduodenostomy (Billroth I) . . . . . . . . . . . . . . . . . . 182
65 Gastrojejunostomy (Billroth II) . . . . . . . . . . . . . . . . . . . . 190
66 Roux-en-Y Gastrojejunostomy. . . . . . . . . . . . . . . . . . . . . 193
67 Gastrectomy and Longmire Gastric Reconstruction.... 195
68 Gastrectomy and Roux-en-Y Gastric Reconstruction . . . 206
Abdominal Cavity: Gallbladder and Bile Ducts . . . . 208
69 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
70 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . 212
71 Exploration of the Common Bile Duct . . . . . . . . . . . . . . 217
72 Hepaticojejunostomy............................ 221
Abdominal Cavity: Liver . . . . . . . . . . . . . . . . . . . . . . . . . . 225
73 Wedge Resection of the Uver . . . . . . . . . . . . . . . . . . . . . 225
74 Hepatic Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
75 Left Hepatic Lobectomy.......................... 231
76 Hepatic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
77 Port Catheter of the Hepatic Artery . . . . . . . . . . . . . . . . 240
Abdominal Cavity: Pancreas . . . . . . . . . . . . . . . . . . . . . . 243
78 Necrosectomy of the Pancreas . . . . . . . . . . . . . . . . . . . . 243
79 Pseudocystojejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . 246
80 Resection of the Tail of the Pancreas . . . . . . . . . . . . . . . 250
Abdominal Cavity: Spleen . . . . . . . . . . . . . . . . . . . . . . . . 254
81 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
82 Partial Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
83 Splenic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
84 Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . 261
Abdominal Cavity: Peritoneum . . . . . . . . . . . . . . . . . . . 264
85 Peritonitis and Laparostoma . . . . . . . . . . . . . . . . . . . . . . 264
86 Peritoneovenous Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Abdominal Cavity: Small Intestine. . . . . . . . . . . . . . . . 272
87 Segmental Resection of the Small Intestine . . . . . . . . . . 272
88 Intraluminal Stenting of the Small Intestine (Dennis
1\Jbe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
89 Meckel Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
90 End Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
91 Loop Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Abdominal Cavity: Large intestine . . . . . . . . . . . . . . . . 292
92 Appendectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
93 Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . 300
94 Loop Transverse Colostomy . . . . . . . . . . . . . . . . . . . . . . 305
95 End Sigmoidostomy (Hartmann Procedure) . . . . . . . . . 309
96 Stoma Oosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
97 Colotomy and Polypectomy . . . . . . . . . . . . . . . . . . . . . 318
98 Palliative Anastomosis between the Distal Ileum and
Transverse Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
99 Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 325
1 00 Ileocecal Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
1 01 1\Jbular Resection of the Sigmoid Colon . . . . . . . . . . . . 334
1 02 Radical Resection of the Sigmoid Colon . . . . . . . . . . . . 340
1 03 Laparoscopic Resection of the Sigmoid Colon . . . . . . . 342
104 Left Hemicolectomy............................ 347
1 05 Anterior Rectum Resection . . . . . . . . . . . . . . . . . . . . . . 355
1 06 Rectum Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Retroperitoneum ................................. 375
107 Adrenalectomy................................ 375
108 Laparoscopic Adrenalectomy . . . . . . . . . . . . . . . . . . . . 379
Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
109 Hemorrhoidectomy (Miles-Gabriel) . . . . . . . . . . . . . . . 381
11 0 Perianal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
111 Fistula-In-Ano (Including Sliding Flap). . . . . . . . . . . . . 388
112 Perianal Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
113 Lateral Sphincterotomy (Parks).. . . . . . . . . . . . . . . . . . 395
114 Pilonidal Sinus (Schrudde-Olivari) . . . . . . . . . . . . . . . . 397
External Genital Organs . . . . . . . . . . . . . . . . . . . . . . . . . . 401
115 Testicular Hydrocele . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
116 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
117 Local Anesthesia for Inguinal Hernia Repair . . . . . . . . 406
118 Dissection for Inguinal Hernia Repair . . . . . . . . . . . . . . 409
119 Inguinal Hernia Repair (Shouldice)................ 417
120 Inguinal Hernia Repair (Bassini) . . . . . . . . . . . . . . . . . . 421
121 Inguinal Hernia Repair (lichtenstein).............. 424
122 Transinguinal Preperitoneal Mesh Repair (TIPP) . . . . . 427
123 Preperitoneal Inguinal Hernia Repair . . . . . . . . . . . . . . 431
124 Laparoscopic Inguinal Hernia Repair . . . . . . . . . . . . . . 438
125 Femoral Hernia Repair (Crural Approach) . . . . . . . . . . 443
126 Femoral Hernia Repair (Inguinal Approach;
I.otheissen, McVay) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
127 Femoral Hernia Repair (Inguinocrural Approach) . . . . 451
128 Epigastric Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
129 Umbilical Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
130 Incisional Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
131 Spigelian Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
132 Inguinal Hernia in Children . . . . . . . . . . . . . . . . • . . . . 467
133 Orchidopexy for Inguinal Testes {Shoemaker) . . . . . . . 472
134 Circwndsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . 478
135 Pyloromyotomy (Weber-Ramstedt) . . . . . . . . . . . . . . . 481
Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
136 Femoral Embolectomy.... . ... . .... . ... ... . . . . . . 483
137 Femoral Thrombectomy . . . . . . . . . . . . . . . . . . . • . . . . 486
138 Crossectomy, Long Saphenous Vein Stripping. and Perforator
ligation . . . . . . . . . . . . . . . . . . • . • . . . . . . . . . . 490
139. Dialysis Shunt (Cimino Arteriovenous Fistula) . . . . . . 497
Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
140. Finger and Toe Amputation . . . . . . . . • . . . . . . • . . . . • 499
141. Below-Knee Amputation . . . . . . . . . . . . . . . . . . . . . . . 502
142. Above-Knee Amputation . . . . . . . . . . . . . . . . . . . . . . . 505
Traumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
143 Traction Management of Fractures . . . • . . . . • . . . . . . • 510
144 Harvesting Cancellous Iliac Bone for Grafting . . . . . . . 516
145 Septic Arthritis of the Knee . . . . . . . . . . . . . . . . . . . . . 519
146 Fasdotomy of the Lower Leg . . . . . . . • • • . . . . . . . . . . 522
147 Per- and Supracondylar Fracture of the Hwnerus
(Child) . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . 525
Table of Contents
148 Olecranon Fracture-Tens ion Band Wiring . . . . . . . . . 527
149 Fracture of the Radius Shaft-ORIF Plate Fixation . . . . 530
150 Distal Radius Fracture-ORIF Plate Fixation . . . . . . . . . 534
151 Distal Radius Fracture-Kirschner Wire Fixation . . . . . 538
152 Dupuytren Fasciectomy . . . . . . . . . . . . . . . . . . . . . . . . . 541
153 Flexor Tendon Repair . . . . . • . . . . . . . . . . . . . . . . . . . . 544
154 Extensor Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . 547
155 Carpall\mnel Release . . . . . • . . . . • . . . . . . . . . . . . . . . 550
156 Pelvic External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . 552
157 Dynamic Hip Screw (DHS) . • . . . . • . . . . . . . . . . . . . . . 555
158 Proximal Femoral Nailing . . • . . . . . . . . . . . . . . . . . . . . 561
159 Femoral Head Replacement (Hemiarthroplasty) . . . . . 567
160 Femoral Shaft-ORIF Plate Ftxation. . . . . . . . . . .. . ... 572
161 Patella Fracture-Tension Band Wiring . . . . . . . . . . . . 576
162 Intramedullary Nailing of the Tib ia . . . . . . . . . . . . . . . 580
163 Lower Leg-External Fixation . . . . . . . . . . . . . . . . . . . . 584
164 Medial Malleolus- ORIF . . . . . . . . . . . . . . . . . . . . . . . . . 587
165 Lateral Malleolus-ORIF . . . . . . . . . . . . . . . . . . . . . . . . . 590
166 Fibular ligament Suture and ligament Reconstruction
with a Periosteal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . 595
167 Achilles Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . 598
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
Index ...... . .... . .... . . . . . . . ..... ... . . . .. . . ..... .. 605

Citation preview

Volker Schumpelick In collaboration with Reinhard Kasperk Michael Stumpf

I

Thieme

Atlas of General Surgery Volker Schumpelick, MD Professor and Chairman Department of Surgery University Hospital Aachen Aachen, Germany With the collaboration of Reinhard Kasperk and Michael Stumpf 1223 illustrations

Thieme Stuttgart · New York

library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized and revised translation of the 2nd German edition published and copyrighted 2006 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Operationsatlas Chirurgie.

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production

of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Ewry user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Contributors: Reinhard Kasperk, MD Professor Director of the Surgical Clinic St. johannes-Hospital Catholic Clinic Duisburg Duisburg, Germany

Michael Stumpf, MD Adj. Professor Supervising Physician Department of Surgery University Hospital Aachen Aachen, Germany

Translator: Dr. Grahame Larkin, MD, East Sussex. UK Illustrator: Gisela Tambour, Adrian Cornford, and Rose Baumann

© 2009 Georg Thieme Verlag,

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Riidigerstra.Be 14, 70469 Stuttgart, Germany http:lfwww.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001. USA http://www.thieme.com Cover design: Thieme Publishing Group Typesetting by Druckhaus Gotz, Ludwigsburg Printed in China by Everbest Printing, Hongkong

ISBN 978-3-13-144091-4

1 2 3 4 56

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

v

Preface

Surgery can no more be learned from text books than can cycling or swimming. Similarly, hardly any other discipline is both a teaching and learning profession with such a dose teacher-pupil relationship. But rarely does the young surgeon of today have the opportunity to gain enough continuous practice under supervision to the point of reaching subcortical implementation. The restrictions of workingtime reduction, rare opportunities to practice techniques on laboratory animals, and the early division of surgery into subspecialties have completely changed the face of mandatory training guidelines for basic surgical operations. As a result, the young surgeon rarely gets to see many an operation, and those operations in which he has managed to gather a greater amount of personal experience are few and far between. Even surgical simulators, which are becoming increasingly available and provide excellent training opportunities, especially in the field of laparoscopic surgery, cannot convey the entire spectrum of basic surgical operations. In some specific fields they do allow manual skills and tactile coordination to be practiced, but cannot provide broad surgical expertise together with the understanding and mastering of standard operative techniques. Alongside video films, surgical atlases are therefore the most important sources of information for the young surgeon when it comes to practicing all the stages of certain operations. The concept of this surgical atlas is directed toward presenting the most common 16 general and 150 special operations of everyday surgical practice to surgeons in training, to students as well as to qualified surgeons. In this respect, it is neither my intention with this single-volume atlas to vie with the more detailed, multi-volume surgical atlases nor to undermine the essential principle of specializa-

tion. Its content is general surgery-not that which remains after separation of the specialist disciplines, but rather that which a general surgeon from the respective specialist disciplines must learn in order to stand his ground as a surgeon. We are glad that this concept has proven itself to the extent that an English edition is now available. The aim of this surgical atlas is to serve trainee surgeons as a reference book, to allow them to learn new things, and to arouse their curiosity to learn more. But even qualified surgeons may use the opportunity to recall a technique they have already learned and to compare standards. For easy memorization and mental preparation of the respective operations, all the operative stages are structured and schematized so that the continuity of the operation is divided into labeled and reproducible single steps. just as racing drivers mentally prepare themselves before the race by imagining each individual leg of the race course, the surgeon should, before any operation, recall before his or her mind's eye each operative stage step by step so as to to proceed only along familiar lines at the operating table. We are grateful to the staff of Thieme Publishers for their support during the preparation of this English edition. But above all we should also like to thank Mr. Grahame Larkin for his excellent work in translating this atlas into English. We are looking forward to an equally favorable English-speaking readership of this Atlas of Generol Surgery. Volker Schumpelick

VI

List of Abbreviations

ASA DC DIP DSA EEA EPT ERC ERCP FFP IORT MCP OPSI ORIF PDS PCA PIP PTC PTCD RBCC

Acetylsalicylic add Dynamic compression Distal interphalangeal Digital subtraction angiography End-to-end anastomosis Endoscopic papillotomy Endoscopic retrograde cholangiography Endoscopic retrograde cholangiopancreatography Fresh frozen plasma Intraoperative radiotherapy Metacarpophalangeal Overwhelming postsplenectomy infection Open reduction and internal fiXation Polydioxanone suture Polyglycolic acid Proximal interphalangeal Percutaneous transhepatic cholangiography Percutaneous transhepatic cholangiodrainage Red blood cell concentrate

VII

Table of Contents

General Aspects

1

General Aspects ..................................

2

Preliminary Remarks on the Surgical Intervention .... Use of Scalpel, Needle Holder, Forceps, and Scissors ... Ugation and Suture Ugation ...................... Knots ........................................ Skin Suture ................................... Drains ........................................ Urinary Catheter ...............................

2 4 6 8 11 14 17

1 2 3 4 5 6 7

8 9 10 11 12 13 14 15 16

Venous Access ................................. Central Venous Port ............................. Venous Cutdown ............................... ]oint Punctures ................................ Pleural Punctures ("Thoracentesis) .................. Urinary Bladder Puncture ........................ Ascites Puncture (Paracentesis) . .................. Fine-Needle Aspiration Biopsy .................... Arterial Puncture and Arterial Catheterization . ......

21 25 26 28 31 33 34 35 36

39

Skin and Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40

Thoracic Wall and Cavity . . . . . . . . . . . . . . . . . . . . . . . . .

17 18 19 20 21 22 23 24 25 26 27 28 29 30

Excision of Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . . . Removal of Soft Tissue 1\unors . . . . . . . . . . . . . . . . . . . . Removal of Inguinal Lymph Node . . . . . . . . . . . . . . . . . . Wound Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carbuncle of the Neck........................... Bursectomy (Elbow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . V-Y Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . Z-plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Split-Skin Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ganglion (Wrist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Panaritium (Felon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paronychia (Run-around) . . . . . . . . . . . . . . . . . . . . . . . . Ingrown Toenail (Unguis lncarnatus; One-third Wedge Resection) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40 43 45 47 49 51 53 55 57 59 61 63 64

38 39 40 41 42 43 44 45 46 47 48 49 50

Neck .............................................

69

31 32 33 34 35 36 37

69 71 76 79 85 91 94

Removal of Cervical Lymph Node... . . . . . . . . . . . . . . . Tracheotomy (Open and Percutaneous Tracheostcma) . Exposure of the Jugular Vein . . . . . . . . . . . . . . . . . . . . . Subtotal Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . Total Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zenker Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . .

67

98

Axillary Lymph-Node Oearance . . . . . . . . . . . . . . . . . . . Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subcutaneous Mastectomy . . . . . . . . . . . . . . . . . . . . . . . Mastectomy (Auchindos-Patey) . . . . . . . . . . . . . . . . . . . Chest Drain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Median Sternotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Posterolateral Thoracotomy . . . . . . . . . . . . . . . . . . . . . . Axillary Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . Atypicallung Resection Open . . . . . . . . . . . . . . . . . . . . Atypical Thoracoscopic Lung Resection . . . . . . . . . . . . . Right Superior Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . Pneumonectomy ............................... Thoracoscopic Pleurectomy . . . . . . . . . . . . . . . . . . . . . . .

98 101 103 105 109 112 116 120 123 126 129 132 135

Abdominal Cavity: Diaphragm....................

138

51

Rupture of the Diaphragm . . . . . . . . . . . . . . . . . . . . . . .

138

Abdominal Cavity: Esophagus . . . . . . . . . . . . . . . . . . . .

140

52 53 54 55

140 144 148 154

Hiatal Hernia Repair (Lortat-]acob Hiatoplasty)....... Fundoplication (Nissen-Rosetti and Toupet) . . . . . . . . . Laparoscopic Fundoplication . . . . . . . . . . . . . . . . . . . . . . Cardiomyotomy for Achalasia (Gottstein-Heller) . . . . . .

Abdominal Cavity: Stomach . . . . . . . . . . . . . . . . . . . . . .

156

Percutaneous Endoscopic Gastrostomy (PEG) . . . . . . . . Gastrostomy (Witzel) . . . . . . . . . . . . . . . . . . . . . . . . . . . Oosure of a Perforated Ulcer . . . . . . . . . . . . . . . . . . . . . Oversewing of a Bleeding Peptic Ulcer...... . . . . . . . . Gastrojejunostomy.............................. Pyloroplasty (Heineke-Mikulicz, Finney, jaboulay) . . . . Selective Proximal Vagotomy . . . . . . . . . . . . . . . . . . . . . Truncal Vagotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gastroduodenostomy (Billroth I) . . . . . . . . . . . . . . . . . . Gastrojejunostomy (Billroth II) . . . . . . . . . . . . . . . . . . . . Roux-en-Y Gastrojejunostomy. . . . . . . . . . . . . . . . . . . . . Gastrectomy and Longmire Gastric Reconstruction.... Gastrectomy and Roux-en-Y Gastric Reconstruction . . .

156 159 162 165 168 172 175 180 182 190 193 195 206

Abdominal Cavity: Gallbladder and Bile Ducts . . . .

208

69 70 71 72

Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . Exploration of the Common Bile Duct . . . . . . . . . . . . . . Hepaticojejunostomy............................

208 212 217 221

Abdominal Cavity: Liver . . . . . . . . . . . . . . . . . . . . . . . . . .

225

73 74 75 76 77

Wedge Resection of the Uver . . . . . . . . . . . . . . . . . . . . . Hepatic Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left Hepatic Lobectomy.......................... Hepatic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Port Catheter of the Hepatic Artery . . . . . . . . . . . . . . . .

225 227 231 236 240

Abdominal Cavity: Pancreas . . . . . . . . . . . . . . . . . . . . . .

243

Necrosectomy of the Pancreas . . . . . . . . . . . . . . . . . . . . Pseudocystojejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . Resection of the Tail of the Pancreas . . . . . . . . . . . . . . .

243 246 250

Abdominal Cavity: Spleen . . . . . . . . . . . . . . . . . . . . . . . .

254

81 82 83 84

Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Partial Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Splenic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . .

254 257 259 261

Abdominal Cavity: Peritoneum . . . . . . . . . . . . . . . . . . .

264

85 86

Peritonitis and Laparostoma . . . . . . . . . . . . . . . . . . . . . . Peritoneovenous Shunt . . . . . . . . . . . . . . . . . . . . . . . . . .

264 268

Abdominal Cavity: Small Intestine . . . . . . . . . . . . . . . .

272

56 57 58 59 60 61 62 63 64 65 66 67 68

78 79 80

87 88 89 90 91

Segmental Resection of the Small Intestine . . . . . . . . . . Intraluminal Stenting of the Small Intestine (Dennis 1\Jbe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meckel Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . End Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Loop Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

272 276 280 283 289

Abdominal Cavity: Large intestine . . . . . . . . . . . . . . . . 92 93 94 95 96 97 98

292

Appendectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . Loop Transverse Colostomy . . . . . . . . . . . . . . . . . . . . . . End Sigmoidostomy (Hartmann Procedure) . . . . . . . . . Stoma Oosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colotomy and Polypectomy . . . . . . . . . . . . . . . . . . . . . Palliative Anastomosis between the Distal Ileum and Transverse Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . Ileocecal Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1\Jbular Resection of the Sigmoid Colon . . . . . . . . . . . . Radical Resection of the Sigmoid Colon . . . . . . . . . . . . Laparoscopic Resection of the Sigmoid Colon . . . . . . . Left Hemicolectomy............................ Anterior Rectum Resection . . . . . . . . . . . . . . . . . . . . . . Rectum Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

292 300 305 309 315 318

Retroperitoneum .................................

375

107 108

Adrenalectomy................................ Laparoscopic Adrenalectomy . . . . . . . . . . . . . . . . . . . .

375 379

Proctology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

381

109 11 0 111 112 113 114

Hemorrhoidectomy (Miles-Gabriel) . . . . . . . . . . . . . . . Perianal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fistula-In-Ano (Including Sliding Flap). . . . . . . . . . . . . Perianal Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . Lateral Sphincterotomy (Parks).. . . . . . . . . . . . . . . . . . Pilonidal Sinus (Schrudde-Olivari) . . . . . . . . . . . . . . . .

381 385 388 392 395 397

External Genital Organs . . . . . . . . . . . . . . . . . . . . . . . . . .

401

115 116

Testicular Hydrocele . . . . . . . . . . . . . . . . . . . . . . . . . . . Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

401 404

Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

406

117 118 119 120 121 122 123 124 125 126

406 409 417 421 424 427 431 438 443

99 100 101 102 103 104 105 106

127 128 129 130 131

Local Anesthesia for Inguinal Hernia Repair . . . . . . . . Dissection for Inguinal Hernia Repair . . . . . . . . . . . . . . Inguinal Hernia Repair (Shouldice)................ Inguinal Hernia Repair (Bassini) . . . . . . . . . . . . . . . . . . Inguinal Hernia Repair (lichtenstein).............. Transinguinal Preperitoneal Mesh Repair (TIPP) . . . . . Preperitoneal Inguinal Hernia Repair . . . . . . . . . . . . . . Laparoscopic Inguinal Hernia Repair . . . . . . . . . . . . . . Femoral Hernia Repair (Crural Approach) . . . . . . . . . . Femoral Hernia Repair (Inguinal Approach; I.otheissen, McVay) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Femoral Hernia Repair (Inguinocrural Approach) . . . . Epigastric Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Umbilical Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incisional Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spigelian Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

321 325 332 334 340 342 347 355 369

446 451 454 456 460 464

Table of Contents

Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

467

132 133 134 135

Inguinal Hernia in Children . . . . . . . . . . . . . . . . • . . . . Orchidopexy for Inguinal Testes {Shoemaker) . . . . . . . Circwndsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . Pyloromyotomy (Weber-Ramstedt) . . . . . . . . . . . . . . .

467 472 478 481

Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

483

136 137 138

Femoral Embolectomy.... . ... . .... . ... ... . . . . . . Femoral Thrombectomy . . . . . . . . . . . . . . . . . . . • . . . . Crossectomy, Long Saphenous Vein Stripping. and Perforator ligation . . . . . . . . . . . . . . . . . . • . • . . . . . . . . . . Dialysis Shunt (Cimino Arteriovenous Fistula) . . . . . .

483 486

Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

499

140. 141. 142.

499 502 505

139.

Finger and Toe Amputation . . . . . . . . • . . . . . . • . . . . • Below-Knee Amputation . . . . . . . . . . . . . . . . . . . . . . . Above-Knee Amputation . . . . . . . . . . . . . . . . . . . . . . .

490 497

148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166

Olecranon Fracture-Tension Band Wiring . . . . . . . . . Fracture of the Radius Shaft-ORIF Plate Fixation . . . . Distal Radius Fracture-ORIF Plate Fixation . . . . . . . . . Distal Radius Fracture-Kirschner Wire Fixation . . . . . Dupuytren Fasciectomy . . . . . . . . . . . . . . . . . . . . . . . . . Flexor Tendon Repair . . . . . • . . . . . . . . . . . . . . . . . . . . Extensor Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . Carpall\mnel Release . . . . . • . . . . • . . . . . . . . . . . . . . . Pelvic External Fixation . . . . . . . . . . . . . . . . . . . . . . . . . Dynamic Hip Screw (DHS) . • . . . . • . . . . . . . . . . . . . . . Proximal Femoral Nailing . . • . . . . . . . . . . . . . . . . . . . . Femoral Head Replacement (Hemiarthroplasty) . . . . . Femoral Shaft-ORIF Plate Ftxation. . . . . . . . . . .. . ... Patella Fracture-Tension Band Wiring . . . . . . . . . . . . Intramedullary Nailing of the Tibia . . . . . . . . . . . . . . . Lower Leg-External Fixation . . . . . . . . . . . . . . . . . . . . Medial Malleolus- ORIF . . . . . . . . . . . . . . . . . . . . . . . . . Lateral Malleolus-ORIF . . . . . . . . . . . . . . . . . . . . . . . . . Fibular ligament Suture and ligament Reconstruction with a Periosteal Flap . . . . . . . . . . . . . . . . . . . . . . . . . . Achilles Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . .

527 530 534 538 541 544 547 550 552 555 561 567 572 576 580 584 587 590

Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

603

Index ...... . .... . .... . . . . . . . ..... ... . . . .. . . .... . ..

605

167

Traumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

510

143 144 145 146 147

510 516 519 522

Traction Management of Fractures . . . • . . . . • . . . . . . • Harvesting Cancellous Iliac Bone for Grafting . . . . . . . Septic Arthritis of the Knee . . . . . . . . . . . . . . . . . . . . . Fasdotomy of the Lower Leg . . . . . . . • • • . . . . . . . . . . Per- and Supracondylar Fracture of the Hwnerus (Child) . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . .

525

595 598

IX

I General Aspects 1 Preliminary Remarks on the Surgical Procedure .. . 2 2 Use of Scalpel, Needle Holder, Forceps, and Scissors ... 4 3 Ligation and Suture Ligation .. . 6 4 Knots ... 8 5 Skin Suture . .. 11 6 Drains ... 14 7 Urinary Catheter . . . 17 8 Venous Access . .. 21 9 Central Venous Port ... 25 10 Venous Cutdown .. . 26 11 joint Punctures .. . 28 12 Pleural Punctures (Thoracentesis) ... 31 13 Urinary Bladder Puncture . . . 33 14 Ascites Puncture (Paracentesis) ... 34 15 Ane-Needle Aspiration Biopsy ... 35 16 Arterial Puncture and Arterial Catheterization . .. 36

2

1 Prelmlnllry

......_on the Surglal ProCiedure

1 Preliminary Remarks on the Surgical Procedure

1 General Preoperative Investigations The following minimal requirements must be fulfilled before a surgical operation: ... Basic laboratory tests: blood count, electrolytes, coagulation studies, human immunodeficiency virus (HIV) state for elective operations ... Chest X-ray and electrocardiogram (ECG) for patients over 40 years of age Additional investigations may be required, depending on age, previous disorders, and current state of health of the patient

2 Absolute Contraindications ... ...

Patient in a general inoperable state Informed consent for elective operations not recorded in the notes (must be available at least 1 day prior to surgery)

3 Relative Contraindications Relative contraindications arise from a disproportion between the threat posed by the presenting illness, the extent of the planned operation, and the risk arising from nonintervention. This disproportion is highly dependent upon local and temporal factors.

The remarks in the following chapters regarding the frequency of postoperative complications are to be understood as an orientation and are based on averages reported in the literature.

5 Perioperative Standards Preoperative

... ... ... ...

...

...

... ...

Contraindications relating in particular to video-assisted endoscopic operations are constantly undergoing change. Some degree of restraint has particularly been necessary with regard to oncological and septic operations.

...

4 General Patient Information and Consent

... ...

...

...

...

Information regarding the course of events: length of hospital stay, any necessary period of intensive care, drains, necessity of active cooperation with physiotherapy, breathing exercises, and so forth Cessation of certain unhealthful practices during hospital stay, especially smoking (if necessary, enter a remark in the patient's notes or on the consent form) General points regarding patient information and consent for the operation: - Wound healing problems, wound breakdown - Perioperative hemorrhage - Allogeneic blood transfusion, possibility of donating autologous blood before the operation - Adhesion-related ileus - Scar formation/incisional hernia - Thromboembolic event - For laparoscopic operations: intraoperative conversion to open surgery may become necessary and is not regarded as a complication.

...

Prophylaxis against thrombosis: compression stockings, early mobilization, heparin administration Consider perioperative antibiotic prophylaxis/therapy and, if necessary, initiate. Following trauma: consider tetanus prophylaxis. Ensure nothing by mouth for at least 6 hours before surgery, possibly longer for gastric stenosis or bowel paralysis; alternatively, or if in doubt, insert a nasogastric tube. Before surgery for malignancies, consider ordering a frozen section in the pathology laboratory before the operation and clarify, for example, when there is suspicion of a lymphoma or sarcoma. whether a native specimen is required. If indicated or available: plan for IOKT. Practice with the patient any necessary important physiotherapy and breathing exercises before surgery. Insert a central line before surgery. X-ray verification of its position is possible, and if necessary parenteral nutrition can be initiated preoperatively. Organize availability of blood substitutes (RBCC, FFP, concentrated platelets, autologous blood). Shave the operative site or use chemical depilation.

Intraoperative ... Take culture samples (also from traumatic wounds).

Use an instant or digital camera for photodocumentation. Whenever the abdomen Is opened, the opportunity should be taken to perform a short, but full, exploratory palpation, if this is possible without any relevant additional risk.

Postoperative

... ... ...

...

Prophylaxis against thrombosis: see earlier Prophylaxis against stress ulcer: antadds, H2 blockers, H-pump blockers, early enteral nutrition Dietary progression: indicators include reflux via the nasogastric tube, auscultation for bowel sounds, passing of stool and/or wind, abdominal ultrasound. Procedure: first allow sips of water or tea, then free drink, then yogurt/zwieback/white bread, and finally normal diet Postoperative measures to promote bowel movements: consider propulsive IV medications from day 3 (e.g., metoclopramide), for stubborn postoperative intestinal atony after abdominal operations (and after complete healing of any anastomosis), consider IM pyridostigmine bromide or 250 mg erythromycin t.d.s. (motilin effect), enemas, or oral laxatives (e.g. Gastrografin ~ investigation and therapy).

3

...

... ... ... ...

...

Monitor the postoperative course using ultrasound: retention of fluids, free intra-abdominal fluid, peristaltic movement. dilatation of hollow organs. Postoperative retention (seroma, hematoma, bilioma, abscess) can be punctured under ultrasound guidance and, if necessary, drained percutaneously (Sonnenberg, Otto, or similar catheters), provided the clinical condition of the patient is stable. Remove subcutaneous suction drains on postoperative day 2 . Remove sutures in the region of the face or neck after 4 to 6 days, otherwise remove sutures after 10 to 12 days. Inform the patient about the possibility of a posthospital rehabilitation program and, if necessary, plan it under cooperation with the sodal service staff. Explain the necessity and course of any, possibly long-tenn, postoperative follow-up care, such as cancer aftercare. Inform patients about self-aid groups.

6 Laparoscopic Interventions

...

Umbilical disinfection overnight Perioperative insertion of nasogastric tube and urinary catheter Endoscopic surgery may require special positioning measures, which may differ from conventional methods. Usually a feet down (reversed Trendelenburg) position of 10 to 20 degrees is appropriate fur surgery of the upper abdomen and, conversely, a Trendelenburg position of 1 0 to 20 degrees head down for operations of the lower abdomen. Corresponding positions are required fur exposure of lateral regions of the abdominal cavity. Changes of position are often necessary several times during the operation and demand a stable fixation of the patient on the operating table.

4

General Aspects

:ill Use fll Salpel. Needle Holcler. Forceps. mel Sclllan

2 Use of Scalpel, Needle Holder, Forceps, and Scissors

Scalpel The scalpel Is held with three tlngers, using the thumb and middle flnger to actually hold the Instrument. while the Index flnger, placed on the back of the knife, steadies the Instrument A skin Incision Is made by using the belly of the scalpel while the contralateral hand places the skin to be Incised

a

under tension and stabilizes lt. The movements of the knife should be harmonic and continuous, avoiding several repeated attempts. The knife requires very little pressure for the Incision.

:ill Use of Salpel. Needle Holder, Force... •nd Sclllan

b

General Aspects

-

Forceps and needle holder As a rule, tfle lengtfl of tfle instrument should match the depth of tfle operative field. The strengtfl of tfle tip of tfle instrument. on the other hand, depends on tfle stability of the structures to be handled, which in tum determines tfle needle size. Toothed (surgical) forceps are generally used only for skin and fascia sutures. Otherwise. nontootfled (anatomical) forceps, with straight or angled Ups, are more favorable. Forceps should always be pressed together lightly, only so much as to allow tfle tissue structure to be lightly grasped. Any unnecessary firm squeezing of the blades should be avoided. A distinction is made between locking and nonlocking needle holders. The nonlocking needle holder, whid'l tfle authors usually use, places greater demands on tfle handling b! 300 mL or increasing amounts as demonstrated on short-term ultrasound follow-ups) or direct ultrasound evidence of a lesion to the hepatic parenchyma, in particular in hemodynamically unstable patients secondary to blunt abdominal trauma Almnatlve Procedures: Manage expectantly under intensive-care monitoring and with an operating room on standby for hemodynamically stable patients with less than -300 ml of fluid in the abdomen, as demonstrated on ultrasound, and under tight (i.e., the possibility of half-hourly/hourly) follow-up.

0 IYPes of liver injury 0 Exposure

2 Preoperative Preparation

...

Preoperative Investigations: illtrasound (option of exploratory paracentesis to reveal free intra-abdominal fluid); peritoneal lavage in rare cases; consider computed tomography for hemodynamically stable patients; coexisting injuries must be excluded (e.g., thoracic) Patient Preparation: Large-bore vascular access; volume fluid replacement; urinary catherer; perioperative antibiotic prophylaxis

...

0

0 0

Packing Resection Uver sutures

8 Relevant Anatomy, Serious Risks, Trkks ...

...

Associated intra-abdominal injuries should not be overlooked (e.g., rupture of the diaphragm, rupture of the small intestine, pancreatic lesions, mesenteric tears). Perform completE mobilization of the liver as a general principle. The Pringle maneuver fails to control hemorrhage (i.e., bleeding from the hepatic veins or vena cava .. at least grade 3). Hypotension and open vena cava increase the risk of an air embolus.

9 Measures for Specific Complications 3 Specific Risks, Patient Information, and Consent .... .... ... .... .... ....

Lethal in cases of grade 4 or 5 liver injury (> 80%) Clotting abnormalities (massive transfusion) jaundice (multifactorial cause: transfusion, disturbances of liver function) Bile leakfhemobilia Liver abscess Patients without disturbances of consdousness who are being managed expectantly should be informed about the possibility of an operation in the further course of events.

...

...

...

Bleeding from the hepatic vein or the retrohepatic vena cava usually requires the total vascular isolation of the liver (i.e., supra- and infrahepatic damping of the cava vein plus the Pringle maneuver. If it is not possible to locare and deal with the source of hemorrhage within a relatively short space of time, the patient should be duly ,packed" and transferred to the intensive care unit for stabilization (use absorbable mesh to dose the abdomen). After packing, wait at least 24 hours before any renewed attempt at meticulous surgical hemostasis; use the time to stabilize the circulation and clotting functions.

4 Anesthesia

10 Postoperative Care

General anesthesia (intubation). autotransfusion machine

Medical Aftercare: Depends on the overall situation: ultrasound and laboratory studies, consider Duplex ultrasound, computed tomography. If drculation is stable postoperatively and there are no signs of hemorrhagic or bilious fluid in the drains, remove the nasogastric tube on day 2 and the drains on day 4 or 5.

5 Positioning Supine

6 Approach Complete midline laparotomy, possibly with an additional transverse extension to the right; completE transverse upper laparotomy with extension to the xiphisternum

Caution: Be careful with postoperative positive end-expiratory pressure ventilation, watch out for fonnotion of pleural effusion Dietary Progression: Depends on the overall situation, advance quickly in cases of pure hepatic trauma. MobiUzatfon: Immediately after definitive management Physiotherapy: Breathing exercises nme Off Woti 30%) Multiple laparotomies/laparostoma

>50%)

...

... ...

Avoid formal partial resection of the pancreas in the acute situation. carefully explore all necrotic areas and perform conservative blunt debridement In the presence of considerable necroses outside the lesser sac, combine bursa Ia~ with planned revisions (provisional dosure of the abdomen with an absorbable mesh, covered by an adhesive foil~

Caution: Wotrh out for organ erosion (rom leaving drains in situ too long, especially the colon (use soft drains: silicone)

9 Measures for Specific Complications ...

...

Abdominal packs may be required to tamponade any diffuse bleeding arising from necrosectomy, and these should be left for 24 to 48 hours. Intestinal fistulae must be managed surgically. Manage expectantly if the pancreas fistula is well drained and only revise after the patient has completely recovered. There is a high probability of spontaneous closure.

4 Anesthesia

10 Postoperative Care

General anesthesia (intubation)

Medical Aftercare: Remove the lavage catheter only when laboratory values are dearly returning to normal and the drain effluent is dear. Terminate planned revisions when the inflammatory necrotic process in the peritoneal cavity is subsiding and the clinical situation has become stable. Leave the drains until drainage subsides; consider percutaneous drainage for recurrent formation of circumscribed collections or abscesses. Dietary Progression: Begin when the laboratory values are largely returning to normal and bowel function has returned to normal. Bowel Function: Give supportive medication, consider oral laxatives. Mobilization: As soon as the general situation allows Physiotherapy: Breathing exercises and general physiotherapy Time Off Work: Possibly several months

5 Positioning Supine

6 Approach Transverse upper laparotomy

7 Operative Steps 0 Skin incision

0 Opening the lesser sac 0 Identification of necroses 0 0 0

Necrosectomy Lavage of the lesser sac

dosure of the lesser sac

244

Abdominal Cavity: Pancreas

Operative Technique 0 0 0 0 0 0

Skin incision Opening the lesser sac Identification of necroses Necrosectomy Lavage of the lesser sac OosW'e of the Jesser sac

0 Skin incision Access to the pancreas may be gained via a right subcostal Incision or even a transuerse upper laparotomy. The transverse upper laparotomy Is especially recommended for processes In the body and tall of the pancreas because of the better accessibility.

o

Opening the lesser sac

Exposure of the panaeas begins with the opening of the lesser sac. For this purpose the gastrocolic ligament is divided in a stepwise manner between Overholt damps along the greater curvature of the stomach. Grasping the greater curvature with Duval clamps wtll allow the stomach to be displaced In a aanlaventral direction, thus exposing the panaeas In the depth of the cavity.

o

Identification of necroses

After completely opening the greater curvature of the stomach by dividing the gastrocolic ligament, retractors can be inserted behind the stomach to expose the entire anterior surface of the pancreas. Necrotic areas are characterized by blackish or grayish discoloration, In part combined with hemorrhagic areas. A distinction cannot always be made macroscopically between pancreas necrosis and necrosis of the pertpancreatlc tissue.

Abdominal Cavity: Pancreas

( o Necrosedomy

o Lavage of the lesser sac

Necrotic material Is removed by flnger-fracture technique. a Volkmann spoon, or even by superficial excision. Dissection Is continued until capillary bleeding of the pancreatic substance slgnlfles the border with viable pancreas tissue. Under no circumstances should well perfused pancreas tissue be removed because this willlarer cause problems with the subsequent function of the pancreas as well as with regard to rebleeding. Special 31Untion should be paid to the splenic vein and the superior mesenteric vein, which must not be damaged In the course of necrosectomy. This would result In severe and hardly controllable bl~ Ing.

Complete removal of all necrotic material from the lesser sac should then be followed by continuous lavage. For this purpose, the lesser sac Is continuously lnigated with up to 20 L of saline In 24 hours via two afferent and two efferent drains. This results in removal of necrotic material, endotx» 4 em, espedally with evidence of displacement symptoms and

increased size Contralndlcations: Pseudocysts shortly after acute pancreatitis < 6 weeks). If cyst-related complications arise (hemorrhage, rupture, abscess, erosion into the intestine), then simple drainage is inadequate. Suspected cystic neoplasm of the pancreas (cystadenocarcinoma). AIU!matlve Procedures: Percutaneous drainage; endoscopic placement of a cystogastrostomy; partial pancreas resection.

2 Preoperative Preparation Preoperative lnwstigations: Ultrasound, computed tomography, consider ERCP, angiography following hemorrhage and for suspected pseudoaneurysm Patient Preparation: Nasogastric tube: perioperative antibiotic therapy

3 Specific Risks. Patient Information. and Consent ... • ... • ...

Consider simultaneous management of any gallbladder stones. Acute pancreatitis Anastomotic failure (1 to 5%) Pancreatic fistula (< 5%) Abscess ( < 5%)

... ...

... ... ...

...

Caution: Watth out for injury ro the middle colic artery and vein when opening a cyst below the colon Caution: Wotrh out for a ruptured aneui)'SIJl in the presence of a pulsating cyst achieve proximal control of the vessel before opening the cyst. con-

sider explorvl:ory puncture with a fine cannula

9 Measures for Specific Complications ...

4 Anesthesia General anesthesia (intubation)

Cystojejunostomy (40 em long limb) is the standard procedure; if the cyst is closely adherent to the duodenal or gastric wall, then a cystoduodenostomy or cystogastrostomy is a good alternative. Do not drain cysts with evidence of an arterial pseudoaneurysm, resect them (e.g., resection of the tail of the pancreas). Always digitally explore the cysts, connect secondary cysts to the primary cyst. take a bacteriology swab of cystic contents. Always take a biopsy of the cyst wall (frozen section). A cyst lined with epithelium is not a pseudocyst and should be resected, not drained. Ensure good hemostasis, espedally in the region of the cyst wall: consider oversewing the indsion margin/anastomosis with a running stitch. Do not force an internal drainage if the possibility of anastomosing the cyst wall is questionable, but conclude the operation with an external drain and revise later after achieving a stable fistula.

...

If rupture of a pseudoaneurysm into a cyst has been confirmed by angiography, try to control the bleeding radiologically by preliminary use of an occlusion balloon catheter. Pancreatic fistula: if well drained, manage expectantly while providing parenteral nutrition and possibly somatostatin, spontaneous closure probable.

5 Positioning Supine

6 Approach Transverse upper laparotomy, midline laparotomy in rare cases

7 Operative Steps 0 Skin indsion 0 Opening the lesser sac 0 Identification of the pseudocyst 0 Opening the pseudocyst

0 0 0 0

Necrosectomy of the pseudocyst Roux-en-Y loop Cystojejunostomy Roux-en-Y loop

10 Postoperative Care Med"Kal Aftercare: Remove the nasogastric tube on day 1 or 2, remove the drain on day 5 through 8, and perform sonographic and laboratory follow-ups. Positive swab result will require antibiotic therapy to be continued for 7 days. Dietary Progression: Allow sips of clear liquid from day 2 and allow to drink freely from day 3, solid diet when bowel movements are normal and laboratory data are within normal range. Bowel Function: Consider peristaltic stimulants or oral laxatives. Mobilization: Immediately Physiotherapy: Breathing exerdses nme Off Work: 1 to 2 weeks

Abdominal Cavity: Pancreas

Operative Technique 0 0 0 0

Skin incision Opening the lesser sac Identification of the pseudocyst Opening the pseudocyst Necrosectomy of the pseudocyst Rou:x-en-Y loop

0 0 0 Cystojejunostomy 0 Rou:x-en-Y loop

o Skin incision

o Opening the lesser sac

The skin incision may be a right subcostal incision or a tranS\Ief'Se upper laparotomy. The transverse upper laparotomy is recommended for processes In the body and tall of the pancreas for better visualization.

The lesser sac is opened to expose the pancreas. For this purpose, the gastrocolic ligament is divided between Ovemolt clamps along tne greater curvature of the stomach. Vessels are ligated (3-0 PGA). GraspIng the greater curvature of the stomach with Duval clamps will now allow ldetltiftcatlon of the pancreas.

o Identification of the pseudocyst Elevation of tne stomach and securing it behind sheathed Langenbeck hooks allows identification of the cyst. Confirmation may be achieved Intraoperatively by puncture and aspiration of pancreas secretions. A fresh, nat yet hardened, cyst Is not suitable for a cystoJejunostomy. This applies to all pancreas necroses with a cyst history of less than 6 weeks. In these cases, the procedure of choice Is the extemal drainage with delayed management of the cyst

247

248

Abdominal Cavity: Pancreas

o

Opening the pseudocyst

The exposed cyst is generously opened using dia1f1enny by performing a wedge-shaped excision of tile anterior wall. During this, care should be taken to suture ligate any transversely coursing vessels in order not to risk losing visualization due to bleeding. The roof of tile cyst is removed such as to leave a wide ventrnl opening.

o

Necrosedomy of the pseudocyst

The cyst wall is spread open between stJy sutures. The cystic contents in tile deptfls are inspected. Often substmtial amounts of necrotic material are found at tile base of tile cyst and should be completely evacuated. In doing so, care should be taken not to cause ;my major bleeds from vascular injury, which could above all involve tfle superior mesenteric vein, as shown here by the location of tfle cyst.

o

Roux-e...v loop

The cyst Is anastomosed side-to-side with a defunctloned Roux~-Y jejunal loop. For this purpose, it is recommended to bring the jejunal loop Into the upper abdomen 'lila a retrocollc route and to secure It with lntemJpted sutures before actually suturing ttte cystoJeJunostomy. The redundant end of the jejunal loop should be closed as a blind stump. The wldttt of ttte anastomosis of ttte cystoJejunostomy should be at least 5 an. After opening the jejunum, ttte posterior wall Is anastomosed first witt1 interrupted sutures (3-0 PGA). This is followed by suture of the anterior wall using an intemJpted suture technique. The suture line should be w.rtertight and hemostatic.

Abdominal Cavity: Pancr•a'

250

80 Resection of the Tail of the Pancreas

1 Indications

7 Operative Steps

EJecHve: Pathological lesions limited to the body and tail of the pancreas AIUI'natlve Procedures: Local excision of benign lesions

0 Skin incision 0 Opening the omental bursa

2 Preoperative Preparation

0

Preoperative Investigations: Ultrasound, computed tomography, angiography of the celiac/mesenteric arteries, hormone status for

suspected active endocrine neoplasms. consider ERCP

3 Specific Risks, Patient Information, and Consent ... ... ... ... ...

Splenectomy Pancreatic fistula Acute pancreatitis Diabetes mellitus Injury to the gastric wall

4 Anesthesia General anesthesia (intubation)

0 0 0

0

Mobilization of the spleen Division of the splenic arrery and vein Transection of the tail of the pancreas Management of the tail of the pancreas aosure with staples

8 Relevant Anatomy, Serious Risks, Tricks ... ... ...

...

...

The inferior mesenteric vein courses below the lower border of the pancreas. There is a dose positional relationship between the spleen and stomach in the region of the short gastric artery and vein. Infiltration of the venous confluence of the portal vein-superior mesenteric vein by neoplasms of the body of the pancreas is usually associated with nonresectability. If there is any doubt regarding identification of the splenic artery, always occlude it manually or with a vascular clamp first and check the pulse of the hepatoduodenalligament. Cut surface of the pancreas: when performing suture closure. suture the pancreas duct separately, suture the parenchyma in a fish-mouth fashion or with deep sutures (3-0 PGA). If the reliability of the suture is uncertain, cover with the Roux-en-Y loop.

5 Positioning Supine

9 Measures for Specific Complications

6 Approach

Pancreatic fistula: if well drained, manage expectantly under parenteral nutrition, consider giving somatostatin intravenously; the fistula usually closes spontaneously.

Left upper abdominal transverse incision, in rare cases midline laparotomy

10 Postoperative Care Medkal Aftercare: Remove the nasogastric tube on day 1 or 2, tight laboratory checks initially (amylase, lipase, glucose). Remove the drain after 4 to 6 days. Dietary Progression: Allow sips of dear liquid from day 1 or 2, advance quickly if it is well tolerated and bowel movements present. Bowel Function: Consider peristaltic stimulants or oral laxatives. Mobilization: Immediately Physiotherapy: Breathing exercises lime Off Work: 2 weeks

Abdominal Cavity: Pancreas

Operative Technique 0 0 0 0 0 0 0

Skin incision Opening the omental bursa Mobilization of the spleen Division of the splenic artery and vein Transection of the tilil of the pancreas Management of the tail of the panaeas. Oosure with staples

0 Skin incision The approach to the tall of the pancreas can be via a left subcostal Incision or, preferably, a transverse upper laparotomy.

o

Opening the omental bursa

The lesser sac must be opened wide to expose the tall of the pancreas. The gastrocolic llgamet1t Is dMded between OVerholt clamps along the greater curvature of the stomach. Vessels are ligated. Dissection must be continued as far as the gastric fundus in order to completEly expose the tail of the panaeas.

o

Mobilization of the spleen

The next step after completely opening the omental bursa and eJq>OSing the enUre pancreas Is to mobilize the spleen from Its lateral adhesions. Traction by the surgeon's left hand on the dome of the spleen and dissection with the scissors in the right hand will en;able the retroperitoneal adhesions of the spleen to be freed up on all sides and the spleen to be lifted venb"ally.

251

252

Abdominal Cavity: Pancreas

0 Division of the splenic artery and vein Once the spleen has been completely mobilized, the tall of the pancreas can be folded over ventrally and largely separab!d from the retroperftoneum by a combination of blunt and sharp dissection. Collateral vessels to the colon are suture ligated separately. Preservation of the spleen Is not usually possible when reseding tfte tail of tfte pancreas, mainly because tfte splenic vein runs in the immediate vicinity of tfte pancreatic parenchyma. For this reason. resection of the tail of the pancreas usually involves splenectomy. For this purpose, the spleen must be separated from the short gastric veins along the gastric curvature. Depending on the precise location of the pancreas tall resection. division of the splenic artery may be done at Its origin from the cellae trunk or further distally. The resection margin for processes In the tall and body of the pancreas courses Immediately left of the superior mesenteric vein. The artery and vein are Isolated separately and divided between suture ligatures (2-0 PGA).

o

Transedion of the tail of the pancreas

After securing the splenic vessels, the tail of the pancreas is now divided between stay sutures using the scalpel or diathermy. Pulsating vessels are grasped separately and secured by suture ligation.

Abdominal Cavity: Pancreas

0 Management of the tail of the pancreas The pancreatic duct Is easily Identified In the resection surface and Is occluded by suture ligation (3-0 PGA). The parenchyma of tile pancreas can be closed in a fisi'Hnouth fashion using mattress sutures or inter· ruptEd sutures (3-0 PGA) to prevent postoper.rtive fistula formation. If proximal drainage is uncertain, then anastomosis with a Roux-en-Y jejunal loop is recommended in the fonn of a Roux-en-Y pancreaticojejunostomy.

o

Closure with staples

In principle, tilere is also the option of transecting the tAil of tile panaeas with the aid of a stapler. However, in only a few cases is 1ttis as simple as shown here, because 1tte stiff staples of 1tte stapling device often crush the parenchyma. result:Jng In necroses Instead of a continuous staple line. Managing the parenchyma In this manner Is only occasionally possible with a tender and slender organ. In all such cases, we have also covered such stumps, which have been closed with staples, with an additional Roux-en-Y jejunal loop for safety reasons to prevent the formatlon of a ftst:JJia.

253

254

81 Splenectomy

1 Indications

7 Operative Steps

ElecUve: 1\unors of the spleen, splenic cysts, splenic abscesses, primary and secondary hypersplenism, hereditary anemia, idiopathic thrombocytopenic purpura (Werlhof disease), lymphoproliferative diseases Absolute Indications: Grade 4/5 lesions secondary to trauma Alternative Procedures: Partial resection, laparoscopic splenectomy

0 Skin incision 0 Skeletonization of the short vessels 0 Skeletonization of the splenic hilus 0 Mobilization of the spleen 0

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Preoperative Investigations: illtrasound, computed tomography; consider hematological tests; dotting tests P.Uent Preparation: Consider perioperative administration of antibiotics. Immunize against pneumococcal infection 2 weeks preoperatively for elective cases, otherwise 2 weeks postoperatively; increase the dose for patients Wlder steroid medication.

..

0

.... ..

3 Specific Risks, Patient Information, and Consent ~

.. .. .... .. ~

..

Hemorrhage/hypovolemic shock Injury to the stomach (2%) Injury to the pancreas, pancreatic fistula (< 5%) Injury to the colon Subphrenic abscess (5 to 10%) Postoperative susceptibility to infection (sepsis in 5%, very rarely OPSI) Susceptibility to thrombosis

....

....

4 Anesthesia

5 Positioning Supine

6 Approach Left subcostal incision, midline abdominal laparotomy for trauma cases

There is a dose relationship between the spleen and stomach (short gastric artery and vein), between the splenic hilus and the tail of the pancreas, as well as between the lower pole of the spleen and the left colonic flexure. Primary ligation of the splenic artery facilitates dissection, especially in cases of extreme splenomegaly. There are accessory spleens in -10% of cases, located particularly in the region of the splenic hilus and the gastrosplenic, splenocolic, and splenorenalligaments; in the peripancreatic and perirenal regions; in the omentum; and in the mesentery. It is imperative in cases of hematological systemic diseases to deliberately seek and remove accessory spleens. Try to preserve the spleen in children, for which a complete mobilization of the spleen is required.

9 Measures for Specific Complications ..

General anesthesia (intubation)

Retrograde dissection of the spleen Hemostasis of the splenic bed

..

Use inverting interrupted sutures to repair injury to the greater gastric curvature. A postoperative left-sided pleural effusion is common: pWlcture if> 300 mL For a pancreatic fistula, manage expectantly if well drained, provide parenteral nutrition, consider somatostatin.

10 Postoperative Care Medical Aftercare: Remove the nasogastric tube on day 1; remove the drain on day 2 or 3. UltrasoWld and laboratory tests: consider determining amylase levels in the drain secretion; a moderate postoperative leukocytosis is normal; if reactive thrombocytosis > 1000 g/L give ASA medication for a short period; pneumococcal immunization 2 weeks after surgery. Oral penicillin prophylaxis for 1 to 2 years (especially for ages under 21 years). Dietary Progression: Provide drink from day 1 if well tolerated, advance quickly. Mobilization: Immediately Physiotherapy: Intensive breathing exercises Time Off Work: 1 week, depending on the overall situation

Abdominal Cavity: Spl..n

Operative Technique 0 0 0 0 0 0

Skin incision SkeletDnization of the short vessels SkeletDnization of the splenic hilus Mobilization of the spleen Retrograde disS&tion of the spleen Hemostasis of the splenic bed

,..... /

.......

I

I I I I I

0 Skin incision Asplenectomy can be performed vla a left subcostal Incision or an upper midline laparotomy. Acosmetically good alternative Is the transverse upper laparotomy (not Illustrated).

''

''

''

.......

'-

I .o-, ..,__

.

/

I

o Skeletonfzation of the short vessels

o Skeletonization of the splenic hilus

After complete exposure of tfle spleen, tfle short vessels between the greater gastric curv.rture and tfle upper splenic hilus are divided. An Overholt clamp is passed benealtl them and tfley are divided between sutlJre ligatures. These vessels are often very well developed, especially In the presence of fundal varices, and require meticulous suture ligation.

The spleen receives its vascular supply from tfle splenic hilus. Clamps are passed beneath tfle vessels at their origins from tfle splenic artery and vein at tfle tip of tfle tail of tfle pancreas, and tfley are divided succer slwly between suture llgatllres. Including boltl artery and win In one ligature should be avoided In order to prevent development of a subsequent arteriovenous ftstula.

255

256

Abdominal Cavity: Spleen

o

11Spllnadamy

Mobilization of the spleen

Once the spleen has been completely dissected at its pedicle. it may be lifted forward from its bed. For tnis purpose the retroperiwneal adhesions of tne spleen wl1tl the diaphragm and the retroperltoneum need to be released by a combination of blunt and sharp dl.ssectfon with the aid of scissors. Smaller collaterals to the diaphragm and retroperitoneum, renal capsule, or colon are coagulated wl1tl the diathenny or secured by suture ligation.

o

Retrograde dissection of the spleen

Once the spleen has been completely mobilized, it may be reflected in a craniomedial direction. This will reveal the last of the retrograde vessels, which course from the tall of the pancreas to the splenic hilus. They are dlvlded between OVertlolt clamps and secured by suture ligation.

O Hemostasis of the splenic bed Once the spleen has been brought forward and removed, tflere follows meticulous hemostasis of the splenic bed. The most common sources of bleeding are neglected vessels on the greater curvature, at the tall of the pancreas, on the renal capsule. and engorged diaphragmatic veins. The surgeon must tlke time to secure all sources of bl~ing by systematic hemostasis. Adrain for 48 hours, closure of the abdominal Willi in layers, and skin sutures complete tne operation.

82 Partial Splenectomy

1 Indications

7 Operative Steps

Relative Indications: Pathological lesions confined to the upper and lower halves of the spleen. This is the preferred procedure in children and adolescents due to the finn capsule, which supports sutures well. Alternative Procedures: Splenectomy

0 Partial resection of the spleen/resection margin 0 Hemostasis of the splenic resection surface 8 Relevant Anatomy, Serious Risks, Tricks ...

2 Preoperative Preparation

There is a dose relationship between the spleen and stomach (short gastric artery and vein), between the splenic hilus and the tail of the pancreas, as well as between the splenic pole and the left colonic flexure. The complete mobilization of the spleen is required for partial resections.

Preoperative Investigations: Ultrasound, computed tomography; consider hematological tests; dotting tests

...

3 Specific Risks, Patient Information, and Consent

9

Measures for Specific Complications

...

Use inverting interrupted sutures to repair injury to the greater gastric curvature. A postoperative left-sided pleural effusion is common: puncture if> 300 mL For a pancreatic fistula. manage expectantly if well drained, provide parenteral nutrition. consider somatostatin.

... ... ... ... ... ...

Hemorrhage Injury to the stomach Injury to the tail of the pancreas, pancreatic fistula Injury to the colon Subphrenic abscess Complete removal of the spleen

...

...

4 Anesthesia

10 Postoperative care

General anesthesia (intubation)

Medical Aftercare: Remove the nasogastric tube on day 1 and the drain on day 2 or 3. Ultrasound and laboratory tests: consider determining amylase levels in the drain secretion; a moderate postoperative leukocytosis is normal. Dietary Progression: Provide drink from day 1 if well tolerated, advance quickly. Mobilization: Immediately Physiothel'illpy: Intensive breathing exercises. Time Off Work: 1 week, depending on the overall situation

5 Positioning Supine

6 Approach Left subcostal incision. transverse left laparotomy

258

Abdominal Cavity: Spleen

12 Pllrllal Splanadanly

Operative Technique 0 Partial resedion of the spleen/resection margin 0 Hemostasis of the splenic resection surface

o

Partial resection of the spleen/resection margin

After mobilization of tile spleen and dMslon of the short vessels, tile splenic hilus can be grasped between tile finger and tilumb and, If necessary, preliminarily clamped. The spleen is tilen lifted forward and tile resection margins dearfy marked. The location of the cyst will detennine the resection margin. For reasons of hemostasis, it is recommended to leave behind those parts of the cyst wall tilat adjoin the spleen. The extent of tile tumor will detennine tile resection margin in cases of partial resection of tile spleen for the purpose of tumor rem011al or a biopsy (above all In children). Partial resection of tile spleen Is easy In tilose cases In which tile spleen has a dlchotomlc blood supply (I.e., a supply In two segments with a dearfy defined "watershed.. area In tile middle of the spleen). Here, parUaln!Sectlon of tile spleen Is tile simplest. It commences with dissection of the vessels In this region with systematic division In tile region of tile watershed under meticulous hemostasis.

b

o

Hemostasis of the splenic resection surface

Hemostasis of the splenic resection surface can be achieved with deep sutures (2-0 PGA. 0 chromic catgut; a-c), or alternatively with fibrin tissue adhesive and collagen fleece (c) or using laser coagulation. The

finner tile capsule, tile easier Is hemostasis. Partial splenectomy for a soft spleen will sometimes end in a complete splenectomy.

83 Splenic Rupture

1 Indications

8 Relevant Anatomy. Serious Risks. Tricks

Relative Indications: Extensive parenchymal disruption of the spleen Alternative Procedures: Splenectomy

...

2 Preoperative Preparation

.... ...

Preoperative Investigations: Ultrasound Patient Preparation: Blood replacement. optimization of coagulation

3 Specific Risks. Patient Information. and Consent ... ... ... ... ... ...

Injury to the stomach Injury to the pancreas, pancreatic fistula Injury to the colon Subphrenic abscess Splenectomy Postoperative hemorrhage

There is a dose relationship between spleen and stomach (short gastric artery and vein), between splenic hilus and the tail of the pancreas, as well as between the lower pole of the spleen and the left colonic flexure. Preliminary damping of the splenic hilus facilitates dissection. It is essential to try to preserve the spleen in children, for which a complete mobilization of the spleen is required.

9 Measures for Specific Complications ....

.... ....

Use inverting interrupted sutures to repair injury to the greater gastric curvature. A postoperative left-sided pleural effusion is common: puncture if> 300 mL For a pancreatic fistula. manage expectantly if well drained, provide parenteral nutrition, consider somatostatin.

10 Postoperative Care 4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Left subcostal indsion, midline laparotomy for trauma cases

7 Operative Steps 0

Hemostasis by compression

Medical Aftercare: Remove the nasogastric tube on day 1 and the drain on day 2 or 3. Ultrasound and laboratory tests: consider determining amylase levels in the drain secretion; a moderate postoperative leukocytosis is normal. Dietary Progression: Provide drink from day 1 if well tolerated, advance quickly. Moblllzalfon: Immediately Physiotherapy: Intensive breathing exercises Time Off Work: 1 week, depending on the overall situation

260

Abdominal Cavity: Spleen

Operative Technique 0 Hemostasis by compression

o Hemostasis by compression Among the numerous options for hemostasis of the spleen (suture, hotair coagulation, diathermy, argon-beam coagulation, infrared coagulation, and the application of hemostatic fleeces), the last resort is to enclose the spleen In an absorbable mesh (PGA mesh bag), which places the fragments of the spleen under compression so they can no longer bleed. For this purpose the spleen Is completely wrapped In a PGA mesh bag, which Increases the compressive pressure on the splenic capsule by sever.~! concentric marginal weaves, which spare out the hilus and thus achieve hemostasis. This maneuver is a last resort before splenectomy; isolated resection and specific measures for hemostasis should all have been tried beforehand.

84 Laparoscopic Splenectomy 1 Indications

7 Operative Steps

ElecUve: TUmors of the spleen, splenic cysts, hereditary anemia, idiopathic thrombocytopenic purpura (Werlhof disease), lymphoproliferative diseases Alternative Procedures: Open approach

0 0 0

2 Preoperative Preparation

0

Patient Preparation: Consider perioperative administration of antibiotics. Immunize against pneumococcal infection (e.g., Pneumovax, Merck & Co.. Inc., Whitehouse Station, NJ) 2 weeks preoperatively for elective cases, otherwise 2 weeks postoperatively; increase the dose for patients under steroid medication.

0

0

Achieving a pneumoperitoneum Introduction of the optic trocar and positioning the operating trocar Mobilization of the spleen with division of the colosplenic and phrenicosplenic ligaments Skeletonization of the short vessels Division of the splenic artery and vein, including their bifurcations, between endoclips or alternatively with the linear stapling instrument Retrieval of the spleen in a retrieval bag via a transverse incision, if necessary after blunt fragmentation

8 Relevant Anatomy, Serious Risks, Tricks 3 Specific Risks, Patient Information, and Consent ... ... ... ... ... ... ... ...

Hemorrhage/hypovolemic shock Injury to the stomach (2%) Injury to the pancreas, pancreatic fistula(< 5%) Injury to the colon Subphrenic abscess (5 to 10%) Postoperative susceptibility to infection (sepsis in 5%, very rarely OPSI) Susceptibility to thrombosis Option of converting to the open procedure

4 Anesthesia

Caution; Close positional relationship to the toil of the pancreas

If possible, primary management of the splenic artery with dips

9 Measures for Specific Complications ...

... ... ...

Use inverting interrupted sutures to repair injury to the greater gastric curvature. A postoperative left-sided pleural effusion is common: puncture if> 300 mi. For a pancreatic fistula. manage expectantly if well drained, provide parenteral nutrition, consider somatostatin. In the event of bleeding or insuffident overview, do a timely conversion to the open approach via a left subcostal indsion.

General anesthesia (intubation)

10 Postoperative Care 5 Positioning Supine, left side elevated

6 Approach Three to four trocarsfports along the left subcostal margin

Medical Aftercare: Remove the nasogastric tube on day 1; remove the drain on day 2 or 3. Ultrasound and laboratory tests: consider determining amylase levels in the drain secretion; a moderate postoperative leukocytosis is normal; if reactive thrombocytosis > 1000 gfL give ASA medication for a short period; pneumococcal immunization 2 weeks after surgery. Oral penicillin prophylaxis fur 1 to 2 years (especially for ages under 21 years). Dietary Progression: Provide drink from day 1 if well tolerated, advance quickly. Mobilil.ill:ion: Immediately Physiotf1erapy: Intensive breathing exercises Time Off Work: 1 week, depending on the overall situation

262

Abdominal Cavity: Spleen

Operative Technique 0 Division of the splenic ligaments 0 Division of the short vessels 0 Division of the splenic artery and vein 0 Retrieval of the spleen

o Division of the splenic ligaments Traction on the spleen with a spongcH!oldlng forceps will allow the colosplenlc and phrenlcosplenlc ligaments to be divided and thus facll!trte moblllzauon of the lower pole of the spleen. The lateral attachments to the abdominal wall and the diaphragm are also divided.

0 Division of the short vessels The next sb!p Involves Identification and traction of the gastrosplenic ligament for dMslon of the short gastric arteries and veins. This Is a~ compllshed most quickly and most safely with the aid of the ultrasound scalpel, or alternatively between endodips. The spleen is now only at· tached to the vascular pedicle of the splenic artery and vein.

Abdominal Cavity: Spl..n

o DMslon of the splenic artery and vein Division of the gastrosplenic ligament will reveal the splenic artay and vein, which divide at the upper border of the pancreas. We prefer the selective dissection of the vessels and the placement of endoclips. Alternatively, division may also be accomplished witn the aid of a linear stapling device with a vascular white cartridge. Injuries to the tail of the pancreas must be avoided when positioning the stapling Instrument.

0 Retrieval of the spleen After dMslon of the splenic hilus. only the remaining ligamentous adhesions need to be released. The separated spleen can then be placed In a retrieval bag. On closing the purse-strtng suture. the bag Is withdraYJn through the abdominal wall via the trocar. Depending on the size of the spleen, the organ may be extracted whole via an extension of the incision or aft:rr blunt fragmentation in the retrieval bag.

263

264

85 Peritonitis and Laparostoma

1 Indications

7 Operative Steps

Elective/Absolute Indications: dinical diagnosis of an "acute abdomen" with suspected diffuse (purulent or fecal) peritonitis, objectification of the finding using scoring systems is recommended (e.g., Mannheim Peritonitis Index). Generous irrigation and routine drains for mild cases (score < 20). Irrigation and closure of the abdomen after placing drains in all quadrants plus dosed continuous lavage for more severe cases (score 20 to 29). Irrigation and laparostoma with a planned relaparotomy ("staged lavage") for the most severe cases (score> 30).

0 Exploration 0 Irrigation of the abdominal cavity 0

0

8 Relevant Anatomy, Serious Risks, Tricks ~ ~

2 Preoperative Preparation Preoperative Investigations: Depending on the situation: merely an ultrasound study, plain abdominal X-ray for unequivocal clinical findings; computer tomography, upper and lower GI tract X-ray (water-soluble contrast medium!), endoscopy, angiography for equivocal findings. Patient Preparation: Monitoring under intensive-care conditions and adequate therapy: central line, volume fluid replacement, broadspectrum antibiotic therapy (consider percutaneous collection of material for antibiotic testing), nasogastric tube, or possibly the preoperative endoscopic placement of a Dennis tube into the proximal jejunum.

~

~

~ ~

3 Specific Risks, Patient Information, and Consent ~

~ ~ ~ ~ ~

Planned revisions for prolonged septic processes Intra-abdominal abscess Intestinal injury with subsequent fistula/anastomotic leak (10 to 20%) Stoma creation Incisional hernia Mortality in up to > 50%

4 Anesthesia

Continuous peritoneal lavage Laparostoma

~

Systematic exploration of all quadrants and of the entire intestinal tract, also during revision surgery (if accessible) cases where the source of infection is primarily not apparent: exploration of gallbladder-esophagus/cardia region-anterior and posterior gastric wall-open bursa: pancreas-duodenum (Kocher maneuver)-large intestine (colonic flexures, sigma)small intestine?-both subphrenic spaces; consider instillation of a diluted dye solution or air via the nasogastric tube or per rectum; intraoperative endoscopy. Drain the deepest recesses of the abdomen: the pouch of Douglas-left dorsal subphrenic space (splenic bed)-right dorsal subphrenic space (retrohepatic). All drains should be of very flexible material (silicone); no stiff latex or rubber tubes. A paralytic ileus is always present, so place a Dennis tube at the first operation. Abdominal repair with the aid of an absorbable PGA mesh, cover with abdominal packs and adhesive foil, open the mesh in the middle of the wound for revision surgery (to protect the fascial margins). Aim for high flow volumes when performing a continuous lavage: 20 to 40 Lfday solution (e.g., Ringer) at body temperature.

9 Measures for Specific Complications ~ ~

Adequate surgical management for organ complications Injuries to the proximal small intestine: attempt to oversew; injury of the distal small intestine/colon: create a defunctioning stoma, if unsuccessful or impracticable: adequate drainage and await the formation of a stable fistula.

General anesthesia (intubation)

10 Postoperative Care 5 Positioning Supine

6 Approach Complete midline or transverse laparotomy

Medical Aftercare: Depends on cause and subsequent course of therapy

•

Ptlrltonltls .... Lapa.......

Abdominal Cavity: Peritoneum

Operative Technique 0 0 0 0

Exploration Irrigation of the abdominal cavity Continuous peritoneal lavage Laparostoma

o

Exploration

E>cplor.~tion of tfle abdominal cavity requires a clear access. A complete midline laparotomy usually offers the best overview. In cases of secondary peritonitis, 1tle primary incision should be lnduded In 1tle exploration and If necessary extended. In no case should a peritonitis be surgically tackled without the possibility of a direct Inspection of all four quadrants. After opening 1tle peritoneum, the abdomen Is explored systematically. The most Important locations for abscesses and collections are tfte bilateral subphrenic, subhepatic, bilateral paracollc, retrocecal, lnteretlteric regions, and the pouch of Douglas. All these areas are to be systematically explored and inspected for abscess foci. Abscesses are removed by suction, irrigated, and drained.

265

266

Abdominal Cavity: Peritoneum

15 ,.rltonltls and LapaNIIama

0 Irrigation of the abdominal cavity A diffuse peritonitis demands tflat tfle intestinal loops are exposed and, after releasing and elevating tfle greater omentum, generously i~ gated wltf1 saline or Ringer solution at body temperature. Fibrinous layers are peeled off, the entire abdominal cavity Is systematically cleaned. For this purpose, 10 to 20 liters of I~ gatlon fluid are necessary.

0 Continuous peritoneal lavage The decision for an open or closed approach depends on tfle extent of tfle peritonitis. Peritonitis scores (e.g., tfle Mannheim Peritonitis Index) help In reaching a decision. A closed form of approach Is justifiable with a score up to 25. Mild forms of peritonitis are lnfgated lntTaoperatlvely and drained. Moderate forms can be sufllclentfy managed by closed four-quadrant drainage and continuous abdominal lnigation (20 to 40 LIn 24 hours). The drains are placed In the four qu~ rants and In the pouch of Douglas. For purposes of a more exact fluid balance, the creation of a closed system wittl defined afferent and efferent drains is recommended.

•

Ptlrltonltls .... Lapa.......

o

Abdominal Cavity: Peritoneum

Laparostoma

If a severe form of peritonitis is encoun~red. Ute open approach with the creation of a laparostoma should be chosen to facilitate ttte necessary repeated laparotomies wtttt planned lavage. A laparostoma also sefWS to reduce Intra-abdominal pressure (I.e. avoids an abdominal compartment syndrome). The ttterapeut!c concept Involves the flexible closure of ttte peritoneal cavtt.y with an artificial mesh, which holds ttte irrtestines in situ, yet at ttte same time allows access for planned re-laparotomies while protecting ttte wound margins. For tflis purpose we use PGA meshes, sewn in with continuous size 0 PGA sutures. These meshes can remain in situ once the peritonitis has healed; tttey become covered with granulation tissue and are absorbed within 6 to 10 weeks. This granulation tissue may possibly be resurfaced with a mesh graft at a later date. The wide dehiscence of ttte fascial margins later Inevitably results In an lnclslonal hemla, which should be closed after 3 to 6 months at ttte ea1ilest.

267

86 Peritoneovenous Shunt

1 Indications

7 Operative Steps

ElecUve: Cirrhotic ascites, refractory to diuretic therapy, in patients who are not candidates for liver transplantation. Malignant ascites after exploiting all other measures and life expectancy > 1 month. Contralndlcations: Bacterially contaminated ascites Alternative Procedures: Repeated therapeutic paracentesis, operatively or radiologically inserted transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation

0 0 0 0 0

Shunt location and skin incisions Placement of the abdominal cathetEr Insertion of the catheter Insertion of a chest catheter Venous access at the neck

8 Relevant Anatomy, Serious Risks, Tricks 2 Preoperative Preparation

...

Preoperative lnwstigations: Thorough investigation of the underlying liver disease; ascites analysis: bacteriology, cytOlogy, clotting substances (fibrin split products), clotting tests Patient Preparation: Perioperative antibiotic prophylaxis, consider fluid and electrolyte replacement

... ...

,..

3 Specific Risks, Patient Information, and Consent ,.. ,.. ,.. ,.. ,.. ,..

Obstruction and infection of the cathetEr systEm (20 to 40%) Systemic dotting abnormalities(< 10%; serious) Peritonitis(< 5) Hemorrhage ( < 5%) Dislodgment of the port-catheter systEm (< 5%) 1\Jmor-cell embolus in the presence of malignant ascites (rare)

4 Anesthesia General anesthesia (intubation), also consider local anesthesia

5 Positioning Supine, with slightly elevated right side of the body

6 Approach Via the sternocleidomastoid muscle and in the right or left upper abdomen

The peritoneal closure around the abdominal limb of the catheter must be watertight The commonest systems are the Denver shunt (with compressible chamber) and the Le Veen shunt (without pump function). Intraoperative replacement of the ascites with physiological saline or Ringer solution is recommended (human albumin is less common). The shunt volume can be influenced by simple maneuvers: increased by abdominal pressure, forced inspiration, and laying the upper part of the body flat

9 Measures for Specific Complications ... ,..

Infection will require removal of the entire shunt system Investigations for shunt occlusion include increased pump resistance, duplex ultrasonography, radiological examination in the form of a "shuntogram" after direct puncture; a blocked system will usually need replacing.

10 Postoperative Care Medical Aftercare: Tight postoperative monitoring of circulation, fluid balance, and clotting (intensive care unit), removal of the nasogastric tube on day 1 Dietary Progression: Provide drink from day 1 and increase while carefully monitoring fluid balance. Mobilization: Immediately llme Off Work: Depends on the overall situation

Operative Technique 0 0 0 0 0

Shunt location and skin incisions Placement of the abdominal cathetEr Insertion of the catheter Insertion of a chest catheter Venous access at the neck

b

c:

o Shunt location and skin incisions

o Placement of the abdominal catheter

The perit:oneovenous (Denver) shunt forms a connection between the abdominal cavity and the jugular vein. It is usually placed on the righthand side. Three skin Incisions are required: below the right sulxostal margin, over the light Jugular vein and, If necessary, all auxiliary lnclsloll lateral to the 11ipple.

The abdominal cavity should be opened sparingly, protecting the muscles in order to avoid leakage of ascites fluid. Transverse incision three ftngerbreadths below the right subcostal margin {a), transverse dMslon of the fascia (b), longltudlllal dMsloll of the muscles by blunt separaUo11 YAt:h scissors (c).

270

Abdominal Cavity: Peritoneum

•

o

Insertion of the catheter

After identification of dte peritoneum, it is grasped with one, or preferably two, concentric purse-string sutures (a). The shunt catheter may already have been placed subcutaneously, or will be Inserted lab!r. It Is Important that sufficient room Is made over the costal marglll for the shunt body by blunt dissection. Next, after removing Ute ascites by suction, Ute peritoneal limb of Ute catheter is inserted under vision into Ute abdominal cavity and secured in a watertight fashion with purse-string sutures to avoid any leakage of ascites (b).

0 Insertion of a chest catheter The shunt body Is placed over dte light subcostal marglll to provide support for the pump function. Blunt subcutaneous dlssectioll allows the vet1ous limb to be brought up to the neck and out through a cervical incision.

a

b

o

Venous access at the neck

The jugular vein, which courses behind tfle sternocleidomastoid musde, is exposed via tfle cervical incision (a). This is achieved by blunt dissection aftEr identifying the easily palpable coul'3e of tfle carotid artery. The vein is exposed, encirded by two vessel loops, and a purse-string suture (5-0 polypropylene) Is placed. The vein Is occluded by traction on tne vessel

loops, aftEr which an lndslon Is placed In tne center of the purse-string suture, and tne venous limb of the catheter Is advanced as far as the superfor vena cava (b, c). The position of tne catheter at the level of the light abium is documentEd by image intensifier. Subcutaneous suture, skin sutures, and dressing complete the operation.

272

~

Seg....all R••dlon ol the SIMIIInhltiM

87 Segmental Resection of the Small Intestine

1 Indications

8 Relevant Anatomy, Serious Risks, Tricks

EJecHve: Circumscribed pathological lesion (tumor, Crohn disease, mesenteric infarction, and the like) AIUI'natlve Procedures: Bypass surgery if unresectable (palliative operation)

...

2 Preoperative Preparation

...

Preoperative Investigations: Ultrasound, computed tomography, contrast imaging (Sellink method; if obstruction is suspected then upper gastrointestinal tract X-ray using water-soluble contrast). Patient Preparation: Nasogastric tube

3 Specific Risks, Patient Information, and Consent ... ... ... ...

Anastomotic failure (rare, e.g., with Crohn disease and after radiation therapy) Anastomotic stenosis (rare occurrence with end-to-end technique) Vascular injury Short-bowel syndrome afrer loss of> 50% of small intestine

Determine the resection margins using transillumination while giving due consideration to the vascular arcades.

Caution: Watch out for Injury to the superior mesenteric artery and vein when skeletonizing the mesentery of the smaU intestine

...

...

... ...

...

...

4 Anesthesia

Always create an end-to-end anastomosis and only use a sideto-side anastomosis for construction of a palliative bypass. With lumen discrepancy secondary to a longer-standing obstruction, cut the smaller lumen obliquely toward its antimesenteric border. The serosa in the area of the mesenteric attachment must be freed for a short distance of fat and vessels in preparation for the anastomosis: circumferential serosa-to-serosa approximation. Exert a controlled pull on the threads when knotting, do not overtighten. Use a standardized approach. Comer ..... posterior wall ..... comer ..... anterior wall, always begin at the mesenteric or antimesenteric border. After completing the anastomosis, carefully inspect the entire circumference for gaps between the stitches. If the viability of the intestinal segment is in question (intestinal ischemia}. either resect and bring the ends out as stomas or create an anastomosis and plan a second-look procedure after 24 hours.

General anesthesia (intubation)

Caution: watrh out for primary anastomosis in the presence of peritonitis

5 Positioning

...

Consider intraoperative endoscopy when looking for sources of bleeding in the small intestine.

Supine

9 Measures for Specific Complications 6 Approach

...

Usually midline laparotomy

7 Operative Steps 0 Principle of small-intestine resection 0 Skeletonization of the mesentery of the small intestine I 0 Skeletonization of the mesentery of the small intestine II 0 Resection of the segment of the small intestine 0 Posterior wall anastomosis

0 Anterior wall anastomosis 0 0

Confirmation of lumen width Closure of the mesenteric defect

...

Intraoperative ischemia of the anastomosed segment of small bowel (e.g., due to injury to the vessels within the mesentery): take down the anastomosis, resect back to healthy tissue, and construct a new anastomosis. Anastomotic breakdown. but well drained and without peritonitis: manage expectantly, perform immediate revision at the first clinical and laboratory signs of inflammation.

10 Postoperative Care Medical Aftercare: Depends on the overall situation. Remove the nasogastric tube on day 1 to 3. Dietary Progression: Allow drinking from day 4 and a solid diet once bowel sounds have returned. Bowel Function: Consider administering a small-volume enema Mobilization: Immediately Physiotherapy: Breathing exerdses Time Off Work: 1 to 2 weeks

fn s.gn.ntal....,• of the Snlllll......,n•

Abdomrnal Cavrty: Small Intestine

Operative Technique 0 0 0 0 0 0 0 0

Principle of small-intEstine resection SkeletDnization of the mesentEry of the small intestine I SkeletDnization of the mesentEry of the small intestine II Resection of the segment of the small intestine Posterior wall anastDmosis Anterior wall anastomosis Confirmation of lumen width QosW'e of the mesenteric defect

o

Principle of smaiJ.fntestlne resedlon

Regardless of the type of small bowel disease In question (Inflammation, tumor, defect. Ischemia, or necrosls), the approach to segmentAl! resection of the small intestine is always the same. The principle involves resection of tile affected bowel segment. while being as conservative as possible witt! tile resection margins. These should lie macroscopically in healthy tissue and be guided by tile vascular supply of the mesenteric pedicle. The distal and proximal resection margins must have an adequa~ blood supply to guarantee safe healing of the anastomosis. Marking the resection margins is best accomplished by using transillumination to Identify the vascular arcades.

o

Skeletonfzation of the mesentery of the small Intestine I

Skeletonization of the vascular arcades within the mesentery begins close to the bowel. A thlckl!ned and Inflamed mesentery may make the boundary betwun mesentery and bowel difficult to ~ognize; it is best identified by palpation between the index finger and thumb.

o

Skeletonization of the mesentery of the small Intestine II

The mesenteric vessels are divided between OVerholt clamps and the vessel stumps ligated. A very friable or fat-laden mesentery will require suture ligatures (3-o PGA). Smaller vessels are grasped witt! mosquito clamps.

273

274

Abdominal Cavity: Small Intestine

17 Segmental ll8ladlon of tha Smalllntastl•

O Resection of the segment

of the small intestine After skeletonization. the bowel is divided between damps. Noncrushing clamps are placed on those segments of the small intestine to be anastomosed, while crushing clamps are applied to the specimen. An antlseptfc-$0Ciked swab Is placed beneath the cut surfaces to avoid contamination of the abdominal cavity.

o

Posterior wall anastomosis

After resection of the bowel segment. the ends are approximated and anastomosed. Asingle-layer anastomosis using 3-0 PGA Is creab!d. The sutures are inserted at distJnces of -0.5 em. Care must be taken to take

small bites of mucosa and large bites of serosa when guiding the needle through the bowel wall In order to achieve broad contact of the serosa. The comer sutures of the posterior wall are ldentffled with damps.

fn s.gn.ntal....,• of the Snlllll......,n•

o

Anterior wall anastomosis

Suturing the anterior wall proceeds using the same suture technique. The last posterior-wall sub.Jre was deliberatEly left long and is now folded into the lumen and oversewn with an outer stitch.

o

Closure of the mesenteric defect

Closure of the mesentery Is accomplished using an lnb!rrupted sub.Jre technique and avoiding Injury to the vascular arcade. Injury to a vessel could jeopardize the viability of the bowel, which would present a risk of anastomotic failure.

o

Abdomrnal Cavrty: Small Intestine

Confirmation of lumen width

After completion of the suture, careful palpation between the thumb and index finger allows confirmation of adequate lumen width. The index finger should easily slide into the lumen so that the thumb can palpate its tJp, ensuring that It Is surrounded on all sides by the ring of the anastomosis. In addition, careful compression of the Intestinal lumen on either side of the suture ring also allows further conflnrnatlon of watertJghlness.

275

88 Intraluminal Stenting of the Small Intestine (Dennis Tube) 1 Indications

7 Operative Steps

Elective: As a prophylaxis against recurrence of adhesional obstruction following extensive adhesiolysis Relative Indications: For the management of intra-abdominal disorders associated with severe intestinal paralysis (e.g., peritonitis). Contraindications: Isolated, circumscribed acute obstruction by a single adhesion band Alternative Procedures: Noble or Childs-Phillips suture plication of the small intestine (rarity)

0 0 0 0 0

8 Relevant Anatomy, Serious Risks, Tricks ~

2 Preoperative Preparation Preoperative Investigations: Ultrasound, abdominal X-ray (consider a left-lateral position), contrast imaging (upper gastrointestinal tract X-ray using water-soluble contrast) Patient Preparation: Nasogastric tube, consider endoscopic placement of the Dennis tube in the proximal jejunum (avoids manual passage through the duodenum, which can be traumatizing. especially after previous surgery of the upper abdomen); central venous line, volume fluid replacement. correction of electrolyte and add-base imbalances.

Prindple of stenting the small intestine Obstruction from an adhesion band Intestinal obstruction from multiple adhesions Placement of a tube into the small intestine I Placement of a tube into the small intestine II

~

~

~

The bowel and omentum are often adherent to an old scar. The easiest access into the abdominal cavity is achieved by slightly extending the incision at one of the wound ends. Dissection always proceeds from "familiar" to "unfamiliar." Once the fasdal margins have been identified, controlled traction on the fasda with Mikulicz clamps is useful when further detaching intra-abdominal organs from the abdominal wall. A thorough inspection of all segments of the bowel is undertaken after dividing all adhesions: consider resuturing theserosa, oversewing, or resection.

9 Measures for Specific Complications 3 Specific Risks, Patient Information, and Consent ~ ~

~

Injury to the small intestine/peritonitis Segmental resection of the small intestine Recurrent bowel obstruction (10% after initial episode)

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Midline laparotomy, consider reopening the old scar

Any segments of bowel that have been damaged while dividing the adhesions should be resected.

10 Postoperative Care Medical Aftercare: Deflate the balloon of the Dennis tube on postoperative day 1. Leave tube in situ for 10 to 14 days. Also leave the nasogastric tube until minimal reflux is registered; prokinetic medication: dexpanthenol, metoclopramide, erythromycin, consider perioperative antibiotic treatment. Dietary Progression: Allow sips of dear liquid as soon as reflux via the nasogastric tube is minimal (day 3 to 5), with solid diet only after the first postoperative bowel movement and confirmed bowel sounds. Bowel Function: If necessary, promote bowel function with smallvolume enemas. Mobilization: Immediately Physiotherapy: Breathing exerdses Time Off Work: 2 to 4 weeks

lllnll'lllu.nlnal Sblnt. . of the Sinal lniMIIn• (DIIris Tuba)

Abdomrnal Cavrty: Small Intestine

Operative Technique 0 Principle of stenting the small intestine 0 Obstruction from an adhesion band 0 Inrestinal obstruction from multiple adhesions 0 Placement of a tube into the small intestine I 0

Placement of a tube into the small intestine II

/

/ /

I

I

I

"

'

''

''

'\ \

\

I

\

I

\

I

''

I

I

\

I

I I

I I

I

\ \

I

I I I

o

\

I

:;>,;

\..v

I \ I I I

Prindple of stenting the small intestine

In an elective or acute situation, tfle indication to divide adhesions may be made for chronic pain secondary to recurrent obstruction from abdominal adhesions. However, the indication should be d~ fined extremely consenr.rtively in elective cases, given that recuJTences are common. In 1tle emergency slnlatlon of Intestinal obstruction, however, there Is usually no alternative. The aim of the operation Is always the release of adhesions between bowel loops, followed by stenttng of 1tle small Intestine. St:Enting with long intestinal tubes serves botfl to prevent postoperative obstruction, and to encourage furtfter adhesions between tfle bowel loops in an inevitable, yet controlled manner (I.e. nonoccluding). The principle is transnasal stenting using a Dennis tube. which should be advanced as far as tile cecum. The tube should be left In slnl for at least 10 days to sufficiently preclude recurrent Intestinal obstruction. If necessary, tile tube may be placed under mild suction and the balloon deflated on postoperative day 1. Intraoperative placement of 1tle tube Is facilitated by advancing It preoperatively as far as, or beyond, the ligament of Treltz with tfle aid of an endoscope.

277

278

Abdominal Cavity: Small Intestine

o

a lntNbnl•l Stanllng of th• Smalllntasll•llhnnls Tuba)

Obstruction from an adhesion band

The abdominal cavity is usually opened via a midline incision, and the small intestine is carefully inspectEd. Even now, the sitE of dle obstruc· tion may be suspected by discovering a prestenotic dilated segment of bowel and a poststenotic collapsed bowel. The situation is particularly easy If an Isolated adhesion band connecting two loops almost comple-

o

tely occludes a segment of bowel In between, resulting In the aforement:Joned constellat:Jon. DMslon of the band with scissors or cutting dladtemry will promptly eliminate the cause. Stent:Jng of the small Intestine Is not requln:!d In this kind of sltuatfon, given that the risk of recurrence Is extremely low.

Intestinal obstruction from multiple adhesions

More often, howewr, multlple adhesions between the bowel loops are encounten:!d. The bands are dMded sharply and, If necessary, bluntly released. The entire small Intestine must be exposed, from the ligament of Treltz to the Ileocecal valve, and the bowel adhesions taken down. The

bowel should be grasped as carefully as possible during this manipulation and should not be crushed by overdue pressure of the forceps. It is also necessary to keep the bowel surface moist so as nat to promote subsequent adhesions.

lllnll'lllu.nlnal Sblnt. . of the Sinal lniMIIn• (DIIris Tuba)

Abdomrnal Cavrty: Small Intestine

0 Placement of a tube into the small

intestine I Once the bowel has been completely freed of adhesions and elongated, it is stented with an inner tube to guard against recurrent obstructions. The balloon Is slightly Inflated (10 to 20 ml of air) and the tube advanced blmanually through the small Intestine. Any anastomoses or stenoses may be negatlatl!d by deflating the balloon. This mane~J~~er should be undertaken very carefully to avoid causing any additional damage to the bowel wall.

o

Placement of a tube Into the small lntesUne II

The Dennis tube Is advanced as far as the cecum, where It Is secured by Inflating the balloon. The small Intestine Is elongatl!d far enough over the tube to allow its completE insertion and to ensure that it is not coiled within the stomach. If the tube does not reach the cea.~m, the bowel should still be stentl!d as far as possible.

279

89 Meckel Diverticulum 1 Indications

7 Operative Steps

ElecUve: On establishing the diagnosis, given that complications are assoctated with 40% of cases Contralndlcations: Diffuse peritonitis; no contraindications for complicated diverticula Alternative Procedures: Laparoscopic removal

0 0 0 0 0

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Preoperative Investigations: Usually an incidental intraoperative finding, consider a Sellink double-contrast imaging technique; in rare cases angiography, sdntiscan (so-called Meckel scan).

... ...

3 Specific Risks, Patient Information, and Consent

.... .... ....

...

... ...

Clinically acute symptoms located in the mid- or right abdomen may be a possible indication of the presence of Meckel diverticulum (1 to 2% of the general population). Suture dehiscence Peritonitis

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Usually midline laparotomy

Skeletonization of the diverticulum Determining the resection margin Removal of the diverticulum Oversewing the staple line Confirmation of lumen width

Located in the terminal ileum. up to -1 m proximal to the ileocecal valve of Bauhin (frequency as high as 4%) Meckel diverticula are always located on the antimesenteric border. Selectively ligate the diverticulum's own separate mesentery. Excision is also possible using a stapling device {3.5 mm). Suture closure is always perpendicular to the longitudinal axis of the bowel.

9 Measures for Specific Complications A short-segmental resection with an end-txrend anastomosis is indicated for a very broad-based diverticulum.

10 Postoperative Care Medical Aftei'Cillre: Depends on the overall situation. In the case of a solitary removal of a diverticulum. remove the nasogastric tube on day 1 or 2. Dietary Progression: Allow sips of dear liquid from day 2, solid diet from postoperative day 4 if good bowel sounds are detected. Mobilization: Immediately Time Off Work: 1 to 2 weeks

8 M_... D.....,culu.n

Abdo.nrnal Cavity: Small Intestine

Operative Technique 0 0 0 0 0

SkeletDnization of the diverticulum Detennining the resection margin Removal of the diverticulum Oversewing the staple line Confirmation of lumen width

o

Skeletonlzatlon of the diverticulum

Meckel dlverUculum Is a relatively common Incidental finding at laparotomy, but It Is rarely the cause of disease. Its lntraoperatrw discovery Is sufficient justification for its removal, however, given that complications such as pelior.rtion or hemorrhage are relatively common in the long tenn and their diagnosis and differential diagnosis possibly remain ehr siw. Resection of a Meckel diverticulum begins with skeletonization of its own separate mesenteric pedide. The mesentery traverses the lateral bowel wall and supplies only the Meckel diverticulum. All Ovemolt clamp is passed beneatfl it before it is divided between ligatures.

o

Determining the resection margin

The resection margin should lie dose to the mesenteric attachment to the bowel. where stay sub.Jres are placed to apply transverse traction on the bowel.

281

282

Abdominal Cavity: Small Intestine

o

Removal of the diverticulum

The Meckel diverticulum is excised between the stay sutures. This may be accomplished with the aid of a TA-30 stapler or also by an open technique. Interrupted sutures (3-0 PGA) are used for the open procedure, although the stapling technique is the simpler option. A~r activating the stapling device, the redundant margin of bowel Is transected sharply along the staple line with the scalpel. A transwrse dlrectlon of resection Is chosen to avoid narrowing the jejunal lumen.

0 Confinnation of lumen width On completion of the suture line. the lumen width Is chedred using the Index flnger-thumb test.

o

Oversewlng the staple line

The stiple line is oversewn with irrtemJpted sutures (3-0 PGA). This suture line is not obligatory, but the authors use it. if only for reasons of hemostlsis.

!JOEndl.........,

90 End Ileostomy

1 Indications

7 Operative Steps

EJec:Hve: After proctocolectomy {e.g., for Crohn disease, ulcerative colitis, familial adenomatous polyposis, and multiple carcinomas of the colon). Alternative Procedures: Loop ileostomy after subtotal colectomy and ileoproctostomy, temporary end ileostomy after Hartmann discontinuity resection

0 Approach 0 Siting the stoma 0

Proximal resection margin

0 Preparation of the ileostomy aperture I 0

Preparation of the ileostomy aperture II

0 Preparation of the ileostomy aperture Ill 0 Preparation of the ileostomy aperture IV 0

Preparation of the ileostomy aperture V

2 Preoperative Preparation

0 Exteriorization of the terminal ileum

Preoperative Investigations: Depends on the underlying disorder (e.g., endoscopy plus biopsy, contrast imaging. contrast enema, consider using water-soluble contrast if there is a risk of perforation). Patient Preparation: Explain the permanent stoma (consider referral to an enterostomal therapist). Mark the stoma site and check it with the patient in standing and supine positions. Perform orthograde bowel lavage, and provide perioperative antibiotic treatment.

m Enlarging the aperture in the abdominal wall

3 Specific Risks, Patient Information, and Consent Depends on the underlying disorder, ileostomy-specific concerns (totaling as much as 15%): stomal prolapse-retraction or stenosis of the stoma-parastomal hernia-loss of fluid and electrolytes via the stoma with subsequent need for a change of diet and possible use of antiprokinetic medication

6t)

Oosure of potential hernial opening

® Stoma creation I ® Stoma creation n ~ Stoma creation m 8 Relevant Anatomy, Serious Risks, Tricks

...

Always position the stoma within the rectus abdominis muscle. For this purpose, separate the muscle bluntly, do not incisel Fashion the stoma with a 2 to 3 em spout.

9

Measures for Specific Complications

...

Stomal complication: optimize care, otherwise do revision surgery, consider renewed implantation.

...

4 Anesthesia

10 Postoperative Care

General anesthesia (intubation)

Medical Aftercare: Remove the nasogastric tube on the day 1 to 3, provide prokinetic medication from day 3, consider administering a small-volume enema via the stoma; initiate instructions for stoma care and nutritional counseling before discharge. Dietary Progression: Allow sips of dear liquid from day 1 to 2, solid diet if bowel movements are good and the stoma is functioning. Bowel Function: Consider antiprokinetic medication for the medium term (loperamide or similar agents~ Moblhzatfon: Immediately Physiotherapy: Breathing exercises Time Off Work: 1 to 3 weeks

5 Positioning Supine

6 Approach Midline laparotomy

284

Abdominal Cavity: Small Intestine

IGEndll..a..y

Operative Technique 0 0 0 0

Approach Siting the stoma Proximal resertion margin Preparation of the ileostDmy aperture I 0 Preparation of the ileostDmy aperture II 0 Preparation of the ileostDmy aperture ID 0 Preparation of the ileostDmy aperture IV 0 Preparation of the ileostDmy aperture V 0 Exteriorization of the tenninal ileum (0 Closure of potential hernial opening Enlarging the apertUre in the abdominal wall CD S1Dma creation I a> S1Dma creation D S1Dma creation m

m

m

o

Approach

Nowadays, end Ileostomy tends to be rather a rare procedure, given that usually a subtotal colectomy Is perfonned together with the creation of an lleoproctostomy for patients with Crohn disease and an lleoanal pouch Is fashioned for ulcerative colitis or familial adenomatosis of the colon. Total colectomy Is usually undertaken vfa a midline laparotomy. This Incision Is also best suited for an end Ileostomy, given that It leaves the rectus abdomlnls muscle Intact and thus allows the stoma to be burled In the region of the muscle. This muscule~r collar guards e~gainst a subsequent incisione~l hernia or prolapse.

o

Siting the stoma

The stoma site should be marked preoperatively. This Is best done using an Indelible martcer with the patient standing. The site usually lies on a line connecting the umbilicus and ttle anterior superior lilac spine, although Individual circumstances should be respected. Atrial wearing of ttle stoma appliance before surgery allows adjustment of ttle stoma position to allow for sk!n creases, bony prominences, and so forth, and consequently enables a later leak-proof flt.

.End •.......,

Abdomrnal Cavity: Small Intestine

o

Proximal resection margin

The Ileum Is transected as near to the cecal pole as possible. If It was possible to preserve the Ileocolic artery at colectomy, part of It Is left attached to the ileum. Bowel tr.msedion is ac· complished with a linear stapling device, which allows closure of bath lumina.

O Preparation of the ileostomy aperture I

O Preparation of the ileostomy aperture II

The layers of the abdominal wall at the midline lndslon are stabilized with the aid of towel clips and drawn medially to their original poslt:Jon. The sldn Incision Is drcumferentfal. It has prawn useful to grasp the skin with a towel clip and make a tangential excision with the scalpel. The subcutaneous adipose tissue Is divided w1tt1 a cutting diathermy and the fascia Identified.

The subcutaneous fat and the sldn are retracted with Kocher clamps. A crudate Incision Is made In the fascia with the cutttng diathermy.

285

286

Abdominal Cavity: Small Intestine

o

IGEndll..a..y

Preparation of the Ileostomy aperture Ill

The muscle is separnted bluntfy (e.g., wittJ scissors or an Overholt clamp). Any vessels encountered must be isolated and ligatEd. The inferior epigastric vessels in particular may lie in the region of tfle incision and should be securely ligated. Mere coagulation of these vessels with the dlathenny Is Inadequate.

o

Preparation of the Ileostomy aperture IV

After sufficientfy splitting tfle muscle longitudinally, it is held apart with Kocher clamps and Langenbeck hooks to allow identification of the peritoneum, which is incised in a cruciate or slitlike fashion.

0 Preparation of the ileostomy aperture V The aperture must be wide enough to comfortably accommodate two fingers. Duling this dissection, the entire abdominal wall Is grasped by the wound margins with towel clips and held together to prevent the layers of tfle abdominal wall from inadvertently retr.Jcting.

.End •.......,

Abdomrnal Cavity: Small Intestine

0 Exteriorization of the terminal ileum

~

Using a broad lung forceps, the terminal ileum is grasped inside the abdomen via the aperture and withdr.JWll from the abdominal cavity with mild tr.Jction. It must glide easily out to come to lie on the abdominal wall and must have a well-perfused mesen~ry. Viability of 1tle exteriorized bowel segment must be painstakingly examined; even an only slightly pale discoloration of the bowel segment requires the bowel to be resected back and refashioned.

The mese~ry is secured to the l~ral abdominal wall to close any potential hernial opening. This ~P is not obligatory and will not always be possible. If tttere is a large distance from ttte abdominal wall, the mese~ry may also be left unattached witttout any problem.

([) Enlarging the aperture In the abdominal wall It is essential not to entrap 1tle mesentery in the abdominal-wall aperture. In cross-section, 1tlere should be neither displacement of the layers of ttte abdominal wall nor entr.tpment of the mesenteric blood supply. If there Is any doubt. ttten the aperture should be widened once again using two flngers. Afterward the mesentery Is secured to the lateral abdominal wall by lntenrupted sutures (3-0 PGA).

Closure of potential hernial opening

287

288

Abdominal Cavity: Small Intestine

IGEndll..a..y

a

m Stoma creation I The prominent end of tile lla~m Is skeletonized between OVerilolt clamps over a distance of -5 em. The mesentery should be resected close to the bowel.

b

c:

a> Stoma creation II

~

The tenninal staple line is removed witfl scissors, after which the cut surface of the small intestine should demonstrate obvious bleeding points. Some vessels may require selective coagulation. It is recommended, however, to secure tile bowel to tile subcutaneous tissue beforehand witt. a stay suture to prevent .stoma recession.

The most importmt step in creating a stoma is the formation of a prominent spout. For tilis purpose, tile bowel wall is everted like tile fingers of a glove and tile bowel secured to tile abdominal w.~ll with mucocutaneous interrupted sutures. Eversion is facilitated by either carefully grasping tile margin of 1tle bowel with lung forceps {a) or everting with tile aid of a peanut swab (b). In either case, complete prominence of tile stoma Is guaranteed by the suitable placement of sutures. The sutures should grasp the extemal bowel wall at the lower part and thus secure tile prominence of the stoma (c). Attachment of the .stomal appliance completes the operation.

Stoma creaUon Ill

91 Loop Ileostomy

1 Indications

7 Operative Steps

Elective: Protective measure after subtotal colectomy or after proctocolectomy with pouch creation Alternative Procedures: End ileostomy after the Hartmann discontinuity resection.

0 0

2 Preoperative Preparation Preoperative Investigations: Depends on the underlying disorder: endoscopy plus biopsy, contrast imaging Patient Preparation: Explain the temporary stoma (consider referral to an enterostomal therapist). Mark the stoma site and check it with the patient in a standing and supine position. Perform orthograde bowel lavage, and provide perioperative antibiotic treatment

3 Specific Risks, Patient Information, and Consent Depends on the underlying disorder, but with particular reference to ileostomy (totaling as much as 15%): ~ Retraction, stenosis, and prolapse of the stoma ~ Parastomal hernia ~ Peristomal skin damage ~ Loss of fluid and electrolytes via the stoma

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Midline laparotomy

0 0 0

0

Siting the stoma Placing the sling beneath the ileal loop Positioning the ileostomy rod Opening the small intestine Stoma creation I Stoma creation II

8 Relevant Anatomy, Serious Risks, Tricks ~

~

Always position the stoma within the rectus abdominis muscle. For this purpose, bluntly separate the muscle, do not incise! After securing the ileostomy rod, incise the small intestine immediately above the level of the skin, on the side of the efferent limb, and evert the caudal bowel wall: this will result in a largely prominent stoma.

9 Measures for Specific Complications Stoma complications: optimize stoma care, otherwise do revision surgery

10 Postoperative Care Medical Aftercare: Remove the ileostomy rod after 10 days, remove the nasogastric tube on day 1 to 3, consider administering a smallvolume enema via the stoma and prescribe prokinetic medication from day 3. Dietary Progression: Allow sips of clear liquid from day 1 to 2, solid diet if bowel movements are good and the stoma is functioning. Mobilization: Immediately Physiottlerapy: Breathing exercises Time Off Work: 2 to 4 weeks

290

Abdominal Cavity: Small Intestine

Operative Technique 0 0 0 0 0 0

Siting the stoma Placing the sling beneath the ileal loop Positioning the ileosiDmy rod Opening the small intestine Stoma creation I Stoma aeation n

! .... •\

... -~~.

o

Siting the stoma

The loop Ileostomy Is usually placed In the right lower abdomen, In projection of the lateral rectus abdomlnls muscle and Is only rarely a definitive procedure. A weiJ..est:abllshed Indication Is presented here, takIng the Ileal pouch-anal anastomosis as an example. Recommendations for positioning the afferent and efferent limbs are often contradictory. We have abandoned tfle idea of always placing the afferent limb in a caudal position in favor of the principle of ensuring as little ~tion on the mesentery as possible. We therefore orient tfle prominent stnmal part of tfle afferent limb according to the mesenteric axis (I.e., in a cranial position). This avoids any rotation and facilitates later reconstruction.

o

Placing the sling beneath the ileal loop

A rubber sling Is passed beneath the terminal Ileal loop, close to the bowel wall, with the aid of an OVemolt clamp. The stnmal aperture In the abdominal wall coJTesponds to that for an end lleostnmy (cf. chap. 90, p. 284) and must comfortably accommodate two fingers.

11 I.Gop .........,

o

Positioning the ileostomy rod

Abdomrnal Cavity: Small Intestine

0 Opening the small intestine

An Ileostomy rod Is passed beneath the small-bowel loop with the aid of an OVerholt clamp over the abdominal wall where It Is secured.

The Ileostomy rod Is afftxed to the skin with lnteiTUpted sutures to prevent It from slipping and the small-bowel loop from retracting. The small bowel is 1tten opened aS)'I'I'Imetrically and transversely with the cutting dlathenny, so that 1tte larger of 1tte bowel-wall flaps Is on 1tte side of 1tte afferent limb.

o

o

Stoma creation I

The afferent limb is everted with the aid of a Duval damp and a peanut

swab. The everted proximal end is sutured as a prominent ileostomy with mucocutaneous lnteiTupted stitches, which Include the bowel-wall cosa In each bite.

m~

Stoma creation II

The distal part of the stoma is secured at skin level with interTUpted stitches (PGA 3-G). Attachment of the stomal appliance compl~ the operatlon.

291

92 Appendectomy

1 Indications

5 Positioning

EJecHve/Absolute Indications: Oinically unequivocal tenderness of the right lower abdomen, which is reprodudble, in cases of doubt, at short-term interval checks (i.e~ every few hours). Contralndlcatlons: None Alternative Procedures: Laparoscopic procedure

Supine

6 Approach Oassic McBurney incision, transrectal or paramedian approach, occasionally also lower midline laparotomy

2 Preoperative Preparation Preoperative Investigations: Ultrasound, laboratory, and gynecological examinations and findings have merely a supplementary character and serve mainly to exclude other disorders.

3 Specific Risks, Patient Information, and Consent ... ... ... ... ... ... ... ...

Laparotomy is the only sure procedure to prove or exclude an acute appendidtis in the presence of relevant symptoms. Appendiceal stump leakage (< 2%) with fistula formation or peritonitis The presence of Crohn disease or a Meckel diverticulum Abscess formation (intra-abdominal < 5%) Bowel obstruction from an adhesion band (< 4%) Injury to the ilioinguinal nerve Wound infection (as high as 30% in cases of purulent phlegmonous inflammation) Mortality ranging from 0.2% (uncomplicated appendidtis) to as high as> 10% (perforation, peritonitis)

4 Anesthesia General anesthesia (intubation)

7 Operative Steps 0 0 0 0 0 0 0

Access Division of the external oblique aponeurosis Splitting the muscle Indsion of the peritoneum Mobilization of the cecum pole Delivering the cecum pole into the wound Anatomy of the appendix 0 Skeletonization of the appendix 0 Crushing the base of the appendix a!l Ugation and removal Inversion of the appendiceal stump Peritoneal suture (I) Muscle suture ttl Suture of the external oblique aponeurosis Retrocecal appendix Retraction sutures Antegrade appendectomy (0 Mobilization of the ascending colon (t) Delivering the retrocecal appendix forward

m

m

m m

m

8 Relevant Anatomy, Serious Risks, Tricks

9 Measures for Specific Complications

~

Abscess: revision surgery and adequate drainage, consider digital location of an abscess in the pouch of Douglas, followed by transrectal drainage.

~

~ ~

~

~ ~

~

~

~

~

~

~

The diagnosis is a clinical one; normal ultrasound examination and normal laboratory inflammatory parameters do not exclude an acute appendicitis) With very young and very old patients and very obese individuals, the symptoms are often discrete, even in the presence of extensive inflammation. Always place the indsion below the line connecting the two anterior-superior iliac spines. A slightly oblique indsion allows better exposure in cases of atypical location by extension of the incision in a curvilinear fashion laterally and cranially, with a corresponding notch in the internal oblique muscle; also consider extending the incision medially to include the rectus sheath. Course of the ilioinguinal nerve over the internal oblique muscle The position of the appendix is extremely variable; especially with a retrocecal location. the symptoms are often discrete. The taeniae are a guide for locating the appendix. It may be advisable for equivocal cases, especially female patients, to begin with laparoscopy and then go on to perform a laparoscopic appendectomy. A noninflamed appendix will require further exploration of the abdomen: mesenteric lymph nodes, terminal ileum, Meckel diverticulum, ovaries, and fallopian tubes. With a gangrenous appendicitis, the purse-string suture must be placed in the intact wall of the colon. Generous drainage of the abscess region will suffice for an appendix that, having disintegrated within the abscess cavity, is no longer identifiable and where there is also considerable inflammation of the colon wall. Where the colon wall is very edematous, a simple ligation of the appendix stump without inverting it with a purse-string suture will also suffice. After appendectomy for a significantly inflamed (i.e., phlegmonous or gangrenous) appendix, do not proceed to explore the small intestine because of the risk of spreading bacteria into the abdominal cavity.

10 Postoperative Care Medical Aftercare: Remove the nasogastric tube on day 1, antibiotic treatment begun intraoperatively for a perforated appendix should be continued. Remove drainage on day 2 to 4. Dietary Progression: Allow sips of clear liquid on the evening of day 1, solid diet from day 2 to 3. Bowel Function: Consider small-volume enema or mild oral laxative. Mobilization: Immediately Time Off Work: 1 to 2 weeks

294

Abdominal Cavity: Large Intestine

Operative Technique 0 0 0 0 0 0 0 0

0 (0

CD CD

a>

m m m

m CD

(D

Access Division of the external oblique aponeurosis Splitting the muscle Incision of the peritoneum Mobilization of the cerum pole Delivering the cecum pole Into the wound Anatomy of the appendix Skeletonization of the appendix Crushing the base of the appendix Ligation and removal Inversion of the appendiceal stump Peritoneal suture Muscle suture Suture of the external oblique aponeurosis Retrocecal appendix Retraction sutures Antegrade appendectomy Mobilization of the ascending colon Delivering the retrocecal appendix forward

o

Access

The skin incision is horizontal, following the direction of the relaxed skin lines, slightly above the extension of the pubic hairline. It should be placed clearly below tile line connecting the anterior-Inferior lilac spine and tile umbilicus. A paramedian Incision Is an alternative, although It does leave a poor cosmetic result

o

Division of the external oblique aponeurosis

After Incising the skin, subdennls, and Scarpa suba.ttaneous fascia, the external oblique aponeurosis Is ldentitled. It Is divided In a laterocranlal to mediocaudal direction, along the direction of the flbers. (The Illustrations show the surgical site from the surgeon's view: left - top, right bottom).

o

Splitting the muscle

The internal oblique and the transversus muscles are identified and blurrtly spread apart with scissors and forceps. Pay due regard to the intennediate layer between the musdes, which is particularly distinct laterally. The muscles are held apart with two Roux retractors.

Abdominal Cavity: Large Intestine

o

lndslon of the peritoneum

o

Mobilization of the cecum pole

After the muscles have been held apart by retRctors, the tr.msverse fascia and the peritooeum are exposed. They are divided between for· ceps, the direction of incision being oblique to the vertical axis.

After opening the peritoneum, the cecum pole is located and the c~um mobilized. Careful traction with the fOI'C.l!ps (C~uUon: Watch out for crushing the bowel wall) will allow identification of the cecum and the attrched vennifonn appendix.

o

o

Delivering the cecum pole into the wound

After definite identification, the c~um is grasped with a damp swab and delivered fo~w.~rd into the wound. This is facilitorted by applying anterior traction alternatively in a caudal and cranial direction, lifting the cecum forward In a stepwise fashion.

Anatomy of the appendix

The vennifonn appendix lies in the extension of the taenia Iibera (anterior taenia). The mesoappendix extends behind the ileum, over the mar· ginal arcade of the ileocolic artery. Skeletonization of the mesoappendix thus proceeds on the posterior surface of the Ileum.

295

296

Abdominal Cavity: Large Intestine

.---,_______

-

0 Skeletonization of the appendix

0 Crushing the base of the appendix

After tile cea.Jm pole has been delivered completely Into tile wound, the mesoappendix Is grasped with a Pean clamp. Skeletonization of the a~ pendlx commences close to tile bowel wall wlttl Olledlolt clamps. dM~ lng tile vessel In a serial fashion. Attention must be paid to tile adjacent artefy, which must be deflnltely ldentifled and ligated.

After completely skefetonlzfng the appendix. Its base Is tilen aushed with a clamp. This crushing maneuver serves to devlti!ll:ze the mucous membrane and avoid subsequent mucocele fonnatlon. In tile light of experience gained from laparoscoplc appendectomy, howewr, tills maneuver hardly seems to have any rational justification. A ligation suture placed In tile crush mali< Is less able to cut tilrough an appendix swollen by I~ flammatlon and edema.

(0

Ugation and removal

The appendix Is ligated In tile crush mark and transected aver a swab wlttl a scalpel. 0.5 em distal to the mark. The scalpel, swab, and appendix are now contaminated with bowel contents and, for reasons of asepsis, should be handed to tile scrub nurse for separate disposal.

Abdominal Cavity: Large Intestine

m Inversion of the appendiceal stump The appendiceal stump is inverted into tne cecum with a purse-string suture, using a separate forceps. Prior to tnis, tne stump is cleansed with a disinfection solution (e.g., Betrdine).

~

Peritoneal suture

The peritoneal margins are iderrtified with four Mikulicz damps and the peritooeum approximated with a continuous absorbable suture (2-0 PGA).

CD Muscle suture

(tl

Suture of the external oblique aponeurosis

Closure of tne transversus and lrttemal oblique muscles Is accomplished w1tt1 deep lntem.Jpted sutures (2-0 PGA).

The external oblique aponeurosis may be repaired with a running suture (2-0 PGA) or, In tne presence of severe Inflammation, wlttl lnterTupted sutures.

297

298

Abdominal Cavity: Large Intestine

~

Retrocecal appendix

Of the numerous normal variations of the appendix, the retrocecal position is dte most common. It sometimes renders the approach unclear

and technically demanding. Consider extending a tr.msverse lower abdominal incision medially or laterally to form a complete right transverse lower abdominal incision and to achieve a better ovenliew.

tt> Retraction sutures

m Antegrade appendectomy

If dte appendix Is so adherent to the retroperltona~m dtat It Is Impossible to deliver It forward, then drawing the cea.Jm laterally sometimes permits dte appendix bed to be positioned to allow Its excision under direct vision. However, even this Is often not possible, so that the appendix will have to be delivered In an antegrade manner. For this purpose, It Is recommended to apply several stay sutures (•retraction sutures") to the appendix In a serial fashion In order to mobilize the appendix In steps of 1 to 2 em.

After transectlng dte appendix. the stump Is closed and Inverted with the aid of a purse-:mlng suture. The next stage Is the stepwise mobilization and separation of the appendix, together with Its mesentery. care should be taken to extract the whole appendix In Its entirety.

Abdominal Cavity: Large Intestine

m Mobilization of the ascending colon With a long appendix and severe retrocecal fixation, It Is sometimes unavoidable to have to release ttae ascending colon from Its adhesions and displace it medially. The later.~l adhesions are usually avascular, altnough it is recommended to place damps when required.

\D

Delivering the retrocecal appendix

After complete mobilization of 1tte cecal pole, it 1tten becomes possible to mobilize the appendix under direct vision. This maneuver should be petformed with caution, given 1ttat 1tte appendix may be in the immediate 'llldnlty of ttae r1ght ureter and 1tte duodenum, rendering 1tt~r Injury a posslblllty.

299

93 Laparoscopic Appendectomy

1 Indications

7 Operative Steps

ElecUve-Relatlve Indications: In the course of a diagnostic laparoscopy (e.g., for lower abdominal pain of unclear origin). For extreme obesity and suspected, yet uncertain. appendicitis in young women (after exclusion of any underlying gynecological cause). Contralndlcatfons: Generalized appendicitis (suspected free perforation); suspected malignancy; high suspicion of significant adhesions Alternative Procedures: Conventional procedure

0 0

2 Preoperative Preparation Preoperative IIMi!stlgatlons: illtrasound, laboratory, and gynecological examinations and findings have merely a supplementary character and serve mainly to exclude other disorders. Patient Preparation: Disinfect the umbilicus on the ward. Insert a nasogastric tube and urinary catheter after induction of anesthesia (or alternatively, empty the bladder directly before the operation).

3 Specific Risks, Patient Information, and Consent ... ... • ... •

Injury to a hollow viscus or vascular injury by laparoscopic instruments Error during creation of pneumoperitoneum Gas embolus Conversion to a conventional procedure Otherwise, as for conventional appendectomy (cf. chap. 92, p. 292)

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine Surgeon on the left Assistant (and camera) on the right Video unit at foot end

6 Approach Camera trocar: umbilicus: working trocars: left and right lower abdomen

0 0 0

0 0 0 0

m

m

Approach Identification of the appendix Skeletonization of the appendix Bleeding from the mesoappendix Ugation of the appendix Ugation of the appendix base Suture removal Coagulation of the appendix stump Transection of the appendix Drainage Endo-GIA usage

8 Relevant Anatomy. Serious Risks, Tricks A safe, albeit more expensive, alternative to ligating the appendix base with a Roeder loop is transection using an endoscopic stapling device to simultaneously grasp both the appendix and appendix mesentery. CDution: watch out for secondary hemorrhoge due to differences in tissue

layer thidtness.

Watch out for injury to the colon wall from leakage current or the effect of heat when coagulating the appendix near to the colon.

9 Measures for Specific Complications ... ...

Trocar lesions: repair after laparotomy Appendiceal stump leakage secondary to transmural coagulation or loop slippage: laparotomy

10 Postoperative Care Medkal Aftercare: Remove the nasogastric tube after completion of anesthesia. Remove the drain on day 2 to 4. Dietary Progression: Allow sips of dear liquid 6 hours after anesthesia, normal light diet from day 1. Mobllzatlon: Immediately lime Off Work: 3 to 5 days

Abdominal Cavity: Large Intestine

Operative Technique 0 0 0 0 0 0 0 0

0

Approach Identification of the appendix SkeletDnization of the appendix Bleeding from the mesoappendix Ligation of the appendix IJga.tion of the appendix base Suture removal Coagulation of the appendix stump Transection of the appendix

(0 Drainage CD Endo-GIA usage

o

Approach

Laparoscopic appendectomy is justified for diagnostically equivocal find· ings, partiaJiarfy in young women, to reach a diagnosis and possibly for treatment It is not superior to the indicated and ther.Jpeutically intended appendectomy, but definitely more expensive. Access is via three trocars, of which one lies In an lnfraumblllc.al locat:Jon and two lngulnally, etther side of the pubic hairline. The operation begins with the creation of a pneumoperitoneum via the lnfraumblllcal trocar. The camera Is Introduced under direct vision using transillumination to avoid InJury to the epigastric vessels, followed by Introduction of the other two trocars In the Inguinal region.

o

Identification of the appendix

After exploration of the abdominal cavity, the appendix Is ldentitled. It Is grasped with the grasping forceps via the right trocar and gradually drawn into the trocar sleeve.

301

302

Abdominal Cavity: Large Intestine

o Skeletonlzatlon of the appendix The mesoappendix is coagulated with the bipolar diathermy forceps and divided piecemeal. This maneuver is time consuming and may possibly cause bleeding. Using the linear sQpler (see Fig. 93.11, page 304) will

considerably facilitate skeletonlzatlon of the appendix. but It Is also more expensive.

0 Bleeding from the mesoappendix Pulsatile bleeding from the appendicular artery occasionally oocurs durfng skeJetonization of the appendix. The artery must be grasped with the dlathenny forceps and coagulated. Ugation with a Roeder loop Is recommended for more significant bleeds.

Abdominal Cavity: Large Intestine

O Ligation of the appendix base When tne Roeder loop is lying di~ly over tne base of tne appendix, it is drawn tight to ligate tne appendix.

o

Suture removal

The long tnread of tne Roeder loop is cut with scissors and removed.

o

Ugation of the appendix

The appendix Is skeletonized down to Its base and gradually withdrawn Into the trocar sleeve. Then a Roeder loop Is Introduced tnrough tne left trocar and slid over the appendix.

o

Coagulation of the appendix stump

The appendix may be coagulated wittl1tle bipolar diathermy forceps to avoid contamination. It is important here that the coagulation margin is at least 1 em distal to tne Roeder loop, otherwise leakage currents may cause coagulation neaosls at the appendix ligature or at the cecum pole.

303

304

Abdominal Cavity: Large Intestine

0 Transection of the appendix After optional coagulation of the appendix, It Is transected with scissors and wittldrawn into the right lower trocar. The trocar is removed, together with the appendix; the appendix stump is cleansed with a disin· fection swab and moved to a retroperilDneal position.

~

Drainage

Severe suppuration and periappendiceal abscess fonnation will require insertion of a drain in the retrocecal region or in the pouch of Douglas, via the right trocar opening, and final correct placement using the grasping forceps introduced through the left trocar.

m Endo-GIA usage Use of an Endo-GIA stapler is also possible and allows simultaneous tnmsection of the appendix and its mesentety, either in two stages or, witf1 a vefY thin appendix. in one. The Endo-GIA is introduced via the left inferior 12 mm trocar.

305

94 Loop Transverse Colostomy

1 Indications

7 Operative Steps

ElecUve: Defunctioning distal parts of the colon as a temporary/ diverting or palliative/permanent measure Contralndlcations: Proximal stenoses Alternative Procedures: Ueostomy, enteroenteral bypass

0 Siting the colostomy 0 Laparotomy

2 Preoperative Preparation Preoperative Investigations: Depends on the underlying condition:

ultrasound and plain abdominal X-ray are sufficient fur colonic obstruction, otherwise in an elective setting exclude further lesions in the intestinal tract and, with malignandes, an extraintestinal spread with the aid of endoscopy plus biopsy, ultrasound, computed tomography, consider contrast imaging of the large/small intestine (use water-soluble contrast medium in unclear situations). Patient Preparation: Place a nasogastric tube for colonic obstruction, and correct fluid and electrolyte imbalances. Provide perioperative antibiotic treatment Consider preoperative marking of the stoma site.

3 Specific Risks. Patient Information. and Consent .. .. .. ..

Peritonitis Injury to the stomach Stoma complications: prolapse, stenosis, retraction, parastomal hernia, peristomal skin damage (in total 5 to 10%) Possibility of stoma reversal or leave as it is

4 Anesthesia General anesthesia (intubation)

0 0 0

0 0 0

Identification of the right transverse colon Placement of a damp beneath the transverse colon Placement of the ostomy rod Oosure of the abdominal wall Opening the colon Securing the stoma

8 Relevant Anatomy. Serious Risks. Tricks ... .. ...

Place the stoma aperture in the region of the rectus abdominis muscle. Maintain sufficient distance from the costal margin (to facilitate care of the stoma appliance). With a very fat-laden omentum, consider detaching it from the transverse colon for a short distance to facilitate exteriorization.

9 Measures for Specific Complications Stomcl Complications: Optimize stoma care, otherwise perform revision surgery and renewed placement

10 Postoperative Care MediCill AfteTCCIIre: Depends on the overall situation .. After emergency operations, perform bowel lavage and complete diagnostic workup (e.g., endoscopy via the stoma). ... Remove the ostomy rod after 10 days. .. Instruct the patient and relatives on stoma care. Dietary Progression: Allow

5 Positioning Supine

6 Approach Short transverse upper right laparotomy, consider laparoscopic procedure using the three-trocar technique

sips of dear liquid from day 1 for a permanent stoma, solid diet once the stoma is functioning. Bowel Function: Administer a small-volume enema via the stoma from day 3. Moblhzatfon: Immediately lime Off Work: Depends on the overall situation

306

Abdominal Cavity: Large Intestine

!M 1.80p TnniWine Celaslamy

Operative Technique 0 Siting the colostomy 0 Laparotomy 0 Identification of the right transverse colon 0 Placement of a damp beneath the transverse colon 0 0 0 0

Placement of the ostomy rod OosW'e of the abdominal wall Opening the colon Securing the stoma

o

Siting the colostomy.

The creation of a tr.msverse loop colostomy is usually a preliminary operation to protect anastomoses of the distal colon or to defunction segmenl:$ of the colon. It is only rarely indicated as a definitive measure. The ideal siting for a colostomy is in the region of tne right upper abdomen, over tne right transverse colon. If only tne creation of the colostomy is intended, tnen a small transverse upper abdominal incision will suffice.

o

Laparotomy

After making a transverse skin incision, divide the subcutaneous layer with tne cutting diathermy. Identification of tne fascia and gradual division of tne lateral parts of tne rectus abdominis muscle. The muscle vessels must be individually grasped and coagulated. The superior epigastric vessels will occasionally need to be secured wltn ligatures. Simple blunt muscle splitting will also occasionally suffice for a poorly developed rectus abdomlnls muscle. After complete dMslon or splitting of the muscle, tne posterior wall of tne rectus sheatn is identified by appropriate traction with retractors. The posterior rectus sheath and peritoneum are divided under direct vision to avoid injury to deeper structures (e.g., adherent bowel).

Abdominal Cavity: Large Intestine

0 Identification of the right transverse colon After opening the abdominal wall, the light transverse colon often lies hidden behind the Qn!ater omentum. The close positional relationship of the greater gastric curvature to the transwrse colon fac!lltates orfentatlon In undear situations. The greater omentum must be detached piecemeal, especially when It Is very thick. using blunt and sharp dl~ tion while coagulating or ligating the vessels.

o

Placement of the ostomy rod

A rubber sling, or even the ostomy rod, can now be passed bene.rth the transverse colon. The length of the rod should be chosen so that it is wide enough after closure of the skin margins, yet does not interfere with the attachment of the stoma bag.

0 Placement of damp beneath the

transverse colon Mobilization is only required so much as to guarantee a tension-free exteriorization of the right transverse colon onto the abdominal wall. Preferably, a segment near to the right flexure should be selected for exteriorization, given that here the mesocolon is the longest. Palpation between the thumb and index finger will allow reliable identification of the boundary between the mesentery and bowel wall, where an 0\let'holt clamp Is Inserted beneattl the transverse colon, under the guidance of the palpating Index tlnger.

o

Closure of the abdominal wall

The ostomy rod is secured to the skin with interrupted sutures, after which the fascia is repaired from medial to lateral. After the final suture the fascial gap should still comfortably accommodate two fingers to allow afferent and efferent limbs sufficient space and adequate perfusion.

307

308

Abdominal Cavity: Large Intestine

!M 1.80p TnniWine Celaslamy

o Opening the colon

o Securing the stoma

The skin incision is partially closed on either side with a few interrupted sub.! res, witftout constricting the exteriorized bowel. The tr.msverse colon is opened using the scalpel. It should not be opened witft the diathenny to avoid a methane gas explosion. Bleeding from bowel-wall vessels can be sparingly coagulated after releasing the bowel gas.

The opened bowel wall is sewred on a level with the abdominal wall skin using mucocutaneous interrupted sutures (3-o PGA). Attachment of the stoma appliance completes the operation.

95 End Sigmoidostomy (Hartmann Procedure)

1 Indications

7 Operative Steps

Elective: Mter rectum amputation or discontinuity resection of the rectum Alternative Procedures: Reanastomosis after resection in the region of the distal colon and diverting transverse loop colostomy

0 Siting the colostomy 0 Approach

2 Preoperative Preparation Preoperative Investigations: Depends on the underlying condition: exclude further pathological alterations of the proximal colon or, with malignandes, an extraintestinal spread, especially by endoscopy plus biopsy, ultrasound, computed tomography, consider intravenous pyelogram (IVP). Patient Preparation: Perform orthograde large bowel lavage after excluding higher-grade stenosis, mark the stoma site and check it with the patient in a standing and supine position, explain the stoma (consider referral to an enterostomal therapist), provide perioperative antibiotic treatment.

3 Specific risks, Patient Information, and Consent .... .... .... .... .... .... ....

Depends on the underlying disorder, but with spedal respect to the ostomy Prolapse (5 to 15%) Ischemia (5 to 15%) Stenosis (2 to 10%) and retraction of the stoma Bleeding from the region of the stoma (< 10%) Parasternal hernia (5 to 15%) Peristomal skin damage (10 to 40%)

0 0 0

Mobilization of the rectosigmoid junction I Mobilization of the rectosigmoid junction II Mobilization of the proximal rectum 0 Resection 0 Oversewing the rectal stump 0 Stoma creation I 0 Stoma creation II a!> Stoma creation III CD Stoma creation IV ® Securing the stoma

8 Relevant Anatomy, Serious Risks, Tricks ....

Stoma aperture site in the region of the rectus abdominis musde must be wide enough to accommodate the sigmoid colon together with an adequate part of the mesocolon.

Caution: Avoid twisting the sigmoid colon when delivering it through the abdominal WDII,

....

The stoma must be placed loosely at the level of the skin; allow for a certain "reserve length" to avoid separation of the stoma secondary to distension of the abdominal wall.

9 Measures for Specific Complications Stuma Complications: Optimize stoma care, otherwise perform revision surgery and consider renewed implantation or renewed placement of the stoma

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine, lithotomy position

6 Approach Midline laparotomy, consider oblique extension above the umbilicus toward the left subcostal margin. Consider possible laparoscopic procedure using three- to four-trocar technique.

10 Postoperative Care Medical Aftercare: Depends on the overall situation, remove the nasogastric tube on day 1 or 2, initiate instructions in stoma care before discharge, provide advice regarding self-help groups. Dietary Progression: Allow sips of dear liquid from day 2 to 3, solid diet once the stoma is venting flatus or passing feces. Bowel Function: Administer a small-volume enema into the stoma and mild oral laxative from day 4. Mobilization: Immediately Physiotherapy: Breathing exercises Time Off Work: 2 to 3 weeks

310

Abdominal Cavity: Large Intestine

15 End SlgmaldasbNny (Hartmann ProcllduN)

Operative Technique 0 0 0 0

Siting the colostomy Approach Mobilization of the rectosigmoid junction I Mobilization of the rectosigmoid junction D Mobilization of the proximal rectum

0 0 Resection 0 Oversewing the rectal stump 0 Stoma aeation I Stoma aeation n (0 Stoma aeation m CD S1Dma aeation IV

0

CD Sealring the stoma

o

Siting the colostomy

The Hartmann procedure for colon resectlon serves the removal of deEp sigmoid colon and rectum lesions without restoratfon of continuity. It Is Indicated as a preliminary operation for Inflammatory diseases and tumors, but also as a definitive measure for unresectable tumors located in the peMc cavity. The prlndple Involves fashioning an end sigmoidostomy and creating a blind closure of the rectal stump. Even If the Hartmann situation is only produced as a temporary measure, a properly fashioned stoma is extremely impoltlnt The sigmoidostomy should alw.lys be created in a tnmsmuscular fashion, in the region of the lateral rectus abdominis muscle. The exact position is best detennined with the patient standing. In principle, the position lies in the middle third of the line connecting the umbilicus with the anterior superior lilac spine.

o

Approach

The conventional approach Is a lower midline laparotomy, which may be extended left around the umbilicus. Any Inflammatory or tumorous lesion In the lower abdomen can be easily Inspected and treated from this approach.

15 End SlgmaldasbNny (Hartmann Proclldure)

o

Abdominal Cavity: Large Intestine

Mobilization of the rectosigmoid junction I

After opening the abdominal wall and Inserting retractors, the sigmoid colon Is released from Its lateral adhesions. Careful traction on the sigmoid colon with the aid of Duval clamps or even manually has proven effective. Dissection should proceed Immediately adjacent to the bowel wall to avoid Injury to the ureter. The left ureter should always be identified to guarantee its protedion.

o

Mobilization of the rectosigmoid junction II

Complete mobilization of the sigmoid colon requires detachment of the Inflammatory or neoplastic tumor from the lateral abdominal wall. If possible, the bowel may be encircled with a sling, Immediately proximal to the tumor. Release of lateral adhesions Is continued until a free part of the proximal rectum is reached. The ureter can be identified as it crosses over the iliac vessels retroperiltlneally, together with the spermatic/ owrian vessels coursing parallel to it.

311

312

Abdominal Cavity: Large Intestine

15 End SlgmaldasbNny (Hartmann ProcllduN)

o

Mobilization of the proximal redum

Mobilization must often be continued dO'M'I Into the peMc cavity In order to adequately release the rectum from Its retroperitoneal adhesions. This may possibly achieve a valuable length of bowel to be able close the rectum safely in a healthy segment The mesorectum is divided between Over· holt clamps and secured with suture ligatures (3-o PGA).

o

Resedlon

Once the rectum has been mobilized and the mesorectum skeletonized, the rectum can be transected. This may be achieved in an open fashion between stay sutures, with the closure of 1tle bowel being achieved with lnteiTUpted sutures. We prefer resectlon with the use of theTA-55 stapling device. It Is used twice: once In 1tle region of the proximal and then, as lllustrated, In the region of the distal resection margin. The lumen of the bowel to be resected Is dosed on either side with Kocher clamps.

o

Oversewlng the rectal stump

The staple line at the blindly closed rectill stump is also oversewn with inteiTUpted sutures (3-0 PGA). The mesorectum area is once again checked for hemostasis. Then the end sigmoidostomy is fashioned in the same conventional form as for a rectum amputation.

15 End SlgmaldasbNny (Hartmann Proclldure)

o

Stoma creation I

After placing the abdominal wall on streb.:h with a towel clrp holding the wound margin, a circumferential Incision Is made at the preoperatively marked site. Here too, use of a towel clrp has proven helpful. The subcutaneous tissue is divided with the cutting diathermy and the muscle

o

Abdominal Cavity: Large Intestine

Stoma creation II

The t.Jsda Is Incised In a cruclate fashion and the muscle Is separated bluntly and held apart with retractors. The peritoneum Is Identified In the depths and also Incised In a cruclate manner. The aperture must comfortably accommodate at least two fingers.

fascia identified.

m Stoma creation Ill

«l Stoma creation IV

The bowel end, which had previously been closed with the mple line, is brought through the .stomal aperture and may be preliminarily secured at skin level with an Interrupted suture to prevent It from retractlng back Into the abdomen. Intra-abdominally, the lateral opening between the lateral peritoneum and bowel limb Is closed with a pursMtrlng suture to prevent the formation of an Internal hernia.

Resection of the mple line opens the bowel lumen, which is then cleansed with a swab soaked in polyvidone iodine. Any escaping bowel contents are Immediately suctloned.

313

m Seruring the stoma The stoma Is secured with mucocutaneous lnterTUpted sutures (3-0 PGA). The sttlma should always be bloodless but viable (I.e., the mucosa should present a rosy coloration). lMd discoloration wllllnevltably require resection of the bowel back to healttly tissue and refashioning of the stoiTiil. AppllGitlon of the sttlma appliance completes the operation.

315

96 Stoma Closure

1 Indications

8 Relevant Anatomy, Serious Risks, Tricks

ElecUve: The stoma is no longer needed; the timing of closure is determined more by general drcumstances than by when the stoma was created: from week 4 to 6 after construction of a diverting stoma. Contralndlcatfons: Distal stenosis, anastomotic failure, or dysfunction

...

... ...

2 Preoperative Preparation Preoperative Investigations: Investigation of the distal segment: endoscopy or contrast imaging Patient Preparation: Orthograde lavage as well as irrigation of the distal limb for colostomies, perioperative antibiotic treatment

With an ileostomy (also as with unclear situations in general) it is often advisable to resect the stoma completely and create a formal end-to-end anastomosis. Ensure adequate excision of the stoma skin margins: do not attempt reanastomosis using edematous or scarred margins Confirm patency of the anastomosis with the index fingerthumb test.

9 Measures for Specific Complications ...

Anastomotic failure: provided a distal obstruction has been excluded and there is good drainage and absence of inflammatory signs, a spontaneous closure under parenteral nutrition may be expected. Wound breakdown: open the wound widely and await secondary healing.

3 Specific Risks, Patient Information, and Consent

...

... ... ... ...

10 Postoperative Care

Anastomotic failure/fistula (< 1 0%) Intra-abdominal abscess (< 5%) Wound breakdown (10 to 20%) Anastomotic stricture

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Short, elliptical, circumferential incision of the stoma

7 Operative Steps

0 0 0 0 0 0

Circumferential indsion of the stoma Dissection at the subcutaneous level Dissection at the fascia level Dissection of the bowel wall Suture of the bowel wall dosure of the laparotomy wound

Medical Aftercare: Remove the nasogastric tube on day 1 or 2, the suction drain on day 2, and the abdominal drain on day 5 to 7. Dietary Progression: Allow sips of dear liquid from day 3, solid diet once the stoma is venting flatus or passing feces. Bowel Function: Prokinetic medication from day 4, consider mild oral laxatives from day 5 to 7. Moblllzalfon: Immediately lime Off Work: 2 weeks

316

Abdominal Cavity: Large Intestine

Operative Technique 0 0 0 0 0 0

Circumferential incision of the stoma Disse Dissection margins The plane of dissection Is better demonstramd In ttte sagittal plane. It proceeds Immediately In front of the sacrum, taking care not to InJure the presacral Waldeyer fascia. Dissection continues down to the muscular floor of tile pelvis, in ttte region of ttte levator muscles. Anteriorly, the retrovesical plane is developed, while protecting the Denonvilliers fascia. Seminal vesicles and ttte prostate gland should remain covered by ttte fascia. The resection margin for a low arrterlor resection lies Immediately over the pelvic floor, le 50%)

~

~

~

4 Anesthesia

Injury to the presacral veins between the Waldeyer fascia and the periosteum of the sacrum: bleeding from the veins indicates that dissection is proceeding in too deep a layer (exception: direct tumor invasion), attempt to achieve hemostasis by suture ligation, coagulation, and possibly bone wax (injured veins retract into the sacral foramina), if not achieved promptly: local application of hemostatic agents and packing. Presacral dissection should always be sharp dissection under direct vision until gaining access below coccygeal level, then dissection may proceed bluntly with a finger in a lateral direction to be able to better define the lateral ligaments (the socalled paraproctia). Preservation of male erectile function requires protection of the fibers of the hypogastric nerves: the preaortal nerve plexus, which courses in several cords on its respective side of the body down over the sacral promontory on the posterolateral pelvic wall. Always identify the ureter: it crosses over the iliac artery at the latter's division into its external and internal branches ( characteristic contraction of the ureter after mechanical irritation). Transect the inferior mesenteric artery distal to the origin of the left colic artery (-4 em from the aorta), high division is only necessary in the presence of suspicious lymph nodes in the region of its origin. Colostomy creation: always in the region of the rectus abdominis muscle, ensure a good blood supply in the region of transection as well as sufficient length.

General anesthesia (intubation)

5 Positioning

9 ~

Supine, lloyd-Davies modified lithotomy position

6 Approach Midline laparotomy, extension of the incision above the umbilicus to the left subcostal margin; vertical elliptical circumferential incision around the anus. Consider a laparoscopic approach with an open perineal stage to retrieve the specimen.

7 Operative Steps

0 Siting the stoma and approach 0

Criteria for resection

0 Stoma creation I 0 Stoma creation II 0

Stoma creation Ill 0 Stoma creation IV 0 Closure of the anal canal 0 Perirectal dissection 0 Dissection of the pelvic floor I Cl) Dissection of the pelvic floor II Dissection of the pelvic floor Ill

m

~

Measures for Specific Complications Perineal wound breakdown: at signs of infection (fever, raised white blood cell count, local tenderness) open up the wound and irrigate. Impaired intestinal transit: if the stoma is still not functioning after 6 or 7 days, consider contrast imaging of the bowel (watersoluble contrast medium).

10 Postoperative Care Medical Aftercare: Remove the nasogastric tube on day 2 to 4 and the abdominal and perineal drains on day 5 to 7. Continue perioperative administration of antibiotics for -7 days. Remove the bladder catheter on day 2 to 4. Dietary Progression: Allow sips of clear liquid from day 3 or 4, solid diet after the first postoperative bowel movement via the stoma approximately from day 7. Bowel Function: Consider applying an enema via the stoma from day 4 and IV administration of a prokinetic agent. Mobilization: Immediately Physiotf1erapy: Breathing exercises Time Off Work: 2 to 4 weeks

370

Abdominal Cavity: Large Intestine

1G&Radum......,n

Operative Technique 0 Siting the stoma and approach 0 Criteria for reseaion 0 Stoma creation I 0 Stoma creation D Stoma creation m Stoma aeation IV OosW'e of the anal canal Perirectal dissection 0 Dissection of the pelvic floor I (0 Dissection of the pelvic floor II Dissection of the pelvic floor Ill CD Dissection of the pelvic floor IV a> CIOSW'e of the pelvic floor

0 0 0 0

m

O Siting the stoma and approach Before surgery, the stoma site should be marked on the patient In a standing position. The trial attachment of a stoma bag has proven useful for this purpose. The approach corresponds to that for an anterior rec:tum resection (I.e., a low midline laparotDmy Incision, which Is extended around the umbllrcus toward the left subcostal margin). The following dissection down to the pelvic floor corresponds to that for a low anb!rlor resection. The decision for a low' anterior resedion or an abdominoper· ineal resection may remain open until reaching the level of the peMc floor.

o

Criteria for resedion

An abdominoperineal rectum resection must be perfonned If the sphincter apparatus has been invaded by the tumor or the lower border of the tumor lies lower than 4 em above the anocutaneous line. For this purpose, the bowel Is transected In the region of the rectosigmoid jun~: tion and the two ends are closed as blind stumps. This may be achieved either by a strong ligature or with the aid of a stapling device. The sigmoid colon Is first reflected cranially. The surgeon continues dissection from an anterior approach down to the pelvic floor and mobilizes the rectal stump around its entire circumference. Resection of the rectum is, however, the last stage of the operation.

1•1ac1um.._...n

o

Stoma creation I

o

Abdominal Cavity: Large Intestlne

Stoma creation II

The creation of a sigmoid colostomy does not differ from the technique already described for a Hartmann procedure (cf. chap. 95, p. 309). The abdominal wall Is grasped with a towel clip and drawn medially to rts original position. The marked stoma site is also grasped with a towel clip. The stoma is excised circumferentially with a scalpel.

The rectus abdomlnls muscle Is separated bluntly and held apart wlttl retractors. As done previously w1tt1 the anterior fascia, a cruclate Incision Is made In the transversus fascia and the peritoneum to create an aperbJre that will comfortably accommodate two fingers.

0 Stoma creation Ill

0 Stoma creation IV

To avoid a subsequent Internal hemla, It Is Important to close the gap between the abdominal wall and sigmoid colon w1tt1 a pursMtrlng suture. On completion of this suture and exteriorization of the stump of the sigmoid colon through the stoma aperture, the abdominal cavity Is liTigated, the pelvic cavity is drained with two easy-flow drains, and the abdominal wall is closed after inserting a subcutaneous suction drain.

To avoid contamination of the wound, the abdominal subJre line Is flrst covered w11t1 a spray dressing and sterile swabs. Only then Is the blind stump of the sigmoid colon limb opened. Fixation of the stoma at skin level with lnb!rrupted subJres Is similar to the previously described technique (cf. chap. 95, p. 309).

371

372

Abdominal Cavity: Large Intestine

o

1a&Radum......,n

Closure of the anal canal

After pladng tile patient In the lithotomy position, the perineal sttge of the operation Is begun. Here tile anus Is closed with a strong purse-string suture (size 2 polypropylene), tile skin around it is incised in tile fonn of an ellipse, and tile subdennis is gradually coagulated with tile cutting diathenny (intell\lpted line).

o

Perirectal dissection

The perirectal fat Is dMded under vision with the cutting dlathenny; larger vessels must be selectively grasped and ligated or coagulated. Dissection p~s piecemeal and circumferentially, changing tile position of 1tle retractors and applying traction on the purse-string suture in 1tle course of 1tle procedure.

o

Dissection of the pelvic floor I

On reaching 1tle muscular floor of tile pelvis, dissection should proceed away from 1tle recrum to achieve local radicality and to avoid opening the rectum, which would result in contamination or b.Jmor seeding. The vessels, especially the inferior rectal artery, must be isolated, divided between Overholt damps, and ligated. The muscles of 1tle pelvic floor should be divided gradually, while meticulously securing hemostasis. The ligamentous attachments to 1tle coccyx must be dMded; It Is occasionally helpful to detach 1tle coccyx at tile sacrococcygeal ligament and remove lt. Orientation and dissection are facilitated by carefully creating a gap on etther side of the coccyx by sharp dissection to allow the Intraperitoneal Insertion of a flnger to hook onto, and place on stretch, tile levator muscles.

1•1ac1um.._...n

Abdominal Cavity: Large Intestlne

€0 Dissection of the pelvic floor II The finger Is hooked around the levator muscle, while the Waldeyer fascia may Initially be swept cranially. It Is recommended to ligate the muscles, given that vessels often course within them.

\

€D Dissection of the pelvic floor Ill DMslon of the levator muscles on either side largely frees up the rectum from Its supporting structures. The layer visible posteriorly, down In the deptlls, Is the Waldeyer fascia. If not done already, It should now be dMded sharply to avoid any Inadvertent detachment of the presacral fascia, which would result In hemonftage and possibly nerve InJury. With the peritoneal cavity open, the surgeon can now grasp the rectJI stump from a sacral direction and extract any abdominal towel, which may have been previously placed in the lesser pelvis. If undertlking a synchronous abdominoperineal approach, the hand of the perineal operator will now encounter that of the abdominal operator.

373

374

Abdominal Cavity: Large Intestine

1a&Radum......,n

(f)

Dissection of the pelvic floor IV

The rectum is now retracted posteriorly to expose 1tle anterior muscle group. Special care Is needed In this phase of the operation to avoid Injury to the urethra. It should be stented, and thus marlred, with a bladder catheter. The pubococcygeal muscles are gradually divided on either side between the rectum and prostate gland and between the rectum and bladder. Here too, It has proven useful to hook a finger around the muscle group to protect deeper-lying structures. Dissection continues anteriorly on the Denonvilliers fascia. The puborectal muscle with its two bellies is also divided between clamps and ligated. The final sttge is the division of the pelvic fascia, which extends to the prostrte. Prostate and seminal vesicles are Identified and protected. After complete anterior dissection and provided that Intra-abdominal dlssect:Jon has already reached the pelvic floor, the rectum should now be completely free. If not, the remaining portions of the lateral ligaments will require division. The proximal rectal stump Is now manually exteriorized, grasped with a Duval clamp, and delivered in a lJ.shaped fashion posteriorly, placing the final anterior muscular str.mds on stretch. The rectum, together with 1tle sphincter apparatus, is now completely excised.

a> Closure of the pelvic floor Removal of the rectum Is followed by meticulous hemostasis and the Insertion of a size 16 suct:Jon drain Into the pelvic cavity. The muscles of the peMc floor are approximated, as far as possible. with lntenrupted sutures. A

second size 10 suction drain is placed subcutaneously, while subcutaneous sutures and skin sutures complete the operation.

107 Adrenalectomy 1 Indications

7 Operative Steps

ElecUve: Hyperplasia or neoplasia of the suprarenal gland Relative Indications: Hormone-producing tumor of the brain. which is not amenable to direct therapy and results in bilateral hyperplasia of the suprarenal glands Alternative Procedures: Minimally invasive approach (rare occurrence and only for unilateral findings)

0 0 0

0 0

0 0

Approach Anatomy Identification of the right suprarenal gland Dissection of the right suprarenal gland Skeletonization of the right suprarenal gland Diagrammatic approach to the left suprarenal gland Exposure of the left suprarenal gland

2 Preoperative Preparation Preoperative IINeStigations: Ultrasound, computed tomography, hormone analysis, exclusion of a multiple endocrine neoplasia (MEN) syndrome, consider angiography with selective blood sampling Patient Preparation: Alpha-/P blockers for pheochromocytoma

3 Specific Risks. Patient Information. and Consent ... ... ... ...

Postoperative hormone replacement Hypertensive crises Injury to spleen, pancreas or liver Vascular injury

8 Relevant Anatomy. Serious Risks, Tricks ...

...

... ...

4 Anesthesia General anesthesia (intubation)

... ...

5 Positioning Supine, consider also prone

6 Approach Upper transverse laparotomy for bilateral or large unilateral spaceoccupying lesion and for the exploration of further ganglia in the presence of a pheochromocytoma. Posterior approach through the bed of the twelfth rib is also an option for a unilateral lesion.

The suprarenal glands cover the superomedial pole of the kidneys, a diaphragmatic crus lies posteriorly on either side, the vena cava is situated medially on the right and the aorta medially on the left, the right gland is covered anteriorly by the bare area of the liver, whereas the left gland is covered by the pancreas and the splenic vessels. Multiple small arterial branches are found on either side, originating from the inferior phrenic artery, the aorta, and the renal artery. Each gland usually has a principal vein, draining on the right into the vena cava and on the left into the renal vein. Aa:essory suprarenal tissue: perirenal, para-aortal (paraganglia, in particular the organ of Zuckerkandl, anterior to the bifurcation of the aorta): 10% of pheochromocytomas are extra-adrenal. Manipulate the suprarenal glands as little as possible during surgery. Always explore systematically all probable locations: contralateral, perirenal, para-aortal (even if a circumscribed space-occupying lesion has already been identified on one side).

9 Measures for Specific Complications No particular measures are required.

10 Postoperative Care Medical Aftercare: Close monitoring of blood pressure. fluid and electrolyte balance, and blood volume. Remove the nasogastric tube on day 1 to 3 and drains on day 4 or 5. Dietary Progression: Drinking is allowed from day 1 ; advance rapidly if well tolerated. Mobilization: Immediately Physiotherapy: Breathing exercises Time Off Work: 2 weeks

376

Ratroperltoneum

107 ............,

Operative Technique 0 Approach 0 Anatomy 0 Identification of the right suprarenal gland 0 DiSS&tion of the right suprarenal gland 0 Skeletonization of the right suprarenal gland 0 Diagrammatic approach to the left suprarenal gland 0 Exposure of the left suprarenal gland

o Approach The suprarenal glands are situated on1tte left and right,. over Ute cr.anial part of each kidney. The surgical approach may be via an oblique lumbar incision, a longitudinal lumbar incision, an upper midline laparotomy, or an upper tr.ansverse laparotomy. The extraperltoneal exposure of the supr.arenal glands has also recently been successful. The approach presentEd here Is regarded as the standard access to botfl supr.arenal glands because It allows management of bllater.al lesions as well as the exploration of the contr.alateral side. An upper transverse laparotomy takes a cranially convex course between botfl subcostal margins.

o

Anatomy

Surgety of the suprarenal glands requires an exact knowledge of their anatomy. Whereas the right supr.arenal gland Ires In the Immediate vicinity of Ute vena cava, the left suprarenal gland is closely associated with tfte later.al wall of Ute aorta. Botft suprarenal glands have tftree feeding artl!ries and veins, each of wftich needs to be ligated. 1, vena cava; 2, aorta; 3, right supr.arenal vein; 4, left supr.arenal vein; 5, right renal artl!ry; 6, left renal artery; 7, right supr.arenal artery; 8, left supr.arenal artery.

117 Alhnlladalllf

R•troperltonaum

o Identification of the right suprarenal gland

o Dlssedlon of the right suprarenal gland

Identification of the right suprarenal gland begins with a Kocher mobili· zation of the duodenum. After division of the secondary peritoneal attachments of the duodenum, it is swept as far medially as possible to allow' good 'VIsualization of the posterior surface of the pancreas, the vena cava, and, In the deptlls, the perirenal fat.

After insertion of two liver retracto~. the liver is displaced far cranially. The suprarenal gland is visible, dorsal to the liver, on the cranial circumference of the kidney. Using sharp and, at times, blunt dissection, the suprarenal vein Is Identified and drvtded between ligatures. Ungentle dissection, especially wldl a malignant lesion In this area, can result In tearing the vena cava.

o Skeletonlzatlon of the right suprarenal gland Dissection of the right suprarenal gland continues piecemeal, ligating all feeding vessels. Especially the vascular branches extending to the diaphragm must be dMded separately and under 'VIsion. After complete detJchment. also from the renal vessels, the suprarenal gland can be removed from the perirenal fat. For reasons of radlcallty, It Is also recommended to remove the surrounding pararenal and retroperttoneal adipose tissue.

377

378

Ratroperltoneum

o

107 ............,

Diagrammatic approach to the left suprarenal gland

The left suprarenal gland Is situated over ttte anteromedlal part of the left kklney and Is covered anteriorly by ttte spleen and pancreas. Mobil~ zatlon of ttte spleen and the tall of the pancreas will expose the suprarenal gland. An alternative approach Is via the omental bursa, aftl!r de-

o

tachlng the gastrocolic ligament or tttrough the mesocolon. For very obese patients, we prefer the approach via ttte omental bursa and for slim patients mobilization of ttte spleen.

Exposure of the left suprarenal gland

After mobilization of ttte spl~n and ttte tail of ttte pancreas, ttte left kidney and suprarenal gland are exposed (a). The feeding veins and arteries are divided between ligatures in a stepwise manner, and ttte suprarenal gland Is completely skeletonized (b). This approach demands careful protection of the tall of the pancreas and the spleen to avoid an

unplanned splenectomy. With tttls approach, the suprarenal gland may be easily and completely removed, togettter with ttte retroperitoneal adipose tissue. The approach via the omental bursa does not provide as good vlsualfzatlon, but ttte spleen and pancreas are less at risk.

108 Laparoscopic Adrenalectomy 1 Indications

7 Operative Steps

ElecUve: Not for malignancies Alternative Procedures: Open approach, transabdominal laparoscopic approach

0 Placement of the first trocar under finger guidance 0 Creation of pneumoperitoneum and insertion of further trocars

2 Preoperative Preparation Preoperative lmlestlgatlons: Ultrasound. See chapter 107

"Adrenalectomy," p. 375.

0 Sweeping off the retroperitoneal adipose tissue and identifica0 0 0

3 Specific Risks. Patient Information. and Consent • • • •

Postoperative hormone replacement. hypertensive crises Injury to spleen. pancreas or liver Vascular injury Conversion to the open procedure

tion of the suprarenal gland Identification of the right vena cava and division of the suprarenal vein between clips and securing of several small suprarenal arteries Division of the left suprarenal vein originating from the renal vein Complete mobilization of the suprarenal gland

8 Relevant Anatomy. Serious Risks. Tricks ...

...

Early identification and division of the suprarenal vein, draining into the vena cava on the right and into the renal vein on the left Multiple small arterial branches originating from the inferior phrenic artery, the aorta, and the renal artery

4 Anesthesia

9 Measures for Specific Complications

General anesthesia (intubation)

No particular measures required

5 Positioning Prone

6 Approach Three trocars caudal to the eleventh or twelfth rib. Blunt dissection technique with the finger for the first trocar, via which the pneumoperitoneum is created, followed by the insertion of further trocars under direct vision.

10 Postoperative Care No drains. Immediate dietary progression. Otherwise as for "Adrenalectomy," p. 375.

380

Ratroperltoneum

101 Laparosceplc .......lactonly

Operative Technique 0 0 0

Surgical field for right retroperitoneoscopic adrenalectomy Surgical field for left retroperitoneoscopic adrenalectomy

o

Approach

Approach

The patient is positioned prone with the hips slightly flexed. Insertion of the first trocar, caudal to the twelfth rib. After the skin incision and division of the fascia and muscle layer, a finger Is used to bluntly Identify the retropentoneal space. After Inserting the trocar, a pneumoperItoneum Is established under vision. For this purpose, the retropentoneal fat Is elevated from the Gerota fasda by careful blunt manipulation with the camer.! in the avascular layer. This creates a hollow cavity, partially bordered by the diaphragm and peritoneum as well as anteriorly by the retroperimneal organs. There next follows insertion of the two other trocars under direct vision.

o

Surgical field for right retroperitoneoscopic adrenalectomy

o

Surgical field for left retroperitoneoscopfc adrenalectomy

1, suprarenal tumor; 2, suprarenal vein; 3, lnfertor vena cava; 4, supra-

1, suprarenal tumor; 2, suprarenal vel11; 3, suprare11al artery; 4, tall of the

renal artery.

pa11creas; 5, Inferior phre111c vel11.

109 HemorltlolclectDmr(~)

109 Hemorrhoidectomy (Miles-Gabriel) 1 Indications

7 Operative Steps

ElecUve: Symptomatic (usually second- to third-degree) hemorrhoids: bleeding, prolapse, skin maceration Contralndlcations: Asymptomatic hemorrhoids, pregnancy (usually improve after childbirth), chronic inflammatory large-bowel disease Alternative Procedures: Rubber band ligation, sclerotherapy

0 0 0 0 0

2 Preoperative Preparation

0 0

0

Preoperative Investigations: Exclusion of proximal pathological lesions (especially after rectal bleeding): coloscopy or adequate contrast enema; anal sphincter manometry for advanced inrontinence Patient Preparation: Enema on the evening before surgery, smallvolume enema on the morning of the operation

3 Specific Risks. Patient Information. and Consent ... ... ... ...

Injury to the anal sphincter/incontinence (1%) Rebleeding (1%) Anal stenosis (1%) Bladder dysfunction (10%)

Oamping the hemorrhoidal cushion Infiltration of the hemorrhoidal cushion Dissection of the vascular pedicle I Dissection of the vascular pedicle II Ugation of the vascular pedicle Resection of the hemorrhoid Suture of the drainage gulleys T-shaped closure of the defect

8 Relevant Anatomy. Serious Risks. Tricks ... ... ...

JYpicallocation of the hemorrhoids at the 3, 7, and 11 o'clock positions Severe pain is not a symptom of hemorrhoids, with the exception of an acute thrombosis: look for an anal fissure. It is imperative that a bridge of normal anoderm (1 to 1.5 em wide) remains between adjacent hemorrhoids after excision to avoid anal stenosis and to maintain the sensory function of anal rontinence.

9 Measures for Specific Complications Rebleeding: if severe, then revision surgery is indicated, otherwise pack the wound with lubricated petroleum jelly gauze.

4 Anesthesia General anesthesia (intubation), spinal or epidural anesthesia

5 Positioning Supine, lithotomy position

6 Approach Small circumferential incision around each hemorrhoid. protecting the anoderm

10 Postoperative Care Medical Aftercare: Daily sitz baths, especially after each bowel movement, simple showering after a few days and after discharge; digital examination prior to discharge and after 1 week to prevent adhesions forming between opposing wound margins; local application of ointment or benzocaine ointment Dietary Progression: Normal diet from 6 hours after general anesthesia Bowel Function: Mild oral laxatives for -2 to 3 weeks postoperatively Moblhzatfon: Immediately Time Off Work: 1 week

381

382

Operative Technique 0 0 0 0

Camping the hemorrhoidal cushion Infiltration of the hemorrhoidal cushion Dism:tion of the vascular pedide I Dism:tion of the vascular pedide n Ligation of the vascular pedide

0 0 Resection of the hemorrhoid 0 Suture of the drainage gulleys 0 T-shaped dosure of the defect

0 Clamping the hemorrhoidal cushion After placing the patlent In the lithotomy position, the hemorrhoidal cushions, Y.ttlch are usually typically located at the 3, 7, and 11 o'clock posltlons, are ldentlfled. It has proven useful to place two Kocher clamps on each hemorrhoidal cushion, with tile first graspIng the anocutaneous line and the second the hemorrhoidal tissue itsdf. Unless it has already b~n done preoper.~tively, the surgeon should alwiys begin tile oper.~tion with a proctoscopic or rectoscopic examination.

0 Infiltration of

the hemorrhoidal cushion

-~.,._--

Each hemorrhoidal cushion Is placed on controlled tr.~ct:Jon by tile clamps and selectively Infiltrated at Its base wltfl, for example. 1% meplvacaine plus adrenaline. Approximately 3 to 5 ml are required for each hemorrhoidal cushion. Diglt!l control of this injedion is helped by inserting tile finger tip into the anal canal. The injection renders the postoper.rtive course less painful, dissection is less bloody, and separation of the planes of dissection is facilitated.

383

o Dissection of the vascular pedide I The wedgelike incision is directed toward 1tte vascular pedicle of the hemormoidal cushion. Constant and controlled traction on the clamps allows the hemormoidal tissue to be gradually dissected off 1tte internal anal sphincter muscle, which appears whitish In the depths, and off the

extemal anal sphincter muscle, which is peripheral and more reddish in color. Dissection must proceed within 1tte sphincters, which are to be identified and protected.

0 Dissection of the vascular pedide II After completely detaching the hemormoidaltissue from the sphincter muscles, the hemoJThold remains only attached to Its vascular pedlde. A

wedge-shaped exclslonal defect of anoderm has resulted, whereas the sphincter muscles have beEn spared.

384

o

Ugation of the vascular pedicle

o

Resection of the hemorrhoid

The dissected hemonnoid is tnen twisted on its axis and the vascular pedicle secured at its base with a 2-o PGA suture ligature.

After excising tne hemormoidal tissue, tne vascular pedicles retract into tne anal canal. After once more checking for hemostasis, the operation may be concluded by placing a gau2e ribbon, soaked in tannin, into tne anal canal for hemostasis of the wound surface.

o

o

Suture of the drainage gulleys

It is gener.~l practice. however, to close tne drainage gulleys. Here care should be taken to avoid narrowing tne lumen. It is imperative, tnerefore, to leave a sufficiendy wide bridge of intact anodem between each drainage gulley. The suture may be contlnuous or also take tne fum of a Tshaped dosure to avoid narrowing tne anal canal.

T-shaped closure of the defect

Oosing all defects with a T-5haped suture of tne drainage gulleys particularly ensures tnat a stenosis of tne anal canal does not result. Advantages of tnis technique are the patient's reduced pain sensation and a somewhat accelerated wound healing. The gauze ribbon soaked In tannin and Inserted Into tlle anal canal Is removed on tlle evening of the operation.

11 0 Perianal Abscess 1 Indications

7 Operative Steps

Absolute: On establishing the diagnosis

0 Abscess site 0 Skin excision

2 Preoperative Preparation Preoperative lnwstigations: Digital rectal examination, proctoscopy, and rectoscopy if possible. Endorectal ultrasound is helpful in diagnosing intersphincteric abscesses. Patient Preparation: Consider a small-volume enema.

0

0 0

8 Relevant Anatomy, Serious Risks, Tricks ~

3 Specific Risks, Patient Information, and Consent ~

~ ~ ~

Recurrence (5 to 10%) Fistula formation (5 to 10%) Injury to the anal sphincter (< 5%) Bladder dysfunction

4 Anesthesia General anesthesia (mask or intubation), spinal or epidural anesthesia

Wide exposure of the abscess cavity Curettage Packing

~

Exclude intraoperatively by palpation and rectoscopy the presence of an anal fistula, which is present in 40 to 60% of cases. Ensure wide enough exposure

Caution: Watch out (or premature adhesion of the wound margins with formation of a recurrent abscess.

9 Measures for Specific Complications Recurrent fever, with or without raised white blood cell count or renewed symptoms, in the postoperative course is suggestive of an incomplete decompression: undertake prompt revision.

10 Postoperative Care 5 Positioning Uthotomy position

6 Approach Radial elliptical incision of the abscess, directly over the site of maximum swelling or maximum pain, and excision

Medical Aftercare: Sitz baths for a few days; regulate bowel activity; consider repeating diagnostic investigations under more optimal conditions after the acute phase has resolved (e.g., exclude the presence of Crohn disease). Dietary Progression: Immediately Bowel Function: Consider mild laxatives Mobilization: Immediately Time Off Work: 1 to 2 weeks

,,..................

386

Operative Technique 0 Abscess site 0 Skin excision 0 Wide exposure of the abscess cavity 0 Curettage 0

Packing

o Abscess site Abscess incision is the basic principle of the surgical treatment of infection: ubi pus, ibi evacua. The perianal location is a common site for a perianal abscess and is situated subcutaneously in the area of the anocutaneous line, usually external to the sphincters. lntersphlncterlc abscesses, which sometimes extend high up the anal canal, are difficult to locate.

o Skin excision The perianal swelling is identified with the patient in the lithotomy position, and a radial, elliptical excision of the skin lying above it is made with the scalpel. The sphincter muscles should be carefully protected.

, .......... .....

o

Wide exposure of the abscess cavity

Once the abscess cavity Is open, aerobic and anaerobic cultures are taken. The abscess cavity is exposed wide enough to avoid retention. Am,t tmcts extending into tfte depths are tmced and excised, and all pus and necrotic tissue are removed.

o

Packing

The abscess cavity is loosely packed witft iodine ribbon gaum for hemostasis, which is removed on tfte following day. Open wound management with sitz baths and showering of tfte wound are then prescribed.

o

Curettage

The floor of the abscess is curetted witft a Volkmann spoon. Subsequent hemostlsis is essential.

387

111 Fistula-In-Ana (Including Sliding Flap) 1 Indications

8 Relevant Anatomy. Serious Risks. Tricks

Absolute Indications: On establishing the diagnosis Relative Indications: Damaged anal sphincter Alternative Procedures: Temporary creation of a transverse colostomy

...

2 Preoperative Preparation Preoperative Investigations: Digital examination, rectoscopy, consider endorectal ultrasound, anal manometry; exclude Crohn disease: coloscopy plus biopsy, gastrointestinal tract X-ray (Sellink) Patient Preparation: Enema on the preoperative evening, smallvolume enema on the morning of the operation

3 Specific Risks. Patient Information. and Consent .... .... ... ...

Sphincter damage (up to 30%) Fistula recurrence (up to 10%) Bladder dysfunction (10%) Anal stenosis

...

...

The anorectum consists of two concentric muscular cylinders: the inner cylinder is the internal anal sphincter muscle as a continuation of the rectal wall, the outer cylinder is the external anal sphincter muscle, which merges at the level of the puborectal muscle (consisting of the anorectal ring and puborectal sling) into the levator ani muscle, which then divides in a funnel-shaped fashion. The ischiorectal space is situated below the "pelvic diaphragm," the pelvirectal space above. Goodsall rule: The anal line - the transverse line drawn across the anal verge between the 3 and 9 o'clock positions, the fistulous tract is located anterior to the anal line: the radial tract of the fistula; the fistulous tract is located posterior to the anal line: the curved fistulous tract leads to the posterior midline of the rectal lumen. Estimated frequency distribution of fistula types in an unselected population: - Intrasphincteric 50 to 60% - Transsphincteric 20 to 30% - Others below 5%

Caution: Division of the puboreetrJI muscle when dividing the fiStula leads to incontinence.

4 Anesthesia General anesthesia (intubation), spinal or epidural anesthesia

... ...

Severe pain in the anal region in the absence of a fistula may indicate the presence of an intersphincteric abscess Pelvirectal (supralevator) abscess: fever, raised white blood cell count, gluteal and/or perineal pain

5 Positioning Supine, lithotomy position

6 Approach

9 Measures for Specific Complications Incontinence following fistula division: extensive investigations of anal function (manometry, electromyography, etc.) and repair in a center for proctological surgery after > 3 months

Depends on finding

10 Postoperative Care 7 Operative Steps 0

Location of the internal and external fistula openings f) Probing the fistula I 0 Probing the fistula II 0 Fistula division I 0 Fistula division II 0 Partial division of the sphincter muscles f) Hemostasis

Medical Aftercare: Daily sitz baths, especially after each bowel movement; wound check initially daily, then 1 to 2 times a week Dietary Progression: High-fiber diet Bowel Function: Mild oral laxatives for -2 to 4 weeks Mobilization: Immediately Time Off Work: 1 to 3 weeks

111 Flllul....,..o (lndudlng Sliding Fl•)

Operative Technique 0 0 0 0

Location of the internal and external fistula openings Probing the fistula I Probing the fistula D Fistula division I Fistula division II Partial division of the sphincter musdes

0 0 0 Hemostasis

o

Location of the internal and external fistula openings

Distinctions are made according to the location of internal and external fistula openings as well as the course of the fistula tr.Jct: - lntr.Jsphincteric fistulae, which may take a subcutaneous or submucous route - Transsphlncterlc fistulae, which usually lead to the crypts - Extrasphlncteffc fistulae, which lie external to the external anal muscle and usually reach the Ischiorectal space - lntersphlncterlc fistulae, which extend between the external and Internal sphincter muscles. The surgical approach Is determined by the relationship of the fistulae to the sphincter apparatus. Complex therapeutic techniques are usually required for treating extrasphlncteffc and Ischiorectal flstulae, the description of which would be beyond the scope of the present atlas. The authors will confine themselves to the intr.Jsphincteric and transsphincteric fistulae, insofar as they involve the IOW"er two thirds of the anal canal.

0 Probing the fistula I With the patient In the lithotomy position, an attempt should be made to probe the fistula tract In order to locate Its Internal anal or rectal openIng. This Is extremely Important for the choice of surgical procedure and the final result of the operation. A bimanual approach has proven helpful, guiding and palpating the end of the probe with the index finger. This examination must proceed extremely carefully in order nat to produce a false channel. If the surgeon is able to successfully advance the probe into the rectum without difficulty, then the level of the intemal opening will decide the further procedure. If the opening lies in the lower third of the anal canal, dearly below the puborectll sling, then the fistula may be completely divided with Impunity.

389

390

111 Rlblla-1111-Ano (lnclldng Sliding Filip)

o

Probing the fistula II

The commonest cause of fistula formation and. at the same time. the commonest sitE of origin is the aypts of the anal canal. Should complete probing of the fistula tr.act be unsuccessful from outside, an attempt may be made to locate an internal fistula opening in the region of the anal crypts by bending the probe into a hook and using it to selectively palpate an opening. A further option Is to Inject dye (mettlylene blue) Into the extErnal flstula opening with the aid of a blunt cannula. Sometimes the Internal flstula opening can be locatEd by the exit of the dye.

0 Fistula division I

0 Fistula division II

Skin and subcutaneous tissue are generously exdsed CNer the probe using a cutting diathermy. One should avoid making contact between the diathermy and the probe to prevent an extensive bum Injury.

Skin and subcutaneous tissue are exdsed with the diathermy until wide exposure of the fistula tr.act Is achieved. The fistula tract Itself should also be completely excised.

111 Flllul....,..o (lndudlng Sliding Fl•)

o Partial dMslon of the sphincter muscles The affected sphincter muscles are also dfvided over the probe, after the Integrity of the puborectal sling and of the proximal half of the external anal sphincter muscles has been confinned. The remaining cr.mial sphincter musdes should be at least 2 em long to guarantee an adequate degree of continence.

o Hemostasis After making a control inspection for hemostasis, tfte oper.rtion is completEd with the insertion of a gauze ribbon soaked in tmnin, which is removed on tfte evening of tfte oper.rtion day.

391

112 Perianal Thrombosis

1 Indications

7 Operative Steps

Absolute: On establishing the diagnosis Alternative Procedures: Conservative management

0 0 0

2 Preoperative Preparation Preoperative Investigations: The severe pain usually predudes any diagnostic measures (proctoscopyfrectoscopy).

3 Specific Risks, Patient Information, and Consent .... .... ....

Recurrence Injury to the sphincter musdes Hemorrhage

4 Anesthesia Local anesthesia, rarely general anesthesia (mask)

5 Positioning Lithotomy position

6 Approach Radial incision over the thrombosis

0

Local anesthetic Incision Hematoma evacuation Drainage

8 Relevant Anatomy, Serious Risks, Tricks If possible intraoperatively, consider proctoscopyfrectoscopy to exdude a fissure-in-ano, hemorrhoids, or abscess.

9

Measures for Specific Complications

Persistent pain: probably inadequate decompression, reincision required; exclude other causes (fissure-in-ano, abscess)

10 Postoperative Care Medical Aftercare: Initially, daily wound check, sitz baths, or showering after each bowel movement Bowel Function: Consider measures to regulate bowel movements (regular, soft consistency). Time Off Work: 2 to 5 days

112,.rllnlll1hro.nbells

Operative Technique 0 Local anesthetic 0 Incision 0 Hematoma evacuation 0 Drainage

o

Local anesthetic

With the patient in the litnotomy position, the anus is separated and local anesthetic Is Injected Into the base of the perianal thrombus. Approximately 5 to 10 ml of 1% local anesthetic are required.

o

Incision

After achieving complete anesthesia, a radial incision is made 011er the most prominent part of the hematoma, usually In the form of an elliptical exdslon to keep the wound open.

393

394

112 ,.rllllllllhro.nbells

o

Hematoma evacuaUon

Once the skin has been opened up, abundant dottEd blood and old thrombi are expressed. The tftrombolic material may be removed witft the aid of forceps or a Volkmann spoon to expose the entire cavity, which is then irrigated with saline. The wound margins should then be further excised if they show a tendency to spontaneously collapse together after evacuation of the hematoma. The wound should remain open for at least 24 hours.

o

Drainage

A small iodine ribbon gauze may be insertEd for hemost!sis and also to drain the hematoma cavity. It is removed after 24 hours, after which sitz batns are presaibed.

113 Lateral Sphincterotomy (Parks)

1 Indications

7 Operative Steps

Elective: Acute and chronic fissure-in-ano Contraindications: Borderline sphincter function Alternative Procedures: Sphincter dilatation, electrocoagulation, excision

0 Incision 0 Muscle dissection

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Preoperative Investigations: Digital examination, proctoscopy, rectoscopy; consider excluding Crohn disease, ulcerative colitis, malignancy: coloscopy plus biopsy Patient Preparation: Small-volume enema if possible

.... ...

0

.... .... ....

Damage to the sphincter muscles/incontinence (< 5%) Recurrence (-5%) Bladder dysfunction (10%)

90% of all chronic fissures lie posterior to the midline. Sentinel skin tag is an inflammatory thickening of the skin at the distal end of the fissure, which should be removed during surgery.

....

3 Specific Risks, Patient Information, and Consent

Muscle splitting

0 Suture closure

... ... ....

All excised material must always be sent for histological examination. Divide only the distal 1.5 em of the internal anal sphincter, i. e. only as far as the level of the dentate line. Look for (possible incomplete) anal fistula. Also treat any concomitant hemorrhoids.

9 Measures for Specific Complications 4 Anesthesia General anesthesia (intubation), spinal or epidural anesthesia

5 Positioning Supine, lithotomy position

6 Approach Short (1 to 2 em) curvilinear incision at the 3 o'clock position

Treat bleeding with local compression; place any sutures only under direct vision.

10 Postoperative Care Medical Aftercare: Wound check, consider short-term mild analgesics Dietary Progression: High-fiber diet Bowel Function: Mild oral laxatives for -2 to 3 weeks. Time Off Work: Less than 1 week

396

113 LabiNI Sphlncl8roto111J (.....)

Operative Technique 0 0 0 0

Incision Muscle dissection Muscle splitting Suture closure

o

Incision

o

Musde dissection

After placing the patient in the lithotomy position, the operation com· mmces with a digital examination and proctoscopy, should this have not been possible preoperatively due to pain. An anal retractor is inserted and, under controlled spreading, the sphincter muscles are placed on stretch. An -2 em long, curvlllnear Incision Is placed left-laterally through the skin with the scalpel at about the 3 o'clock position and through the subcutaneous tissue with the dlathenny.

The skin and mucosa are carefully dissected off the easily palpable internal anal sphincter muscle and the lower margin of the muscle is also exposed laterally. The skin of the anal canal should under no circum· stlnces be injured during dissection because this could result in fistulae.

o

o

Muscle splitting

The isolated muscles are incised, either with the cutting diathermy or scalpel. Smaller vessels should be individually coagulated. The extent of the incision of the internal anal sphincter muscle is -2 em.

Suture closure

After meticulous hemostasis, the skin is closed with intetlrupted sutures. Completeness of the sphincterotomy may be palpated as a deep groove at about 3 o'clock in the lithotomy position.

114 Pilonidal Sinus (Schrudde-Oiivari) 1 Indications

8 Relevant Anatomy. Serious Risks. Tricks

Absolute: On establishing the diagnosis, urgently if an abscess is suspected

...

2 Preoperative Preparation

...

Preoperative lm~estigations: Consider fistulogram. ...

3 Specific Risks. Patient Information. and Consent Recurrence (5 to 20%, after either primary or secondary dosure)

...

A fistula with no signs of irritation justifies the complete excision of the defect and immediate resurfacing with a transposition flap; if there is any doubt, then adopt open wound management followed by secondary coverage. Generous excision with wide exposure of the sacrococcygeal ligaments is only justified with a correspondingly deep fistula and is not always necessary. The intraoperative injection (apply only mild pressure!) of methylene blue solution in milk (prevents diffusion of the dye into the tissue) into the fistula opening facilitates complete excision. Ensure adequate mobilization of the wound margins when dosing primarily or secondarily. Do not leave behind any cavities at the skin level.

4 Anesthesia General anesthesia (intubation)

5 Positioning

9 Measures for Specific Complications Wound breakdown after plastic surgical reconstruction: open wound management, consider secondary suture later

Prone, spread buttocks apart and secure with adhesive tape

10 Postoperative Care 6 Approach Vertical elliptical incision around the lesion

7 Operative Steps 0 Surgical principle 0 Subcutaneous dissection 0

0 0

Hemostasis Resurfacing the defect Plastic reconstruction for resurfacing the defect

Medical Aftercare: After plastic surgical coverage, remove the suction drain on postoperative day 2; the patient should avoid sitting or supine positions for the first 5 days. Shower out the wound regularly if adopting open wound management and consider applying a solution to promote the formation of granulation tissue (e.g., 20% saline). careful hygiene in the region of the gluteal fold will be necessary in the long term: significant hair formation should be regularly removed. Dietary Progression: Immediately Bowel Function: Consider mild laxatives. Time Off Work: 2 weeks, possibly longer for considerable physical exertion or sedentary work

398

114 Pllonlcllll ShiS {Sch.,.......,..rl)

Operative Technique 0 Surgical principle 0 Subcutaneous disseaion 0 Hemostasis 0 Resurfacing the defect 0

Plastic r&onstruction for resurfacing the defert

0 Surgical principle The surgical management of a pilonidal sinus requires the removal of all Inflamed t:Jssue, down to the sacral fasda. With extensive Inflammation, the exdslon wound will need to be left open and allowed to heal by secondary lntent:Jon, adhering to the rules of sept:Jc surgery.

o Subcutaneous dlssedlon After an elllpt:Jcal Incision around the external tlstula opening or openIngs, with their corresponding extensions, the area of Inflammation Is dissected In a subcutaneous plane using the cutt:Jng dlathenny. The focus of Inflammation must be completely dissected and removed, if necessary down to the sacral fascia.

114 Pilonidal Shll (Schrudd..Oiwrl)

o

Hemostasis

Extensive and meticulous hemostasis is essential following excision for the subsequent healing process. Each bleeding vessel must be lndlvld~ ally coagulated.

0 Resurfacing the defect An elliptical defect Is left, with the sacral fascia exposed at the floor of the wound. The wound may be left open and. with an Iodine ribbon Inserted, allowed to heal by secondary lrrtentfon or be managed secondarily lab!r, after 4 to 6 days. Primary dosure using a Schrudde-OIIvari plastic surgical procedure Is Indicated for dean wound condltlons. This Involves raising a caudally based transposltlon flap. Intraoperative markIng of the required skin excision with Ink facilitates dissection.

399

400

114 Pllonlcllll ShiS {Sch.,.......,..rl)

O Plastic reconstruction for resurfacing the defect After completely undermining the flap, It should be easily transposed Into the defect wittlout tension (a). The subsequent undermining of the wound margins on all sides ensures a tension-free closure with Interrupted sutures (3-0 polypropylene) (b). Approximation of the wound

margins with subcutaneous lnteiTllpted sutures (3-0 PGA) facilitates tfteir adaptation (c). One or two suction drains should be insel't:Ed prior to this. tntem.Jpted skin sutures complete the closure of the defect (d).

115 Testicular Hydrocele

1 Indications

7 Operative Steps

ElecUve: On establishing the diagnosis, and if symptomatic Contralndlcations: During the first 2 years of life (an open processus vaginalis of peritoneum usually obliterates spontaneously) Alternative Procedures: None

0 0

2 Preoperative Preparation

0 0 0

0 0

Approach Exposure of the hydrocele Opening the hydrocele Resection of the hydrocele sac Eversion of the hydrocele sac Dissection of the processus vaginalis in a child ligature of the base of the processus vaginalis

Preoperative Investigations: Ultrasound

8 Relevant Anatomy. Serious Risks, Tricks 3 Specific Risks. Patient Information, and Consent • • ..

Injury to the testicle (1%) Injury to the spermatic cord (1%) Consider operating an inguinal hernia at the same time.

4 Anesthesia General anesthesia (intubation). Epidural, spinal, or local anesthesia is also a possible option for adults.

5 Positioning Supine

6 Approach Transverse or oblique incision at the base of the scrotum

• •

The congenital hydrocele of a child always communicates with the peritoneal cavity. A hydrocele in a child is operated like an inguinal hernia.

9 Measures for Specific Complications Postoperative epididymitis: cooling, elevation, antibiotics, exclude testicular torsion (Doppler ultrasonography)

10 Postoperative Care Medical Aft:erolre: Remove any suction drain on day 1 or 2. MobiriUtion: Immediately Time Off Wotic:: Up to 1 week

402

External C:enltal Organs

115 Tastlajar IIJciii'OCIIe

Operative Technique 0 Approach 0 Exposure of the hydrocele 0 Opening the hydrocele 0 Resection of the hydrocele sac 0 Eversion of the hydrocele sac 0 Dissection of the processus vaginalis in a child 0 IJga.ture of the base of the processus vaglnalls

0 Approach Skin Incision at the base of the scrotum, parallel to the skin folds. If necessary, extend further down to the scrotum; consider a low Inguinal transverse incision.

o

Exposure of the hydrocele

The spermatic cord is isolated and encircled witfl a rubber sling. The hydrocele sac and scrotum are bluntly released from the scrobJm and brought out through the wound. The testis may be brought out through the skin incision by simple pressure. Fibrous adhesions to the scrotal compartment may require sharp division.

o

Opening the hydrocele

While the scrotum is stabilized manually, the various layers of the hydrocele are divided using the scalpel. Meticulous hemostasis is essential here. Fluid in the hydrocele sac is removed by suction, the margins grasped with clamps.

115 T.acular IIJdi'OCIIIa

o

Resection of the hydrocele sac

o

External Canrtal Organs

Eversion of the hydrocele sac

The Bergmann technique at:tempts to resect as much of tfte hydrocele sac as possible. The hydrocele sac is opened further and grasped with clamps. The wnica vaginalis is resected down to the vessels. Meticulous hemostasis is necessary here. After complete resection of the tunica vaglnalls. a suction drain Is Inserted and the Internal spermatic fasda closed with interrupted sutures (3-(l PGA). Closure of the subdermis and the skin completes the operation.

The Winkelmann metftod restricts itseff to everting the opened hydrocele and closing it witft a sulllre line. The objective is to bring tfte inner surface of tfte hydrocele sac to lie externally. This method may also be combined with 1tle Bergmann resection technique. Asuction drain and closure In layers complete the operation.

o

o

Dlssedlon of the processus vaglnalls In a child

The approach to a hydrocele in a child is 1tle same as for an inguinal hemia. Careful dissection of the delicate open processus vaginalis is important. togeltler with its separation from the vessels and the vas defe. rens. For this purpose, sdssors are passed beneath the processus, which Is then dMded.

Ligature of the base of the processus vaglnalls

Dissection continues as far as the internal inguinal ring. It is recommended to proceed with blunt dissection due to the delicate structures. At the internal inguinal ring, the technique is analogous to that of dealing with a hernial sac (I.e.• a suture ligature Is placed near the base and the sac Is transected). The hydrocele sac found within the scrotum Is opened, partially resected, and left open. The Bergmann or Wlnlcelman11 procedure Is not Indicated In a child. aosure of the Inguinal hernial ling Is accomplished with the usual technique.

403

116 Vasectomy

1 Indications

6 Approach

Relative: Expressed wish of the patient

Over the base of the scrotum along the course of the spermatic cord

2 Preoperative Preparation

7 Operative Steps

Patient Preparation: Consider informing the patient about the possibility of sperm conservation. It is imperative to allow the wife to be present when providing patient information.

0

3 Specific Risks. Patient Information. and Consent .... .... ....

Success of any later attempt at vasectomy reversal is uncertain (< 40%). Injury to the spermatic vessels Loss of a testicle

4 Anesthesia Local, regional, or general anesthesia

5 Positioning Supine

0 0

Skin incision Exteriorization of the ductus deferens Resection of the ductus deferens

8 Relevant Anatomy. Serious Risks. Tricks The ductus deferens runs within the spermatic cord and can be easily identified by palpation.

9 Measures for Specific Complications Caution: watch out for injury to the spennatic vessels.

Infertility is only certain after 6 weeks in conjunction with a negative spermiogram.

10 Postoperative Care Medical Aftercare: No specific aftercare

11& VllladaiiiJ

External Canltal Organs

Operative Technique 0 0 0

Skin incision Exteriorization of the ductus deferens

o

Skin incision

Resection of the ductus deferens

The skin Incision courses on the anterior surface of the base of the scrotum aver the ductus deferens, which Is stabllrzed between the Index finger and thumb. The ductus deferens Is easily ldentifled between the finger and thumb as a hard cord and displaced anteriorly. The skin Incision Is placed directly aver this welj..palpable structure, secured between the finger and thumb.

o

Exteriorization of the ductus deferens

On opening the skin. the ductus deferens is brought into the wound and an Ovemolt clamp is passed beneath it. It is then grasped on either side with damps.

o

Resection of the ductus deferens

After resection of a 2 tD 3 em long section, the stumps of the ductus deferens are secured on either side with nonabsocbable suture ligatures (2-G polypropylene). The ends of the ductus deferens may be additionally tumed over in a lJ-shaped fashion and secured with sutures to prevent the possibility of spontaneous refertilization.

405

117 Local Anesthesia for Inguinal Hernia Repair

1 Indications

7 Operative Steps

ElecUve: Basically possible for all cooperative patients, as well as for recurrent hernias Contralndlcations: Children. patients with severe learning difficulties, and patients with the expressed wish for an alternative form of anesthesia Altl!lnatlw Procedures: Spinal or epidural anesthesia. general anesthesia

0 0

0

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Patient Preparation: Exclude a histnry of allergies to local anesthetics.

~

0 0 0

0

~

3 Specific Risks, Patient Information, and Consent ... ...

The patient must be informed in detail about the course of the procedure. There is an option of converting 1D another form of anesthesia during the operation.

4 Anesthesia See above.

~

~

Innervation of the inguinal region Regional nerve block anesthesia Subcutaneous infiltration Subfascial infiltration Infiltration of the internal inguinal ring Infiltration of the neck of the hernial sac Perineal block

Observe the maximum safe dose of the local anesthetic used (e.g~ mepivacaine ). Venous access and documented continuous monitoring of pulse and blood pressure as well as pulse oximetry are obligatnry. In doubtful cases, always ensure anesthesiological support with the possibility of immediate intervention, including mechanical ventilation and resuscitation. The patient should be observed throughout the procedure by a trained attendant who is not directly involved with the operation but is able to maintain verbal contact while caring for and distracting the patient during the procedure.

9 Measures for Specific Complications Patients at risk of emotional decompensation during the procedure may be brought back under control by mild sedation with 5 to 10 mg of diazepam.

5 Positioning Supine

10 Postoperative Care Medical Aftem~re: Nothing specific

6 Approach See below.

117 Local Anast._. for Inguinal H.,.a 18palr

Operative Technique 0 0 0 0 0 0 0

Innervation of the inguinal region Regional nerve block anesthesia Subcutaneous infiltration Subfascial infiltration Infiltration of the intemal. inguinal ring Infiltration of the neck of the hernial sac Perineal block

o

Innervation of the Inguinal region

Local anesthesia of the inguinal region must take its innervation inb) account. Whereas1tle ilioinguinal (2) and iliohypogastric (1) nerves may be selectively blocked by regional anesthesia, this is less possible for the genitofemoral nerve (3). 1, Iliohypogastric nerve; 2, Ilioinguinal nerve; 3, femoral branch of the genitofemoral nerve; 4, genital branch of 1tle genib)femoral nerve; 5, obturator nerve; 6, lab!ral femoral cutaneous nerve; 7, cutaneous branch of tfte Iliohypogastric nerve; 8, femoral nerve.

//

/;-1!

/."' I/

rf

y /; (!

II It

~

1

~I

~,,

11 II II

o

If

,,

It

It 1 '

,, II

Regional nerve block anesthesia

Local anesthesia of the groin begins with an iliohypogastric and ilioinguinal nerve block. A depot of -20 ml 1% mepivacaine is infiltrated 2 em above, and slightly medial to, the arrtef'lor superior Iliac spine to reach down to the muscle layer. This usually achieves a reliable regional block lasting for several hours.

o

Subartaneous infiltration

The skin incision line is now infiltrated subcutaneously from tftis cranial injection site. Care must be taken to ensure tftat infiltration is complete, otherwise tfte skin Incision wlll be painful (-10 ml 5% meplvacalne).

407

408

117 I.Gai.An..._la far lngul•llltlrnla R8plllr

o

Subfasdal Infiltration

o

Infiltration of the Internal Inguinal ring

After dividing the subdennis, the IOO'ernal oblique aponeurosis is gener· ously blocked with local anesthetic. This may proceed directly along the course of the inguinal canal or on either side of it. Acorrect injection t«hnique will separate the external oblique aponeurosis from the spermatic cord (-10 ml 0.5% meplvacalne).

After complete division of the external oblique aponeurosis, the internal inguinal ring and the cremaster muscle are identified. The internal inguinal ring is infiltrated from all sides with a toGI of six injections (-10 ml 0.5% mepivacaine).

o

o

Infiltration of the neck of the hernial sac

Once the hernial sac has been isolated and opened, a further 10 ml 0.5% mepiwcaine are recommended intr.lperitx:meally and around the neck of the hernial sac. The transversalis fascia may also be blocked in the same manner near the hernial sac.

Perineal block

Large scrotal hernias occasiomllly require a perineal block in the fonn of a semicircular injection around the base of the scrotum. In our experience, this is rarely necessary.

118 Dissection for Inguinal Hernia Repair

1 Indications

7 Operative Steps

Absolute Indications: For diagnosed inguinal hernia. Timing: soon after establishing the diagnosis or urgently for incarceration. Contralndlcatfons: None, other than absolute general inoperability or lack of consent Alternative Procedures: No reasonable alternative

0 Approach 0 Division of the external oblique aponeurosis I 0 Division of the external oblique aponeurosis II 0 Protection of the nerves 0 Longitudinal division of the cremasteric pedide

0 Separation of the cremaster muscle

2 Preoperative Preparation Preoperative Investigations: Ultrasound, Doppler ultrasonography of the testicles for recurrent procedures

3 Specific Risks, Patient Information, and Consent ... ... ... ... ...

11\lury to the spermatic cord (1%) Wound infection (2%) Chronic inguinal pain (< 5%) Recurrence (1 to 10%) Morta1ity (< 0.2%)

0 0 0

Resection of the cremaster muscle Dissection of the hernial sac Dissection of the neck of the hernial sac Division of the external cremasteric veins Dissection of the direct hernial sac ® Management of the hernial sac I ® Management of the hernial sac II ~ Management of the hernial sac III «') Management of the hernial sac IV Removal of a preperitoneal lipoma Assessment of the transversalis fascia

m m

m m

8 Relevant Anatomy, Serious Risks, Tricks ...

4 Anesthesia

The transversalis fascia is the decisive plane for the success of the procedure. It therefore needs to be identified exactly and then reconstructed. For routine cases, repair with reconstruction of the anatomy is still preferable to the insertion of any alloplastic material.

Local anesthesia is preferable for cooperative patients, otherwise consider spinal, epidural, or general anesthesia (intubation).

...

5 Positioning

9 Measures for Specific Complications

Supine

... ...

Vascular injury: suture repair under direct vision (5-0 to 7-0 polypropylene) Injury to the ductus deferens: direct suture repair {7-0 PGA)

6 Approach Transverse or slightly oblique incision above the inguinal crease

10 Postoperative Care Medical Aftercare: Remove any suction drain on day 2. Male patients should wear tight-fitting underwear during the first few days. Inform the patient about gradually resuming physical exertion or sports {provide an informational leaflet). Dietary Progression: Immediately Bowel Function: Consider small-volume enema Mobilization: Immediately Physiotherapy: Not necessary lime Off Work: 1 to 2 weeks

410

118 D111adlon for Inguinal H..,.a Rapa..

Operative Technique 0 0 0 0

Approach Division of the external oblique aponeurosis I Division of the external oblique aponeurosis II Protection of the nerves 0 Longitudinal dMsion of the cremasteric pedicle 0 Separation of the cremaster muscle 0 Resection of the cremaster muscle 0 Dissection of the hernial sac 0 Dissection of the neck of the hernial sac (0 Division of the external cremasteric veins Dissection of the direct hernial sac CD Management of the hernial sac I a> Management of the hernial sac II Management of the hernial sac Ill Management of the hernial sac IV Removal of a preperltoneal Upoma m Assessment of the transversalis fascia

m m m m

o Approach The approach Is vfa a transverse skin Incision In the lower Inguinal fold. Alternatively, an oblique Inguinal Incision may be chosen. 1, Iliohypogastric neJVe; 2, Ilioinguinal nerve.

o DMslon of the external oblique aponeurosis I After deepening the incision through the subcutaneous tissue, the external oblique aponeurosis is identified, as is the external inguinal ring. The external oblique aponeurosis is divided, beginning cranially at the external ring.

111 IXII8d:bl far lngul•l lltlrnla Rapalr

o

Division of the external oblique aponeurosis II

o

Protection of the nerves

If the external Inguinal ling Is dlffiOJit to Identify, then the external oblique aponeurosis may be divided with the scalpel In a cranial to caudal direction, toward the external ling. Sharp clamps are placed to grasp and separam the edges of the fascia. The external oblique aponeurosis, together with the external inguinal ring, must be opened completely.

Once the inguinal canal has been opened, the internal oblique and cremaster muscles are exposed. The ilioinguinal nerve usually courses over the internal oblique muscle, where it is identified, bluntly dissected free, and protected beneath the cranial retractor. Seldom is the genital branch of the genitofemoral nerve immediamly visible, as shown here; it usually lies more dorsally and is not recognizable until the cremaster muscle has been divided.

o

o

Longitudinal division of the cremasteric pedicle

The cremaster muscle ls dMded longitudinally with scissors, using three Roux retractors to expose the surgical field. Division ls taken down as far as the shiny Internal cremasteric fasda, which Is easily separable from the spermatic cord lying beneath. Blunt dissection prevents injury to the structures of the spermatic cord.

Separation of the cremaster muscle

The spennatic cord is separated from the cremasmr muscle by a combj. nation of blunt and sharp dissection. The genital branch of the genitofemoral nerve lying dorsally Is carefully protected and preserved. It usually courses together wl1tl the external aemastertc veins In the Internal Inguinal ling. A sling Is passed around the cord and the two slips of cremaster muscle are bluntly elevated far cranially and caudally.

411

412

118 D111adlon for Inguinal H..,.a Rapa..

o Resection of the cremaster muscle

o Dissection of the hernial sac

The two slips of cremaster are then dMded between damps, resected, and the stumps secured with ligatures.

Gentle traction on the rubber sling around the cord and, If necessary, grasping the hernial sac with a Duval clamp will allow the sac to be gradually separated from the cord and from the transversalrs fascia by a combination of blunt and sharp dissection. In the presence of significant adhesions and in unclear situations, it may occasionally be helpful to already open the hernial sac in this phase of the dissection in order to identify the structures more precisely.

0 Dissection of the neck of the hernial sac Dissection of the hennlal sac must proceed as far as the hemla defect In the transversalis fascia. If, In the case of an Indirect hemia, the defect Is In the intemallnguinal ring, then the Internal ling will need to be completely exposed. Dissection of the spermatic cord must continue down to the internal ring in order to clearfy identify the bifurcation of the ductus deferens and the spermatic veins. The hennial sac must be freed up from the internal ring on all sides and separated from all adhesions with the transversalis fascia.

111 IXII8d:bl far lngul•l lltlrnla Rapalr

CO Division of the external aemasteric veins

(I) Dissection of the direct hernial sac

The external cn!mastef'lc veins, which drain Into the Inferior epigastric veins. must be dMded and secured with suture ligations. The genital branch of the genitofemoral ner~~e Is constantfy found In this region, and the authors strive to preserve It whenever poss!ble. D!vls!on of the external cremasteric vel11s Is 11ot obligatory, but It does provide a better eJCPOSUre around the lntemallllgulllal ring.

With direct Inguinal hemlas, the hernial sac In the transversalis fascia Is lndsed clraJmferelltfally to create cranial a11d caudal fascial edges capable of securely holdl11g the sutures.

m Management of the hernial sac I There are various aspects to consider when deall11g with the hernial sac. It may be twisted and suture ligated at the level of the Internal ring. The redundallt part of the sac Is exdsed. Th!s Is the simplest method of manag!11g the hem!al sac; !t Is also the most commo11ly used.

413

414

118 D111adlon for Inguinal H..,.a Rapa..

a

G)

Management of the hernial sac II

If the contents of the sac are nat easily reduced or tttere Is suspected

c

lntr.rabdomlnal Involvement (Incarceration, metastases, etc.), then ttte hemlal sac will need to be opened. For tttls purpose the sac Is grasped between clamps, opened longitudinally and spanned out between four clamps (a, b). Adherent bowel segmenl:$ may be separated with scissors if ttteir attachments are not too extensive (c). Otherwise, ttte bowel should not be extensively dissected free, but instead the hernial sac should be closed and buried wlttt an external purse-string suture.

111 IXII8d:bl far lngul•l lltlrnla Rapalr

m Management of the hemlal sac Ill Direct Inguinal hernias, hemlal sacs with adherent bowel segments, which cannot be separated, and sliding hernias are burted with an external purse-string suture. The purse-string suture must be placed carefully to ensure that no internal stn.Jctures are injured.

il

b

€D Management of the hemlal sac IV Direct hernial sacs do not usually need to be opened, and the sac may be buried directly with an external purse-string suture. After reducing the sac, the suture is tightened and the sac buried below the level of the fascia. During this maneuver, It Is Important to completely dMde the

transversalis fascia flrst and hold It apart with clamps (a). This Is the only way to bury the sac without Involving the transversalis fasda, which Is later so decisive for the repair (b).

415

416

118 D111adlon for Inguinal H..,.a Rapa..

ai Assessment of the transversalis fascia b

c:

a:> Removal of a preperltoneal lipoma After (and occasionally before) dealing with the hernial sac, it is essential to remove any preperitooeal lipoma. It is separated from the spei'Tllitic cord by sharp dissection, suture ligated at its base, and transect:ed (a-c).

After exposing the posterior wall of the Inguinal canal, the stability of the transversalis fascia Is assessed by Inserting an Index finger Into the Internal Inguinal ring. If the fascia Is easily displaced and barely stable, then complete repair of the posterior wall is required. An intraoperative dassification of the hernia type is then made; the authors distinguish be~n lateral (L) - indirect hernias and medial (M) - direct hernias with orifice si~ I (< 1.5 em), II (< 3 em), and Ill (> 3 em). Ll and Ml hernias may be repaired directfy, Lll and Mil hernias by complete plication of the fascia, and larger hernias possibly by the insertion of a polypropylene mesh. The most important procedures will now be described, which may be used to repair 85 to 95% of all Inguinal hernias. Small Indirect Inguinal hernias may be reconstructed with an Isolated Zlmmennann repair of the lntemallngulnal ring. Here too, however, the procedure of choice Is usually to dMde the transversalis fascia completely and repair It using the Shouldlce method of plication.

417

119 Inguinal Hernia Repair (Shouldice)

1 Indications

7 Operative Steps

Absolute: For diagnosed inguinal hernia. Timing: soon after establishing the diagnosis or urgently for incarceration. Contralndlcations: None, other than absolute general inoperability or lack of consent Alternative Procedures: No reasonable alternative

0 0

2 Preoperative Preparation Preoperative Investigations: Ultrasound, Doppler ultrasonography of the testicles for recurrent procedures

3 Specific Risks, Patient Information, and Consent ... ... ... ... ...

Testicular atrophy (< 1%) Wound infection (2%) Chronic inguinal pain (< 2%) Recurrence (0.8 to 4%) Mortality(< 0.1%)

Principle of repair Incision of the transversalis fascia 0 Preperitoneal dissection 0 Excision of the weak transversalis fascia 0 Shouldice suture I 0 Shouldice suture II 0 Management of the suprapubic defect 0 Shouldice suture III 0 Shouldice suture IV a!) Closure of the external oblique aponeurosis

8 Relevant Anatomy, Serious Risks, Tricks ...

...

The transversalis fascia is the decisive plane for the success of the procedure. It therefore needs to be identified exactly and then reconstructed. For routine cases, repair with reconstruction of the anatomy is still preferable to the insertion of any alloplastic material.

9 Measures for Specific Complications 4 Anesthesia Local anesthesia is preferable for cooperative patients, otherwise spinal, epidural, or general anesthesia (intubation).

5 Positioning Supine

6 Approach Transverse or slightly oblique incision above the inguinal crease

Ischemic orchitis: Ultrasound, testicular Doppler ultrasonography; local cooling, elevation, anti-inflammatory agents. Revision surgery is of use in only the first 4 hours and for hematoma.

10 Postoperative Care Medical Aftercare: Remove any suction drain on day 2. Male patients should wear tight-fitting underwear during the first few days. Inform the patient about gradually resuming physical exertion or sports activities (provide an informational leaflet). Dietary Progression: Immediately Bowel Function: Consider small-volume enema. MobiriDI:ion: Immediately Physiotherapy: Not necessary llme Off Work: 1 to 2 weeks

418

1111ngul•l lltlrnla Rapllr (Shou. .ca)

Operative Technique 0 0 0 0 0 0 0 0

m

Principle of repair Incision of the transversalis fascia Preperitoneal dissection Excision of the weak transversalis fascia Shouldice suture 1 Shouldice suture n Management of the suprapubic defect Shouldlce suture Dl Shouldlce suture IV Closure of the external obJique aponeurosis

o

Prtndple of repair

0

o

Incision of the transversalis fascia

The principle of the Shouldice inguinal hernia repair is the plication of the defective transversalis fascia with two continuous suture lines and the approximation of the transversus abdominis and the intemal oblique muscles to the Inguinal ligament. each with a continuous suture line. The spennatlc cord Is replaced anterior to the musdes and posterior to the external oblique aponeurosis.

Repair begins with the division of the attenuated transversalis fascia, from 1tle intemal inguinal ring to the pubic tubercle. The deep-lying epigastric vessels must be carefully protected.

0 Preperitoneal dissection

0 Excision of the weak transversalis fascia

The fascial edges are dissected In a cranial direction from the underiyfng preperitoneal fat, until the lateral edges of the rectus sheath and the aponeurotic arc of the transverse muscles (*white line•) are visualized. The caud;d leaf should only be mobilized with caution due to the risk of bleeding.

If the fascia Is weak or has a hernia defect. then the entire frail part of the transversalis fascia Is excised to achieve edges capable of supporting sutures. The aponeurotic arc of the transverse musdes cranially and the iliopubic tract caudally are always present to hold the sutures.

111lngulllll lllrnla •pair (Shouldlal)

o

Shouldlce suture I

The transversalis fascia is plicated to repair 1tle posterior wall. For this purpose, the free edge of the caudal leaf of the divided tr.msversalis is attached deep to 1tle cranial flap of 1tle transversalis with a continuous suture, which begins in the medial comer of the fascia at the pubic tubercle (do not include the periosteum). The undersurface of the rectus sheath, which shines through the transversalis fascia ("white line"), supports the suture medially, whereas laterally the tendinous part of the transverse arcade holds the cranial subJre. The suture Is continuous, the bite distances are 0.6 em, and each bite grasps 0.6 to 1.0 em of tissue. Size 0 monofllament polypropylene Is used as subJre material. This first suture line Is cai'Tied from the medial comer to the Internal Inguinal ring, whose fascial defect it reconstructs.

o

Shouldlce suture II

At the internal ring, the cranial part of 1tle cremaster muscle may be induded in the suture to further reinforce 1tle inguinal ring. Sufficient width of the internal ring is important; it is defined as being able to accommodate an 11.5 Hegar dilator. At the internal ring, the continuous suture line retums medially to the pubic tubercle, attaching the cranial leaf of the transversalis to the caudal edge.

o

Management of the suprapubic defect

At the pubic bJbercle, the suprapubic defect must be sea~rely closed. For this purpose, It has proven useful to continue the second line beyond the first by one or two bites, to prophylactically occlude the suprapubic defect and thus prevent a medial recurrence. Finally, the first subJre, which had been left long, Is knotted. At this point. the posterior wall Is usually finrn enough; the subsequent muscle sutures contribute only little to the stability of the repair. The surgeon may detenrnine the stability of the suture by asking the awake patient to cough.

419

420

1111ngul•l lltlrnla Rapllr (Shou. .ca)

O Shouldice suture Ill

o

The muscle layer Is approximated to the Inguinal ligament with two further continuous suture lines, beginning at the Internal ring. The flrst suture anchors the transverse abdomlnls muscle and the posterior parts of the Internal oblique muscle to the Inguinal ligament.

The suture Is then reversed at the pubic tuben:le, and the anterior parts of the lrrtemal oblique muscles are attached to the Inguinal ligament In a continuous suture technique. The suture Is knotted to the Inguinal ligament together with the flrst thread, whldl had been left long. The suture material Is again size 0 polypropylene.

(1:)

Shouldice suture IV

Closure of the external oblique aponeurosis

The repair Is completed with closure of the extemal oblique aponeurosis using a 2-0 PDS continuous suture. Subcut:ilneous transposition of the spennatlc cord should be avoided, given that It Increases the rate of later.~l recurrence to a significantfy high degree. The operation is completed with closure of the wound in layers, after possibly inserting a suction dr.~in.

_______________________________________________________________1a~_.~..-~~~~~,_.~~L

120 Inguinal Hernia Repair (Bassini)

1 Indications

7 Operative Steps

Absolute Indications: For diagnosed inguinal hernia. Timing: soon after establishing the diagnosis or urgently for incarceration. Contralndlcations: None, other than absolute general inoperability or lack of consent Alternative Procedures: No reasonable alternative

0 Principle of repair 0 Incision of the transversalis fascia 0

0 0

0

Bassini suture I Bassini suture II Knotting the sutures Oosure of the external oblique aponeurosis

2 Preoperative Preparation Preoperative Investigations: Ultrasound, Doppler ultrasonography of the testicles for recurrent procedures

3 Specific Risks, Patient Information, and Consent ... ... ... ... ...

Testicular atrophy (1 to 2%) Wound infection (2%) Chronic inguinal pain (< 5%) Recurrence (5 to 15%) Mortality(< 0.1%)

8 Relevant Anatomy, Serious Risks, Tricks ...

...

9

The transversalis fascia is the decisive plane for the success of the procedure. It therefore needs to be identified exactly and then reconstructed. For routine cases, repair with reconstruction of the anatomy is still preferable to the insertion of any alloplastic material.

Measures for Specific Complications

Ischemic orchitis: ultrasound, Doppler ultrasonography of the testicles; local cooling, elevation, anti-inflammatory agents. Revision surgery is of use only in the first 4 hours after surgery and for hematoma.

4 Anesthesia Local anesthesia is preferable for cooperative patients; otherwise consider spinal, epidural, or general anesthesia (intubation).

5 Positioning Supine

6 Approach Transverse or slightly oblique incision above the inguinal fold

10 Postoperative Care Medical Aftercare: Remove any suction drain on day 2. Male patients should wear tight-fitting underwear during the first few days. Inform the patient about resuming physical exertion or sports gradually (provide an informational leaflet). Dietary Progression: Immediately Bowel Function: Consider a small-volume enema. Mobilization: Immediately Physiotherapy: Not necessary lime Off Work: 1 to 2 weeks

421

422

1211ngul•l lltlrnla Rapllr (Baalnl)

Operative Technique 0 Principle of repair 0 Incision of the transversalis fascia 0 Bassini suture I 0 Bassini suture II 0 Knotting the sutures 0 OosW'e of the external obJique aponeurosis

o

Prindple of repair

Bassin! repair of the Inguinal hemla lnwlves approximating ttle •b1ple layer" of ttle abdominal wall to the Inguinal ligament using a single threelayer row of lntemJpted sutures. The spennatic cord Is placed over the muscle layer, beneath the external oblique aponeurosis.

O Incision of the transversalis fascia Division of ttle transversalis fascia reveals the triple layer of the abdominal wall. The transversalis fascia, ttle transversus abdomlnls, and the Internal oblique muscles are secured to ttle Inguinal ligament using a single threelayer row of lntemJpted sutures. The correct Identification and complete division of ttle transversalis fascia are essential for guaranteeing a layer· for~ayer repair. Neglecting to divide ttle transversalis fascia will result in a superficial, and thus unstable, placement of the sutures.

o

Basslnl suture I

The first stitch includes both muscle layers, the transversalis fascia, ttle periosteum of the pubic tubercle, and the inguinal ligament This stitx:h is secured to ttle so-called falx inguinalis. The suture material is 0 silk or polypropylene.

1211ngul•llltlrnla Rapalr (a..W)

0 Bassini suture II

0 Knotting the sutures

The stitch Is clamped. but not yet knotted. The further four to five stitches grasp ttte two muscle layers. the transversalis fascia, cranially and caudally. and ttte Inguinal ligament tangentially. Five or six stitches are enough to securely anchor ttte muscles of tile abdominal wall to tile Inguinal ligament.

The stitches are knotted from medial to lateral. The Intemallngulnal ring should be narrowed so far as to barely accommodate tile tip of a small finger or an 11.5 Hegar dilator.

o

Closure of the external oblique aponeurosis

The repair Is completed wlttl the suture of the external oblique aponeurosis using a continuous or Interrupted technique. Plication Is unnecessary and the subcutaneous transposition of tile spennatlc cord caJTies ttte risk of recurrence. aosure in layers and ttte optional insertion of a drain complete ttte oper.rtion.

423

121 Inguinal Hernia Repair (Lichtenstein)

1 Indications

7 Operative Steps

Absolute Indications: For diagnosed inguinal hernia, above all for elderly patients Contralndlcations: None, other than absolute general inoperability or lack of consent. Sensitivity for synthetic mesh prostheses. Alternative Procedures: Shouldice or Bassini repair

0 0 0 0 0

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Preoperative Investigations: Ultrasound, Doppler ultrasonography of the testicles for recurrent procedures

...

Principle of repair Tailoring and suture ftxation of the synthetic mesh prosthesis Suture fixation to the inguinal ligament Suture ftxation to the internal oblique muscle Reconstruction of the internal inguinal ring

Select a sufficiently large mesh prosthesis (6 x 14 em).

Caution: Watch

3 Specific Risks, Patient Information, and Consent .. .. ... .. ..

Testicular atrophy (< 1%) Wound infection (2%) Chronic groin pain ( < 2%) Recurrence (0.8 to 4%) Mortality(< 0.1%)

4 Anesthesia Local anesthesia is preferable for cooperative patients, otherwise consider spinal, epidural, or general anesthesia (intubation).

5 Positioning Supine

6 Approach Transverse or slightly oblique incision above the inguinal crease

out for narrowing at the intemol inguinal ring by exces-

sively tight sutures. ... ...

Reliable suture ftxation to the internal oblique muscle Reliable coverage of the pubic bone

9 Measures for Specific Complications If the internal inguinal ring has been narrowed too tightly, open the last suture and place it anew.

10 Postoperative care Med'ICal Aftercare: Remove any suction drain on day 2. Dietary Progression: Immediately Bowel Function: Consider a small-volume enema Mobilization: Immediately Physiotherapy: Not necessary lime Off Work: 1 to 2 weeks

121 lngul•l Hemlll Repair (lkhhnlteln}

Operative Technique 0

Prindple of repair

0 Tailoring and suture fixation of the synthetic mesh prosthesis 0 Suture fixation to the inguinal ligament 0

0

Suture fixation to the internal oblique muscle Reconstruction of the internal inguinal ring

o

Principle of repair

The principle of the Lichtenstein inguinal hernia rep;~ir is the reinforcement of the posterior wall of the Inguinal canal by tailoring a retroperitoneal mesh prosthesis. This mesh is secured to the inguinal ligament and the Internal oblique muscle, coming to lie Immediately behind the spermatic cord.

T

-- -- ----- ..... .....

...,

6 cm

1-----1 - - - - 14 em - - - - - 1

0 Tailoring and suture fiXation of the synthetic mesh prosthesis An ULTRAPRO mesh (Ethlcon) measuring 6 x 14 em Is cut to size to reinforce the posterior wall. At the broad lateral end, a slit is made along the lower half of the mesh. Tailoring is accomplished with a continuous

sLrture, beginning with a lJ-5titch at the pubic tubercle. which is overlapped medially by at least 2 em. The running suture is continued laterally as far as the internal ring. Suture material is 0 polypropylene. Prior to

this, the hernial sac Is reduced and, If necessary, reduction maintained with two gathering sutures. Then the spermatic cord is mobilized without removing the cremaster muscle. The wide overfap of the pubic tubercle with a reliable suture fiXation is important to prevent recurrences at the pubic tubercle, which are the most frequent

425

426

o

Suture fixation to the Inguinal ligament

The running stitch Is continued as far as the Internal ring, where It Is knotted and cut. No gaps should be left along the Inguinal ligament (risk of re CD

® ®

Approach Division of the external oblique aponeurosis Division of the muscles of the abdominal wall Division of the transversalis fascia Reduction of the hernia Oosure of the hernia defect Preperitoneal closure of the femoral ring Preperitoneal repair of an indirect hernia Preperitoneal repair of a direct hernia Pattern and position of the Wantz mesh hernioplasty Placement of the mesh for the Wantz hernioplasty Pattern and position of the Stoppa mesh hernioplasty Placement of the mesh for the Stoppa hernioplasty

8 Relevant Anatomy. Serious Risks. Tricks .... ...

The preperitoneal mesh should always cover all potential hernia defects and overlap by 2 to 3 em on all sides. The unilateral Wantz mesh repair or the bilateral Stoppa mesh repair is recommended for large hernia defects.

4 Anesthesia Local, spinal, epidural, or general anesthesia

5 Positioning

9 Measures for Specific Complications .... ...

Vascular injury: immediate vascular suture repair Bladder injury: two-layer repair (2-0 PGA), bladder catheter for 10 days

Supine

10 Postoperative Care 6 Approach

Medical Aftercare: Remove the suction drain on day 2 or 3.

Transverse incision well above the inguinal crease

Dietary Progression: Immediately

Lower midline abdominal incision for the Stoppa procedure

Bowel Function: Consider a small-volume enema, mild laxatives. Mobilization: Immediately Physiotherapy: Not necessary Time Off Work: 1 to 3 weeks

432

123 Pnlparltanallllngu.... llllrnla •pair

Operative Technique 0 0 0 0

Approach Division of the external oblique aponeurosis Division of the muscles of the abdominal wall Division of the trallSI/ersalis fascia 0 Reduction of the hernia 0 OosW'e of the hernia defect 0 Preperitoneal closure of the femoral ring 0 Preperitoneal repair of an indirect hernia 0 Preperitoneal repair of a direct hernia (0 Pattern and position of the Wantz mesh hemiopJasty CD Placement of the mesh for the Wantz hernioplasty CD Pattern and position of the Stoppa mesh hernioplasty a> Placement of the mesh for the Stoppa hernioplasty

o Approach The preperitoneal inguinal hernia repair is a possible procedure for cases of multiple recurrent hernia. It iiVOids access through scarred areas, the risk of injury to the spermatic cord is smaller, and visualization in nonscam! ReapproxlmaUon of the cremaster muscle

«1 FlxaUon of the Internal oblique muscle

After burying tfte sac, the cremaster muscle fibers can be reapproximated with one or two stitches (6-0 PGA).

Witft a wide internal inguinal ring, tfte internal oblique muscle is fixed tD tfte inguimd ligament in front of the spermatic cord with one or two stitches (4..0 PGA). The continuous suture repair of the external oblique aponeurosis, subcutaneous sutures, and absorbable intradennal sutures (6-o PGA) complete tfte operation.

471

133 Orchidopexy for Inguinal Testes (Shoemaker)

1 Indications

7 Operative Steps

ElecUve: On establishing the diagnosis and after unsuccessful hormone replacement therapy in the second year of life, and always for testicular ectopia. Contralndlcations: Retractile testes

0 Approach 0 Mobilization of the hernial sac and testicle

2 Preoperative Preparation Preoperative Investigations: Ultrasound, consider endocrinological investigations to exclude anorchia.

0 0 0

0 0 0 0

m

m 3 Specific Risks. Patient Information. and Consent ... ... ...

Testicular dysfunction despite successful scrotal transposition Recurrence Simultaneous repair of an inguinal hernia

4 Anesthesia

m

Opening the hernial sac Division of the hernial sac Excision of the hernial sac Retroperitoneal mobilization of the testicular vessels Incision of the scrotal skin Fonnation of a subcutaneous pouch Incision of the tunica dartos Scrotal transposition of the testicle I Scrotal transposition of the testicle II Closure of the scrotal pouch

8 Relevant Anatomy. Serious Risks. Tricks The operation should be used to take a biopsy from the affected testicle.

9 Measures for Specific Complications

General anesthesia (intubation)

5 Positioning Supine

6 Approach Transverse incision in the lower abdominal fold

Caution: Awid fvcation of the testicle with the spennatic cord twis12dl Revise immediat1!/y if in doubt

10 Postoperative Care Medical Aftercare: A day-surgery approach is possible. Dietary Progression: 4 to 6 hours after the end of anesthesia

133 Orchldopay far lngul•l T-..IShoa•••r)

Padfatrfc Surgery

Operative Technique 0 0 0 0

Approach Mobilization of the hernial sac and testicle Opening the hernial sac Division of the hernial sac 0 Excision of the hernial sac 0 Retroperitoneal moblllzation of the testicular vessels 0 Indslon of the saotal skin 0 Fonnation of a subcutaneous pouch 0 Incision of the tunia dartos (0 Saotal transposition of the testicle I CD SaotaJ transposition of the testicle II CD Closure of the scrotal pouch

o

Approach

PosiUonlng and approach are the same as for an Inguinal hernia: supine position of the dt!ld with a pad placed beneath the buttodcs to elevate the pelvis, skin Incision In the lower abdominal fold. After deepening the incision through the subcutaneous tissue, the ~mal oblique aponeurosis is identified and completely opened, together with the external inguinal ring. The crema~r muscle fibers are divided longitudinally and the superficial inguinal pouch is mobilized, together with the testide contained within.

o

Mobilization of the hernial sac and testicle

After Identifying the hemlal sac, It Is grasped with a forceps and brought forward. The sac Is separated completely from It suJTOUndlngs, together wl1tl the testlde, and brought out of the wound. This may proceed predominantly bluntly, dissecting the sac to the level of the Internal Inguinal rfng.

473

474

Pediatric Surgery

133 OrcNclapay for lngul•l T-. (Sh...-.r)

o Opening the hernial sac After complete mobilization of 1tle hemial sac, it is grasped between two sharp clamps and opened transversely.

o Division of the hernial sac Wittgenstein scissors are passed benea1t11tle posterior wall of the sac, which is 1tlen divided, while carefully protecting 1tle spennat:Jc cord. The proximal part of the sac Is grasped with four mosquito hemostats and mobilized down to the Internal ring.

133 Orchldopay far lngul•l T-..IShoa•••r)

o

Excision of the hernial sac

After completely mobilizing the hemial sac, it is twisted and transfixed, using a small dissecting swab to ward off the spermatic cord for its protection. The excess sac Is excised.

o

Padfatrfc Surgery

Retroperitoneal mobilization of the testicular vessels

A high retroperitoneal mobilization of the testicular vessels Is essential In order to achieve a bmslon-free orchidopexy. For this purpose a ffne dissecting sw.Jb is used for blunt dissection along the vascular bundle to the level of the retroperitoneum. The fine fibrous strnnds on the lateral aspect of the vessels are divided. Dissection must continue until the testicle can be brought down into the saot:um without tension.

475

476

Pediatric Surgery

o

133 OrcNclapay for lngul•l T-. (Sh...-.r)

Incision of the scrotal skin

Placement of the testicle Into the scrotum begins wtth the fonnatlon of a subcutaneous scrotal pouch. For this purpose. the surgeon Inserts a finger bluntly from the groin indsion down Into the scrotum. The scrotal skin is superficially incised over the tip of the finger for a length of 1 em.

O Fonnation of a subcutaneous pouch The ends of the wound are grasped with fine clamps and a pouch Is developed between the skin and the tunica dartos by blunt dissectlon using scissors. This pouch must be sufflclentfy wide enough to accommodate the testide without tension.

o

Incision of the tunica dartos

The tunica dartos is bulged out by the surgeon's index finger and a short incision is made with the scalpel.

133 Orchldopay far lngul•l T-..IShoa•••r)

~

Scrotal transposition of the testicle I

A clamp Is passed through the flne opening In the tunica dartos and Its tip grasps the testicle. With Its help, the mstlcle Is brought down Into the subcutaneous pouch, ensuring that the spermatic cord is not twisted.

Padfatrfc Surgery

0.4 em) Alternative Procedures: Conservative management if findings are minimal

0 0 0 0

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Preoperative Investigations: Ultrasound, consider contrast imaging Patient Preparation: Nasogastric tube. correction of fluid and electrolyte loss

~ ~

3 Specific Risks, Patient Information, and Consent

9 Measures for Specific Complications

~

~

... ~

Hemorrhage Leakage with peritonitis Injury to adjacent organs Mortality(< 0.1%)

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine

6 Approach Transverse indsion in the right upper abdomen

Positioning, skin incision Myotomy Spreading apart the split muscle Omental coverage

Do not place the skin incision immediately beneath the costal margin because of the relatively large liver. Usually injuries to the mucosa occur typically at the duodenal end of the myotomy.

If the mucosa is accidentally perforated, achieve suture closure using an interrupted suture technique and cover with an omental flap.

10 Postoperative Care Dietary Progression: Oral feeding from 6 hours postoperatively

482

Pediatric Surgery

Operative Technique 0 0 0 0

Positioning, skin incision Myotomy Spreading apart the split muscle Omental coverage

o

Positioning, skin incision

o

Myotomy

With the patient supine and the spine slightly reclined, a transverse Incision of -4 ern In length Is centered over the maximum point of the sonographlc findings (I.e., at the lateral margin of the rectus abdomlnls muscle), two flngerbreadths above the umbilicus.

After opening the abdominal wall, retracb)rs are Inserted and the pyloric tumor Is delivered Into the wound. The pyloric region Is held between the Index flnger and thumb of the left hand and a longitudinal Incision Is made with the cutting diathermy. The diathermy should be set with the energy as low as possible to guarantee control over the cutting depth. The length of the myotomy Is between 1.5 and 2.0 em, with the longer limb coming to lie OYer the sb)mach.

o

o

Spreading apart the split muscle

The myotomy must be carried down to the mucosa without Injuring lt. After partially dlvldlng the muscle wall, the edges of the split muscle are spread further apart with a blunt spreading forceps. down to the mucosa. This proceeds until the mucosa bulges inm the cleft in the musde. The greatest risk of mucosa perforation is at 1tle pyloroduodenal junction, where the 1tlickness of the wall suddenly diminishes. Special care must be taken here not to Injure the mucosa. Should perforation occur, the defect must be oversewn and possibly covered with an omental patch.

Omental coverage

If the mucosa Is In a very vulnerable condition or when a mucosal defect has occulTed, the myommy cleft In the muscle should be covered by an omental patch (if necessary, after repair of the mucosa). The patch is attached to the thick seromuscular layer using two or three interrupted sutures (4-0 PCA).

136 Femoral Embolectomy

1 Indications

8 Relevant Anatomy, Serious Risks, Tricks

Absolute Indications: On establishing the diagnosis

...

2 Preoperative Preparation Preoperative Investigations: Complete assessment of peripheral

... ...

pulses, angiography (IV DSA) Patient Preparation: Full IV heparinization with 20,000 IU daily;

control any diabetes. Exclude any coronary heart disease requiring treatment Check for atrial fibrillation.

•

3 Specific Risks, Patient Information, and Consent

...

... ... •

Recurrent occlusion Amputation Lymphatic fistula

4 Anesthesia General or local anesthesia

5 Positioning Supine, legs spread slightly apart; the contralateral inguinal region must also be accessible. The surgeon should have the possibility of checking foot pulses intraoperatively. Position the patient on a table that is capable of allowing an on-table angiography.

...

...

... ...

...

...

Order of the structures below the inguinal ligament: inside, vein, artery, nerve (IVAN), or nerve, artery, vein, y-fronts (NAVY) The long saphenous vein drains into the femoral vein anteromedially, 3 to 4 em below the inguinal ligament Below the inguinal ligament the common femoral artery gives off four smaller branches, which should be preserved because they may be important for the collateral supply of the leg. Approximately 5 em below the inguinal ligament. the common femoral artery gives off the deep femoral artery laterally or posteriorly (occasionally there is also a duplicate deep femoral artery). The arteriotomy must provide access to the superficial femoral artery and the femoral artery. First perform the proximal embolectomy maneuver and then the distal (all the main branches); do not stop until there is a good flow or baclcflow. After embolectomy, inject heparinized saline into the cleared vessels to prevent stasis-induced thrombosis during manipulation of the other branches. Order histological and microbiological examinations of the embolus. Insert the vascular stitch in such a manner that the distal arteriotomy margin is sutured from inside out (reduces the risk of creating a step in the suture line). At the slightest risk of the suture line producing stenosis of the vessel, harvest and insert a patch from an adjacent vein (never use the long saphenous vein because it may be required later as a bypass graft). Before completing closure of the arteriotomy, perform a flush maneuver by first opening the distal, then the proximal damp before finally knotting the vascular suture.

6 Approach Longitudinal incision over the common femoral artery below the inguinal fold

9 Measures for Specific Complications ...

Intraoperative loss of puJse: renewed Fogarty maneuver, consider an on-table angiogram. Fasciotomy should be performed at the slightest suspicion of a compartment syndrome.

7 Operative Steps

...

0 0 0 0 0

10 Postoperative Care

Anatomy Draping and skin incision Exposure of the common femoral artery Arteriotomy and embolectomy Vascular suture

Medical Aftercare: Systemic heparinization, followed by treatment

with warfarin. Remove the suction drain on day 2. Mobilization: Immediately Time Off Work:

Depending on the overall situation, -1 to 2 weeks

484

13& IWnol'lll E.nw.cto.n,

Operative Technique 0 Anatomy 0 Draping and skin incision 0 Exposure of the common femoral army 0 Arteriotomy and embolectomy 0

Vascular suture

o

Anatomy

An embolus of 1tle femoral artery may nave various locations. It usually lodges directly at the blfurcatlon of 1tle superficial and deep femoral arteries. However, all locations may be Involved, from an aortic saddle

embolus to a peripheral embolus In 1tle region of 1tle trlfurcatlon at 1tle lower leg. Embolectomy in the region of the superficial femoral artery will be desaibec:l here.

0 Draping and skin indsion For an embolectomy, 1tle whole leg Is prepped and draped In a sterile fashion, with 1tle pubic area covered. The skin Incision Is centered over 1tle slt:P where 1tle embolus Is suspect:Pd and Is placed longitudinally to expose as much of the artery as possible. The prerequisite of any e~ bolectomy is the distinction b~n an embolus and an acute arterial thrombosis in the presence of peripheral arterial disease as the underlying disorder. The first step for a peripheral location of the embolus is to obtain an angiogram. An angiogram may be dispensed with in the p~ sence of the impressive clinical picture of a centnl femoral embolus. Surgical management in this case will provide diagnostic confirmation.

o

Exposure of the common femoral artery

After exposing 1tle vessels of the 1tllgh over a distance of at least 10 an, the subcutaneous tissue Is held apart with a self-retaining retractor and the vessels are mobilized on all sides. The superficial femoral, the deep femoral, and 1tle common femoral arteries are controlled wi1tl vessel loops. It Is recommended to ocdude these vessels with nonaushlng vascular clamps or to prepare them for Intermittent ocduslon by passing the vessel loops around them twice. If palpation confirms a healthy vessel wall (embolic occlusion), the artery is opened by a transverse incision, while a longitudinal incision is placed above the femoral bifurcation if pathological changes of the vessel w;ll are present (suspected peripheral arterial occlusive disease). AFogarty catheter is inserted into the external iliac artery, the superficial femoral artery, and the deep femoral artery, and the embolus Is removed.

485

o

Arteriotomy and embolectomy

A transwrse Incision above the femoral bifurcation may suffice for heahtly vessels. Severely altered arterlosderotlc vessels will require a longitudinal Incision, which w111 be repaired later by angloplasty using a vein pab:h harvested from the long saphenous vein to widen tfle artery. In each case, however, a Fogarty catheter is inserted in a cranial-t~istal direction to remove tfle embolic clots from all th~ branches after irtflating the balloon. The embolectomy should be continued until a vigorous arterial badc:flow is confirmed from each artery. Local and systemic heparinization is then initiated to prevent recurrence. This involves irtjecting hepariniled saline into the superficial and deep femoral arteries.

o

Vascular suture

With healthy vessels, a transwrse running suture using double-armed 6...0 polypropylene is used to dose the arteriotomy. Angioplasty with a vein patch may be required to widen the artery In the presence of larger plaques, when Interrupted sutures may be preferable. Always Insert the suture Into the arterial wall from Inside out. especially distally.

137 Femoral Thrombectomy

1 Indications

7 Operative Steps

Absolute Indications: Acute venous thrombosis above the popliteal level Conb'aindications: Old, organized thrombus with collateral circulation Alternative Procedures: Lytic therapy

0 0

2 Preoperative Preparation Preoperative lnwstigations: Ultrasound, ascending phlebography, consider cavography Patient Preparation: IV heparinization with 20,000 IU/day

3 Specific Risks, Patient Information, and Consent ... .... .... ....

Pulmonary embolism Recurrent thrombosis Need for postoperative anticoagulation therapy Possible need for the later closure of an arteriovenous fistula

4 Anesthesia General anesthesia (intubation)

5 Positioning Supine. Also prepare for an emergency thoracotomy.

6 Approach Longitudinal incisions over both groins

0

0 0

0 0

Anatomy Reverse Trendelenburg positioning Draping and skin incision Venotomy Proximal balloon occlusion Wrapping the leg Arteriovenous fistula

8 Relevant Anatomy, Serious Risks, Tricks Always use positive end-expiratory pressure (PEEP) ventilation during central advancement of the Fogarty catheter.

9 Measures for Specific Complications If the backflow is poor, repeat the thrombectomy until successful.

10 Postoperative Care Medical Aftercare: Postoperative anticoagulation for -6 months Dietary Progression: Immediately Mobilization: Immediately Time Off Work: Depends on the overall situation

137 h.norallhron~...._,

Operative Technique 0 0 0 0

Anatomy

Reverse lfendelenburg positioning Draping and skin incision Venotomy Proximal balloon occlusion

0 0 Wrapping the leg 0 Arteriovenous fistula

o

Anatomy

A pelvic vein thrombosis is often located unilaterally and extends from the femoral vein, via the lilac vein to the vena cava. If 1tle dnombus Is not yet organized, then thrombectomy should be undertaken. It begins over the femoral vein, medial to the artery, below the Inguinal ligament

o

Reverse Trendelenburg positioning

The patient Is placed In the reverse Trendelenburg position to avoid coronary and pulmonary embolism (I.e., the upper body Is raised by 40 degrees and the legs are lowered by 10 degrees).

487

488

o

Draping and skin Incision

The surgical field extends from bath lower legs to tile sternal notch; tile pubic area Is covered In a sterile fashion. An extended abdominal access and even a sternotomy must be possible at any time during the opera· tion. The skin incision is over tile inguinal fold, as for an embolectomy.

o

Venotomy

The skin is incised and the incision deepened through the subcutaneous tissue. A retractor is tilen inserted and tile femoral vein exposed. The greater saphenous vein and tile superficial femoral vein are secured with vessel loops and mobilized, while tile side branches are ligated. A long~ tudlnal venotomy Is made over tile confluence of the two veins.

137 h.norallhron~...._,

o

Proximal balloon occlusion

A large-caliber balloon catheter may be inserted from the corrtralater.ll side to prevent the centripetal spread of venous thrombi. This precaution is largely superfluous if positive end-expiratxlry pressure (PEEP) ventilation is used and is only justified in individual cases. The proximal occlusion balloon should hold about SO ml in order to completely block 1fle vena cava. The balloon Is mainly Inserted for the more common (70%) leftsided Iliofemoral thrombosis, where the risk of embolism Is slgnlftcantfy Increased. The reverse Trendelenburg position plus PEEP ventilation ls usually suffldent for right-sided thromboses. After proximal balloon occlusion or appropriate PEEP ventilation, the thrombus Is removed from the affected side with the aid of the Fogarty catheter. For this purpose. the catheter must be inserted in a distal and proximal direction to remove all thrombi. Image intensifier control is recommended to ensure localization of the catheter. Distal1tlrombi are best extracted by manual compression of the leg, which may be reinforced by a compression dressing using elasUc bandages.

0 Wrapping the leg Complete removal of the thrombi from the leg is augmented by wrapping the leg with an elastic rubber bandage as far as the groin (compression thrombectomy). The occlusion sling on the proximal end of the femoral vein may be opened at Intervals to eJCPress the thrombi via the venotomy. Wrapping out the leg replaces inserting the thrombectomy catheter distally, which often proves to be impossible due to the venous valves. The surgeon should be careful not to damage these venous valves by inappropriate manipulation. For this reason, wrapping out the extremity Is the gentler option.

,-"

o

Arteriovenous fistula

The creation of a temporary arteriovenous fistula is recommended to maintain patency of the pelvic venous system following thrombectomy. For this purpose, a side branch of the saphenous vein Is dissected and transected distally. This is followed by Its Implantation Into the superficial femoral artery using monofllament 7-0 polypropylene sutures. The venotomy Is repaired using a continuous suture of the same material.

489

138 Crossectomy, Long Saphenous Vein Stripping, and Perforator Ligation 1 Indications

7 Operative Steps

Elective: Chronic insufficiency of the superficial venous system with varicosis and leg ulcers Conb'aindications: Occlusion of the deep venous system Alternative Procedures: Percutaneous injection sclerotherapy

0 0

2 Preoperative Preparation Preoperative Investigations: Confirm the patency of the deep venous system with phlebography, Doppler ultrasonography. Patient Preparation: Mark the veins preoperatively, especially the perforators.

Anatomy Marking the varicose veins 0 Positioning and skin incision 0 Anatomy of the fossa ovalis 0 Crossectomy 0 Division of the long saphenous vein 0 Suture ligation of the vein stump 0 Distal isolation of the long saphenous vein 0 Insertion of the Babcock probe a!) Proximal ligation of the Babcock probe Stripping of the long saphenous vein from proximal to distal Removal of varicosed venous branches Perforator ligation (tl Technique of subfasctal endoscopic perforator surgery Compression bandage

m

m

m 3 Specific Risks, Patient Information, and Consent ... .... .... ,._

Varicose vein recurrence (5% after 10 years) Vascular injury (femoral artery/vein) Postoperative hemorrhage Nerve injury (saphenous nerve, sural nerve)

m

8 Relevant Anatomy, Serious Risks, Tricks Oose positional relationship on the lower leg between the long saphenous vein and the saphenous nerve and between the short saphenous vein and the sural nerve

4 Anesthesia General, spinal, epidural anesthesia

5 Positioning Supine, legs spread slightly apart

6 Approach The skin incision for subfascial endoscopic perforator surgery (SEPS) is placed along the midline of the medial lower leg, two fingerbreadths dorsal to the posterior tibial border.

9 Measures for Specific Complications Apply constant compression for bleeding; consider suture ligation of the venous branches.

10 Postoperative Care Medical Aftercare: Strict compression: first apply an elastic compression dressing, prescribe custom compression stockings after complete wound healing. Mobilization: Immediately: elevation of the legs when sitting down for the first 6 weeks. Motto for the patient: walking and lying down are good; sitting and standing are bad. Physiotherapy: Not necessary Time Off Work: 1 week

1• CraaacbNnJ. a..g Slphll110111 v.rn Stripping. and rr.rlar1118r Ugllllon

Operative Technique 0 0 0 0

Anatomy

Marking the varicose veins Positioning and skin incision Anatomy of the fossa ovalis 0 Crossecmmy 0 Division of the long saphenous vein 0 Suture ligation of the vein stump 0 Distal isolation of the long saphenous vein 0 Insertion of the Babcock probe (0 Proximal ligation of the Babcock probe CD Stripping of the long saphenous vein from proximal to distal CD Removal of varicosed venous branches Perforator ligation Technique of subfascial endoscopic perforator surgery Compression bandage

m m m

o

Anatomy

The long saphenous velll rulls alollg the lnller aspect of the thigh and divides Into two or three branches on the Inner aspect of the lower leg. The short saphellous vein drains Into the popliteal velll alld rulls subcutaneously Oil the dorsolateral aspect of the lower leg. Whereas the lollg saphenous vein originates in the region of the inner millleolus, the short saphenous vein begins on the posterior surface of the outer malleolus.

491

492

0 Marking the varicose veins

0 Positioning and skin incision

Marked truncal varices with signs of lndplent congestlon provide the lndlcatlon for surgical treatment of varicose veins. Sclerotherapy Is of no use In these cases. Prerequisite for any stripping treatment of tfte long saphenous vein Is the conftnnatlon of patency of tfte deep venous system by phlebography. Preparation for surgefY begins on tfte evening before the operation; with tfte patient standing, the venous convolutes are marked with a felt-tipped pen. Fascial gaps are palpated and the inco~ petent pelforators within them are martced separately (circles or aosses).

The leg to be operated Is positioned In slight external rotation over a padded knee roll. The pubic area and tfte foot are draped In a sterile fashion. The surgkal field extends from tfte anb!rlor superior lilac spine to tfte ankle. The sk!n Incision Is on tfte medial aspect of tfte tftlgh, transverse or oblique, and centered over the easily palpable pulse of the femoral arb!ry, which corresponds to tfte fossa ovalis.

o

Anatomy of the fossa ovalls

After deepening tfte incision tftrough tfte subcut.lneous tissue and insertion of a seff·ret.lining retractor, tfte fossa ovalis is identified. The femoral vein runs on its medial side, together witft tfte long saphenous vein, which branches off medially. The artefY is situated lab!rally. Arterial branches often traverse the veins, crossing o

Skin Incision

The skin incision is longitudinal along the line connecting the greater trochanter and the lateral epicondyle. The subcutaneous tissue is divided down to the ileotibial tract.

o Muscle detachment A~r exposure of the vasb.ls lawralis muscle. it is separated along its dol"5ill milrgin and reflectzd ventrally. Division may be iltcomplished with a scalpel or the cutting diathermy. The att!ichment of the musde is occasionally so far dorsal that t:ransmuscular dlvlslon Is required.

574

Traumatology

o

Fracture exposure

The reflected musde is held cranially with two Hohmann retractors, which are inserted behind the femur. Now tne fracture site Is exposed. Minor vessels are dMded between 0\ierilolt clamps.

o

Cleaning the fracture site

The next step involves cleaning tne fracture site and preparing for reduction. If the fracture is impacted, tnen no furtner reductlon Is required. Often, however, tne fracture ends are dislocated by tne strong tractlon of the thigh muscles and can only be reduced by exerting considerable force. In these cases It Is occasionally necessary to use a femoral dlstractor in order to reduce the fracture ends.

o

Lag screw

After successful reduction, retention is maintained with reduction clamps, with or without a contoured DC plate. lnterfragmentary ftxatlon with a lag screw, which should cross the fracture site at sight angles, Is used to maintain redu~ 1ion.

Traumatology

o

Contouring the DC plate

Once the fracture has been retained by the lag screw (if necessary by several lag saews), a wide neutralization plate or a buttress plate may be placed laterally.

o

Placement of the screws

The use of DC plates is recommended to bring the fracture ends furtfler under compression by placing the screws e(;centrlcally. For this purpose, the screws near the fracb.Jre are Inserted asymmeb'tcally, after which the others are placed In their coJTespondlng holes. Altogedler, It Is sufficient with femoral fractures to have at least seven cortices of purchase in bath main fragments above and below tfle fracture. The saews furthest awifi from tfle fracture mifi be limitEd to having purchase in only one cortex.

0 Drainage. wound closure The lleodblal tract Is repaired over a subfasclal drain with Interrupted sutllres. Sulxutaneous suction drain, sulxutaneous sutures, and sk!n st!ples complete the operation.

575

161 Patella Fractur... e-Tension Band Wiring 1 Indications

7 Operative Steps

Absolute Indications: Any dislocated transverse fracture of the patella Contralndlcations: Contaminated or infected wound conditions. Nondislocated (usually vertical) fractures. Severely comminuted fractures. Alternative Procedures: Screw fixation

0 Skin incision 0 Oeaning the fracture site

0 Variations

2 Preoperative Preparation

8 Relevant Anatomy, Serious Risks, Tricks

Patient Preparation: Consider aspiration of joint effusion when treating conservatively.

... ... ...

3 Specific Risks, Patient Information, and Consent

...

... ... ... ... ...

Infection Nonunion Postoperative hemorrhage Osteoarthrosis Removal of hardware

0 Reduction and retention 0 Kirschner wire ftxation 0 Tension-band wiring

...

It is imperative to restore articular congruity of the patella. Remove any unviable remnants. It is preferable to further resect the joint surface than to leave any incongruities. Evacuate any hematoma by irrigation before reduction and inspect the joint surfaces for any impressions or fractures. Insert Kirschner wires anterior to the midline.

9 Measures for Specific Complications ... ...

Consider using several tension bands and screw ftxations for comminuted fractures. Septic arthritis: insertion of a suction-irrigation drain

4 Anesthesia General anesthesia (intubation), epidural or spinal anesthesia

5 Positioning Supine

6 Approach Transverse indsion, lateral parapatellar incision

10 Postoperative Care Medical Aftercare: Remove the joint drain on day 1 or 2. Remove the hardware after 1 year. Mobilization: Initially without weight bearing after removal of drains Physiotherapy: After removal of drains, immediate physiotherapy, consider using a controlled passive motion machine for the first 5-7 days. Time OH Work: -6 weeks

1&1 Patallla Fradu.,._T. .bl Band Wiring

Traumatology

Operative Technique 0 0 0 0

Skin incision Oeaning the fracture site Reduction and retention Kirschner wire fixation Tension-band wiring

0 0 Variations

o Skin Incision The classic approach Is via a lab!ral parapatellar Incision, alttlough results are just as good YJith a transverse Incision. Reflection of the medial sklnsubdennis flap from the anterior surface of 1tle patella allows access to the fracture site. The now exposed knee joint is thoroughly irrigated. Pari:$ of 1tte extensor expansion, blood clots, and small demched fragments of bone and cartilage are removed with forceps or inigated from the joint. The periosteal coverage Is scraped back from the fracture ends for -2 mm to allow accurate adaptation of 1tte anterior cortex.

o

Cleaning the fracture site

After exposing 1tte fracture site, the proximal end is elevated using a small bone hook, 1tte articular surface is cleaned further, and ttle joint is Inspected. Residual debris and blood clots are removed by Irrigating 1tte joint. The entire joint Is carefully deaned.

o

Reduction and retention

After reducing 1tte bone fragments, the patella is grasped with a redu~ tion clamp and the fragments pressed finnly together. The clamp should be placed as dorsally as possible In order to ftnnly embrace the pab!lla.

577

578

Traumatology

111 Pattlla Fll'lldllre---T•IIIIon a.d Wiring

0 Kirschner wire foortion

0 Tensio,..band wiring

Axial Kirschner wires with a tltlckness of 1.8 to 2.0 mm are tlten drilled through the patella, -2 to 3 an apart. The wires should come to lie more In the anterior part of tlte patella than In the posterior, -5 mm below the cortex. Once the wires have been Inserted with tlte correct alignment. reduction Is assessed with a finger behind the articular surface of the patella. At the same time the correct position of the wire within the bone is checked.

The cranial and caudal ends of tlte wires are bent over to create a secure hold for the tension band. The tension band is formed using a 1.2 to 1.4 mm wire. which is wound in a figure-of-eight fashion around Kirschner wires and tightened by twisting the ends together. Care should be taken to ensure tflat tfle patella does not open up at its dorsal surface, which is achieved by correct placement of the Kirschner wires. The proximal and distal ends of the Kirschner wires are burled with the aid of a hammer and Impactor. The distal ends should be bent over as little as possible to facllltate tltelr later removal in a cranial direction. After achieving an.r tomlcal reduction and flxatlon of the fracture, an Intra-articular suction drain is inserted, tfle joint capsule is dosed, and tfle retinacula are approximated with absorbable sutures.

o

Variations

Comminuted fr'ilctures and oblique fractures require variations in technique, which may comprise drcular wire cerdages, transverse screws, and multiple wire cerdages or Kirschner wires inserted at a distmce from each other.

162 Intramedullary Nailing of the Tibia 1 Indications

7 Operative Steps

Relative Indications: Fractures of the middle third of the tibial shaft Contraindications: 'JYpe II and III open fractures, children (open growth plates). acute and chronic osteomyelitis, tibial fracture with joint involvement Alternative Procedures: Conservative management, traction, external ftxation. plate fixation, unreamedjinterlocked nail

0 0 0 0 0

0 0

Positioning Skin incision Opening the medullary canal Introduction of the guide rod Reaming the medullary canal Insertion of the medullary nail Skin suture and drain

2 Preoperative Preparation Patient Preparation: Consider the prophylactic administration of perioperative antibiotics.

3 Specific Risks, Patient Information, and Consent ... ... ... ... ... ...

Infection (as high as 7%) Delayed union, nonunion (< 5%) Malunion Nerve injury (peroneal nerve) Compartment syndrome Removal of hardware

4 Anesthesia

8 Relevant Anatomy, Serious Risks, Tricks When dividing the patellar ligament. espedally proximally, do not incise too deeply into the venous network found there. Caution: Avoid penetrating the joint with the awll

... ...

Keep the guide pin strictly in the middle of the distal fragment. particularly on the anteroposterior view. Advance the tip of the reamer head/ball-tipped guide rod until it lies immediately above the joint surface of the ankle.

9 Measures for Specific Complications Medullary canal infection: remove the nail, provide external stabilization of the fracture, insert a suction-irrigation drain.

Spinal, epidural, or general anesthesia

10 Postoperative Care 5 Positioning Supine, spedal fracture table, image intensifier

Medical Aftercare: Remove the suction drain on day 2. Monitor closely postoperatively. Caution: Watch out for comportment syndrome.

6 Approach Median incision over the patellar tendon (-5 em)

Allow partial weight bearing from day 5 and full weight bearing from day 10. Mobilization: Immediately, initially without weight bearing Physiotherapy: Early range of motion exercises of the knee and ankle joints lime 011 Work: 6 to 10 weeks

1&2 lnlrll.n.....larr Nallng of t•11111a

Traumatology

Operative Technique 0 Positioning 0 Skin incision 0 Opening the medullary canal 0 Introduction of the guide rod 0 Reaming the medullary canal 0 Insertion of the medullary nail 0 Skin suture and drain

0 Positioning The patient Is positioned supine, with the knee flexed over a support bar. The lower leg should be placed under traction to achieve reduction and retention of the fragments.

o Skin Incision

o Opening the medullary canal

The skin incision is distill to the lower margin of the patella, diredly over the patellar tendon, which is split along the direction of its fibers with blunt scissors.

After longitudinal division of the patellar tendon. the two halves are sepaJGted with two blunt retractors, and the medullary canal is opened at the tibial tuberosity with an awl. The entry portal should lie in the extension of the medullary canal (I.e., slightly medial to the tibial tuberosity). as far proximal as possible, without breaching the anterior margin of the tibial plateau. The awl should first be Inserted at right angles to penetrate the cortex and then be advanced obliquely Into the medullary canal. The direction of the axis of tile shaft Is always tile direction of tile awl.

581

582

Traumatology

112 lniNmadullllry Nailing eltha nbla

0 Introduction of the guide rod

0 Reaming the Medullary Canal

The 3 mm ball-tipped guide rod with a curved tip Is passed distally Into the tibia across the fracture site under Image-intensifier guidance until the tip comes to lie in tfle distJI tibial epiphysis, just above tfle ankle joint. The flexible shaft with tfle attached medullary reamer head is inserted over the guide rod, first using the shafts with the firmly attached drill heads and later the shafts with the exchangeable 8 mm and 10 mm drill heads.

Reaming should proceed as far as the fracture requires it. The tendency for maximal reaming of the medullary canal has now been replaced by unreamed medullary nailing.

1&2 lnlrll.n.....larr Nallng of t•11111a

Traumatology

0 Insertion of the medullary nail

0 Skin suture and drain

After ttte medullary canal has been completely reamed, the nail Is In-

The medullary canal should be drained with a suction drain. The patellar tendon and skin are repaired with Interrupted sutures. If postoperative bleeding is observed, 1tlen suction should be removed from 1tle drain, at least intermitterrtfy.

serted using ttte Insertion device for precise flt:tfng. The approplfate length of the nail should be measured beforehand and its diameter should coJTeSpond to the size of ttte drill canal. Insertion should proceed witt! controlled taps of ttte mallet, directing tne ~ion of tne nail with

the insertion device. It is imperative not to create a further fracture by tapping tne nail in the wrong direction or by selecting tne wrong widtn of the drill canal. If tnere Is any Instability In the region of the fracture site, then consider loddng (not depleted here).

583

163 Lower Leg-External Fixation

1 Indications

7 Operative Steps

Relative Indications: Fractures with considerable soft tissue damage, type 1 and type Ill open fractures, comminuted fractures. fracture infections, and nonunion infections, fur severe concomitant joint involvement (consider here a bridging external faxatDr). Alternative Procedures: Internal flXation

0 0 0 0

Orientation of the fracture Placing the Schanz screws Direction of drilling Application of the external fixatDr

8 Relevant Anatomy, Serious Risks, Tricks 2 Preoperative Preparation Preoperative Investigations: Assess peripheral motor function, sensation, and perfusion.

3 Specific Risks, Patient Information, and Consent ~

~ ~

Loosening/need for correction of alignment Pin-track infection (5 to 10%) Later change of procedure

~

Cautjon: Wakh out (or malrotution. ~ ~

~

~

4 Anesthesia Loca~

regional, or general anesthesia

Start assembly with the screws furthest away from the fracture.

~

Anchor the Schanz screws in the far cortex. Long bones should have four cortices of secure purchase on either side of the fracture (i.e., at least two screws should be inserted in each main fragment, and at least three in the femur). Stability may be increased by placing tension on the Schanz screws and by assembling a two-tier rod system in the longitudinal axis. joint-bridging assembly is also possible with multilevel fractures. Combination with minimal bone fixation techniques is possible in the region of the fracture site.

5 Positioning

9 Measures for Specific Complications

Supine, consider image intensifier

Pin-track infection: remove the Schanz screw, curette the drill hole, place a new screw at a different site.

6 Approach Anterior when applying a unilateral flXator

10 Postoperative Care Medical Aftem~re: Daily checks of the pin sites and axis position, consider X-ray controls Mobilzation: Immediately, without weight bearing of the involved limb Time Off Woric Depends on the overall situation

585

Operative Technique 0 Orientation of the fracture 0 Placing the Schanz screws 0 Direction of drilling 0 Application of the external fixatnr

o Orientation of the fracture The application of an ~ma l focatxlr is indicated for cases with extensive soft tissue damage, comminuted fracture or fracb.Jres with bone defects, infecb!d nonunion, and similar situations. The aim of the operation Is to Insert at least two Schanz saews or Sl21nmann pins In e.~d1 (main) fragment St21nmann pins are used for fram~type flxators. In ttle present case of a unilateral ftxatnr, immobiliZiltion is achieved with two Schanz SCil!'WS in each frag-

ment

0 Placing the Schanz screws The Sd1anz screws are placed under Image-Intensifier control. The screw hole Is predrilled ttlrough a small skin lndslon and a drill sleeve using drills of various sizes (3.2 mm, 3.6 mm, 4.5 mm). n: has prcM!n effective to Incline ttle Schanz screws at an angle of -15 degrees to each other to obtain better stability.

586

Traumatology

o

Direction of drilling

The direction of drilling begins on dle antErior bor· der of the tibia and just about finds purdlase in dle posterior cortex (a). After predrilling, dle Schanz saew is inserted manually using 1tte standard technique (b). The soft tissue should only be peneb"ated unila~rally.

b

o

Application of the external fixator

After dle last screw has been placed, the tlxator can be applied. Care should be taken to ensure dlat dle tibia Is reduced and held In proper alignment In both planes. Distraction should be avoided, as should compression In the presence of extensive comminution.

164 Medial Malleolus-ORIF 1 Indications

7 Operative Steps

Absolute Indications: Dislocated fractures of the medial malleolus (isolated fractures of the medial malleolus are rare and are usually combined with fractures of the lateral malleolus). Contralndlcations: Infection. severe osteoporosis Alternative Procedures: Conservative management of nondislocated fracture

0 0

2 Preoperative Preparation Preoperative IIIWlstigations: Exclusion of lateral malleolus or fibular involvement Thigh tourniquet Operation within 8 hours after injury or after 5 days.

3 Specific Risks, Patient Information, and Consent ... ... ... ... ...

Injury to the superficial peroneal nerve (-1%) Metal allergy Infection Postoperative hemorrhage Hardware removal

0

0 0

Skin incision Oeaning the fracture site Reduction and screw fiXation I Reduction and tension-band wiring I Tension-band wiring II

8 Relevant Anatomy, Serious Risks, Tricks Caution: Protect the long sophenous vein, saphenous netw, and posterior tibial artery. Under image-intensifier control, insert the malleolar screw with the thread only in the proximal fragment

9 Measures for Specific Complications ... ... ...

Evacuate hematomas early. Early infections require immediate revision and debridement. Avoid skin suture under tension.

10 Postoperative Care 4 Anesthesia General anesthesia (intubation) or spinal or epidural anesthesia

5 Positioning Supine, foot in external rotation, tourniquet control

6 Approach Axial skin incision over the medial malleolus

Medical Aftercare: Elevation, local cooling of soft tissues, suction drain removal on day 2, hardware removal from month 6 Mobilization: Dorsiflexion exercises from postoperative day 1. Partial weight bearing up to 20 kg after -1 week, full weight bearing from postoperative week 6. Physiotherapy: Early motion exercises immediately after removing the drains Time Off Work: 6 weeks

588

Traumatology

114 MMIIII Mllllaoi....OIIF

Operative Technique 0 Skin incision 0 Oeaning the fracture site 0 Reduction and screw fixation I 0 Reduction and tension-band wiring I 0

Tension-band wiring II

o

Skin Incision

Axiill skin incision over the medial malleolus, dividing the skin and subdennis down to the periosteum. Protection of the long saphenous vein, the saphenous nerve, the posterior tibial artery, and the flexor tendons dorsal to them.

o

Cleaning the fracture site

After exposing the fracture site, the fracture gap is identified. Any fold of periosteum tucked between the fracture surfaces will need to be carefully extracted, and the fracture edges sparingly deared. Any small loose bony fragments and entrapped muscle must be removed. For this purpose, the distal malleolar fragment may be pulled down distally with a small bone hook to visuallll! the fracture site In Its entirety. The fracture sitE must be exposed sufficiently enough to be able to ensure an exact anatomical reduction of the fragment After reduction of the distal malleolar fr.tgment. temporary focation is obtained with a reduction clamp.

o

Reduction and screw fixation I

Retention is accomplished with malleolar SCI't'WS or with tension band wiring. Preliminary fixation is achieved with the insertion of a Kirschner wire, followed by predrilling with a 2.5 mm bit parallel to the Kirschner wire. Then two smal~fragment cancellous screws with short threads and washer are insertEd as lag saews. Care should be taken to ensure that the thread lies proximal to the fracture site In order to achieve c~ pression. Screw and fracture positions are checked under the Image Intensifier. Suction drain, subcutaneous suture, sk!n suture, and possibly a below-knee plaster splint complete the operation.

114 MMial Mllllaoi....OIIF

o

Reduction and tension-band wiring I

After reducing the fracture, two axial Kirschner wires are Inserted across the fracture site In a dlstal-to-proxfmal direction. A drill hole (2.5 mm) at right angles to tfte axis of tfte leg serves as a hold for tfte tensiofloband wiring fixation. A screw may also be used to secure tfte tension band. Care should be taken when drilling to ensure tflat tfle drill hole is not made too superficially, otherwise tfle t:ensiofloband wire may cut out

o

Traumatology

Tenslo..-band wiring II

After passing tfle wire tflrough the drill hole In the tibia, It Is wourtd rourtd the Kirschner wires In a ffgu~f-elght fashion artd tlght:erted on tfte later.JI side. The Kirschrter wires are bent over, att short, and buried in tfte soft tissue. Hemostlsis, subcutarteous suction dr.Jin, subcutaneous sutures, and skin closure complete tfle oper.ttion. Posfx)perative immobilization is in a below-knee plaster splint.

589

165 Lateral Malleolus-ORIF

1 Indications

7 Operative Steps

Absolute Indications: Any dislocated fracture of the la~ral malleolus Contralndlcations: Severe soft tissue damage, extreme osteoporosis Alternative Procedures: Conservative management of nondislocated Weber A/B fractures

0 0 0 0

2 Preoperative Preparation

0 0

0

Weber classification of malleolar fractures Skin incision and exposure of the fracture Reduction and retention with a lag screw Contouring the one-third tubular plate Syndesmotic transfJXation screw Suture repair of the syndesmosis Tension-band wiring

Patient Preparation: Operation within 8 hours of injury or from day 5

8 Relevant Anatomy. Serious Risks. Tricks 3 Specific Risks. Patient Information. and Consent .. .. .. ...

Injury to the superficial peroneal nerve Infection Postoperative hemorrhage Hardware removal

...

Protect the superfidal peroneal nerve.

...

Exact restoration of fibular length and avoidance of a rotation

deformity are essential. Caution: Failure to recognize a Maisonneuve fracture (•h;gh• Weber C). Always identify the syndesmosis and if necessary repair it.

...

4 Anesthesia

...

Fractures of the tibial margin should be treated if more than one fourth of the joint surface is involved. Avoid entrapment of capsular and ligamentous tissue.

General anesthesia (intubation) or spinal or epidural anesthesia Caution: Avoid positioning the screw within the tulofrbular joint

5 Positioning

...

Supine, foot in internal rotation, tourniquet control. Forefoot in a sterile surgical glove.

9 Measures for Specific Complications

6 Approach

Open the wound immediately in the presence of hematoma, early infection, or edema with blister formation.

Axial skin indsion over the lateral malleolus, forefoot in a sterile surgical glove

10 Postoperative Care

Avoid wound dosure under tension.

Medkal Aftercare: Elevation, remove the suction drain on day 2. Dorsal plaster splint until removal of sutures. Six weeks plaster immobilization fOllowing suture repair of syndesmosis or medial ligament. Remove syndesmotic screw from postoperative month 6. Hardware removal from postoperative month 6. Mobilization: Immediately. Partial weight bearing up to 10 kg after swelling has receded. FuJI weight bearing 6 to 8 weeks after surgery. Physiotherapy: Early range of motion exercises after removal of the suction drain (not after repair of the syndesmosis or medial ligament) Time Off Work: 7 to 10 weeks

115 LabiNIMalaol....oiiF

Traumatology

Operative Technique 0 Weber classification of malleolar fractures 0 Skin incision and exposure of the fracture 0 Reduction and retrntion with a lag screw 0 Contouring the one-third tubular plate 0 Syndesmotic ttansflxation screw 0 Suture repair of the syndesmosis 0 Tension-band wiring

o

Weber classification of malleolar fractures

AWeber Afracture Involves fracture of the fibula at the level of the joint space or distal to It This Injury may be combined with a shear fracture of the medial malleolus. The syndesmosis is always intact With a Weber B fracture, the fracture line is through the later.~! malleolus at the level of the syndesmosis. An additional avulsion fracture of the medial malleolus or rupture of the deltoid ligament may also be present. In SO% of cases there Is rupture of the anterior syndesmosis. AWeber C fracture Involves

a fracture line above the syndesmosis. The syndesmosis Is always RJf> tured. The lnb!rosseous membr.~ne Is also tom up to the level of the fibular fracture. In addition there is always an avulsion fracture of the medial malleolus or an equivalent rupture of the deltDid ligament. There is often a tendency to dislocate. A special loon of the Weber type C fracture is the Maisonneuve fracture with a high, oblique fracture of the fibula and an associated fracture of the medial malleolus.

591

il

o

Skin Incision and exposure of the fracture

The straiglrt indsion is deepened through the subOJt:aneous tissues and the fascia down to the bone (a). In the depths, the hematoma around the fracture site is identified and removed by suction. The perio~um is carefully raised with il periosteill elevitor and the fracture site is freed of periosteum for a distmce of 2 mm on either side (b). Entrapped periosteum, blood clots, as well as bone partides are removed. The fracture site is irrigated. Tissue fragments and entrapped tissue are removed.

b

0 Reduction and retention with a lag screw After completely cleaning tfle fracture site, the fracture Is reduced anatomically and preliminarily retained with a reduction clamp. Witt! delaY'!d fracture management It Is often necessary to achieve reduction by continuous traction on tfle soft tissues, which are often contracted. Reduction Is secured with a lag .scll!W crossing tfle facture site. For tflls purpose,

a gliding hole is drilled using a 3.5 mm bit, and a 2.5 mm thread hole is drilled over the drill guide. After measuring and tilpping, a small-fragment cortex screw is inserted. The saew is tightened while carefully observing the fracture gap.

115 LabiNIMalaol....oiiF

Traumatology

o Contouring the one-third tubular plate For definitive fracture management, a five- to six-hole one-third tubular plate is contoured to fit 1fle bone. At least thru saews should be used for the main fragment Preference should be given to cancellous screws in the presence of severe osteoporosis.

o Syndesmotic transflxatlon screw If the ankle mortise can be opened up by lateral tr.lction with a hook. then a talofibular syndesmotic screw is required to restDre stability to the ankle. This screw is drilled through the plate -1 to 2 em above the syndesmosis, with the direction of Insertion angled 30 degrees anteriorly. The screw should ftnd purchase In both cortlces of the flbula and the lateral cortex of the tfbla. Acortex screw of appropriate length Is used. It should be removed after 6 weeks.

o Suture repair of the syndesmosis The next stage is suture repair of the syndesmosis with a 3-0 PGA thread. A bony avulsion will require repair of the syndesmosis with a syndesmotic screw on the awlsion side or with transosseous sutures. A suction drain, subcutaneous sutures, skin sutures, and a bel~ee plaster cast complete the operation.

593

,•

....................olllf

0 Tension-band wiring Dlstallab!ral malleolar mctures wltf1 a small distal fragment can be managed wltf1 tension-band wire fixation. For this purpose. two axial parallel Kirschner wires are inserted to engage the pfOlCimal medial cortex of the tibia and bent over at the tip of the malleolus. A 1A mm wire is pissed through 01 tRnsosseous hole drilled it the level of the syndes-

mosis and bent around the wires in the typical figure-of-eight bshion. Twisting the wire ends tight then places the fragments under compression. The procedure should only be used with a firm cortex because otherwise sufficient stability cannot be guaranb!ed.

166 Fibular Ligament Suture and Ligament Reconstruction with a Periosteal Flap 1 Indications

7 Operative Steps

Absolute Indications: Open injuries Relative Indications: On establishing the diagnosis: especially in young patients who partidpate in active sports Contraindications: Severe soft tissue damage Alternative Procedures: Purely conservative management with a special orthosis. Screw ftxation for bony avulsion.

0 Skin indsion 0 Identification of ligament rupture 0

0

Inspection of the joint Direct suture repair of the ligaments

8 Relevant Anatomy, Serious Risks, Tricks 2 Preoperative Preparation Preoperative Investigations: Clinical examination, stress views (positive talar tilt/anterior draw sign: comparison with the contralateral side)

3 Specific Risks, Patient Information, and Consent ~ ~

~ ~

....

Nerve injury joint infection Thrombosis Renewed rupture Chronic instability (as high as 20%)

4 Anesthesia Local or epidural anesthesia, rarely general anesthesia (intubation)

5 Positioning Supine, consider tourniquet control, forefoot in a sterile surgical glove

6 Approach Curvilinear incision, immediately behind the lateral malleolus

~ ~

~

Protect the superfidal peroneal nerve Thorough irrigation of the intra-articular hematoma, inspection of the joint surfaces Inspect all three ligamentous components and possibly also the syndesmosis

9 Measures for Specific Complications Infection of the joint: suction-irrigation drain

10 Postoperative Care Medical Aftercare: Remove the suction drain on day 2. Use a belowknee plaster cast until the sutures are removed, then a below-knee walking cast for 3 to 4 weeks. Alternatively, external stabilization with spedal splints/shoes for 4 to 6 weeks. Mobilization: Immediately, initially without weight bearing Physiotherapy: Advisable after removal of the plaster cast. Time Off Work: 2 to 8 weeks, depending on the profession

596

Traumatology

Operative Technique 0 Skin incision 0 Identification of ligament rupture 0 Insp&tion of the joint 0 Direct suture repair of the ligaments

o

Skin incision

The traditional approach is a longitudinal incision over the posterior border of the fibula, curving anteriorly about 5 mm caudal to the tip of the lateral malleolus to proceed anteriorly for -3 em. Alternatively, an anterior Incision may be used, beginning at the anterior border of the lateral malleolus and extending from there In a distal and dorsal direction. This approach caJTies the risk of possible Injury to the branches of the superficial peroneal nerve, the intermediate dorsill cutaneous nerve, and the medial dorsal a.ttlneous nerve. The malleolar nerve Ciln also be injured with tftis approach. For this re01son, the novice in particular should give preference to tfte dorsal skin incision. It is also possible to extend tfte incision in a cranial direction to undertake a lateral ligament reconrtruc;tlon.

o

Identification of ligament rupture

After division of the subcutaneous layer and the subcutaneous fascia, the lateral ligamentous complex is identified. The anterior talofibular ligament Is almost always ruptured, tfte calcaneoftbular ligament wltft Its twofold construction Is usually only tom along Its anterior portion, whereas the posterior taloflbular ligament situated dorsally Is only rarely Involved.

o

Inspection of the joint

After cleaning the ligament stumps, releasing any entrapped soft tissue and lnigatfng out the hematoma, the joint Is Inspected. It Is Important here to salvage any flake fractures and entrapped lrgamentous parts and possibly reattach them. Inspection of the Joint Is an Integral part of any ligament repair.

il

b

o Dlred suture repair of the ligaments To reconstruct the ligamentous system, the tom ends of the ligaments are approximated witf1 the ankle In a functional position (•) using Interrupted sutures (3-o PGA). One shoold be under no illusion here regarding the stability of this suture apprOl(imation: it lllilinly serves the ildaptation of the tom ends ;md does not provide sufficient loading stilbility. If there is a bony avulsion of the ligilments, then the fr.lgment must be reduced and se01red with transosseous sutures or screws. If the lig•

ments are not long enough tn take sutures, then the incision should be extended proximally and ligament reconstruction using a pertosteal flap (Kuhner) or a Watson-jones reconstructive procedure be performed (see the approprtate specialist literature). A suction drain, subcutaneous sutures, and skin sutures complete the operation (b). Postoperative lmmoblllutlon should be In a synthetic splint or In a spedal shoe to limit movements of eversion for 5 weeks.

167 Achilles Tendon Repair

1 Indications

7 Operative Steps

Elective: On establishing the diagnosis Alternative Procedures: Purely functional management

0 Positioning and skin incision 0 Division of the subcutaneous fascia 0

2 Preoperative Preparation Preoperative Investigations: Standing on the toes is not possible on the involved side. mtrasound: primary functional management is especially successful if complete adaptation of the tendon stumps under plantar flexion is possible.

3 Specific Risks, Patient Information and Consent ... .... .... .... ....

Renewed rupture (2 to 5%) Wound infection (< 5%) Injury to the sural nerve (1%) Deep vein thrombosis (1%) Reduced range of motion

4 Anesthesia

0 0

0 0

Identification of the rupture Direct suture repair Modified Bunnell criss-cross suture Fibrin glue Plantaris tendon weave

8 Relevant Anatomy, Serious Risks, Tricks ... .... ...

Already prepare the plaster back-slab in plantar flexion (110 degrees) preoperatively. carefully reconstruct the tendon sheath. Always take a biopsy of the tendon (for possible insurance purposes).

9 Measures for Specific Complications Especially in the presence of considerable damage to the tendon, it has proven useful to cover the rupture site with a turndown fascial graft from the Achilles tendon.

General anesthesia (intubation)

10 Postoperative Care 5 Positioning Prone, tourniquet, roll beneath the ankle joint to produce plantar flexion

6 Approach Dorsal along the medial margin of the Achilles tendon

Medical Aftercare: Remove the suction drain after 2 days. Place a below-knee plaster splint with the foot in passive plantar flexion for 2 weeks followed by a below-knee weight bearing cast in a 90 degree position for 2 weeks, followed possibly by bilateral 1 to 2 em heel lifts placed in the shoes for 4 weeks. Mobilization: Immediately, the affected leg should be without weight bearing for 4 weeks, The patient should abstain from sports for 4 months. Physiotherapy: Essential Time Off Work: 4 to 8 weeks, depending on the profession

1&7 Achlllas T•nclan .....,

Traumatology

Operative Technique 0 Positioning and skin incision 0 Division of the subcutaneous fascia 0 Identification of the rupture 0 Direct suture repair 0 Modified Bunnell criss-cross suture 0 Fibrin glue 0 Plantaris tendon weave

o

Positioning and skin lndslon

The paUent Is positioned prone. a tourniquet Is applied. the uninvolved leg is lowered. and the affected foot is placed over tfte edge of tfte tlble witft tfte distal lower leg lying on a rolled towel. The skin incision is on the medial side of tfte tendon, beginning at tfte heel and extending proximally, medial to tfte easily palpable tendon, and along tfte midline of the calf muscles. The short saphenous vein and the sural nerve lateral to the Achilles tendon must be carefully protected.

0 Division of the subcutaneous fascia The skin Incision Is deepened through the subcl.ltaneous tissues and the superflclallamlna of the lower-leg fascia. The ruptured tendon with Its tendon sheath now lies in the depths of tfte wound. The insertion of sharp retractors allows good exposure of the operative site.

599

600

Traumatology

117 Achll'- Tandon Rapa..

o

Identification of the rupture

Division of the tendon sheath and evacuation of the hematoma. which is always etlcountered, will allOW' identification of tfte tendon caudally and cranially. Botti tendon stumps are found and assessed wltft regard to tftelr ability to support sutures adequately. Frayed necrotic tendinous tissue Is resected from tfte tendon ends and Setlt for histological examination. Plantar flexion of tfte foot will allOW' approximation of the tendon stumps. The plantaris tet1don is usually idet1tifiable medial to the Achilles tetldon. It is almost always intact. The decision regarding managemet1t is made on the basis of assessment of the tendon stumps and tfte extetlt of the rupture. It is not usually possible to achieve direct approximation of the tendon stumps with short sutures because of the frayed nature of tfte tendon. Restoration of stability Is almost always only achievable wtth an additional modlfted Bunnell criss-cross suture or a tendon weave.

o

Direct suture repair

After resection of necrotic and frayed tendon ends. the ruptured stumps are directly reapproximated with (3-0 PGA) interrupted sutures. These sutures do not guar.m~ sufficiet1t stability. They only serve to provide congruity of the approximation.

o

Modified Bunnell criss-cross suture

In order to restore sufficient stability. a modified Bunnell criss-cross suture is indicated. This involves weiiVing a double-anmed suture with a straight needle (size 0 PDA or polypropylene) from cranial to caudal through tfte tendon, finishing with a knot in tfte distal tendon stump. This suture should be pulled tight etlough to allow tfte adapting interrupted sutures to lie witftout tension. Suction drain, suture repair of the tendon sheath and subcutaneous layer. and skin staples complete the operation. Postoperatlve Immobilization Is In a below-knee splint In slight plantar flexion (1 0 to 20 degrees) for 2 weelcs.

1&7 Achlllas T•nclan .....,

o

Traumatology

Fibrin glue

With significantfy frayed tendons it is occasionally advisable not to attempt direct suture repair, but ratner to apply fibrin glue. In order to achieve as large a surface area for gluing as possible, the proximal and distal tendon stumps are combed out with a sharp retractor and then the frayed ends glued together. Approximation Is achlewd by the application of ffbrtn glue In the region of approximation. Closure of the tendon sheatn, the subcutaneous fascia, and the skin complem the operation.

o

Plantaris tendon weave

Repair of the Achilles tendon using a plantaris tendon transfer provides the option of dispensing with a suture weave in favor of autologous material. The plantaris tendon lies medial to the Achilles tendon and is easily Identifiable. It ls divided as far cranially as possible with the aid of a tendon stl'lpper. It Is occasionally necessary to locate It through a second lndslon on the medial aspect of the calf and dividing It under direct vision. It Is often possible, however, to dispense with a second Incision by using the tendon stripper. The plantaris tendon Inserts distally onto the tuber calcanei, which provides a firm hold. Once a sufficiently long length of tendon has been harvested, It Is passed through both ends of the Achilles tendon in a criss-aoss fashion using a Reverdin needle and secured with interrupted sutures (3-(l PGA). The rupture site is often uneven; it is therefore recommended to •ran• out the proximal part of the plantaris tendon and convert it into a protective layer over the tendon, secured with interrupted sutures. Closure of the tendon sheath, the subcutaneous layer, and the skin completes the operation.

601

603 Further Reading

Further Reading

Allgower Metal. (1981): Chirurgische Gastroenterologie. Vol. I-ll. Springer, Berlin.

Kremer K, lierse W, Platzer W, Schreiber HW, Weller S (1989): Atlas of Operative Surgery. Thieme, Stuttgart-New York

Baumgart! F, Kremer K, Schreiber HW (1969): Spezielle Chirurgie fUr die Praxis. Thieme, Stuttgart-New York.

Kremer K, Schumpelick V, Hierholzer G (1992): Chirurgische Operationen. Thieme, Stuttgart-New York.

Breitner B (1987): Chirurgische Operationslehre. Vol. VIII. Urban & Schwarzenberg, Munich.

Kremer K, Platzer W, Schreiber HW, Steichen FM (1999): Minimally Invasive Abdominal Surgery. Thieme, Stllttgart-New York

Caine R, Pollard SG (1992): Operative Surgery. Gower Medical Publishing, London.

MacFadyen BV (2004): Laparoscoplc Surgery of the Abdomen. Springer, New York, Berlin, Heidelberg.

Cameron jl (1990): Atlas of Surgery. BC Decker Inc., Toronto. Chassln Jl (1994): Operative Strategy in General Surgery. Springer, New York

Muller ME, AllgOwer M, Schneider R, Willenegger H (1977): Manual der Osteosynthese. Springer, Berlin.

Dudley HD, Carter DC, Russel RCG (1986): Atlas of General Surgery. Butterworths, London. Fielding LP, Goldberg SM (1993): Surgery of the Colon, Rectum and Anus. Butterworths Heinemann ltd., london. Glredman Ml (1990): Atlas of Surgical Techniques. McGraw-Hill Inc., New York Gotz F, Pier A, Schippers E, Schumpellck V (1993): Color Atlas of Laparoscoplc Surgery. Thieme, Stuttgart-New York. Gschnltzer F, Kern E. Schweiberer L (1989): Breitner Chlrurgische Operationslehre. Urban & Schwarzenberg, Munchen. Hierholzer G, Allgi>wer B, Riiedi Th (1985): Fixateur-ext:efne.osteo synthese. Springer, Berlin. Hierholzer G, Allgower B, Riiedi Th, Schatzker J (1985): Manual on the AO/ASIF Tubular External Fixator. Springer, Berlin.

Muller-Wiefel H (1979}: Elngriffe an den Arterien. In: Breitner, B.: Operationslehre. Urban & Schwarzenberg, Munchen. Pichlmaier H, Schildberg FW (1987): Thoraxchirurgie. Springer, Berlin. Rehner M, Oestern HJ (1997): Chlrurgische Facharztweiterbildung. Operationsatlas. Thieme, Stuttgart-New York. Rob Ch (1976): Operative Surgery. Butterworths, london. Schumpelick V, Bleese N, Mommsen U (2006): Kurzlehrbuch Chirurgie, 7th edition. Thieme, Stuttgart-New York. Schumpelick V (2000}: Hernien, 4th edition. Thieme, Stuttgart-New York. Winkeltau

GJ, Schumpelick V (1996): VISZeralchirurgie.

Enke, Stuttgart.

Zollinger RM, Zollinger RM jr. (1975): Atlas of Surgical Operations. MacMillan, New York.

605 Index

Index Page numbers in italics refer to illustrations

A

abdominal drains 14, 14 drainage areas of the abdominal cavity 16, 16

abscess communicating horseshoe 64, 64 perianal385 387, 386387 achalasia, cardiomyotomy 154 155, 155 Achilles tendon repair 598 601, 599 601 adhesions, intestinal obstruction 278, 278 adrenalectomy 375 378, 376 378 laparoscopic 379 380,380 retroperitoneoscopic 380, 380 air-leak test 127, 127 amputation above-elbow 506, 506 above-knee 505 509, 506 509 below-elbow 506, 506 below-knee 502 504, 503 504 finger and toe 499 501, 500 501 anastomosis anterior wall 275,275, 331, 331, 338,338 arteriovenous 498, 498 Braun enteroanastomosis 171, 171, 192, 192 hand-sewn 323 324, 323 324 palliative, between distal ileum and transverse colon 321 324, 322 324 posterior wall274, 274, 331, 331, 338,338 rectum dissection 365, 365 retrocolic 194, 194 stapled 324, 324, 365, 365 ankle joint puncture 30, 30 appendectomy 292 299, 294 299 antegrade 298, 298 laparoscopic 300 304, 301 304 appendix anatomy 295, 295 retrocecal 298, 298 arterial catheterization 36 37, 3 7 hepatic artery, port catheter 240 242, 241242

arterial puncture 36, 36 arteriotomy, femoral 485, 485 arteriovenous fistula 489, 489 Cimino 497 498, 498 arthritis, septic 519 521, 520 521 arthrotomy 520, 520 ascites puncture 34, 34 Auchinclos-Patey mastectomy 105 108, 106108

axillary lymph-node clearance 98100,99100

bile duct exploration 217 220, 218 220 irrigation 220, 220 stone extraction 219, 219 T tube drainage 220, 220 Billroth I gastroduodenostomy 182 189, 183189

Billroth II gastroduodenostomy 190 192, 191192

biopsy breast 101102, 102 fine-needle aspiration 35, 35 Bohler traction stirrup 512, 512 bone grafting, cancellous iliac bone harvesting 516 519, 517 519 Braun enteroanastomosis 171, 171, 192, 192 breast, biopsy 101102, 102 see also mastectomy bronchus division 134, 134 bursectomy (elbow) 53 54, 54

c calcaneal traction 511, 511, 515, 515 calot triangle dissection 209, 209, 214, 214 cancellous iliac bone harvesting 516 519, 517 519

cannula gastroduodenal artery 242, 242 indwelling venous 21 22,21 tracheal 74, 74 see also catheter capsulotomy 528, 528 carbuncle, neck 51 52, 52 cardiomyotomy, for achalasia 154155, 155 carpal tunnel release 550 551, 551 catheter abdominal 269 270, 269 270 chest 270, 270 gastric 161, 161 see also arterial catheterization; cannula; urinary catheter; venous access central venous port 25, 25 cephalic vein exposure 78, 78 cervical lymph node removal 69 70, 70 chest drain 16, 16, 109111, 110111 children circumcision 478 480, 479 480 humerus fracture 525 526, 526 inguinal hernia 467 471, 468 471 orchidopexy for inguinal testes 472 477,

proximal transection 364, 364 radical resection 340 341,341 tubular resection 334 339, 335 339 transverse colon division 330, 330 colostomy 310, 310 loop transverse 305 308, 306 308 colotomy 318 320, 319 320 common bile duct see bile duct common femoral artery exposure 484, 484 communicating horseshoe abscess 64, 64 consent 2 contradictions to surgery 2 Cooper ligament 449, 449 corticocancellous bone harvesting 518, 518 cremaster muscle division 469, 469 resection 412, 412 crossectomy 490, 493, 493 cyst, hepatic 227 230, 228 230 cystectomy, hepatic 229, 229 cystic artery division 210, 210, 215, 215 cystic duct division 210, 210, 214,214 cystojejunostomy 249, 249

D

Dennis tube 276 279, 277 279 dialysis shunt 497 498, 498 diaphragm rupture 138139, 139 associated colon herniation 139, 139 disarticulation knee 506, 506 upper arm 506, 506 diverticulum Meckel 280 282, 281 282 Zinker 94 97, 95 97 drains 1416 abdominal 14, 14 drainage areas of the abdominal cavity 16, 16 chest 16,16,109111, 110111 closed 15, 15 fiXation of 14, 14 semiopen 15, 15 suction 14, 14 ductus deferens resection 405, 405 Dupuytren fasciectomy 541 543, 542 543 dynamic hip screw (DHS) 555 560, 556 560

E

473477

B Babcock probe 494, 494 Bassini hernia repair femoral hernia 445, 445 inguinal hernia 421 423, 422 423

pyloromyotomy 481 482, 482 cholecystectomy 208 211, 209 211 laparoscopic 212 216,215216 circumcision 478 480, 479 480 colon herniation 139, 139 sigmoid colon 342 346, 343 346

elbow joint bursectomy 53 54, 54 puncture 28, 28 embolectomy, femoral 483 485, 484 485 end ileostomy 283 288, 284 288 end sigmoidostomy 309 314, 310 314 Endo-GIA stapling device 171, 171, 304,304

epigastric hernia 454 455, 455 multiple 455, 455 esophagus abdominal, resection 202, 202 myotomy 178, 178 sling placement 181, 181 extensor tendon repair 547 549, 548 549

F Fabricius femoral hernia repair 445, 445 fasciotomy, lower leg 522 524, 523 524 anterolateral 524, 524 medial 524, 524 femoral embolectomy 483 485, 484 485 femoral head replacement 567 571, 568 571 femoral hernia repair crural approach 443 445, 444 445 inguinal approach 446 450, 447 450 inguinocrural approach 451 453, 452 453 femoral thrombectomy 486 489, 487 489 femoral traction 511, 511 femur division 508, 508 femur fractures see fractures fibrin glue 601, 601 fibula division 504, 504 fibular ligament reconstruction with periosteal flap 595 597, 596597

suture 595 597,596 597 fine-needle aspiration biopsy 35, 35 finger amputation 499 501, 500 501 Finney pyloroplasty 172, 174 fistula arteriovenous489,489 Cimino 497 498, 498 in-ano 388 391, 389 391 flexor tendon repair 544 546, 545 546 forceps 4, 5 fossa ovalis 492, 492 fractures distal radius 534 537, 535 537, 538 540,

fundoplication laparoscopic 148153, 149153 Nissen-Rosetti 144147, 145 147 Toupet 144147, 145 147, 153, 153

c; Galeazzi fracture 530 gall bladder excision see cholecystectomy ganglion (wrist) 61 62, 62 gastrectomy with Hunt-Rodino pouch 207, 207 with Longmire gastric reconstruction 195 205, 196205 with Roux-en-Y gastric reconstruction 206 207,207 gastric artery division 186, 186, 187, 187, 201,

556560

femoral head replacement 567 571, 568571

ORIF plate fiXation 572 575, 573 575 proximal femoral nailing 561 566, 562 566

humerus, child 525 526, 526 lateral malleolus 590 593, 591 593 lower leg, external fixation 584 586, 585586

medial malleolus 587 589, 588 589 olecranon 527 529, 528 529 patella 576 579, 577 579 pelvic 552 555, 553 555 radius shaft 530 533, 531 533 tibia 580 583, 581 583 traction 510 515, 511 515 fundic fold formation 151, 151 fundopexy 143, 143

150

incisional 460 463, 461 463 Spigelian 464 466, 465 466 umbilical 456 459, 457 459 see also femoral hernia repair; inguinal hernia repair herniorrhaphy, laparoscopic 439, 439 hiatal hernia repair 140 143, 141143, 150, 150

hip joint puncture 29, 29 humerus fracture, child 525 526, 526 Hunt-Rodino pouch 207, 207 hydrocele 401 403, 402 403

201

gastric puncture 157, 157 gastric ulcer see peptic ulcer gastric vein division 201,201 gastrocolic ligament division 327,327, 351, 351

gastroduodenal artery cannulation 242, 242 ligation 166, 166 gastroduodenostomy anterior wal1189, 189 Billroth I 182 189, 183 189 Billroth II 190 192, 191192 posterior wall188, 188 terminolateral189, 189 gastroduodenotomy 166, 166 gastrojejunostomy 168 171, 169 171 Roux-en-Y 193194, 194 using stapling device (GIA) 171, 171 gastrostomy percutaneous endoscopic (PEG) 156158, 157158

Witzel159161, 160 161 Gottstein-Heller cardiomyotomy 154155, 155

539540

femur dynamic hip screw (DHS) 555 560,

epigastric 454 455, 455 multiple 455, 455 hiatal hernia repair 140 143, 141143, 150,

H Harmann procedure 309 314, 310 314 Heineke-Mikulicz pyloroplasty 172, 173 hemiarthroplasty 567 571, 568 571 hemicolectomy left 347 354, 348 354 right 325 331, 326 331 hemijejunoplication 205, 205 hemorrhoidectomy 381 385, 382 385 hepatic artery, port catheter 240 242,241 242 hepatic cyst 227 230, 228 230 hepatic lobectomy 231 235, 232 236 hepatic rupture 236 239, 237 239 hepatic vein division 235, 235 hepaticojejunostomy 221 224, 222 224 anterior wall 223, 223 posterior wall 223, 223 hepatocolic ligament division 328, 328 hernia colonic, with diaphragm rupture 139, 139

ileocecal resection 332 333, 333 ileostomy end 283 288, 284 288 loop 289 291, 290 291 incisional hernia 460 463, 461 463 indwelling venous cannula 21 22,21 inferior thyroid artery division 89, 89 ligation 83, 83 informed consent 2 ingrown toenail 67 68, 68 inguinal hernia repair Bassini 421 423, 422 423 children 467 471,468471 dissection for 409 416, 410416 laparoscopic 438 442, 439 442 lichtenstein 424 426, 425 426 local anesthesia 406 408, 407 408 preperitoneal431437, 432 437 Shouldice 417 420, 418 420 transinguinal preperitoneal mesh repair (TIPP) 427 430, 428 430 inguinal lymph node removal45 46, 46 inguinal region innervation 407,407 inguinal testes, orchidopexy 472 477,473 477 instrument knotting 10, 10 intercostal muscle division 118, 118 internal jugular vein catheter 22, 77 78, 77 78 intersphincteric resection 366, 366 intestinal obstruction 278, 278 intramedullary nailing, tibia 580 583, 581 583

J jaboulay pyloroplasty 172, 174 jejunoduodenostomy 205, 205 jejunostomy, lateral 223, 223 joint punctures 28 30, 28 30 jugular vein exposure 76 78, 77 78 internal jugular vein catheter 22, 77 78, 7778

607

K

Kirchmeyr-Kessler suture repair 546, 546 Kirschner wire fixation 526, 526, 529, 529, 539 540, 539 540, 578, 578 temporary 548, 548 insertion 512, 512 Kleinert dynamic traction splint 546, 546 knee joint disarticulation 506, 506 puncture 30, 30 septic arthritis 519 521, 520 521 knots 810 index finger techniques 8, 8 instrument knotting 10, 10 middle finger techniques 9 10, 9 10 KOchermaneuver164, 164, 187,18~ 199,199 Kummer femoral hernia repair 445, 445

L

laparoscopic interventions 3 adrenalectomy 379 380, 380 appendectomy 300 304, 301 304 cholecystectomy 212 216,213 216 fundoplication 148153, 149153 inguinal hernia repair 438 442, 439 442 sigmoid colon resection 342 346, 343 346 splenectomy 261 263, 262 263 laparostoma 267, 267 laparotomy 306, 306, 319, 319 Latarjet nerve 176, 176 latissimus dorsi division 117, 117 suture 119, 119 Uchtenstein inguinal hernia repair 424 426, 425426

ligation 6 7 double suture 7, 7 simple 6, 6 suture 6, 6 lipoma, preperitoneal416, 416 liver surgical anatomy 232, 232 types of injury 237,237 wedge resection 225 226, 226 see also hepatic cyst; hepatic lobectomy; hepatic rupture lobectomy left hepatic 231 235, 232 236 right superior pulmonary 129131, 130 131 local anesthesia, inguinal hernia repair 406 408, 407 408 long saphenous vein anatomy 491, 491 division 493, 493 stripping 490, 495, 495 Longmire gastric reconstruction 195 205,

lung resection, atypical open 123 125, 124 125 thoracoscopic 126128, 127128 lymph nodes axillary, clearance 98 100, 99100 compartment II clearance 202, 202 removal cervical 69 70, 70 inguinal 45 46, 46 lymphadenectomy 203, 203

M McVay femoral hernia repair 446 450, 447 450 malleolar fractures lateral 590 594, 591 594 medial 587 589, 588 589 Weber classification 591, 591 mastectomy Auchinclos-Patey 105 108, 106 108 subcutaneous 103 104, 104 Meckel diverticulum 280 282, 281 282 mesenteric root dissection 349, 349 mesh graft 60, 60 mesocolon division 194, 194 mesorectum division 351, 351 Miles-Gabriel hemorrhoidectomy 381 385, 382385

modified Bunnell criss-cross suture 600, 600 Monteggia fracture 530 Moschkowitz hernia repair 450, 450

N neck carbuncle 51 52, 52 necrosectomy, pancreas 243 245, 244 245 needle holder 5, 5 nerve block, inguinal hernia repair 407,407 Nissen-Rosetti fundoplication 144147, 145147

0 olecranon fracture 527 529,528 529 olecranon traction 512, 512 orchidopexy for inguinal testes 472 477, 473477

ORIF plate fixation distal radius fracture 534 537, 535 536 femoral shaft fracture 572 575, 573 575 lateral malleolus fracture 590 594, 591 594 medial malleolus fracture 587 589, 587 589 radial shaft fracture 530 533, 531 533 ostomy rod placement 307, 307

p

196205

loop ileostomy 289 291, 290 291 loop transverse colostomy 305 308, 306 308 Lortat-Jacob hiatoplasty 140 143, 141143 Lotheissen femoral hernia repair 446 450, 447450

palmar aponeurosis 542, 542 excision 543, 543 panaritium (felon) 63 64, 64 pancreas necrosectomy 243 245, 244 245

tail resection 250 253, 251 253 pancreaticoduodenal artery ligation 166, 166 paracentesis 34, 34 parathyroidectomy 91 93, 92 93 Parks sphincterotomy 395 396, 396 paronychia (run-around) 65 66, 66 patella fracture 576 579, 577 579 pectoralis minor muscle resection 108, 108 pelvic external fixation 552 555, 553 555 pelvic floor dissection 372 374, 372 374 peptic ulcer bleeding, oversewing of 165 167, 166167 perforated, closure of 162 164, 163 164 percondylar fracture, humerus 525 526, 526 percutaneous endoscopic gastrostomy (PEG) 156 158, 157158 perforator ligation 490, 496, 496 perianal abscess 385 387, 386 387 perianal thrombosis 392 394, 393 394 perineal block 408, 408 perioperative standards 2 perirectal dissection 372, 372 peritoneovenous shunt 268 271, 269 271 peritonitis 264 267, 265 267 pilonidal sinus 397 400, 398 400 plantaris tendon weave 601, 601 platysma division 81, 81, 87, 87 pleural effusion 31 pleural punctures 3132, 31 32 pleurectomy, thoracoscopic 135137, 136137 pneumonectomy 132134, 133134 pneumothorax 31 32 polypectomy 318 320,319 320 port catheter, hepatic artery 240 242,241 242 postpyloric resection 200, 200 preoperative investigations 2 preperitoneal inguinal hernia repair 431 437, 432437

preperitoneallipoma removal416, 416 Pringle maneuver 233, 233 processus vaginalis dissection 403, 403 pronator quadratus division 536, 536 proximal femoral nailing 561 566, 562 566 pseudocystojejunostomy 246 249, 247 249 pulmonary artery division 134, 134 pulmonary vein division 134, 134 puncture gastric 157, 157 joints 28 30, 28 30 urinary bladder 33, 33 pyloromyotomy 481482,482 pyloroplasty 167,167, 172174, 173174

R radius distal fracture 534 537, 535 537, 538 540, 539540

shaft fracture 530 533, 531533 rectosigmoid junction dissection 344, 344 transection 345, 345 rectum resection 369 374, 370 374 anterior 355 369, 357 369 retrocolic anastomosis 194, 194

retrogastric dissection 185, 185 retrovesical dissection 363, 363 reverse Trendelenburg positioning 487,487 Roux-en-Y gastric reconstruction 206 207, 207 Roux-en-Y gastrojejunostomy 193194, 194 Roux-en-Y loop 223, 223, 249, 249 defunctioned 248, 248 run-around paronychia 65 66, 66 rupture diaphragm 138139, 139 associated colon herniation 139, 139 hepatic 236 239, 237 239 splenic 259 260, 260

5 scalpel4, 4 Schanz screw placement 553, 553, 585, 585 Schrudde-Oiivari procedure 397 400, 398 400 scissors 5, 5 secondary suture 49 50, 50 septic arthritis, knee 519 521, 520 521 serratus anterior division 117, 117, 122, 122 Shoemaker orchidopexy for inguinal testes 472 477, 473 477 shoulder joint puncture 28, 28 Shouldice inguinal hernia repair 417 420,

stenting, small intestine 276 279, 277 279 steri-strips 13, 13 sternotomy, medial112115, 113115 sternum division 114, 114 stoma closure 315 317, 316 317 creation 288,288, 291,291, 313, 313, 371, 371 siting 284, 284, 290, 290, 370, 370 Stoppa mesh hernioplasty 436 437, 436 437 subclavian vein catheter 22, 23 subfascial endoscopic perforator surgery 496, 496

suction drain 14, 14 supracondylar fracture, humerus 525 526, 526 suprapubic catheter see urinary catheter suprarenal gland anatomy 376, 376 see also adrenalectomy surgical tapes 13, 13 suture fibular ligament 595 597, 596 597 modified Bunnell criss-cross 600, 600 removal of 13, 13 secondary 49 50, 50 subcutaneous 42, 42 see also skin suture

T

418420

shunt, peritoneovenous 268 271,269 271 sigmoid colon laparoscopic resection 342 346, 343 346 proximal transection 364, 364 radical resection 340 341, 341 tubular resection 334 339, 335 339 sigmoidostomy, end 309 314, 310314 sinus, pilonidal 397 400, 398 400 skin lesion excision 40 42, 41 42 skin staples 13, 13 removal of 13, 13 skin suture 11 13 Al]gOver vertical mattress 12, 12 continuous 11, 11 subcuticular 12, 12 Donati vertical mattress 11, 11 interrupted 11, 11 subcuticular 12, 12 removal of 13, 13 skin tension lines 42, 42 small intestine intraluminal stenting 276 279, 277 279 segmental resection 272 275, 273 275 soft tissue tumor removal 43 44, 44 sphincterotomy, lateral 395 396, 396 Spigelian hernia 464 466, 465 466 splenectomy 198, 198, 254 256,255 256 laparoscopic 261 263, 262 263 partial 257 258, 258 splenic artery division 252, 252, 263, 263 splenic rupture 259 260, 260 splenic vein division 252, 252, 263, 263 split-skin coverage 59 60, 60 staples 13, 13 Endo-GIA stapling device 171, 171, 304, 304 removal of 13, 13

tendon repair Achilles tendon 598 601, 599 601 anatomy 545, 545 extensor tendon 547 549, 548 549 flexor tendon 544 546, 545 546 tension band wiring lateral malleolus fracture 594, 594 medial malleolus fracture 589, 589 olecranon fracture 527, 529, 529 patella fracture 576 579, 577 579 terminal ileum division 330, 330 testes hydrocele 401 403, 402 403 inguinal, orchidopexy 472 477,473 477 thoracentesis 31 32,3132 thoracotomy axillary 120 122, 121122 posterolateral116119, 117119 thorax anatomy 133, 133 thrombectomy, femoral 486 489, 487 489 thrombosis, perianal 392 394, 393 394 thyroidectomy subtotal 79 84, 80 84 total 85 90, 86 90 tibia division 504, 504 intramedullary nailing 580 583, 581 583 tibial traction 512, 512, 513, 513 toe amputation 499 501, 500 501 toenail, ingrown 67 68, 68 Toupet fundoplication 144147, 145147, 153, 153

tracheotomy 71 75, 72 75 percutaneous 75, 75

traction, fracture management 510 515, 511515

transinguinal preperitoneal mesh repair (TIPP) 427 430, 428 430 transurethral catheter see urinary catheter transverse carpal ligament 551, 551 division 551, 551 transverse colon division 330, 330

u ulcer see peptic ulcer umbilical hernia 456 459, 457 459 unguis incarnatus 67 68, 68 urinary bladder puncture 33, 33 urinary catheter 17 20, 17 insertion technique 17 18, 18, 19, 19 20 suprapubic 19 20 transurethral 17 18

v V-Y advancement flap 55 56, 56 vagal trunk division 201, 201 vagotomy selective proximal 175 179, 177179 truncal180 181, 181 varicose vein surgery 490 496, 491 496 vasectomy 404 405, 405 vena cava catheter 22 24, 23 24 venotomy, femoral 488, 488 venous access 21 24 central (vena cava catheter) 22 24,23 24 internal jugular vein catheter 22, 77 78, 7778 neck 271,271 peripheral (indwelling venous cannula) 2122,21 subclavian vein catheter 22, 23 venous cutdown 26 27,2627

w Wantz mesh hernioplasty 435 436, 435 436 Weber-Ramstedt pyloromyotomy 481 482, 482 wedge resection ingrown toenail 67 68, 68 liver 225 226, 226 Witzel gastrostomy 159 161, 160 161 wound management 47 48, 48 cleaning 48, 48 excision or debridement 48, 48 wrist joint ganglion 61 62, 62 puncture 29, 29

z Z-plasty 57 58, 58 Zenker diverticulum 94 97, 95 97