Operative techniques in vascular surgery [Volume 1, 2] 9781451186314, 1451186312, 9781451190205, 1451190204, 9781496319005, 1496319001

Table of contents :
Cover
Title page
Copyright
Contributing Authors
Preface
Contents
Volume One
Part 1 Operative Techniques in Thoracic and Esophageal Surgery
Section I Trachea
1 Open Tracheostomy
2 Cricothyroidotomy
3 Tracheostomy: Endoscopic
4 Tracheal Resection and Reconstruction
Section II Lung
5 Lobectomy: Open
6 Lobectomy: Thoracoscopic
7 Lobectomy: Robotic
8 Pneumonectomy: Open
Section III 34
9 Thymectomy
10 Thoracoscopic Sympathectomy
11 Mediastinoscopy
Section IV Esophagus
12 Cricopharyngeal Diverticulum: Open Repair
13 Cricopharyngeal Diverticulum: Endoscopic Repair
14 Epiphrenic Diverticulum Treatment
15 Long Myotomy for Diffuse Esophageal Spasm
16 Laparoscopic Heller Myotomy and Anterior Fundoplication for Esophageal Achalasia
Section V Diaphragm
17 Repair of Congenital Defects: Morgagni Diaphragmatic Hernia
18 Repair of Congenital Defects: Bochdalek Congenital Diaphragmatic Hernia
Section VI Treatment of Paraesophageal Hernias
19 Paraesophageal Hernia Repair: Laparoscopic Technique
20 Collis Gastroplasty
21 Transthoracic Hiatal Hernia Repair
Section VII Treatment of Gastroesophageal Reflux
22 Laparoscopic Nissen Fundoplication
23 Laparoscopic Mesh Hiatal Hernia Repair
24 Redo Fundoplication
25 Laparoscopic Partial Fundoplication for Gastroesophageal Reflux Disease
26 The Minimally Invasive Surgical Approach to Gastroesophageal Reflux Disease
Section VIII Treatment of Barrets Esophagus and Early Esophageal Cancer
27 Radiofrequency Ablation of Barrett's Esophagus
28 Endoscopic Mucosal Resection for Barrett Neoplasia
Section IX Treatment of Esophageal Cancer
29 Esophagectomy: Transhiatal and Reconstruction
30 Ivor Lewis Esophagectomy
31 Minimally Invasive Esophagectomy
Section X Treatment of Esophageal Perforation
32 Treatment of Esophageal Perforation: Cervical, Thoracic, and Abdominal
Part 2 Operative Techniques in Gastrointestinal Surgery
Section I Surgery of the Abdominal Wall
1 Inguinal Hernia: Open Approaches
2 Inguinal Hernia: Laparoscopic Approaches
3 lncisional Hernia: Open Approaches
4 lncisional Hernia: Laparoscopic Approaches
5 lncisional Hernia Repair: Abdominal Wall Reconstruction Options
6 Parastomal Hernia
7 Umbilical, Epigastric, Spigelian, and Lumbar Hernias
Section II Surgery of the Stomach and Duodenum
8 Vagotomy: Truncal and Highly Selective
9 Drainage Procedures: Pyloromyotomy, Pyloroplasty, Gastrojejunostomy
10 Antrectomy
11 Subtotal Gastrectomy for Cancer
12 Minimally Invasive Total Gastrectomy
13 Minimally Invasive Distal Gastrectomy
14 Proximal Gastrectomy
15 Total Gastrectomy for Cancer
16 Gastrostomy
17 Feeding Jejunostomy
Section III Bariatric Operations
18 Laparoscopic Gastric Bypass
19 Laparoscopic Sleeve Gastrectomy
20 Laparoscopic Gastric Band
Part 3 Operative Techniques in HepatoPancreato-Biliary Surgery
Section I Surgery of the Biliary System
1 Laparoscopic Cholecystectomy
2 Open Cholecystectomy
3 Radical Cholecystectomy
4 Endoscopic Retrograde Cholangiopancreatography
5 Intraoperative Cholangiogram
6 Percutaneous Transhepatic Biliary Imaging and Intervention
7 Surgically Assisted Endoscopic Retrograde Cholangiopancreatoscopy
8 Roux-en-Y Choledochojejunostomy
9 Minimally Invasive Choledochojejunostomy
10 Choledochoduodenostomy
11 Resection of Hilar Cholangiocarcinoma
12 Intrahepatic Biliary-Enteric Anastomosis
13 Operative Management of Choledochal Cyst
14 Operative Treatment of Biliary Atresia
Section II Surgery of the Liver
15 Surgical Anatomy of the Liver
16 Intraoperative Ultrasound of the Liver
17 Fenestration or Enucleation of Hepatic Cystic Disease
18 Surgical Management of Hepatic Trauma
19 Hepatic Neoplasm Ablation and Related Technology
20 Catheter-Based Treatment of Hepatic Neoplasms
21 Segmental Hepatectomy
22 Minimally Invasive Sectional and Segmental Hepatic Resection
23 Right Hepatectomy
24 Minimally Invasive Right Hepatectomy
25 Left Hepatic Lobectomy
26 Minimally Invasive Left Hepatic Lobectomy
27 Robotic Liver Resection
28 Central Hepatectomy
29 Vena Cava Resection during Hepatectomy
30 Right Hepatic Trisegmentectomy
31 Left Hepatic Trisectionectomy
Section III Surgery of the Pancreas
32 Endoscopic Ultrasonography of the Pancreas
33 Pancreaticoduodenectomy: Resection
34 Pancreaticoduodenectomy: Minimally Invasive Resection
35 Pancreaticoduodenectomy: Robotic-Assisted Resection
36 Pancreaticoduodenectomy: Pancreaticojejunostomy
37 Pancreaticoduodenectomy: Pancreaticogastrostomy
38 Laparoscopic Pancreaticojejunostomy
39 Portal Vein Resection and Reconstruction
40 Open Distal Pancreatectomy
41 Minimally Invasive Distal Pancreatectomy
42 Distal Pancreatectomy with Splenic Preservation
43 Central Pancreatectomy
44 Ampullectomy and Transduodenal Sphincteroplasty
45 Enucleation of Pancreatic Neuroendocrine Tumor
46 Operative Treatment of Gastrinoma
47 Lateral Pancreaticojejunostomy with (Frey) or without (Puestow) Resection of the Pancreatic Head
48 Enteric Drainage of Pancreatic Pseudocysts: Pancreatic Cyst Gastrostomy and Cyst Jejunostomy
49 Pancreatic Debridement
50 Laparoscopic Pancreatic Debridement
51 Endoscopic Pancreatic Debridement and Drainage
Section IV Surgery of the Spleen
52 Splenectomy (Open and Laparoscopic Techniques)
53 Splenorrhaphy
Volume Two
Part 4 Operative Techniques in Colon and Rectal Surgery
Section I Surgery of the Small Intestine
1 Laparoscopic Small Bowel Resection
2 Strictureplasty and Small Bowel Bypass in Inflammatory Bowel Disease
3 Surgical Management of Enterocutaneous Fistula
4 End and Diverting Loop Ileostomies: Creation and Reversal
5 Jejunostomy Tube
Section II Surgery of the Colon, Appendix, Rectum, and Anus
6 Appendectomy: Open Technique
7 Appendectomy: Laparoscopic Technique
8 Appendectomy: Single-Incision Laparoscopic Surgery Technique
9 Right Hemicolectomy: Open Technique
10 Laparoscopic Right Hemicolectomy
11 Right Hemicolectomy: Hand-Assisted Laparoscopic Surgery Technique
12 Right Hemicolectomy: Single-Incision Laparoscopic Technique
13 Transverse Colectomy: Open Technique
14 Laparoscopic Transverse Colectomy
15 Transverse Colectomy: Hand-Assisted Laparoscopic Surgery Technique
16 Left Colectomy for Colon Cancer
17 Left Hemicolectomy: Laparoscopic Technique
18 Left Hemicolectomy: Hand-Assisted Laparoscopic Technique
19 Sigmoid Colectomy: Open Technique
20 Sigmoid Colectomy: Laparoscopic Technique
21 Hand-Assisted Laparoscopic Sigmoidectomy
22 Sigmoid Colectomy: Single-Incision Laparoscopic Surgery Technique
23 Surgical Management of Complicated Diverticulitis: Perforation and Colovesical Fistula
24 Total Abdominal Colectomy: Open Technique
25 Total Abdominal Colectomy: Laparoscopic Technique
26 Total Abdominal Colectomy: Hand-Assisted Technique
Section III Rectal Resections
27 Low Anterior Resection and Total Mesorectal Excision/Coloanal Anastomosis: Open Technique
28 Low Anterior Rectal Resection: Laparoscopic Technique
29 Low Anterior Resection: Hand-Assisted Laparoscopic Surgery Technique
30 Low Anterior Rectal Resection: RoboticAssisted Laparoscopic Technique
31 Total Mesorectal Excision with Coloanal Anastomosis: Laparoscopic Technique
32 Abdominoperineal Resection: Open Technique
33 Abdominoperineal Resection: Laparoscopic Technique
34 Hand-Assisted Laparoscopic Abdominoperineal Resection
35 Abdominoperineal Resection: Robotic-Assisted Laparoscopic Surgery Technique
36 Restorative Proctocolectomy: Open Technique (Ileal Pouch-Anal Anastomosis)
37 Restorative Proctocolectomy: Single-Incision Laparoscopic Technique (Including Pouch Ileoanal Anastomosis)
38 Restorative Proctocolectomy: Hand-Assisted Laparoscopic Surgery Ileal Pouch-Anal Anastomosis
39 Pelvic Exenteration
40 Transanal Excision of Rectal Tumors
41 Transanal Endoscopic Microsurgery
42 Transanal Single Port Excision of Rectal Lesions
43 Laparoscopic Diverting Colostomies: Formation and Reversal
44 Surgical Management of Hemorrhoids
45 Surgical Management of Anal Fissures
46 Operative Treatment of Rectal Prolapse: Perineal Approach (Aitemeier and Modified Delorme Procedures)
47 Operative Treatment of Rectal Prolapse: Transabdominal Approach
48 Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Dissemination of Colorectal Cancer
Part 5 Operative Techniques in Breast, Endocrine, and Oncologic Surgery
Section I Breast Surgery
1 Fine Needle Aspiration of a Breast Mass
2 Wire Localized Breast Biopsy
3 Subareolar Duct Excision
4 Cryoablation of Breast Fibroadenomas
5 Lumpectomy for Breast Cancer
6 Oncoplastic Breast Surgery
7 Brachytherapy Catheter Insertion for Breast Cancer
8 Sentinel Lymph Node Biopsy for Breast Cancer
9 Internal Mammary Sentinel Node Biopsy
10 Simple Mastectomy
11 Skin-Sparing and Nipple/ Areolar-Sparing Mastectomy
12 Modified Radical Mastectomy
13 Techniques for Correcting Lumpectomy Defects
Section II Breast Reconstruction
14 Direct-to-Implant Breast Reconstruction
15 Two-Stage Implant Breast Reconstruction
16 Pedicled Latissimus Dorsi Flap Breast Reconstruction after Mastectomy
17 Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction
18 Free Transverse Rectus Abdominis Musculocutaneous Flap Reconstruction after Mastectomy
19 Deep Inferior Epigastric Perforator Flap Breast Reconstruction after Mastectomy
20 Nipple-Areolar Reconstruction
21 Reduction Mammoplasty
Section III Melanoma
22 Wide Excision of Primary Cutaneous Melanoma
23 Advancement and Rotational Flaps
24 Skin Grafts
25 Digit Amputations
26 Resection of Head and Neck Melanoma
27 Sentinel Lymph Node Biopsy for Melanoma
28 Axillary Lymph Node Dissection for Melanoma
29 Inguinal Lymph Node Dissection (Inguinofemoral and Ilioinguinal) for Metastatic Melanoma
30 Minimally Invasive Inguinal Lymph Node Dissection for Melanoma
31 Selective Neck Dissection for Melanoma
32 Popliteal Dissection
33 Isolated Limb Infusion
34 Isolated Limb Perfusion
Section IV Endocrine
35 Thyroid Lobectomy
36 Total Thyroidectomy
37 Thyroidectomy for Substernal Goiters
38 Subtotal Thyroidectomy for Graves' Disease
39 Minimally Invasive Video-Assisted Thyroidectomy
40 Lymph Node Dissection in Thyroid Cancer
41 Open Neck Exploration for Primary Hyperparathyroidism
42 Subtotal Parathyroidectomy or Total with Autologous Graft
43 Minimally Invasive Parathyroidectomy
44 Endoscopic Parathyroidectomy by Lateral Approach
45 Reoperative Parathyroidectomy
46 Adrenalectomy: Open Anterior
47 Adrenalectomy: Open Thoracoabdominal
48 Adrenalectomy: Open Posterior
49 Laparoscopic Retroperitoneal Adrenalectomy
50 Laparoscopic Adrenalectomy-Lateral Approach
51 Insulinomas
52 Surgery for Glucagonoma
Part 6 Operative Techniques in Vascular Surgery
Section I Cerebrovascular Arterial Surgery/Intervention
1 Arch and Great Vessel Reconstruction with Debranching Techniques
2 Extrathoracic Revascularization (Carotid-Carotid, Carotid-Subclavian Bypass and Transposition)
3 Carotid Surgery: Interposition/Endarterectomy (Including Eversion)/Ligation
4 Carotid Surgery: Bifurcation Stenting with Distal Protection
5 Carotid Surgery: Distal Exposure and Control Techniques and Complication Management
6 Vertebral Transposition Techniques and Stenting
Section II Management of the Thoracic Outlet
7 Neurogenic Thoracic Outlet Syndrome Exposure and Decompression: Supraclavicular
8 Neurogenic Thoracic Outlet Syndrome Exposure and Decompression: Transaxillary
9 Venous and Arterial Thoracic Outlet Syndrome
Section III Upper Extremity Reconstruction/Revascularization
10 Proximal to the Wrist: Upper Extremity Reconstruction/Revascularization
11 Upper Extremity Arterial Reconstruction and Revascularization Distal to the Wrist
Section IV Thoracic Aorta Distal to the Pericardium
12 Exposure and Open Surgical Reconstruction in the Chest: The Thoracoabdominal Aorta
13 Thoracic Aortic Stent Graft Repair for Aneurysm, Dissection, and Traumatic Transection
14 Exposure and Open Surgical Management at the Diaphragm
Section V Hybrid, Open and Endovascular Approaches to the Suprarenal Abdominal Aorta
15 Retroperitoneal Aortic Exposure
16 Hybrid Revascularization Strategies for Visceral/Renal Arteries
17 Snorkel/Chimney and Periscope Visceral Revascularization during Complex Endovascular Aneurysm Repair
18 Branched and Fenestrated Endovascular Stent Graft Techniques
Section VI Celiac, Mesenteric, Splenic, Hepatic and Renal Artery Disease Management
19 Stenting, Endografting, and Embolization Techniques: Celiac, Mesenteric, Splenic, Hepatic, and Renal Artery Disease Management
20 Visceral Reconstruction to Facilitate Cancer Management: Celiac, Mesenteric, Splenic, Hepatic and Renal Artery Disease Management
21 Hepatic- and Splenic-Based Renal Revascularization
Section VII The Abdominal Aorta and Iliac Arterial System
22 Advanced Aneurysm Management Techniques: Open Surgical Anatomy and Repair
23 Advanced Aortic Aneurysm Management: Endovascular Aneurysm Repair-Standard and Emergency Management
24 Advanced Aneurysm Management Techniques: Management of Internal Iliac Aneurysm Disease
25 Occlusive Disease Management: Isolated Femoral Reconstruction, Aortofemoral Open Reconstruction, and Aortoiliac Reconstruction with Femoral Crossover for Limb Salvage
26 Occlusive Disease Management: Iliac Angioplasty and Femoral Endarterectomy
Section VIII lnfrainguinal Arterial Disease Management/Limb Salvage Strategies
27 Management of the Infected Femoral Graft
28 Surgical Exposure of the Lower Extremity Arteries
29 Percutaneous Femoral-Popliteal Reconstruction Techniques: Reentry Devices
30 Percutaneous Femoral-Popliteal Reconstruction Techniques: Antegrade Approaches
31 Maximizing Vein Conduit for Autogenous Bypass
32 Tibial Interventions: Tibial-Specific Angioplasty Considerations and Retrograde Approaches
33 Perimalleolar Bypass and Hybrid Techniques
Section IX Surgical Management of Venous Disease
34 Acute Iliofemoral Deep Vein Thrombosis and May-Thurner Syndrome: Surgical and Interventional Management

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Library of Congress Cataloging-in-Publication Data Operative techniques in surgery I Michael W. Mulholland, editor-in-chief; editors, Daniel Albo, Ronald L. Dalman, Mary T. Hawn, Steven J. Hughes, Michael S. Sabel. p. ; em. Includes bibliographical references and index. ISBN 978-1-4511-8631-4 I. Mulholland, Michael W., editor. [DNLM: 1. Surgical Procedures, Operative-Atlases. WO 517] RD32 617.9-dc23 2014029876 This work is provided "as is," and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare profes­ sionals' examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical j udgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selec­ tions and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are ad­ vised to consult the product information sheet (the manufacturer's package insert) accompa­ nying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any inj ury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com

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Contributing Authors

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PART 1 OPERATIVE T ECHNIQUES IN T HORACIC AND ESOPHAGEAL SURGERY Marco E. Allaix, MD, PhD Postdoctoral Fellow Department of Surgery and Center for Esophageal Diseases Pritzker School of Medicine University of Chicago Chicago, Illinois

Scott A. Anderson, MD Assistant Professor of Surgery Department of Surgery Division of Pediatric Surgery University of Alabama at Birmingham School of Medicine Pediatric Surgery Children's Hospital of Alabama Birmingham, Alabama

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Associate Professor Section Chief Department of Surgery Gastrointestinal and General Surgery Division of General Surgery Vice Chairman Clinical Operations and Quality University of Utah Salt Lake City, Utah

Mike K. Chen, MD Professor Vice Chairman Department of Surgery Director Division of Pediatric Surgery University of Alabama at Birmingham School of Medicine Children's Hospital of Alabama Birmingham, Alabama

Mark J. Eichler, MD

Nathalie Boutet, MD

Awad EI-Ashry, MD Resident Department of General Surgery University of Alabama at Birmingham Birmingham, Alabama

Brett Broussard, MD

Professor of Thoracic Surgery Department of Cardiothoracic Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

George W. Barber Jr. Professor of Surgery Division of Otolaryngology Director Section of Head and Neck Oncology University of Alabama at Birmingham School of Medicine Birmingham, Alabama

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Robert E. Glasgow, MD

Resident Centre Hospitalier de l'Universite de Montreal University of Montreal Montreal, Quebec, Canada

William R. Carroll, MD, FACS

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Robert J. Cerfolio, MD, FACS, FCCP

Associate Professor of Surgery Department of Thoracic Surgery Mayo Clinic Rochester, Minnesota

Resident Department of Surgery UAB School of Medicine Birmingham, Alabama

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Professor of Surgery Chief Thoracic Surgery James H. Estes Endowed Chair for Lung Cancer Research University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Instructor Minimally Invasive and Bariatric Fellow Department of Surgery Division of General Surgery Oregon Health & Science University Portland, Oregon

Shanda Haley Blackmon, MD, MPH

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Peter Ferson, MD

Luke M. Funk, MD, MPH Assistant Professor of Surgery Minimally Invasive and Bariatric Surgery University of Wisconsin Madison, Wisconsin

Catherine Go, MD Resident Department of Surgery Division of Vascular Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Tyler Grenda, MD House Officer Department of Surgery Section of General Surgery University of Michigan Health System Ann Arbor, Michigan

William Grist, MD Associate Professor of Otolaryngology Department of Otolaryngology Division of Head & Neck Surgery Emory University Atlanta, Georgia

Mary T. Hawn, MD, MPH Professor, Chief of Gastrointestinal Surgery Department of Surgery Division of Gastrointestinal Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Alexander T. Hillel, MD Assistant Professor Department of Otolaryngology-Head and Neck Surgery Division of Laryngology Johns Hopkins University School of Medicine Baltimore, Maryland

John G. Hunter, MD Professor and Chair Department of Surgery Division of General Surgery Oregon Health & Science University Portland, Oregon v

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CONTRIBUTING AUTHORS

Ryan Levy, MD Assistant Professor of Thoracic Surgery Department of Cardiothoracic Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Moishe Liberman, MD, PhD Director CHUM Endoscopic Tracheobronchial and Oesophageal Center Division of Thoracic Surgery Assistant Professor of Surgery University of Montreal Montreal, Quebec, Canada

Jules Lin, MD, FACS Assistant Professor Department of Surgery Section of Thoracic Surgery University of Michigan Health System Ann Arbor, Michigan

Klaus Monkemuller, MD, PhD, FASGE

Professor Department of Gastroenterology Basil Hirschowitz Endoscopic Center of Endoscopic Excellence University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Ryan A. Macke, MD Clinical Instructor Department of Cardiothoracic Surgery University of Pittsburg School of Medicine Pittsburgh, Pennsylvania

John Christopher McAuliffe, MD, PhD

Resident University of Alabama at Birmingham School of Medicine Birmingham, Alabama

W. Scott Melvin, MD Professor of Surgery Chief Division of General and Gastrointestinal Surgery Director Center for Minimally Invasive Surgery Department of Surgery The Ohio State University Columbus, Ohio

Robert E. Merritt, MD Associate Professor of Surgery Division of Thoracic Surgery The Ohio State University Wexner Medical Center Columbus, Ohio

Douglas Minnich, MD, FACS Assistant Professor of Surgery Department of Surgery Division of Cardiothoracic Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Assistant Professor Department of Gastroenterology Basil Hirschowitz Endoscopic Center of Endoscopic Excellence University of Alabama at Birmingham School of Medicine Birmingham, Alabama

C. Daniel Smith, MD Ellen H. Morrow, MD Senior Fellow Acting Instructor Center for Esophageal and Gastric Surgery University of Washington Medicine Seattle, Washington

Christopher R. Morse, MD Department of Surgery Division of Thoracic Surgery Massachusetts General Hospital Boston, Massachusetts

James D. Luketich, MD Professor of Thoracic Surgery Department of Cardiothoracic Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Shajan Peter, MD

Jason Leonard Muesse, MD Fellow Thoracic Surgery Emory University School of Medicine Emory University Hospital Atlanta, Georgia

David D. Odell, MD, MMSc Assistant Professor Department of Cardiothoracic Surgery Division of Thoracic and Foregut Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Brant K. Oelschlager, MD Director Center for Esophageal & Gastric Surgery Surgical Specialties Center University of Washington Medical Center Byers Endowed Professor in Esophageal Surgery Department of Surgery Division of General Surgery University of Washington School of Medicine Seattle, Washington

Professor of Surgery Department of Surgery Mayo Clinic Jacksonville, Florida

Cameron T. Stock, MD Resident Division of Thoracic Surgery Massachusetts General Hospital Boston, Massachusetts

Elizabeth A. Warner, MD Senior Fellow Acting Instructor Center for Esophageal & Gastric Surgery Surgical Specialties Center University of Washington Medical Center Department of Surgery Division of General Surgery University of Washington Medicine Seattle, Washington

Benjamin Wei, MD Assistant Professor Division of Cardiothoracic Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

C. Mel Wilcox, MD, MPH, FASGE Professor Department of Gastroenterology Basil Hirschowitz Endoscopic Center of Endoscopic Excellence University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Sam T. Windham, Ill, MD Mark Orringer, MD Professor, Section of Thoracic Surgery University of Michigan Hospitals Ann Arbor, Michigan

Marco G. Patti, MD Professor of Surgery Department of Surgery and Center for Esophageal Diseases Pritzker School of Medicine University of Chicago Chicago, Illinois

Associate Professor of Surgery Co-Director Surgical Intensive Care Unit Section of Burns, Trauma, and Surgical Critical Care Department of General Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

James Wiseman, MD Resident Houston Methodist Hospital Houston, Texas

CONTRIBUTING AUTH ORS

Kirk P. Withrow, MD

Ashley Augspurger Davis, MD

Matthew M. Hutter, MD, MPH

Assistant Professor of Surgery Division of Otolaryngology University of Alabama at Birmingham Birmingham, Alabama

Resident University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Assistant Professor in Surgery Harvard Medical School Associate Visiting Surgeon Department of Surgery General and Gastrointestinal Surgery Massachusetts General Hospital Boston, Massachusetts

PART 2 OPERATIVE T ECHNIQUES IN GASTROINTESTINAL SURGERY Waddah B. AI-Refaie, MD, FACS Chief Surgical Oncology MedStar Georgetown University Hospital Surgeon-in-Chief Lombardi Comprehensive Cancer Center Washington, DC

Melissa M. Alvarez-Downing. MD Resident Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Florida Weston, Florida

Rebeccah B. Baucom, MD Resident Department of General Surgery Vanderbilt University Medical Center Nashville, Tennessee

Susan M. Cera, MD, FACS, FASCRS Clinical Professor Chief of Staff Department of Colorectal Surgery Physicians Regional Healthcare System Physicians Regional Medical Group Naples, Florida Clinical Professor Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Florida Weston, Florida

Eugene A. Choi, MD, FACS Assistant Professor of Surgery Department of Surgery Section of Surgical Oncology The University of Chicago Medicine Chicago, Illinois

John D. Christein, MD Associate Professor Department of Surgery Division of Gastrointestinal Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Ronald H. Clements, MD, FACS Professor of Surgery Director Center for Surgical Weight Loss Department of Surgery Vanderbilt University Nashville, Tennessee

Elizabeth A. Dovec, MD Advanced Minimally Invasive and Bariatric Surgery Fellow Department of Surgery Vanderbilt University Nashville, Tennessee

Vikas Dudeja, MD Department of Surgery University of Minnesota Minneapolis, Minnesota

Mary T. Hawn, MD, MPH Professor, Chief of Gastrointestinal Surgery Department of Surgery Division of Gastrointestinal Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Todd Heniford, MD, FACS Chief Division of Gastrointestinal and Minimally Invasive Surgery Carolinas Medical Center Clinical Professor of Surgery Department of General Surgery University of North Carolina School of Medicine Chapel Hill, North Carolina

Martin J. Heslin, MD, MSH A Professor Surgical Oncology Department of Surgery Division of General Surgery Chief Section of Surgical Oncology University of Alabama at Birmingham School of Medicine Birmingham, Alabama

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Kamal M.F. ltani, MD Chief of Surgery VA Boston Healthcare System Professor of Surgery Boston University Boston, Massachusetts

Patrick G. Jackson, MD, FACS Associate Professor of Surgery Chief of Gastrointestinal Surgery MedStar Georgetown University Hospital Washington, DC

J. Spencer Liles, MD Resident Department of Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Ozanan R. Meireles, MD General and Gastrointestinal Surgery Department of Surgery Massachusetts General Hospital Boston, Massachusetts

Marcovalerio Melis, MD, FACS Assistant Professor of Surgery Department of Surgery New York University School of Medicine New York, New York

Filip Muysoms, MD Senior Surgeon Department of General Surgery AZ Maria Middelares Ghent, Belgium

Elliot Newman, MD, FACS Michael D. Holzman, MD, MPH, FACS Associate Professor of Surgery Chief Division of General Surgery Vanderbilt University Medical Center Nashville, Tennessee

Associate Professor of Surgery Department of Surgery New York University Group Surgical Associates New York University School of Medicine New York, New York

John Daniel Hunter, Ill, MD

Pavlos K. Papasavas, MD, FACS

Minimally Invasive Fellow Department of Surgery Division of General Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Section of Metabolic and Bariatric Surgery Department of Surgery Hartford Hospital Hartford, Connecticut

Michael D. Paul, MD, MPH Department of General and Vascular Surgery Dartmouth-Hitchcock Concord, New Hampshire

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CONTRIBUTING AUTHORS

John Roland Porterfield, Jr., MD, MSPH, FACS

Associate Professor Department of Surgery Division of General Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Benjamin K. Poulose, MD, MPH, FACS Associate Professor Division of General Surgery Associate Director Gastrointestinal Endoscopy Suite Vanderbilt University Medical Center Nashville, Tennessee

Sushanth Reddy, MD Assistant Professor of Surgery Department of Surgery Division of General Surgery Section of Surgical Oncology University of Alabama at Birmingham School of Medicine Birmingham, Alabama

Michael J. Rosen, MD Professor of Surgery Chief, Division of GI and General Surgery Director, Case Comprehensive Hernia Center Case Medical Center Cleveland, Ohio

George A. Sarosi, Jr., MD Professor Robert H. Hux Professor Department of Surgery Division of General Surgery University of Florida College of Medicine Vice Chairman for Education Surgery Residency Program Director Surgery Residency Program North Florida/South Georgia VA Medical Center Gainesville, Florida

Michael G. Sarr, MD James C. Masson Professor of Surgery Department of Surgery Division of General and Gastroenterologic Surgery Mayo Clinic Rochester, Minnesota

John K. Saunders, MD, FACS Assistant Professor of Surgery Department of Surgery New York University School of Medicine New York, New York

Mark D. Sawyer, MD

David L. Bartlett, MD

Assistant Professor of Surgery Department of Surgery Division of General and Gastroenterologic Surgery Mayo Clinic Rochester, Minnesota

Department of Surgery Chief Division of Surgical Oncology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Eric G. Sheu, MD, DPhil

Edward R. Woodward Professor and Chairman of Surgery Department of Surgery Division of General Surgery University of Florida College of Medicine Gainesville, Florida

Kevin E. Behrns, MD Minimally Invasive/Bariatric Surgery Fellow Department of Surgery Massachusetts General Hospital Boston, Massachusetts

Darren S. Tishler, MD, FACS Department of Surgery Section of Metabolic and Bariatric Surgery Director Bariatric Surgery Program Hartford Hospital Hartford, Connecticut

Kristopher Williams, MD Minimally Invasive Surgery Fellow Department of Gastrointestinal and Minimally Invasive Surgery Carolinas Medical Center Charlotte, North Carolina

PART 3 OPERATIVE T ECHNIQUES IN HEPATO-PANCREATO­ BILIARY SURGERY David B. Adams, MD, FACS Professor and Head Division of Gastrointestinal and Laparoscopic Surgery Director Digestive Diseases Center Medical University of South Carolina Charleston, South Carolina

Reid B. Adams, MD Claude A. Jessup Professor of Surgery Department of Surgery Chief Division of Surgical Oncology Hepatobiliary and Pancreatic Surgery University of Virginia Health System Charlottesville, Virginia

Megan B. Anderson, MD Resident Department of Surgery University of Colorado Aurora, Colorado

Carlton C. Barnett, Jr., MD, FACS Director of Surgical Oncology Denver Health Medical Center Professor of Surgery University of Colorado Denver School of Medicine Aurora, Colorado

Kfir Ben-David, MD Assistant Professor of Surgery Division of General Surgery University of Florida College of Medicine Gainesville, Florida Michael E. Debakey VA Medical Center Baylor College of Medicine Houston, Texas

Neil H. Bhayani, MD, MHS Clinical Instructor of Surgery Penn State Milton S. Hershey Medical Center Penn State Hershey College of Medicine Hershey, Pennsylvania

Walter L. Biffl. MD, FACS Professor of Surgery Associate Director of Surgery Assistant Director of Patient Safety and Quality Denver Health Medical Center University of Colorado Denver School of Medicine Aurora, Colorado

Mark Bloomston, MD, FACS Director Surgical Oncology Fellowship Program Associate Professor of Surgery Department of Surgery Division of Surgical Oncology The Ohio State University Wexner Medical Center Columbus, Ohio

Richard J. Bold, MD Professor Chief Department of Surgery Division of Surgical Oncology UC Davis Medical Center Sacramento, California

Brian A. Boone, MD Resident Department of General Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

CONTRIBUTING AUTH ORS

Adam S. Brinkman, MD

Kristopher Croome, MD

Andres Gelrud, MD, MMSc

Department of Surgery University of Wisconsin Health Madison, Wisconsin

Resident Department of Surgery Division of Subspecialty General Surgery Mayo Clinic Hepatopancreatobiliary Surgery Fellowship Mayo Medical School Rochester, Minnesota

Associate Professor of Medicine Center for Endoscopic Research Department of Gastroenterology Therapeutics Section University of Chicago Medicine Chicago, Illinois

Dawood G. Dalaly, DO, MS

The Oncologic Institute Tel Aviv Sourasky Medical Center Tel Aviv University Tel Aviv, Israel

Jon S. Cardinal. MD Assistant Professor of Surgery Department of Surgery Division of Surgical Oncology West Virginia University Morgantown, West Virginia

Jason A. Castellanos, MD Resident Research Fellow Department of Surgery Vanderbilt University Medical Center Nashville, Tennessee

Eugene P. Ceppa, MD Assistant Professor of Surgery Section of Hepatopancreatobiliary Surgery Indiana University School of Medicine Indianapolis, Indiana

Shailendra S. Chauhan, MD Associate Professor of Medicine Division of Gastroenterology, Hepatology, & Nutrition University of Florida College of Medicine Gainesville, Florida

Ravit Geva, MD Surgical Critical Care Fellow Department of Surgery UF Health Shands Hospital Gainesville, Florida

Ryan T. Groeschl, MD Daniel J. Delitto, MD Department of Surgery Division of General Surgery University of Florida College of Medicine Gainesville, Florida

Resident Department of Surgery Division of Surgical Oncology Medical College of Wisconsin Milwaukee, Wisconsin

Barish H. Edil. MD, FACS

Anand R. Gupte, MD

Associate Professor of Surgery Director Pancreas and Biliary Surgery Gastrointestinal Tumor and Endocrine Surgery University of Colorado Denver, Colorado

Assistant Professor of Medicine Division of Gastroenterology University of Florida North Florida/South Georgia VA Medical Center Gainesville, FL

Laureano Fernandez-Cruz. MD, FRCS Ed (Hon) FCRSI (Hon)

Disaya Chavalitdhamrong. MD Division of Gastroenterology, Hepatology, & Nutrition University of Florida College of Medicine Gainesville, Florida

Department of Surgery Hospital Clinic University of Barcelona Hospital Clfnic de Barcelona Villarroel, Barcelona, Spain

Charles S. Cox, Jr . MD .

Professor Department of Surgery Michael E. DeBakey VA Medical Center Director Elkins Pancreas Center Baylor College of Medicine Houston, Texas

Medical Director Division of Surgical Oncology Providence Cancer Center Portland, Oregon

Kathleen Hertzer, MD, PhD Division of General Surgery University of California, Los Angeles Los Angeles, California

T. Clark Gamblin, MD, MS

Trauma and Surgical Critical Care Fellow Department of Surgery UF Health Shands Hospital Gainesville, Florida

Chief Surgical Oncology Stuart D. Wilson Professor of Surgery Department of Surgery Division of Surgical Oncology Medical College of Wisconsin Milwaukee, Wisconsin

Chasen A. Croft, MD

Brian S. Geller, MD

Assistant Professor of Surgery Department of Surgery Division of Acute Care Surgery UF Health Shands Hospital Gainesville, Florida

Assistant Professor Chief Department of Radiology Division of Vascular and Interventional Radiology University of Florida UF Health Shands Hospital Gainesville, Florida

Vanessa Cranford, MD, FRCSC

Niraj J. Gusani, MD, MS, FACS Associate Professor of Surgery Department of Surgery Section of Surgical Oncology Penn State Milton S. Hershey Medical Center Penn State College of Medicine Hershey, Pennsylvania

Paul D. Hansen, MD, FACS William E. Fisher, MD

Children's Fund Distinguished Professor of Pediatric Surgery Department of Pediatric Surgery Director Pediatric Trauma Program Children's Memorial Hermann Hospital University of Texas Health Science Center at Houston Houston, Texas

iX

Robert Hetz, MD Resident Children's Memorial Hermann Hospital University of Texas Health Science Center at Houston Houston, Texas 0. Joe Hines, MD Professor Chief Division of General Surgery University of California, Los Angeles Los Angeles, California

X

CONTRIBUTING AUTHORS

Steven J. Hughes, MD

Kenneth K. W. Lee, MD, FACS

ldo Nachmany, MD

Cracchiolo Family Professor Chief General Surgery Division of General Surgery University of Florida College of Medicine Gainesville, Florida

Jane and Carl Citron Professor of Surgery Division of Surgical Oncology Vice Chair for Graduate Education and Program Director Department of Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Hepatobiliary, Transplant, and Laparoscopic Surgery Tel Aviv Sourasky Medical Center Tel Aviv, Israel

Kamran ldrees, MD Assistant Professor of Surgery Department of Surgery Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee

Aijun Li, MD Associate Chief Hepatobiliary Surgery Department III Associate Professor Eastern Hepatobiliary Surgery Hospital Shanghai, China

Saleem Islam, MD, MPH Associate Professor Department of Surgery Division of Pediatric Surgery UF Health Shands Hospital Gainesville, Florida

W. Cory Johnston, MD Fellow Hepatobiliary and Pancreas Surgery Providence Cancer Center Portland, Oregon

Janeen R. Jordan, MD Assistant Professor Department of Surgery and Anesthesia UF Health Shands Hospital Gainesville, Florida

Tara S. Kent, MD, MS Residency Program Director Department of Surgery Beth Israel Deaconess Medical Center Assistant Professor of Surgery Harvard Medical School Boston, Massachusetts

Mohammad Khreiss, MD Department of Surgery Division of Surgical Oncology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

KMarie Reid Lombardo, MD, MS, FACS

Eric T. Kimchi, MD Associate Professor of Surgery Medical University of South Carolina Charleston, South Carolina

Shawn D. Larson, MBChB Assistant Professor Department of Surgery Division of Pediatric Surgery UF Health Shands Hospital Gainesville, Florida

Udayakumar Navaneethan, MD Department of Gastroenterology Digestive Disease Institute The Cleveland Clinic Cleveland, Ohio

Consultant Associate Professor of Surgery Department of Surgery Division of Subspecialty General Surgery Mayo Clinic Rochester, Minnesota

Assistant Professor of Surgery Department of Surgery University of Michigan Health System Ann Arbor, Michigan

Nipun B. Merchant, MD

Trang K. Nguyen, MD

Professor of Surgery and Cancer Biology Department of Surgery Division of Surgical Oncology Vanderbilt University Medical Center Nashville, Tennessee

Postdoctoral Scholar Department of Surgery Division of Surgical Oncology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Kevin T. Nguyen, MD, PhD

Rebecca M. Minter, MD

Shawnn Nichols, MD, MS, FACS

Associate Professor Department of Surgery Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery University of Michigan Health System Ann Arbor, Michigan

Surgical Oncology Fellow Department of Surgery Division of Surgical Oncology The Ohio State University Wexner Medical Center Columbus, Ohio

Sean P. Montgomery, MD

Janak Parikh, MD

Director Surgical Intensive Care Unit Assistant Professor of Surgery Department of Surgery Division of Acute Care Surgery University of North Carolina School of Medicine Chapel Hill, North Carolina

Co-Director Hepato-Pancreato-Biliary Surgery Program Providence Park Hospital Novi, Michigan

Song Cheol Kim, MD, PhD Department of Hepatobiliary and Pancreatic Surgery University of Ulsan College of Medicine and Asan Medical Center Seoul, South Korea

Bharath D. Nath, MD, PhD Resident Beth Israel Deaconess Medical Center Clinical Fellow in Surgery Harvard Medical School Boston, Massachusetts

Frederick A. Moore, MD Professor Chief Acute Care Surgery Department of Surgery UF Health Shands Hospital Gainesville, Florida

Katherine A. Morgan, MD, FACS Associate Professor Division of Gastrointestinal and Laparoscopic Surgery Medical University of South Carolina Charleston, South Carolina

Purvi Y. Parikh, MD Assistant Professor Albany Medical Center Albany, New York

Timothy M. Pawlik, MD, MPH, PhD, FACS

Professor of Surgery and Oncology Chief Division of Surgical Oncology John L. Cameron MD Professor of Alimentary Tract Diseases Director Johns Hopkins Medicine Liver Tumor Center Multidisciplinary Clinic The Johns Hopkins Hospital Baltimore, Maryland

CONTRIBUTING AUTH ORS

Xi

Darren W. Postoak, MD

Jose G. Trevino, MD

Herbert J. Zeh, MD, FACS

Assistant Professor Department of Radiology Division of Vascular and Interventional Radiology University of Florida College of Medicine Gainesville, Florida

Assistant Professor Division of General Surgery UF Health Shands Hospital Gainesville, Florida

Chief Division of Gastrointestinal Surgical Oncology Co-Director University of Pittsburg Medical Center Pancreatic Cancer Center Associate Professor of Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Christopher D. Raeburn, MD, FACS Associate Professor of Surgery Gastrointestinal Tumor and Endocrine Surgery University of Colorado Denver, Colorado

Allan Tsung, MD Roberta G. Simmons Assistant Professor of Surgery Department of Surgery Division of Hepatobiliary and Pancreatic Surgery UPMC Montefiore Pittsburgh, Pennsylvania

Preston B. Rich, MD, MBA, FACS Professor of Surgery Chief Department of Surgery Division of Acute Care Surgery University of North Carolina School of Medicine Chapel Hill, North Carolina

George VanBuren, II, MD Assistant Professor Department of Surgery Division of Surgical Oncology Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston, Texas

Georgios Rossidis, MD Assistant Professor Department of Surgery University of Florida College of Medicine Gainesville, Florida

Shirin Sabbaghian, MD Fellow of Surgical Oncology Department of Surgery Division of Surgical Oncology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Teviah Sachs, MD, MPH Clinical Fellow in Surgery Division of Surgical Oncology The Johns Hopkins Hospital Baltimore, Maryland

C. Max Schmidt, MD, PhD, MBA Professor of Surgery Section of Hepatopancreatobiliary Surgery Indiana University School of Medicine Indianapolis, Indiana

Ivan R. Zendejas, MD Clinical Assistant Professor Department of Surgery Division of Transplantation and Hepatobiliary Surgery University of Florida College of Medicine Gainesville, Florida

Amer H. Zureikat, MD, FACS Assistant Professor of Surgery Division of Surgical Oncology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Charles M. Vollmer, MD Director Pancreatic Surgery Department of Surgery Division of Gastrointestinal Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania

Mihir S. Wagh, MD Assistant Professor of Medicine Division of Gastroenterology, Hepatology, & Nutrition University of Florida College of Medicine Gainesville, Florida

Susanne G. Warner, MD Clinical Instructor Department of Surgery Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery University of Michigan Health System Ann Arbor, Michigan

Ki Byung Song, MD, PhD

Sharon M. Weber, MD

Department of Hepatobiliary and Pancreatic Surgery University of Ulsan College of Medicine and Asan Medical Center Seoul, South Korea

Professor Department of Surgery Section of Surgical Oncology University of Wisconsin Health Madison, Wisconsin

Kevin Staveley-O'Carroll, MD, PhD

Mengchao Wu, MD

Alice Ruth Reeves Folk Endowed Chair of Clinical Oncology Professor Chief Oncologic and Endocrine Surgery Medical Director Hollings Cancer Center Medical University of South Carolina Charleston, South Carolina

Chief Physician Professor Director Eastern Hepatobiliary Surgery Hospital Shanghai, China

Victor Zaydfudim, MD Assistant Professor of Surgery Department of Surgery University of Virginia Health System Charlottesville, Virginia

Nicholas J. Zyromski, MD Associate Professor Department of Surgery Indiana University School of Medicine Indianapolis, Indiana

PART 4 OPERATIVE T ECHNIQUES IN COLON AND RECTAL SURGERY Matthew Albert, MD Florida Hospital Orlando, Florida

Daniel Albo, MD, PhD Dan L. Duncan Professor and Vice Chairman Director, GI Oncology Michael E. DeBakey Department of Surgery Houston, Texas

Daniel A. Anaya, MD Associate Professor Chief Section of General Surgery and Surgical Oncology Operative Care Line Michael E. DeBakey VA Medical Center Department of Surgery Division of Surgical Oncology Baylor College of Medicine Houston, Texas

Avo Artinyan, MD, MS Assistant Professor of Surgery Division of Surgical Oncology Baylor College of Medicine American Cancer Society Cancer Liaison Physician Michael E. DeBakey VA Medical Center Houston, Texas

Xii

CONTRIBUTING AUTHORS

Erik Askenasy, MD

Bidhan Das, MD

Eric M. Haas, MD, FACS, FASCRS

Assistant Professor of Surgery Michael E. Debakey Department of Surgery Baylor College of Medicine Houston, Texas

Clinical Associate Professor Colon and Rectal Surgery Department of Surgery University of Texas Health Science Center at Houston Staff Surgeon Colon and Rectal Clinic of Houston Staff Colon and Rectal Surgeon Houston Methodist Center for Restorative Pelvic Medicine Staff Colon and Rectal Surgeon Memorial Hermann Hospital System Staff Colon and Rectal Surgeon CHI St. Luke's Health-Baylor St. Luke's Medical Center Houston, Texas

President Colorectal Surgical Associates, Ltd, LLP Program Director Minimally Invasive Colon and Rectal Surgery Fellowship University of Texas Health Science Center at Houston Clinical Associate Professor Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas

Valerie Bauer, MD, FACS, FASCRS Attending Physician Bay Area Colorectal Surgical Associates Texas City, Texas Assistant Clinical Professor of Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas

David Berger, MD, MHCM Professor of Surgery Vice Chair of Surgery Michael E. DeBakey VA Medical Center Vice President Chief Medical Officer Department of Surgery Baylor College of Medicine Houston, Texas

Jaime L. Bohl, MD, FACS Assistant Professor Department of General Surgery Wake Forest School of Medicine Winston-Salem, North Carolina

Reshma Brahmbhatt, MD Resident Michael E. DeBakey VA Medical Center Department of Surgery Division of General Surgery Baylor College of Medicine Houston, Texas

George J. Chang, MD, MS Associate Professor of Surgery Chief Colon and Rectal Surgery Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas

Roosevelt Fajardo, MD, MBA, FACS Department of Surgery Fundacion Santa Fe de Bogota Director Center for Innovation in Health and Education, Fundacion Santa Fe Assistant Professor Los Andes University School of Medicine Bogota, Colombia

Barry Feig, MD Professor Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas

Daniel L. Feingold, MD Associate Professor Department of Surgery Division of Colon and Rectal Surgery New York-Presbyterian Hospital Columbia University Medical Center New York, New York

Wayne A. l. Frederick, MD Interim President Provost and Chief Academic Officer Howard University Hospital Washington, DC

Robert R. Cima, MD, MA Consultant Division of Colon and Rectal Surgery Mayo Clinic Professor of Surgery Mayo Medical School Rochester, Minnesota

Kelly A. Garrett, MD, FACS, FASCRS Assistant Professor of Surgery Department of General Surgery Division of Colon and Rectal Surgery New York-Presbyterian Hospital Weill Cornell Medical College New York, NY

Karin M. Hardiman, MD, PhD Assistant Professor of Surgery Department of Surgery Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan

Andrew G. Hill, MD, EdD, FRACS, FACS

Colorectal Surgeon Department of General Surgery Middlemore Hospital Professor of Surgery and Head South Auckland Clinical School Faculty of Medical and Health Sciences University of Auckland Auckland, New Zealand

Joshua S. Hill, MD, MS Surgical Oncologist Department of General Surgery Division of Surgical Oncology Levine Cancer Institute Charlotte, North Carolina

Mehraneh D. Jafari, MD Department of Surgery School of Medicine University of California, Irvine Orange, California

Douglas W. Jones, MD Resident Department of General Surgery New York-Presbyterian Hospital Weill Cornell Medical College New York, New York

Lillian S. Kao, MD, MS Professor Vice Chair for Quality Department of Surgery University of Texas Health Science Center at Houston Houston, Texas

CONTRIBUTING AUTH ORS

Hasan T. Kirat, MD

Luis Jorge Lombana, MD

Didier Mutter, MD, PhD, FACS

Department of Colorectal Surgery Cleveland Clinic Foundation Cleveland, Ohio

Colon and Rectal Surgeon Hospital Universitario San Ignacio Associate Professor of Surgery Pontificia Universidad Javeriana Bogota, Colombia

IRCAD/EITS Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France

Jacques Marescaux, MD, FACS,

Govind Nandakumar, MD

Hon FRCS, Hon FJSES IRCAD/EITS

Assistant Professor of Surgery Department of Surgery Weill Cornell Medical College New York, New York

Cherry E. Koh, MD, MBBS (Hons),

x ii i

MS, FRACS

Department of Colorectal Surgery Royal Prince Alfred Hospital Clinical Research Fellow Surgical Outcomes Research Centre University of Sydney Sydney, New South Wales, Australia

Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France

Sang W. Lee, MD Associate Professor of Surgery Department of Surgery Weill Cornell Medical College New York, New York

Steven A. Lee-Kong, MD Assistant Professor Department of Surgery Division of Colon and Rectal Surgery Columbia University Medical Center Colon and Rectal Surgery New York-Presbyterian Hospital New York, New York

Joel Leroy, MD, Hon FRCS IRCAD/EITS Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France

Edward A. Levine, MD Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina

John H Marks, MD, FACS, FASCRS Chief Division of Colorectal Surgery Director Minimally Invasive Colorectal Surgery and Rectal Cancer Management Fellowship Lankenau Medical Center Professor Lankenau Institute of Medical Research Wynnewood, Pennsylvania

Assistant Professor of Surgery Department of Surgery Division of General Surgery Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston, Texas

Kathleen R. Liscum, MD Chief Section of General Surgery Ben Taub General Hospital Associate Professor of Surgery Division of General Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas

Pediatric Surgery Fellowship University of Missouri Columbia, Missouri

Rodrigo Pedraza, MD Colorectal Surgical Associates, Ltd, LLP Minimally Invasive Colon and Rectal Surgery Fellowship The University of Texas Medical School at Houston Houston, Texas

Craig A. Messick, MD

Alessio Pigazzi, MD, PhD

Clinical Assistant Professor Department of Surgical Oncology Section of Colon and Rectal Surgery The Universiry of Texas MD Anderson Cancer Center Houston, Texas

Chief Department of Surgery Division of Colorectal Surgery School of Medicine University of California, Irvine Orange, California

Stefanos G. Millas, MD

Harsha Polavarapu, MD

Assistant Professor Department of Surgery Universiry of Texas Health Science Center at Houston Houston, Texas

Florida Hospital Orlando, Florida

Somala Mohammed, MD Mike K. Liang, MD

Tolulope Oyetunji, MD

Resident Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas

Arden M. Morris, MD, MPH Associate Professor of Surgery Chief Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan

Matthew G. Mutch, MD Associate Professor of Surgery Department of Surgery Section of Colon and Rectal Surgery Washington University School of Medicine St. Louis, Missouri

Reese W. Randle, MD Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina

Scott E. Regenbogen, MD, MPH Assistant Professor Department of Surgery Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan

Feza H. Remzi, MD Chairman Department of Colorectal Surgery Cleveland Clinic Foundation Cleveland, Ohio

Saul J. Rugeles, MD Chairman Department of Surgery Titular Professor of Surgery Gastrointestinal Surgeon Hospital Universitario San Ignacio Pontificia Universidad Javeriana Bogota, Colombia

xiv

CONTRIBUTING AUTHORS

Tarik Sammour, BHB, MBChB, PhD

John H. Stewart, IV, MD, MBA

Surgical Registrar Department of General Surgery Middlemore Hospital Auckland, New Zealand

Department of Surgery Wake Forest School of Medicine Winston-Salem, North Carolina

James Suliburk, MD William Sanchez, MD, FACS Professor of Surgery Chair Department of Surgery Hospital Militar Central Universidad Militar Nueva Granada Bogota, Colombia

Attending Surgeon Ben Taub General Hospital Assistant Professor of Surgery Michael E. DeBakey VA Medical Center Department of Surgery Division of General Surgery Baylor College of Medicine Houston, Texas

Shiva Seetahal. MD Minimally Invasive Surgery/Bariatric Surgery Fellowship Atlanta Medical Center Atlanta, Georgia

David Taylor, MBBS, FRACS

Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina

Colorectal Surgeon Colorectal Unit Department of Surgery Royal Brisbane and Women's Hospital Senior Lecturer School of Medicine Faculty of Health Sciences University of Queensland Brisbane, Queensland, Australia

Margaret V. Shields, BA

Ryan M. Thomas, MD

Division of Colorectal Surgery Main Line Health Lankenau Medical Center Wynnewood, Pennsylvania

Assistant Professor Department of Surgery North Florida/South Georgia Veterans Health System Assistant Professor Department of Surgery University of Florida College of Medicine Gainesville, Florida

Perry Shen, MD

Eric J. Silberfein, MD Ben Taub General Hospital Assistant Professor Michael E. DeBakey Department of Surgery Division of Surgical Oncology Baylor College of Medicine Houston, Texas

Michael J. Solomon, MB ChB, BAO, MSc, FRACS

Senior Colorectal Surgeon Department of Colorectal Surgery Head and Director Surgical Outcomes Research Centre Royal Prince Alfred Hospital Clinical Professor of Surgery Discipline of Surgery University of Sydney Sydney, New South Wales, Australia

Kathrin Mayer Troppmann, MD, FACS

Professor of Surgery Department of Surgery Division of Gastrointestinal and Minimally Invasive Surgery University of California Davis School of Medicine Sacramento, California

Elsa B. Valsdottir, MD Department of General Surgery University Hospital of Iceland Associate Professor University of Iceland Medical School Reykjavik, Iceland

Andrew Stevenson, MBBS, FRACS Head of Unit and Colorectal Surgeon Colorectal Unit Department of Surgery Royal Brisbane and Women's Hospital Senior Lecturer School of Medicine Faculty of Health Sciences University of Queensland Brisbane, Queensland, Australia

Oliver Varban, MD Assistant Professor of Surgery Minimally Invasive Surgery and Bariatrics University of Michigan Health System Ann Arbor, Michigan

Theodoros Voloyiannis, MD, FACS, FASCRS

Clinical Assistant Professor in Surgery Medical Group Memorial Hermann Hospital Colon and Rectal Surgery University of Texas Health Science Center at Houston Houston, Texas

Konstantinos I. Votanopoulos, MD, PhD, FACS

Assistant Professor Department of General Surgery Comprehensive Cancer Center Wake Forest School of Medicine Winston-Salem, North Carolina

Rebecca L. Wiatrek, MD Assistant Professor Department of Surgery University of Texas Health Science Center at Houston Houston, Texas

Curtis J. Wray, MD Associate Professor Department of Surgery University of Texas Health Science Center at Houston Houston, Texas

Y. Nancy You, MD, MHSc Assistant Professor Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas

PART 5 OPERATIVE T ECHNIQUES IN BREAST, ENDOCRINE, AND ONCOLOGIC SURGERY Amy K. Alderman, MD, MPH Plastic Surgeon Researcher Breast Reconstruction The Swan Center for Plastic Surgery Alpharetta, Georgia

Benjamin 0. Anderson, MD, FACS Director Breast Health Clinic Seattle Cancer Care Alliance Professor of Surgery and Global Health Medicine University of Washington Seattle, Washington

CONTRIBUTING AUTH ORS

Peter Angelos, MD, PhD

Anees B. Chagpar, MD, MSc, MPH, MA

Paul G. Gauger, MD

Linda Kohler Anderson Professor of Surgery and Surgical Ethics Chief Endocrine Surgery Associate Director MacLean Center for Clinical Medical Ethics The University of Chicago Medicine Chicago, Illinois

Director The Breast Center-Smilow Cancer Hospital at Yale-New Haven Associate Professor Department of Surgery Yale School of Medicine New Haven, Connecticut

Professor Endocrine Surgeon A. Alfred Taubman Health Care Center University of Michigan Health System Ann Arbor, Michigan

Amy S. Colwell, MD, FACS Sa'id C. Azoury, M D Resident The Johns Hopkins Hospital Baltimore, Maryland

Assistant Professor Harvard Medical School Division of Plastic Surgery Massachusetts General Hospital Boston, Massachusetts

Jonathan Bank, MD Department of Surgery Division of Medicine and Biological Sciences Section of Plastic and Reconstructive Surgery The University of Chicago Chicago, Illinois

Peter D. Beitsch, MD FACS Director Dallas Breast Center Dallas, Texas

Russell S. Berman, MD Chief Division of Surgical Oncology Program Director General Surgery Residency Associate Professor Department of Surgery New York University School of Medicine New York, New York

Judy C. Boughey, MD Associate Professor of Surgery Department of Surgery Mayo Clinic Rochester, Minnesota

David L. Brown, MD, FACS Associate Professor of Surgery Section of Plastic Surgery University of Michigan Health System Ann Arbor, Michigan

Kristine E. Calhoun, MD Associate Professor Department of Surgery University of Washington School of Medicine Breast Health Clinic, Seattle Cancer Care Alliance Seattle, Washington

Glenda G. Callender, MD, FACS Assistant Professor Department of Surgery Section of Endocrine Surgery Director Endocrine Surgical Oncology Clinical Trials Yale School of Medicine New Haven, Connecticut

Jeffrey E. Gershenwald, MD Professor Department of Surgical Oncology Division of Surgery Medical Director Melanoma and Skin Center The University of Texas MD Anderson Cancer Center Houston, Texas

Amy C. Degnim, MD Associate Professor of Surgery Consultant Division of Subspecialty General Surgery Department of Surgery Mayo Clinic Rochester, Minnesota

Joseph 5. Giglia, MD, FACS Associate Professor of Surgery Department of Surgery Division of Vascular Surgery University of Cincinnati Cincinnati, Ohio

Vasu Divi, MD

Raymon H. Grogan, MD

Assistant Professor Department of Otolaryngology Division of Head and Neck Surgery Stanford University Stanford, California

Assistant Professor Department of Surgery Section of General Surgery Director Endocrine Surgery Research Program Pritzker School of Medicine University of Chicago Chicago, Illinois

Gerard M. Doherty, MD Surgeon-in-Chief Boston Medical Center Utley Professor Chair Surgery Boston University Boston, Massachusetts

Steven C. Haase, MD Associate Professor Department of Surgery Section of Plastic Surgery University of Michigan Health System Ann Arbor, Michigan

Frank Fang, MD Department of Surgery Section of Plastic Surgery Resident Section of Plastic Surgery University of Michigan Health System Ann Arbor, Michigan

Eric G. Halvorson, MD Assistant Professor of Surgery Harvard Medical School Division of Plastic Surgery Brigham and Women's Hospital Boston, Massachusetts

Amy C. Fox, MD

Jean-Fran�ois Henry, MD, FRCS

Endocrine Surgeon Regions Hospital St. Paul, Minnesota

Professor of Surgery Consultant Department of Endocrine Surgery University-Hospital La Timone Marseilles, France

Douglas L. Fraker, MD, FACS Jonathan E. Rboads Professor of Surgical Science Vice Chairman Research Chief Division of Endocrine and Oncologic Surgery Department of Surgery Deputy Director Clinical Services Abramson Cancer Center Penn Medicine: University of Pennsylvania Health System Philadelphia, Pennsylvania

Oscar E. Imhof. EKP/ECCP Clinical perfusionist Heartbeat University Medical Center of Utrecht Utrecht, The Netherlands

XV

XVi

CONTRIBUTING AUTHORS

William B. lnabnet Ill, MD

Anna Kundel, MD

Claire W. Michael, MD

The Mount Sinai Hospital Eugene W. Friedman Professor of Surgery Chief Division of Metabolic, Endocrine and Minimally Invasive Surgery The Mount Sinai Hospital New York, New York

Department of Surgery Mayo Clinic Rochester, Minnesota

Professor of Pathology Director Clinical Research Program and Faculty Career Development Director Cytopathology Fellowship Department of Pathology Case Western Reserve University University Hospitals Case Medical Center Cleveland, Ohio

James W. Jakub, MD Section Head Breast and Melanoma Surgery Division of Gastroenterologic and General Surgery Department of Surgery Mayo Clinic Rochester, Minnesota

Michael G. Johnston, MD Department of Surgery Division of Gastrointestinal and Endocrine Surgery Columbia University College of Physicians and Surgeons New York, New York

Edwin L. Kaplan, MD Professor Department of Surgery Section of General Surgery Pritzker School of Medicine University of Chicago Chicago, Illinois

Cary 5. Kaufman, MD, FACS Associate Clinical Professor of Surgery University of Washington Bellingham Regional Breast Center Bellingham, Washington

Michael Kim, MD Fellow in Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas

Jeffrey H. Kozlow, MD, MS Clinical Assistant Professor Section of Plastic Surgery University of Michigan Health System Ann Arbor, Michigan

James A. Lee. MD Assistant Professor of Clinical Surgery Department of Surgery Division of Gastrointestinal and Endocrine Surgery Chief Endocrine Surgery Columbia University College of Physicians and Surgeons New York, New York

A. Marilyn Leitch, MD Professor of Surgery Division of Surgical Oncology The University of Texas Southwestern Medical Center Dallas, Texas

Valerie Lemaine, MD, MPH, FRCSC Assistant Professor of Plastic Surgery Vice Chair for Research Department of Surgery Division of Plastic Surgery Mayo Clinic Rochester, Minnesota

Emeritus Professor of Surgery Skin and Melanoma Center Department of Surgery The Netherlands Cancer Institute Amsterdam, The Netherlands

Memorial Sloan Kettering Cancer Center Section of Plastic Surgery New York, New York

Adeyiza 0. Momoh, MD Department of Surgery Clinical Assistant Professor of Surgery Section of Plastic Surgery University of Michigan Health System Ann Arbor, Michigan

Maurice Y. Nahabedian, MD, FACS Department of Plastic Surgery Georgetown University Washington, DC

Gabriele Materazzi, MD

Lisa Newman, MD, MPH, FACS

Department of Surgery University of Pisa Pisa, Italy

Director University of Michigan Breast Care Center Professor of Surgery University of Michigan Health System Ann Arbor, Michigan

Christopher R. McHenry, MD Vice Chairman Department of Surgery MetroHealth System Professor of Surgery Case Western Reserve University School of Medicine Cleveland, Ohio

Omgo E. Nieweg, MD, PhD Surgeon Melanoma Institute Australia The Poche Centre North Sydney, Australia

Barnard J. A. Palmer, MD, MEd Assistant Professor Department of Otolaryngology-Head and Neck Surgery University of Michigan Health System Ann Arbor, Michigan

Kelly M. McMasters, MD, PhD Anita R. Kulkarni, MD

Barbra S. Miller, MD Staff Physician Assistant Professor Department of Surgery Division of Endocrine Surgery University of Michigan Health System Ann Arbor, Michigan

Catherine A. Madorin, MD Department of Surgery General Surgery Association of South Bay Surgeons Torrance, California

Scott A. Mclean, MD, PhD Bin B.R. Kroon, MD, PhD, FRCS

Paolo Miccoli, MD, FACS Department of Surgery University of Pisa Pisa, Italy

Ben A. Reid, Sr., MD Professor and Chairman Hiram C. Polk, Jr., MD Department of Surgery University of Louisville School of Medicine Louisville, Kentucky

Assistant Clinical Professor of Surgery Department of Surgery UCSF East Bay Surgery Program Oakland, California

Judy C. Pang, MD Assistant Professor Department of Pathology University of Michigan Health System Ann Arbor, Michigan

CONTRIBUTING AUTH ORS

xvii

Julie E. Park, MD

Brian D. Saunders, MD

Tiffany A. Torstenson, DO

Assistant Professor of Surgery Director Breast Reconstruction Associate Program Director Department of Surgery Division of Medicine and Biological Sciences Section of Plastic and Reconstructive Surgery University of Chicago Chicago, Illinois

Assistant Professor of Surgery and Medicine Department of Surgery Penn State Milton S. Hershey Medical Center Penn State College of Medicine Hershey, Pennsylvania

Breast Surgical Oncology Fellow Department of Surgery Mayo Clinic Rochester, Minnesota

Ashok R. Shaha, MD

Chief Breast Surgery President American Medical Women's Association MedStar Georgetown University Hospital Washington, DC

Ketan M. Patel. MD Assistant Professor of Surgery Division of Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, California

Richard A. Prinz, MD Department of Surgery Surgery Oncology NorthShore University Health System Evanston, Illinois

Eleni Tousimis, MD, FACS Attending Surgeon Jatin P. Shah Chair Head and Neck Service Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York

Dale Collins Vidal. MD, MS Andrew G. Shuman, MD Surgical Fellow Head and Neck Service Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York

Rache Simmons, MD Andrea L. Pusic, MD, MHS Department of Surgery Section of Plastic Surgery Memorial Sloan Kettering Cancer Center New York, New York

Chief Brest Surgery Department of Surgery Weill Cornell Medical College New York, New York

Emily B. Ridgway, MD

Vernon K. Sondak, MD

Division of Plastic Surgery Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire Instructor in Surgery Geisel School of Medicine at Dartmouth Hanover, New Hampshire

Chair Department of Cutaneous Oncology H. Lee Moffitt Cancer Center and Research Institute Professor Departments of Surgery and Oncologic Sciences University of South Florida Health Morsani College of Medicine Tampa, Florida

Merrick I. Ross, MD Charles A. McBride Professor of Surgical Oncology Chief of the Melanoma Section Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Charles McBride Houston, Texas

Michael S. Sabel. MD Chief, Division of Surgical Oncology Associate Professor of Surgery University of Michigan Health System Ann Arbor, Michigan

Amod A. Sarnaik, MD Assistant Member Department of Cutaneous Oncology H. Lee Moffitt Cancer Center and Research Institute Assistant Professor Department of Oncologic Sciences University of South Florida Health Morsani College of Medicine Tampa, Florida

Professor of Surgery Geisel School of Medicine at Dartmouth Chief Plastic Surgery Director Center for Shared Decision Making Dartmouth-Hitchcock Hanover, Hew Hampshire

Sebastian Winocour, MD, MSc, FRCSC Resident Department of Surgery Division of Plastic Surgery Mayo Clinic Rochester, Minnesota

Martha A. Zeiger, MD, FACS, FACE Professor of Surgery Department of Surgery Chief of Oncology, Cellular, and Molecular Medicine Section of Endocrine Surgery Johns Hopkins University School of Medicine Baltimore, Maryland

PART 6 David H. Song, MD, MBA, FACS Cynthia Chow Professor Chief Plastic and Reconstructive Surgery Vice Chairman Department of Surgery Division of Medicine and Biological Sciences University of Chicago Chicago, Illinois

Jeffrey J. Sussman, MD, FACS Professor Director Department of Surgery Division of Surgical Oncology University of Cincinnati Cincinnati, Ohio

Geoffrey B. Thompson, MD Subspecialty General Surgery Department of Surgery Mayo Clinic Rochester, Minnesota

OPERATIVE T ECHNIQUES IN VASCULAR SURGERY

Georges E. AI Khoury, MD Assistant Professor of Surgery Department of Surgery Division of Vascular Surgery University of Pittsburg School of Medicine Pittsburgh, Pennsylvania

George J. Arnaoutakis, MD Fellow in Cardiothoracic Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

Ramin E. Beygui, MD, FACS Associate Professor Department of Cardiothoracic Surgery Stanford University Stanford, California

Elizabeth Blazick, MD Fellow Division of Vascular and Endovascular Surgery Massachusetts General Hospital Boston, Massachusetts

xviii

CONTRIBUTING AUTHORS

Danielle E. Cafasso, DO

Scott M. Damrauer, MD

Geetha Jeyabalan, MD

Department of Surgery Tripier Army Medical Center Honolulu, Hawaii

Instructor in Surgery Fellow Department of Surgery Division of Vascular Surgery and Endovascular Therapy Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

Assistant Professor of Surgery Department of Surgery Division of Vascular Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Rabih A. Chaer, MD Associate Professor of Surgery Department of Surgery Division of Vascular Surgery University of Pittsburgh School of Medicine PittSburgh, Pennsylvania

Venita Chandra, MD Clinical Assistant Professor Department of Surgery Division of Vascular and Endovascular Surgery Stanford University School of Medicine Stanford, California

James Chang, MD Chief Department of Surgery Division of Plastic Reconstructive Surgery Professor of Surgery Plastic and Orthopedic Surgery Stanford University Medical Center Stanford, California

Roberto Chiesa, MD Division of Vascular Surgery Scientific Institute Ospedale San Raffaele Chair of Vascular Surgery School of Medicine Vita-Salute San Raffaele University Milan, Italy

Efrem Civilini, MD Division of Vascular Surgery Scientific Institute Ospedale San Raffaele Chair of Vascular Surgery School of Medicine Vita-Salute San Raffaele University Milan, Italy

Brian G. DeRubertis, MD Associate Professor of Surgery Department of Surgery Division of Vascular Surgery David Geffen School of Medicine at University of California, Los Angeles Los Angeles, California

Julie Ann Freischlag, MD William Steward Halsted Professor Chair Department of Surgery The Johns Hopkins Hospital Johns Hopkins Medical Institutions Baltimore, Maryland

Michael G. Galvez, MD Resident Department of Surgery Division of Plastic and Reconstructive Surgery Stanford University School of Medicine Stanford, California

Sung Wan Ham, MD Vascular Surgery Fellow Vascular Surgery Division University of Southern California Los Angeles County Medical Center Los Angeles, California

E. John Harris, Jr., MD Professor of Surgery Stanford University School of Medicine Stanford, California

Mark F. Conrad, MD

Grace Huang, MD

Assistant Professor of Surgery Division of Vascular and Endovascular Surgery Massachusetts General Hospital Boston, Massachusetts

Resident Surgery University of Southern California Los Angeles County Medical Center Los Angeles, California

Clinical Research Fellow Division of Vascular and Endovascular Surgery Mayo Clinic Rochester, Minnesota

Sharon C. Kiang, MD Vascular Surgery Fellow Department of General Surgery Division of Vascular Surgery Ronald Reagan UCLA Medical Center Los Angeles, California

Alexander Kulik, MD, MPH, FRCSC Cardiovascular Surgeon Lynn Heart & Vascular Institute Boca Raton Regional Hospital Affiliate Associate Professor Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton, Florida

Gregory J. Landry, MD Associate Professor of Surgery Knight Cardiovascular Institute Oregon Health & Science University Portland, Oregon

W. Anthony Lee, MD, FACS Director Endovascular Program Lynn Heart & Vascular Institute Boca Raton Regional Hospital Boca Raton, Florida

Cheong J. Lee, MD Assistant Professor of Surgery Division of Vascular Surgery Medical College of Wisconsin Milwaukee, Wisconsin

Jason T. Lee, MD

Zhen S. Huang, MD

Associate Professor of Vascular Surgery Department of Surgery Stanford University School of Medicine Stanford, California

Fellow in Vascular and Endovascular Surgery Department of Vascular and Endovascular Surgery New York-Presbyterian Hospital Weill Cornell Medical Center New York, New York

Peter H. U. Lee, MD, MPH Clinical Instructor Department of Cardiothoracic Surgery Stanford University Stanford, California

Ronald L. Dalman, MD Chidester Professor of Surgery Division Chief of Vascular Surgery Stanford University School of Medicine Director Quality and Outcome Assessment Cardiovascular Service Line Stanford Hospital and Clinics Stanford, California

Karina S. Kanamori, MD

Nathan ltoga, MD Resident Stanford University Stanford, California

CONTRIBUTING AUTH ORS

Germano Melissano, MD

Enrico Rinaldi, MD

Fred Weaver, MD, MMM

Division of Vascular Surgery Scientific Institute Ospedale San Raffaele Chair of Vascular Surgery School of Medicine Vita-Salute San Raffaele University Milan, Italy

Scientific Institute Ospedale San Raffaele Division of Vascular Surgery Chair of Vascular Surgery School of Medicine Vita-Salute San Raffaele University Milan, Italy

Professor of Surgery Chief Division of Vascular Surgery and Endovascular Therapy Keck Hospital University of Southern California Los Angeles, California

Matthew Mell, MD

Darren B. Schneider, MD

Assistant Professor of Surgery Division of Vascular Surgery Stanford University School of Medicine Stanford, California

Associate Professor of Surgery Chief of Vascular and Endovascular Surgery Weill Cornell Medical College New York-Presbyterian Hospital Weill Cornell Medical Center New York, New York

Joseph L. Mills, Sr., MD Chief Department of Surgery Division of Vascular and Endovascular Surgery Co-Director Southern Arizona Limb Salvage Alliance University of Arizona Health Sciences Center Tucson, Arizona

Peter A. Schneider, MD Department of Surgery Division of Vascular Therapy Hawaii Permanente Medical Group Kaiser Foundation Hospital Honolulu, Hawaii

Benjamin W. Starnes, MD, FACS Mark D. Morasch, MD, FACS Vascular Surgeon Heart and Vascular Center St. Vincent Healthcare Billings, Montana

Professor Chief Department of Surgery Division of Vascular Surgery University of Washington Seattle, Washington

Gustavo S. Oderich, MD Professor of Surgery Director Endovascular Therapy Director Edward Rogers Clinical Research Fellowship Division of Vascular and Endovascular Surgery Mayo Clinic Rochester, Minnesota

F. Gallardo Pedrajas, MD Consultant Angiology and Vascular Surgery Hospital University of Santiago Santiago de Compostela Compostela, Spain

Thomas Reifsnyder, MD Assistant Professor Chief Vascular Laboratory Department of Surgery Johns Hopkins Bayview Medical Center Johns Hopkins Medical Institutions Baltimore, Maryland

Robert W. Thompson, MD Professor of Surgery Radiology Cell Biology Physiology Vice Chair for Research Department of Surgery Director Washington University Thoracic Outlet Syndrome Center Barnes-Jewish Hospital Washington University School of Medicine St. Louis, Missouri

Edward V. Woo, MD Director Regional Vascular Program MedStar Washington Hospital Center Chief Vascular Surgery MedStar Georgetown University Hospital Washington, DC Mohamed A. Zayed, MD, PhD, RPVI Resident Vascular Surgery Department of Surgery Stanford University School of Medicine Stanford, California

Luke X. Zhan, MD, PhD Resident Department of Surgery Division of Vascular and Endovascular Surgery Southern Arizona Limb Salvage Alliance Tucson, Arizona Brant W. Ullery, MD Fellow Division of Vascular Surgery Stanford University Medical Center Stanford, Carolina

Chandu Vemuri, MD Fellow in Vascular Surgery Department of Surgery Barnes-Jewish Hospital Washington University School of Medicine St. Louis, Missouri

Vinit N. Varu, MD Clinical Fellow Vascular Surgery Stanford University Stanford, California

x ix

Wei Zhou, MD Professor of Surgery Stanford University Stanford, California Chief Vascular Surgery VA Palo Alto Health Care System Palo Alto, California

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Prefa ce

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Operative therapy is complex, technically demanding, and

endovascular approaches. In turn, the editors have recruited

rapidly evolving. Although there are a number of standard

contributors that are world-renowned; the resulting volumes

textbooks that cover aspects of general, thoracic, vascular, or

have a distinctly international flavor.

transplant surgery, Operative Techniques in Surgery is unique

Surgery is a visual discipline. Operative Techniques in

in offering a comprehensive treatment of contemporary proce­

Surgery is lavishly illustrated with a compelling combination

dures. Open operations, laparoscopic procedures, and newly

of line art and intraoperative photography. The illustrated

described robotic approaches are all included. Where alterna­

material was all executed by a single source, Body Scientific

tive or complementary approaches exist, all are provided. The

International, to provide a uniform style emphasizing clarity

scope and ambition of the proj ect is one of a kind.

and strong, clean lines. Intraoperative photographs are taken

The text is

organized anatomically in

sections cover­

from the perspective of the operating surgeon so that opera­

ing thoracic surgery, upper gastrointestinal surgery, hepato­

tions might be visualized as they would be performed. The

pancreatico-biliary surgery, colorectal surgery, breast surgery,

result is visually striking, often beautiful. The accompanying

endocrine surgery, and topics related to surgical oncology and

text is intentionally spare, with a focus on crucial operative

modern approaches to vascular surgery.

details and important aspects of postoperative management.

The editors are renowned surgeons with expertise in their

The text is designed for surgeons at all levels of prac­

respective fields. Each is a leader in the discipline of surgery,

tice, from surgical residents to advanced practice fellows to

each recognized for superb surgical j udgment and outstand­

surgeons of wide experience. The incredible pace at which sur­

ing operative skill. Breast surgery, endocrine procedures, and

gical technique evolves means that the volumes will offer new

surgical oncology topics were edited by Dr. Michael Sabel

insights and novel approaches to all surgeons.

of the University of Michigan. Thoracic and upper gastro­

Operative Techniques in Surgery would be possible only

intestinal surgery topics were edited by Dr. Mary Hawn of

at Wolters Kluwer Health, an organization of unique vision,

the University of Alabama at Birmingham, with Dr. Steven

organization, and talent. Brian Brown, executive editor, Keith

Hughes of the University of Florida directing the section on

Donnellan, acquisition editor, and Brendan Huffman, product

hepato-pancreatico-biliary surgery. Dr. Daniel Albo of Baylor

development editor, of Wolters Kluwer Health deserve special

College of Medicine directed the section dedicated to colorec­

recognition for vision and perseverance.

tal surgery. Dr. Ronald Dalman of Stanford University edited topics related to vascular surgery, including both open and

Michael W. Mulholland, MD, PhD

xxi

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Contr i b u t i n g A u t h o rs Preface xxi

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v

Vo l u m e O n e P a rt 1

O p e rative Tec h n i q ues i n Thoracic a n d E s o p h a g e a l S u rg e ry

S e ct i o n

I

Tra chea

1

O p e n Tra ch eosto my 5 Sam T. Windham, Ill and John Christopher McAuliffe

2

Cricothyro i d otomy Sam T. Windham, Ill

3

Trach eosto my: E n d osco p i c Sam T. Windham, Ill

4

Tra cheal Resection a n d Reco n structi o n Alexander T. Hillel and William Grist

S e ct i o n 5

II

11

Crico p h a ryngeal D iverticu l u m : Open Repa i r William R. Carroll and Kirk P. Withrow

13

Crico p h a ry n g e a l D iverticu l u m : E n d osco p i c Repa i r 96 Kirk P. Withro w and William R. Carroll

14

E p i p h re n i c D i ve rti c u l u m Treatment 101 Ryan Levy, Ca therine Go, Ryan A Macke,

15

90

lo n g Myoto my for D iffuse E s o p h a g e a l Spasm 108

Da vid D. Odell and James D. L uketich

21

16

lung

la p a rosco p i c H e l l e r Myoto my a n d Ante r i o r F u n d o p l ication for E s o p h a g e a l Ach a l a s i a 115

Marco E. Allaix and Marco G. Patti

lobecto my: O p e n

27

S e ct i o n

lobecto my: Tho racosco p i c

37

lobecto my: Robotic

52

Tyler Grenda and Jules Lin 8

Esophagus

12

P n e u m o n ecto my: O p e n

V

D i a p h ra g m

17

Repa i r of C o n g e n ita l Defects: M o rgag n i D i a p h rag matic H e r n i a 121 Scott A Anderson and Mike K. Chen

18

Repa i r o f C o n g e n ital Defects : Boch d a l e k Congen ita l D i a p h ra g m atic H e r n i a 128 Scott A Anderson and Mike K. Chen

Tyler Grenda and Jules Lin 7

IV

Peter Ferson, and James D. L uketich 15

A wad EI-Ashry and Robert J. Cerfolio 6

S e ct i o n

65

Christopher R. Morse and Cameron T. Stock S e ct i o n

Ill

S e ct i o n 19

9

Thym ecto my

71

Tho racosco p i c Sym pathecto my

81

20

Brett Broussard, Douglas Minnich, and Benjamin Wei 11

Treatment of Paraeso p h a g e a l H e r n i a s

M e d i ast i n oscopy

85

James Wiseman and Shanda Haley Blackmon

Paraeso p h a g e a l H e r n i a R e p a i r : la p a rosco p i c Tec h n i q u e 136

John G. Hun ter and Mark J. Eichler

Jason Leonard Muesse and Shanda Haley Blackmon 10

VI

M e d iasti n u m

Col l i s Gastro p l a sty

148

John G. Hunter and Mark J. Eichler 21

Tra n sthoracic H i ata l H e r n i a Repa i r

154

Jules Lin and Mark Orringer

xxi i i

xxiv

Secti o n 22

CONTENTS

VI I

Treatment of Gastroesophageal Reflux

La p a rosco p i c N i ssen F u n d o p l ication

2

Benjamin K. Poulose, Michael D. Holzman, and Rebeccah B. Ba ucom

170

Elizabeth A. Warner and Brant K. Oelschlager 23

3

La p a rosco p i c M e s h H i ata l H e r n i a Repa i r 178

24

Redo F u n d o p l icati o n C. Daniel Smith

25

La p a rosco p i c Part i a l F u n d o p l ication for Gastroes o p h a g e a l Reflux D i sease 195

4

185

The M i n i m a l ly I nvasive S u rg i cal A p p roach t o Gastroes o p h a g e a l Reflux D i sease 201 W Scott Melvin and L uke M. Funk

VI I I

l n c i s i o n a l H e r n i a : Lapa rosco p i c A p p roaches 311

5

l n c i s i o n a l H e r n i a Repa i r: Abd o m i n a l Wa l l Reco n struction O pt i o n s 320 Michael 1. Rosen

6

Parasto m a l H e r n i a

7

U m b i l ical, E p i g astric, S p i g e l i a n , a n d L u m b a r H e r n i a s 336

Filip Muysoms

Treatment of Ba rrets E s o p h a g u s a n d

S e ct i o n

28

Rad i ofreq u e n cy Ablation of Barrett's E s o p h a g u s 212 Shajan Peter, C. Mel Wilcox, and Klaus Monkemuller E n dosco p i c M u cosa l Resection for Barrett N e o p l a s i a 217 Shajan Peter, C. Mel Wilcox, and Klaus Monkemuller

330

Melissa M. Alvarez-Downing and Susan M. Cera

E a rly E s o p h a g e a l Cancer 27

289

Todd Heniford and Kristopher Williams

Marco E. Allaix and Marco G. Patti

Secti o n

l n c i s i o n a l H e r n i a : O p e n A p p roaches

Mark D. Sa wyer and Michael G. Sarr

Ellen H. Morrow and Brant K. Oelschlager

26

I n g u i n a l H e r n i a : La p a rosco p i c A p p roaches 281

8

II

S u rg e ry of the Stomach and D u o d e n u m

Vag otomy: Tru n cal a n d H ig h ly Sel ective Mary T. Ha wn, George A. Sarosi Jr., and

349

Ashley Augspurger Da vis 9

D r a i n a g e P roced u res: Pyl o romyoto my, Pyl o ro p l a sty, G astrojej u n osto my 360

George A. Sarosi, Jr.

IX

Secti o n 29

Treatment of E s o p h a g e a l Cancer

10

Esophag ecto my: Tra n s h i ata l and Reco nstructi o n 223

lvor Lewis Esophag ecto my

373

J. Spencer Liles and John D. Christein 11

S u btota l G a strecto my for Cancer

382

Vikas Dudeja, Patrick G. Jackson, and Waddah B. AI-Refaie

Robert E. Glasgow 30

Antrecto my

237

12

Robert E. Merritt

M i n i m a l ly I nvasive Tota l G a strecto my

392

Elliot Newman and Marcovalerio Me/is 31

M i n i m a l ly I nvasive Esophag ecto my

246

Benjamin Wei, Robert J. Cerfo/io, and Mary T. Ha wn Secti o n 32

X

13

14 Treatment of E s o p h a g e a l Perforation

Treatment of E s o p h a g e a l Pe rfo rat i o n : Cervica l, Thoracic, a n d Abd o m i n a l 254

15

Proxi m a l Gastrecto my

404

Tota l Gastrecto my for Cancer

412

Vikas Dudeja, Eugene A. Choi, and Waddah B. AI-Refaie 16

G a strosto my

423

John Daniel Hunter, Ill and John Roland Porterfield, Jr.

P a rt 2

O pe rative Tec h n i q ues i n

17

G a stro i ntesti n a l S u rgery

1

398

Sushanth Reddy and Martin J. Heslin

Na thalie Boutet and Moishe Liberman

Secti o n

M i n i m a l ly I nvasive D i sta l Gastrecto my

John K. Sa unders and Marcovalerio Me/is

I

S u rg e ry of the Abd o m i n a l Wa l l

I n g u i n a l H e r n i a : O p e n A p p roaches

Michael D. Pa ul and Kamal M. F. ltani

Feed i n g J ej u n ostomy

434

John Daniel Hunter, Ill and John Roland Porterfield, Jr.

268

S e ct i o n 18

3

Ba riatric O p e rations

La p a rosco p i c Gastric Bypass

445

Elizabeth A. Davee and Ronald H. Clements

XXV

CONTE NTS

19

La p a rosco p i c S l eeve G a strecto my

16

452

20

La p a rosco p i c G astric B a n d

Fen estration o r E n ucleation of H e patic Cystic D i sease 602 Purvi Y. Parikh

18

S u rg i cal M a n a g e m e n t of H e patic Tra u m a Walter L. Biffl and Carlton C. Barnett, Jr.

19

H e patic N e o p l a s m Ablation a n d Related Tec h n o l ogy 617

O p e rative Tec h n i q ues i n H e pato­ Pancreato- B i l i a ry S u rg e ry

S e ct i o n 1

I

3

La p a rosco p i c C h o l ecystecto my

20

Cath ete r- Based Treatment of H e patic N e o p l a s m s 623 Darren W. Postoak

21

Seg m e nta l H e patecto my 631 Neil H. Bhayani, Eric T. Kimchi, and Niraj J. Gusani

22

M i n i m a l ly I nvasive Sect i o n a l a n d Seg m e nta l H e patic Resection 638 Kevin T. Nguyen

23

R i g ht H e p atecto my

475

O p e n C h o l ecystecto my 485 Sean P. Montgomery and Preston B. Rich Rad i ca l C h o l ecystectomy

491

Richard J. Bold 4

E n dosco p i c Retro g ra d e C h o l a n g iopan creatography

498

6

I ntraoperative C h o l a n g i og ra m

508

Chasen A. Croft and Da wood G. Dalaly

24

Percuta n e o u s Tra n s h epatic B i l i a ry I m a g i n g a n d I nte rve ntion 515

25

26

S u rg i ca l l y Ass i sted E n d osco p i c Retrog rade C h o l a n g iopan creatoscopy 523

Roux-e n -Y C h o l edochoj ej u n osto my

27

528

M i n i m a l ly I nvasive Choledochojej u nostomy

C h o l edoch o d u o d e n osto my

12

I ntra h e patic B i l i a ry- E nte ric Anastomosis

29

30

15

II

554

31

R i g ht H epatic Triseg m e ntecto my

702

Left H e patic Trisection ecto my

709

Jason A. Castellanos and Kamran Jdrees

Ill

S u rg e ry of the Pancreas

575

32

E n d osco p i c U ltraso nog ra p h y of the Pan creas 717

Anand R. Gup te, Disaya Chavalitdhamrong, and Mihir S. Wagh

S u rg e ry of the Liver

S u rg i ca l Anatomy of the Liver

682

Ven a Cava Resection d u ri n g H e patectomy

S e ct i o n

Charles S. Cox, Jr. and Robert Hetz S e ct i o n

Centra l H e patecto my

Ivan R. Zendejas

O p e rative M a n a g e m e n t of C h o l e d o c h a l Cyst 566

O p e rative Treatment o f B i l i a ry Atresia

674

Aijun Li and Mengchao Wu

546

Charles S. Cox, Jr. and Robert Hetz 14

Robotic Liver Resection

Aijun Li and Mengchao Wu

Reid B. Adams and Victor Zaydfudim 13

28

540

Resection of H i l a r C h o l a n g iocarc i n o m a Ryan T. Groeschl and T. Clark Gamblin

M i n i m a l ly I nvasive Left H e patic Lobecto my 666

534

Ka therine A. Morgan and Da vid B. Adams 11

657

Mohammad Khreiss, Allan Tsung, and Da vid L. Bartlett

Janak Parikh, C. Max Schmidt, and Eugene P. Ceppa 10

Left H e patic Lobecto my

Trang K. Nguyen and Amer H. Zureika t

Sha wnn Nichols and Mark Bloomston 9

650

Jon S. Cardinal

Kfir Ben-Da vid and Steven J. Hughes 8

M i n i m a l ly I nvasive R i g ht H e patecto my

Shirin Sabbaghian and Allan Tsung

Brian S. Geller 7

643

Neil H. Bhayani, Niraj J. Gusani, and Kevin Staveley-O'Carroll

Shailendra S. Chauhan 5

608

/do Na chmany and Ra vit Geva S u rg e ry of the B i l i a ry System

Georgios Rossidis 2

593

17

460

Darren S. Tishler and Pavlos K. Papasa vas

P a rt 3

I ntra o p e rative U ltraso u n d of the Liver

Kristopher Croome and KMarie Reid Lombardo

Ozanan R. Meireles, Eric G. Sheu, and Matthew M. Hutter

584

Teviah Sachs and Timothy M. Pawlik

33

Pan creaticod uoden ecto my: Resection

George VanBuren, II and William E. Fisher

726

693

xxvi

34

CONTENTS

Pancreaticod uoden ecto my: M i n i m a l ly I nvasive Resect i o n 739

45

Song Cheal Kim and Ki Byung Song 35

Pancreaticod uoden ecto my: Robotic-Ass isted Resection 749

Megan B. Anderson, Christopher D. Raeburn, and Barish H. Edil 46

O p e rative Treatment of Gastri n o m a

839

Jason A. Castellanos and Nipun B. Merchant

Brian A. Boone and Herbert J. Zeh 36

E n u c l eation of Pan creatic N e u roendocrine Tu m o r 835

47

Pancreaticod uoden ecto my: Pancreati cojej u n osto my 756

Charles M. Vollmer

Late ra l Pancreati cojej u n osto my with (F rey) or without (Pu estow) Resection of the Pancreatic H ead 849

Kevin E. Behrns and Jose G. Trevino 37

Pancreaticod u o d e n ecto my: Pan creaticogastrosto my 767

48

La ureano Fernimdez-Cruz 38

Lapa rosco p i c Pancreati coj ej u n osto my

773

Steven J. Hughes 39

49

Po rta l Ve i n Resection and Reco n struction

40

Open D i sta l Pancreatecto my

41

42

M i n i m a l ly I nvas ive D i sta l Pancreatecto my Pa ul D. Hansen and W. Cory Johnston

Centra l Pancreatecto my

51

E n d osco p i c Pancreatic D e b r i d e m e n t a n d D r a i n a g e 881

52

821

Daniel J. De/itto and Jose G. Trevino 44

875

Udayakumar Na vaneethan and Andres Gelrud S e ct i o n

Adam S. Brinkman and Sharon M. Weber 43

La p a rosco p i c Pan creati c D e b r i d e m e n t 0. Joe Hines and Ka thleen Hertzer

802

D i sta l Pancreatecto my with S p l e n i c Preservati o n 814

867

50

794

Susanne G. Warner and Rebecca M. Minter

Pancreatic D e b r i d e m e n t

Nicholas J. Zyromski

781

Steven J. Hughes and Kevin E. Behrns

E nte ric D r a i n a g e of Pancreatic Pseud ocysts : Pancreatic Cyst Gastrosto my a n d Cyst J ej u n ostomy 856 Kenneth K. W. Lee

4

S u rg e ry of the S p l e e n

S p l e n ecto my (Open a n d La p a rosco p i c Tech n i q ues) 890

Vanessa Cran ford, Janeen R. Jordan, and Frederick A. Moore

A m p u l l ecto my a n d Tra n s d u o d e n a l S p h i n ctero p l a sty 827

53

S p l e n o rr h a p h y

900

Sha wn D. Larson and Saleem Islam

Bhara th D. Na th and Tara S. Kent

Vo l u m e Two P a rt 4

O pe rative Tec h n i q ues i n Co l o n a n d

5

1

I

S e ct i o n

917

6

Oliver Varban 2

3

Strict u re p l a sty a n d S m a l l Bowel Bypass i n I n fl a m m ato ry Bowel D i sease 925 Douglas W. Jones and Kelly A. Garrett

7

S u rg ical M a n a g e m e nt of E nterocuta n e o u s F i stu l a 934

8

E n d a n d D iverti n g Loo p I l eosto m ies: Creation a n d Reversa l 943

Kathrin Mayer Troppmann

S u rgery of the Colon, Append ix,

Appendectomy: O p e n Tec h n i q u e

963

James Suliburk and Da vid Berger Append ecto my: Lapa rosco p i c Tec h n i q u e 970

Roosevelt Fajardo Append ecto my: S i n g l e - I n c i s i o n La p a rosco p i c S u rg e ry Tec h n i q u e 976

Reshma Brahmbhatt and Mike K. Liang

William Sanchez 4

II

Rectu m, and A n u s

S u rg e ry of the S m a l l I ntest i n e

La p a rosco p i c S m a l l Bowel Resection

957

Rebecca L. Wia trek and Lillian S. Kao

Recta l S u rg e ry

Secti o n

J ej u nostomy Tu be

9

R i g h t H e m i co l ecto my: O p e n Tec h n i q u e

Soma/a Mohammed, Ka thleen R. Liscum, and Eric J. Si/berfein

984

xxvii

CONTE NTS

10

La p a rosco p i c R i g ht H e m i co l ecto my

993

S e ct i o n

Craig A. Messick, Josh ua S. Hill, and George J. Chang 11

Low Ante r i o r Resection a n d Total M esorecta l Exc i s i o n /Co l o a n a l Anastomosis: Open Tec h n i q u e 1139 Konstantinos I. Votanopoulos and Jaime L. Bohl

28

Low Ante r i o r Recta l Resect i o n : La p a rosco p i c Tec h n i q u e 1148

R i g h t H e m i co l ecto my: H a n d -Assi sted La p a rosco p i c S u rg e ry Tec h n i q u e 1001

Right H e m i co l ecto my: S i n g l e- I n c i s i o n La p a rosco p i c Tec h n i q u e 1009

Joel Leroy, Didier Mutter, and Jacques Marescaux

Theodoros Voloyiannis 13

Tra n sve rse Col ecto my: O p e n Tec h n i q u e Y. Nancy You

14

La p a rosco p i c Tra nsverse Colectomy Govind Nandakumar and Sang W. Lee

15

Tra n sve rse Colectomy: H a n d -Ass isted La p a rosco p i c S u rg e ry Tec h n i q u e 1033

1017

1025

Left Col ecto my fo r Colon Cancer

32

33

34 1064

35

37

Resto rative Proctocol ecto my: S i n g l e - I n c i s i o n La p a rosco p i c Tec h n i q u e ( I n c l u d i n g Pouch l l eoa n a l An astomosis) 1239

Theodoros Voloyiannis 38

Tota l Abdom i n a l Col ecto my: O p e n Tec h n i q u e 1108

Tarik Sammour and Andrew G. Hill 25

Tota l Abd o m i n a l Col ecto my: La p a rosco p i c Tec h n i q u e 1115

39

Tota l Abd o m i n a l Col ecto my: H a n d -Ass i sted Tec h n i q u e 1127

Daniel Albo

Pelvic Exente rati o n

1261

Cherry E. Koh and Michael J. Solomon 40

Tra n s a n a l Exc i s i o n of Recta l Tu m o rs

1275

Ryan M. Thomas and Barry Feig 41

Tra n s a n a l E n d osco p i c M i c rosu rg e ry Margaret II. Shields and John H Marks

42

Tra n s a n a l S i n g l e Port Exc i s i o n of Recta l Lesi o n s 1293

Matthew G. Mutch 26

Resto rative Proctocol ecto my: H a n d -Assisted La p a rosco p i c S u rg e ry I l e a l Pouch-A n a l Anastomosis 1251

Robert R. Cima

Scott E. Regenbogen 24

Abd o m i n o p e r i n e a l Resect i o n : Robotic-Assisted La p a rosco p i c S u rg e ry Tec h n i q u e 1217

Resto rative P roctocol ecto my: O p e n Tec h n i q u e ( I l e a l Pouch-A n a l Anastomosis) 1228 Hasan T. Kirat and Feza H. Remzi

S i g m o i d Col ecto my: S i n g l e - I n c i s i o n La p a rosco p i c S u rg e ry Tec h n i q u e 1089

S u rg i cal M a n a g e m e n t of Com p l i cated D i ve rti c u l itis: Pe rfo rat i o n and Colovesica l F i stu l a 1099

1208

36

Rodrigo Pedraza and Eric M. Haas 23

H a n d -Ass i sted La p a rosco p i c Abd o m i n o p e r i n e a l Resection

Rodrigo Pedraza and Eric M. Haas

H a n d -Ass isted Lapa rosco p i c S i g m o i d ecto my 1081

Daniel A. Anaya and Daniel Albo 22

Abd o m i n o p e r i n e a l Resect i o n : La p a rosco p i c Tec h n i q u e 1198

Daniel Albo

S i g m o i d Colectomy: La p a rosco p i c Tec h n i q u e 1072

Arden M. Morris 21

Abd o m i n o p e r i n e a l Resect i o n : O p e n Tec h n i q u e 1190

Joel Leroy, Didier Mutter, and Jacques Marescaux

Wayne A./. Frederick, Tofu/ope Oyetunji, and Shiva Seetahal 20

Tota l Mesorecta l Exci s i o n with Coloa n a l Anastomosis: La p a rosco p i c Tec h n i q u e 1177

Curtis J. Wray and Stefa nos G. Mil/as

Left H e m i co l ecto my: H a n d -Assisted La p a rosco p i c Tec h n i q u e 1057

S i g m o i d Colectomy: O p e n Tec h n i q u e

Low Ante r i o r Recta l Resect i o n : Ro botic­ Assisted La p a rosco p i c Tec h n i q u e 1168

John H Marks and Elsa B. Va/sdottir

Left H e m i co l ecto my: La p a rosco p i c Tec h n i q u e 1049

Steven A. Lee-Kong and Daniel L. Feingold 19

30

1041

Erik Askenasy 18

L o w Ante r i o r Resecti o n : H a n d -Ass i sted La p a rosco p i c S u rg e ry Tec h n i q u e 1158

Matthew G. Mutch

31

Sa ul 1. Ruge/es and Luis Jorge Lombana 17

29

Mehraneh D. Ja fari and Alessio Pigazzi

Daniel Albo 16

Recta l Resections

27

Matthew Albert and Harsha Pola varapu 12

Ill

Avo Artinyan and Daniel Albo

1282

xxv i i i

43

CONTENTS

11

la p a rosco p i c D iverti n g Col ostom ies: Formation a n d Reve rsal 1302

Da vid Taylor and Andrew Stevenson 44

Eleni Tousimis and Rache Simmons

S u rg ical M a n a g e m e n t of H e m o rr h o i d s

1314

12

Mod ified Rad i c a l M a stecto my 1451 Tiffany A. Torstenson and Judy C. Boughey

1325

13

Tec h n i q ues for Correct i n g L u m pecto my Defects 1462

Bidhan Das 45

S u rg ical M a n a g e m e n t of Anal Fiss u res

Daniel Albo 46

O p e rative Treatment of Recta l Pro l a pse: Pe r i n e a l A p p roach (Aite m e i e r a n d Mod ified Delorme P roce d u res) 1332

Valerie Bauer 47

S k i n - S p a r i n g a n d N i p p l e/Areo l a r- S p a r i n g M a stecto my 1442

Julie E. Park, Jonathan Bank, and Da vid H. Song S e ct i o n 14

O p e rative Treatment of Recta l Pro l a pse: Tra n s a b d o m i n a l A p p roach 1339

II

B reast Reconstructi o n

D i rect-to- I m p l a n t B reast Reconstruction

1471

Amy S. Colwell 15

Karin M. Hardiman

Two-Stage I m p l a nt B reast Reconstruction

1476

Eric G. Halvorson 48

Cyto red u ctive S u rg e ry a n d Hyperth e r m i c I ntraperito n e a l C h e m ot h e rapy for Perito n e a l S u rfa ce D i s se m i nation of Colorecta l Cancer 1349 Reese W Randle, Konstantinos I. Votanopoulos,

Edward A. Levine, Perry Shen, and John H. Stewart, IV

16

Ped icled latiss i m u s Dorsi F l a p B reast Reco n struction afte r M a stecto my 1488 Frank Fang and Adeyiza 0. Momoh

17

Ped icled Tra nsverse Rectus Abdom i n i s Myocuta neous Flap B reast Reconstruction

1496

Dale Collins Vidal and Emily B. Ridgway

P a rt 5

O p e rative Tec h n i q ues in B reast,

18

F ree Tra nsverse Rectus Abd o m i n i s M u sc u l ocuta n e o u s F l a p Reco nstructi o n after M a stecto my 1502 Ma urice Y. Nahabedian and Ketan M. Pa tel

19

Deep I nferior E p i g astric Perfo rato r F l a p B reast Reco n struction afte r M a stecto my 1512 Adeyiza 0. Momoh

E n docri n e, a n d O n colog i c S u rg e ry

Secti o n 1

I

B reast S u rg e ry

F i n e N eed l e Aspi ration of a B reast M ass

1363

Judy C. Pang and Claire W Michael 2

W i re Loca l i zed B reast B i o psy

20

1370

Michael S. Sabel 3

S u ba reo l a r D u ct Exci s i o n

21

1378

Amy C. Degnim 4

Cryoa blation of B reast F i b roa d e n o m a s

1386

l u m pecto my for B reast Cancer

1394

O n c o p l a stic B reast S u rg e ry

23

B rachyth e ra py Cath ete r I n sertion for B reast Cancer 1414

24

Senti n e l lym p h N o d e B i o psy for B reast Cancer 1421

25

S i m p l e M a stecto my

W i d e Exc i s i o n of Pri m a ry Cuta n e o u s M e l a n o m a 1535

Adva ncement a n d Rotat i o n a l F l a p s

1546

S k i n G rafts

1555

1424

Michael S. Sabel and Lisa Newman

1560

Resection of H ead a n d Neck M e l a n o m a

Scott A. Mclean 27

1432

D i g i t A m p utations

Steven C. Haase 26

Internal M a m m a ry Senti n e l Node Bio psy

A. Marilyn Leitch 10

Melanoma

Da vid L. Brown

Anees B. Chagpar 9

Ill

Jeffrey H. Kozlo w

Peter D. Beitsch 8

1528

Russell S. Berman and Jeffrey E. Gershenwald

1403

Kristine E. Calhoun and Benjamin 0. Anderson 7

Red u cti on M a m m o p l asty

S e ct i o n 22

Michael S. Sabel 6

1522

Sebastian Winocour and Valerie Lemaine

Cary S. Ka ufman 5

N i p p l e-Are o l a r Reco nstruct i o n

Anita R. Kulkarni, Amy K. Alderman, and Andrea L. Pusic

Senti n e l lym p h Node B i o psy for M e l a n o m a 1578

Merrick I. Ross and Michael Kim

1567

CONTE NTS

28

46

Axi l l a ry Lym p h N o d e D i ssection for M e l a n o m a 1594

47

I n g u i n a l Lym p h N o d e D i ssection ( l n g u i nofe m o ra l a n d I l i o i n g u i n al) for M etastatic M e l a n o m a 1605

31

48

49

M i n i m a l ly I n vasive I n g u i n a l Lym p h Node D i ssection for M e l a n o m a 1615 James W. Jakub Sel ective Neck D i ssection for M e l a n o m a

Popl ite a l D i ssection

1626

1763

La p a rosco p i c Retroperito n e a l Ad re n a l ecto my 1769

50

La p a rosco p i c Ad re n a l ecto my-Late ral A p p roach 1775

Geoffrey B. Thompson and Anna Kundel 1634

51

Isol ated L i m b I n f u s i o n

Isol ated L i m b Perfu s i o n

lnsulinomas

1782

Douglas L. Fraker

1641

52

Jeffrey J. Sussman and Joseph S. Giglia 34

Ad re n a l ecto my: O p e n Poste rior

Michael G. Johnston and James A. Lee

Glenda G. Callender and Kelly M. McMasters 33

1755

Barbra S. Miller

Vasu Divi 32

Ad re n a lectomy: Open Thoracoa bdom i n a l

Barbra S. Miller

Amod A. Sarnaik and Vernon K. Sondak 30

1747

Barbra S. Miller

Michael S. Sabel 29

Ad re n a l ecto my: O p e n Ante r i o r

xxix

S u rg e ry for G l ucag o n o m a

1791

Richard A. Prinz and Ca therine A. Madorin

1647

Omgo E. Nieweg, Oscar E. Imhof, and Bin B.R. Kroon

P a rt 6 S e ct i o n

IV

E n docri n e

35

Thyroid Lobecto my 1656 Amy C. Fox and Pa ul G. Gauger

36

Tota l Thyro i d ecto my 1663 Sai"d C. Azoury and Martha A. Zeiger

37

S e ct i o n

Thyro i d ecto my for S u bste r n a l Goite rs

A rch a n d G reat Vessel Reco n structi on with D e b ra n c h i n g Tec h n i q ues 1804 W. Anthony Lee and Alexander Kulik

2

Extrathoracic Revasc u l a rization (Ca rotid-Ca rotid, Ca rotid-S u bclavian Bypass a n d Tra n s position) 1810 Edward Y. Woo and Scott M. Damra uer

3

Ca rotid S u rg e ry: I nterposition/E n d a rte recto my ( I n c l u d i n g Evers i o n)/Ligation 1818

1673

S u btota l Thyroid ecto my for G raves' D i sease 1679

M i n i m a l ly I n vasive V i d eo-Assisted Thyro i d ecto my 1686

Paolo Miccoli and Gabriele Materazzi 40

Vinit N. Varu and Wei Zhou

Lym p h Node Dissection in Thyroid Cancer

1694

Gerard M. Doherty 41

5

S u btota l Pa rathyro i d e ctomy or Tota l with Auto l o g o u s G raft 1711

Brian D. Sa unders 43

4

1723

E n dosco p i c Parathyro i d e ctomy by Late ra l A p p roach 1728

Jean-Franr;ois Henry 45

Reope rative Pa rathyro i d e ctomy

S e ct i o n 7

1739

Barnard J. A. Palmer and William B. lnabnet, /II

Ve rte bral Tra nsposition Tec h n i q ues a n d Stenti n g 1843

Mark D. Morasch

Peter Angelos and Rayman H. Grogan 44

Ca roti d S u rg e ry: D i sta l Expos u re a n d Control Tec h n i q ues a n d Com p l i cation M a n a g e m e n t 1837

Cheong J. Lee 6

M i n i m a l ly I n vasive Pa rathyro i d e ctomy

Ca roti d S u rg e ry: B i f u rcation Ste n t i n g with D i sta l P rotection 1827

Zhen S. Huang and Darren B. Schneider

Open N ec k Expl oration for P r i m a ry Hyperparathyro i d i s m 1700

Christopher R. McHenry 42

Cere b rovasc u l a r Arte r i a l S u rg e ry/

1

Edwin L. Kaplan and Rayman H. Grogan 39

I

I nte rve ntion

Andrew G. Shuman and Ashok R. Shaha 38

O p e rative Tec h n i q ues i n Vascu l a r S u rgery

II

M a n a g e m e n t of the Thoracic Outlet

N e u rogenic Thoracic O utlet Syn d rome Exposu re a n d Decom p ression: S u p raclavicular 1848 Robert W. Thompson and Chandu Vem uri

XXX

8

CONTENTS

N e u ro g e n i c Thoracic O u t l et Syn d ro m e Expos u re a n d Deco m p ress i o n : Tra n saxi l l a ry 1862

George J. Arnaoutakis, Thomas Reifsnyder, and Julie Ann Freischlag 9

S e ct i o n

Ill

Ce l iac, M ese nteric, Splen ic, H e patic a n d Renal Arte ry D i sease M a n agement

19

Ve n o u s a n d A rte r i a l Thoracic O utlet Syn d ro m e 1869 Jason T. Lee

Secti o n

VI

Ste n t i n g , E n d o g raft i n g , a n d E m bo l ization Tec h n i q ues: Ce l i a c, M esenteric, S p l e n i c, H e patic, a n d Renal Arte ry D i sease M a n a g e m e n t 1959

Mohamed A. Zayed and Ronald L. Dalman 20

U p per Extre m ity Reco nstruction/ Revasc u l a rization

Visceral Reconstruction to Facil itate Cancer M anagement: Cel iac, M esenteric, Splen ic, Hepatic and Renal Artery Disease M anagement 1972

Mohamed A. Zayed and E. John Harris, Jr. 10

Prox i m a l to the Wrist: U p p e r Extre m ity Reco nstruction/ Revascu l a rization 1877

21

Mohamed A. Zayed and Ronald L. Dalman 11

U p p e r Extre m ity Arte r i a l Reco n struction and Revasc u l a rization D i sta l to the Wrist 1894

H e patic- a n d S p l e n ic-Based R e n a l Revasc u l a rization 1986

Fred Wea ver, Sung Wan Ham, and Grace Huang

S e ct i o n

VI I

Secti o n

IV

Thoracic Ao rta D i stal to the

22

Pericard i u m 12

Germano Melissano, Efrem Civilini, Enrico Rinaldi, and Roberto Chiesa 13

Thoracic Ao rtic Stent G raft Repa i r for A n e u rysm, D i ssection, and Tra u m atic Tra nsection 1910 Brant W Ullery and Jason T. Lee

14

Expos u re a n d O p e n S u rg i ca l M a n a g e m e n t at the D i a p h ra g m 1921

23

24

Adva n ced A n e u rysm M a n a g e m e n t Tec h n i q ues: M a n a g e m e n t of I nte r n a l I l iac A n e u rysm D i sease 2015 W Anthony Lee

25

Occlu sive D i sease M a nagement: Isolated Femoral Reco nstruction, Aortofe moral Open Reconstruction, a n d Aorto i l iac Reconstruction with Femoral Crossover fo r Li m b Salvage 2024

Na than !toga and E. John Harris, Jr.

Hybrid, O p e n a n d E n d ovasc u l a r

26

A p p roaches t o the S u prare n a l

Retroperito n e a l Aortic Expos u re

1926

Ma tthew Mel/ 16

17

18

Hybrid Revascu l a rizati o n Strate g i e s for Viscera l / R e n a l Arte ries 1931 Benjamin W Starnes S n orkel/Ch i m n ey a n d Periscope V i scera l Revasc u l a rizat i o n d u ri n g Co m p l ex E n dovasc u l a r A n e u rysm Repa i r 1939 Jason T. Lee and Ronald L. Dalman Branched a n d Fen estrated E n d ovasc u l a r Ste nt G raft Tec h n i q ues 1948

Gusta vo S. Oderich and Karina S. Kanamori

Occlusive Disease M a nagement: I l iac Angioplasty and Femoral Enda rterectomy

2034

Venita Chandra

Abd o m i n a l Ao rta 15

Adva n ced Aortic A n e u rysm M a n a g e m e nt: E n d ovascu l a r A n e u rysm Repa i r-Sta n d a rd and E m e rg e n cy M a n a g e m e n t 2006

Vinit N. Varu and Ronald L. Dalman

Peter H. U. Lee and Ram in E. Beygui

V

Adva n ced A n e u rysm M a n agement Tec h n i q ues: Open S u rg i ca l Anatomy a n d Repa i r 1995

Elizabeth Blazick and Mark F. Conrad

Expo s u re a n d O p e n S u rg i ca l Reconstruct i o n i n t h e C h est: T h e T h o racoa bd o m i n a l Ao rta 1902

Secti o n

The Abdom i n a l Ao rta and I l iac Arte r i a l System

Michael G. Galvez and James Chang

S e ct i o n

VI I I

l n f ra i n g u i n a l Arte r i a l D i sease M a n a g e m e nt/ Li m b Sa lvage Strate g i e s

27

M anagement of the Infected Femoral G raft

2044

Matthew Mel/ 28

S u rg i cal Expos u re of the Lower Extre m ity A rte ries 2050 Luke X. Zhan and Joseph L. Mills, Sr.

29

Percuta neous Fe mora l-Po p l iteal Reco nstruction Tech n i q ues: Reentry Devices 2061

Danielle E. Cafasso and Peter A. Schneider

CONTE NTS

30

Percuta n e o u s Femora l-Po p l ite a l Reco n struction Tec h n i q ues: Anteg rade A p p roaches 2068

33

Peri m a l l e o l a r Bypass a n d Hybrid Tec h n i q ues 2105

Geetha Jeyabalan and Rabih A. Chaer

F. Gallardo Pedrajas and Peter A. Schneider 31

M axi m i z i n g Ve i n Co n d u it for Auto g e n o u s Bypass 2082

Gregory J. Landry 32

T i b i a l I n te rventions: T i b i a l - S pecific A n g i o p l a sty C o n s i d e rations a n d Retrog rade A p p roaches 2092

Georges E. AI Khoury and Rabih A. Chaer

xxxi

S e ct i o n 34

IX

Surg ica l M anagement of Venous Disease

Acute I l iofe m o r a l Deep Ve i n T h rom bosis a n d M ay-Th u rn e r Syndrome: S u rg i ca l and l n te rve n t i o n a l M a n a g e m e n t 2116 Sharon C. Kiang and Brian G. DeRubertis

I n d ex

1-1

Th i s page i nte nti o n a l ly l eft b l a n k .

Operative Techniques in Thoracic and Esophageal Surgery

Open Tracheostomy s Sam

T.

Windham,

Ill

and John Christopher McAuliffe

Cricothyroidotomy 11 Sam

T.

Windham,

Ill

Tracheostomy: Endoscopic 75 Sam

T.

Windham,

Ill

Tracheal Resection and Reconstruction 21 Alexander

T.

Hillel and William Grist

Lobectomy: Open 27 Awad EI-Ashry and Robert J. Cerfolio

Lobectomy: Thoracoscopic 37 Tyler Grenda and Jules Lin

Lobectomy: Robotic 52 Tyler Grenda and Jules Lin

Pneumonectomy: Open 65 Christopher R. Morse and Cameron

T.

Stock

Thymectomy 71 Jason Leonard Muesse and Shanda Haley Blackmon

Thoracoscopic Sympathectomy 81 Brett Broussard, Douglas Minnich, and Benjamin Wei

Mediastinoscopy 85 James Wiseman and Shanda Haley Blackmon

Cricopharyngeal Diverticulum: Open Repair 90 William R. Carroll and Kirk

P.

Withrow

Cricopharyngeal Diverticulum: Endoscopic Repair 96 Kirk

P.

Withrow and William R. Carroll

Epiphrenic Diverticul um Treatment 1o 1 Ryan Levy, Catherine Go, Ryan A. Macke, Peter Ferson, and James D. Luketich

Long Myotomy for Diffuse Esophageal Spasm 108 David D. Odell and James D. Luketich

Laparoscopic Hel ler Myotomy and Anterior Fundoplication for Esophageal Achalasia 115 Marco E. Allaix and Marco G. Patti

Repair of Congenital Defects: Morgagni Diaphragmatic Hernia 121 Scott A. Anderson and Mike K. Chen

Repair of Congenital Defects: Bochdal ek Congenital Diaphragmatic Hernia 128 Scott A. Anderson and Mike K. Chen

Paraesophageal Hernia Repair: Laparoscopic Technique 136 John G. Hunter and Mark J. Eichler

Col l is Gastropl asty 148 John G. Hunter and Mark J. Eichler

Transthoracic Hiatal Hernia Repair 154 Jules Lin and Mark Orringer

Laparoscopic Nissen Fundopl ication 170 Elizabeth A. Warner and Brant K. Oelschlager

Laparoscopic Mesh Hiatal Hernia Repair 178 Ellen H. Morrow and Brant K. Oelschlager

Redo Fundoplication 185 C. Daniel Smith

Laparoscopic Partial Fundopl ication for Gastroesophageal Refl ux Disease 195 Marco E. Allaix and Marco G. Patti

The Minimal l y Invasive Surgical Approach to Gastroesophageal Refl ux Disease 201 W.

Scott Melvin and Luke M. Funk

Radiofrequency Ablation of Barrett's Esophagus 212 Shajan Peter, C. Mel Wilcox, and Klaus Monkemuller

Endoscopic Mucosal Resection for Barrett Neoplasia 217 Shajan Peter, C. Mel Wilcox, and Klaus Monkemuller

Esophagectomy: Transhiatal and Reconstruction 223 Robert E. Glasgow

lvor Lewis Esophagectomy 237 Robert E. Merritt

Minimal l y Invasive Esophagectomy 246 Benjamin Wei, Robert J. Cerfolio, and Mary

T.

Hawn

Treatment of Esophageal Perforation: Cervical, Thoracic, and Abdominal 254 Nathalie Boutet and Moishe Liberman

-

I

Chapter

1

Open Tracheostomy ·----------------------------------------------------- ....

Sam

T.

Windham,

DEFINITION •

Tracheostomy is a procedure defined as the creation of a communication between the trachea and the skin of the neck anteriorly. In general, this technique is viewed as a definitive airway for the management of the critically ill patient need­ ing prolonged ventilator support.

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

The history from the patient may be limited as compared to standard history and physical exams normally per­ formed on patients during routine evaluations for surgery; however, the history and physical exam should focus to determine ( 1 ) the indications for tracheostomy, (2) opti­ mal timing for the performance of the tracheostomy, and ( 3 ) which approach will provide the safest tracheostomy for the patient. With respect to the indication for tracheostomy, the first and foremost indication should be that of the patient with a difficult airway who requires prolonged mechanical ventila­ tor support. In these patients, loss of the airway can have devastating consequences. Pertinent history might include a difficult airway at the time of surgery; prior maxillofacial trauma; presence of severe inflammation or edema in the mandibular, pharyngeal, or base of tongue regions; prior head and neck radiation; or conditions that limit the mobil­ ity of the neck (e.g., ankylosing spondylitis, cervical trauma, or fixation) . In these patients, early tracheostomy should be considered. With respect to timing of the tracheostomy, many studies have evaluated this question. When endotracheal tubes were first created, the tubes were less flexible than modern tubes with low-volume, high-pressure cuffs that resulted in more tracheal trauma than modern tubes. However, tracheal trauma and stenosis still occur with modern endotracheal tubes, and as a result, this leads to one of the indications for timing of the tracheostomy. In order to minimize the risk of tracheal stenosis, most recommend performance of tracheostomy in patients for whom 2 weeks of mechanical ventilation is expected. Pena et al. 1 found that 8 6 % of patients requiring laryngotracheal surgery for stenosis had a mean duration of 1 7 days of me­ chanical ventilation. So to minimize this risk, tracheos­ tomy is usually recommended for expected duration of 1 4 days. Other studies have looked at the timing of tracheosto­ mies based on outcomes for the patients . Most studies evaluating performance of tracheostomies within the

•

Ill

John Christopher McAuliffe

first 10 days of intensive care unit ( ICU) course sug­ gest statistically significant improvement in days on ventilator, days in the ICU, need for sedation, costs, and total hospital length of stay. Z-4 In busy hospitals, with increased ICU usage, early tracheostomy should be considered. With respect to timing of the tracheostomy, an important aspect of the history to evaluate is the disease process that required the need for mechanical ventilator sup­ port. In patients with severe brain inj ury/ spinal cord inj ury associated with ineffective cough, severe multi­ ple system organ failure, or in whom multiple-staged operations are planned, early tracheostomy should be considered. The final aspect to the history and physical exam that should be considered alters whether the patient should undergo percutaneous dilatational tracheostomy ver­ sus standard surgical tracheostomy. Certain condi­ tions might warrant open technique over percutaneous tracheostomy. In the setting of altered patient anatomy, the safer option would favor standard surgical tracheostomy with direct exposure of the trachea. With respect to morbid obesity, Byhahn et al.6 reported a greater complication rate with percutaneous dilatational tracheostomy over surgical tracheostomy (43 % vs. 1 8 % ) . If an extended length tracheostomy is anticipated to be needed, then surgical tracheostomy may be safer and eas­ ier approach. The final consideration in preprocedural evaluation is the ventilator settings. In this setting, the surgeon must be comfortable either performing nonbronchoscopic percu­ taneous tracheostomies or choosing an open approach in order to minimize derecruitment.

SURGICAL MANAGEMENT Preoperative Planning •

• •

Prior to taking the patient for open tracheostomy, clotting parameters such as prothrombin time, partial thrombo­ plastin time, and platelet count should be evaluated and optimized. Cervical spine status should be evaluated in the setting of trauma. Periprocedural antibiotics should be administered.

Positioning •

The patient is positioned supine with arms tucked to the side. Often, a pack is placed behind the shoulders to aid with neck extension ( FIG 1 ).

5

6

P a rt 1

OPERATIVE TECH NIQUES IN THORACIC AND ESOPHAGEAL SURGERY

Pack behind shoulders

FIG 1 • Patient is positioned with a pack b e h i n d the sca p u l a e i n order t o i ncrease cervi ca l extension.

•

I NC I S I O N •

A n o . 1 5 b l a d e sca l p e l is used to m a ke a vertical, m i d­ line i ncision a p proxi mately 3 0 to 40 m m a l ong the l ower neck. The c e p h a l a d extent of the incision beg i n s at the l evel of the cricoid cart i l a g e a n d extends ca uda l ly toward the ste r n a l notc h .

Electrocautery division between strap muscles

Forceps on platysma

Forceps on platysma

•

The s k i n e d g es a r e e l evated with Adson forceps a n d t h e d i ssect i o n conti n u es with Bovie e l ectroca utery t h r o u g h t h e p l atys m a a n d between t h e stra p m u scles (FIG 2) . Once between t h e stra p m uscles, a We itlaner retractor may be p l aced to retract the s k i n edges, the subdermal tissue, a n d the stra p m uscles l atera l ly.

H ead

FIG 2

•

D ivision between the stra p m uscles using e lectroca utery.

C h a p t e r 1 O P E N TRAC H E OSTOMY

•

PRETRACH EAL D I S S ECTI O N •

A gently c u rved, rig ht-a n g l e c l a m p is then p l a ced in the pretracheal space at the level of the cricoid ca rt i l a g e . In general, it is safest to deve l o p the p retrachea l space from cephalad to ca u d a l d i rection beg i n n i n g at the l evel of the cricoid carti l a g e (FIG 3A) .

• •

Electrocautery division of

Caudal Forceps hold ing strap muscles

A

Pretracheal tissue

Forceps hold ing strap muscles

Cephalad

Rig ht-ang le clamp elevating pretracheal tissue Divided thyroid isthmus

Bovie e l ectroca utery is used to d ivide the tissue exposed between the rig ht-a n g l e c l a m p . T h e ist h m u s o f the thyroid is then d ivided usi ng the B ovie e l ectroca utery between the rig ht-a n g l e clamp (FIG 38) . A p l a n e is then deve l o ped between the p retracheal tissue a n d the trachea l atera l ly on each side usi ng Bovie e l ectroca utery (FIG 3C, 30) .

B

Right-ang le clamp elevating pretracheal tissue

Thyroid cartilage

� Thyroid carti lage �

C

Tracheal ring 4

Thyroid isthmus divided

Tracheal ring 3

Tracheal ring 3

FIG 3 • A. Division of the p retrachea l tissue using rig ht-a n g l e c l a m p for exposu re a n d e l ectrocautery f o r d ivision o f tissue. B. D ivision of the thyro i d isth m u s u s i n g e l ectroca utery. C. Anterior exposure of the trachea after d ivision of the thyroid ist h m u s and l atera l m o b i l ization of the thyro i d ist h m us. Part (D) is a n i l l ustration of this ste p.

Tracheal ring 4

D

7

8

P a rt 1

OPERATIVE TECH NIQUES IN THORACIC AND ESOPHAGEAL SURGERY

R I N G FIXATION •

Once the a nterior a n d anterior l ate ra l exposure of the trachea has been obta i n ed, a 2-0 Prolene suture is p l a ced t h r o u g h the 3 rd trachea l ring latera l ly o n each side. The en dotrachea l cuff should be briefly defl ated as each stitch is p l aced so as not to i n corporate the cuff with the suture (FIG 4).

Placing suture in tracheal ring 3, right side

Cephalad

Prolene suture in tracheal ring 3, left side FIG 4 • A 2-0 Prolene suture p l acement i nto the 3 rd trachea l r i n g on each side.

Cranial

TRACH EAL ENTRY •

•

•

An i n cision is then m a d e with a no. 1 1 b l a d e sca l pe l in the space between r in g s 2 a n d 3 a n d i n the space between rings 3 a n d 4. The sca l pe l is then used to d ivide the 3 rd r i n g , t h u s cre­ ating a sideways " H -s h a ped " open i n g i n the trachea (FIG S). A Kelly c l a m p or trachea l spreader is then i n serted, open­ i n g the trachea.

-___,,__ Thyroid cartilage

Caudal with incision dividing the middle of ring 3

FIG 5

•

I l l ustration showing H-sha ped incision of the trachea.

C h a p t e r 1 O P E N TRAC H E OSTOMY

•

CAN N U LATI O N OF THE TRACH EA •

The e n d otracheal tube is then s l owly withd rawn u n t i l the t i p is j u st proxi m a l to the tracheotomy site.

•

9

The trach eostomy t u be is then i n serted i nto the trachea (FIG GA,B) . The trach eosto my t u be is conn ected to a n esthesia venti­ l ator and end-t i d a l carbon d ioxide (C02) is confi rmed.

Cephalad

Prolene suture in ring 3

Prolene suture in ring 3

Caudal

A

FIG 6 • A. Trachea l sprea der open i n g of the trachea. N ote the endotracheal t u be has been withd rawn to a l ocation proxi m a l t o t h e tracheotomy. B. I ntrod u ction o f the trach eosto my tube i nto the tracheotomy.

•

CLOSURE •

A 2-0 Pro l e n e suture is then used to rea p p roxi m ate skin edges a bove a n d below the trach eostomy tube.

B

Prolene suture in ring 3

The tracheostomy tube is secu red to the skin usi ng i nter­ ru pted 2-0 Pro lene sutures.

PEARLS AND PITFALLS Pretracheal d i ssection

•

Wo rking from ce p h a l a d to caudad in the p retrachea l p l a n e resu lts in l ess bleed i n g .

R i n g fixati o n

•

Placing the sutu res in the 3 rd r i n g a l l ows for l atera l traction to open the tracheotomy for i nsertion of the trach eostomy tube. The r i n g sutu res a lso a l l ow for rei nsertion of trach eostomy tube i n the case of accidenta l d islodgement before a tract is fo rmed.

•

Trachea l entry

•

• •

A i rway fi res have been described with the use of e l ectroca utery to enter the trachea or to control bleed i n g of the trachea. Sharp e ntry with sca l pe l is the safest means to enter the trachea. Otherwise, fraction of i n s p i red oxyg en (Fi02) needs to be reduced to l ess than 40% to m i n i m ize risk (experim ents have shown f l a m m a b l e co n d itions in F i 02 as l ow as 2 5 % with use of l a ser).7 If d ivision of the 3rd ring is not poss i b l e with sca l p e l , c u rved M ayo scissors can be used . I nsertion of the trach eostomy tube i nto the trachea s h o u l d be at 90 deg rees to the trachea. Ta ngential entry i ncreases the cha nce of p retrachea l p l acement of the trach eosto my tube.

POSTOPERATIVE CARE •

•

The 3rd ring stay sutures should stay until a tract develops between the skin and the trachea. Usually, these are removed after the first exchange of the tracheostomy tube. The tracheostomy tube should be exchanged between days 7 and 12 for hygiene purpose as well as to decrease the granulation tissue ingrowth into the tracheostomy tube.

•

•

Once off the ventilator and as long as secretions are manage­ able, the tracheostomy tube can be downsized. Usually, the tube is downsized every other day, until the tube is size 4 , a t which time decannulation i s performed. A decannulated tracheostomy stoma is covered with sterile gauze and tape and generally closes within 2 to 4 days .

10

P a r t 1 OPERATIVE TECH NIQUES I N THORACIC AND ESOPHAGEAL SURGERY

COMPLICATIONS • • • •

Rate of skin infection at surgical site: 2% to 3 % Bleeding Tracheoinnominate fistula Tracheostomy dislodgement

REFERENCES 1. Pena J, Cicero R, Marin J, et al. Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present. Otolaryngol Head Neck Surg. 2001;125:397-400. 2. Arabi Y, Haddad S, Shirawa N, et al. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care. 2004;8:R347-R352.

3.

4.

5.

6.

7.

Brook AD , Sherman G, Malen J, et al. Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Am J Crit Care. 2000;9:352-359. Rumbak MJ, Newton M, Truncale T, et al. A prospective, randomized study comparing early percutaneous dilational tracheotomy to pro­ longed translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32:1689-1694. Teoh WH, Goh KY, Chan C. The role of early tracheostomy in criti­ cally ill neurosurgical patients. Ann Acad Med Singapore. 2001;30: 234-238. Byhahn C, Lischke V, Meininger D, et al. Peri-operative complications during percutaneous tracheostomy in obese patients. Anaesthesia. 2005;60:12-15. Hermens JM, Bennett MJ, Hirshman CA. Anaesthesia for laser surgery. Anesth Ana/g. 1983;62:218-229.

I

-

Chapter

2

Cricothyroidotomy I

----------------------------------------

-1

-----------------------------------------------------

Sam

T.

Windham,

airway is lost ( such as the emergency department, operat­ ing room, or intensive care unit) will play a role in decid­ ing what other options, equipment, and help are available. If the loss of airway occurs in the operating room where full technical support is available, the full difficult air­ way algorithm may be used. 1 The most common setting for the performance of crico­ thyroidotomy is for the trauma patient in an emergency room. In these patients with multiple injuries, subop­ timal airway exposure due to need to maintain in-line cervical stabilization, and/or facial trauma, cricothy­ roidotomy should be prepared for at the first indication of a difficult airway.

DEFINITION •

Cricothyroidotomy is an emergency procedure to establish airway access when orotracheal intubation is not possible or attempts have failed. As cricothyroidotomy has a high rate of complications compared to orotracheal intubation and tracheostomy, its role is limited to a rescue procedure for emergent airway access.

PATIENT HISTORY AND PHYSICAL FINDINGS •

The circumstances surrounding the loss of airway are para­ mount to the use of cricothyroidotomy for establishment of the airway. These are broken down into patient-specific cir­ cumstances and setting-specific circumstances. Patient-specific circumstances include trauma to face or upper airway, concern for cervical spine fractures, trau­ matic brain injury, limitations to cervical mobility, previ­ ous radiation to head and neck, and other circumstances leading to a difficult airway. In certain circumstances such as potential isolated cervi­ cal spine fracture in a patient with a competent airway, attempts can be made to establish an airway by other means such as awake fiberoptic intubation or other intubation-assist devices . I n the setting of severe maxillofacial trauma where di­ rect laryngoscopy is impeded by deranged anatomy, bleeding, and/or difficulty ventilating the patient, crico­ thyroidotomy should be considered early in the airway management algorithm. Setting-specific circumstances also play a role as to the timing of emergency cricothyroidotomy in the airway al­ gorithm. For example, considering the location where the

·

Ill

SURGICAL MANAGEMENT Preoperative Planning •

•

•

Planning for the cricothyroidotomy begins before the situa­ tion arises, such as familiarization with the steps involved in the procedure and knowledge of the equipment available to perform the procedure. Prepping the neck and obtaining equipment should begin with the second attempt of direct laryngoscopy in the dif­ ficult airway or at any sign of significant desaturation. Direct laryngoscopy may continue as the cricothyroidotomy is begun but should not delay the procedure. The pertinent anatomy and location of the cricothyroid membrane are illustrated in FIG 1.

Positioning •

The patient is placed in the supine position with in-line cervical spine stabilization for trauma patients.

11

12

P a r t 1 OPERATIVE TECH NIQUES I N THORACIC AND ESOPHAGEAL SURGERY

Hyoid bone Thyrohyoid membrane

�

/ ..._---�!Iiiii'!'

Lateral thyrohyoid ligament Superior cornu of thyroid cartilage

Median thyrohyoid ligament -----L:I--

Superior laryngeal nerve and artery Thyroid cartilage

---

Median cricothyroid ligament

Cricothyroid muscle Inferior cornu of thyroid cartilage

Cricoid cartilage

Cricothyroid joint

FIG 1 • Pert i n e nt a n atomy i l l ustrating position of the cricothyro id m e m b r a n e .

PREP •

B etad i n e or ava i l a b l e s k i n prep s h o u l d be used to prep the a nteri o r neck as q u ickly as poss i b l e .

INCISION •

U s i n g a no. 1 0 b l a d e or no. 1 5 b l a d e sca l p e l , a vertica l incision s h o u l d be m a d e from the p ro m i n e nce of the thy­ roid carti l a g e to below the level of the cricoid cart i l a g e . This i ncision s h o u l d be t h r o u g h the epiderm is, derm is, and subderm a l tissues (FIGS 2 and 3) .

Head

Thyroid cartilage

Incision

FIG 2 • I ncision of the a n t e r i o r neck, incising t h r o u g h epiderm is, derm is, and subderm a l tissues.

C h a p t e r 2 C R I COTHYRO I DOTO M V

FIG 3 • Location of the skin rel ative to a n ato m i c l a n d m a rks.

CRI COTHYRO I D M E M B RANE ENTRY •

A c u rved hem ostat is p l aced on the cricothyro id membrane a n d " po p ped " throug h the membrane. The hemo­ stats a re then opened in a vertical-ori ented m a n ner a n d

•

i n cision

l eft i n p l ace to m a i nta i n the open i n g i n the cri cothyro id m e m b r a n e (FIG 4) . A bougie ( 1 5 F r) is adva n ced t h ro u g h the open i n g of t h e hem ostats a n d i nto the trachea (FIG 5) .

Hemostat on cricothyroid mem brane Bougie

FIG 4

•

Curved hem ostat p laced onto cricothyroid membrane.

Hemostat opening cricothyroid membrane

FIG 5 • H e m ostat spread to open cricothyro id m e m b r a n e i n able to i ntrod u ce b o u g i e i nto the trachea.

13

14

P a r t 1 OPERATIVE TECH NIQUES IN THORACIC AND ESOPHAGEAL SURGERY

•

I NTU BATION •

A 6-0 e n d otrachea l tube (ETI) is advanced over the b o u g i e i nto the trachea a n d the ba l l oon is insuffl ated (FIG 6) .

•

Confi rmation of a tube p lacement s h o u l d be perfo rmed with a u scu ltation of the lung fiel ds, end-t i d a l C02 m o n i tor, if ava i l a b l e, a n d porta b l e ch est x-ray. 0 S i l k (or other l a rg e sutu re) is used to secu re the ETI to the s k i n a n d p reve nt accidenta l d islodgement of the tube (FIG 7).

Bougie

6-0 ETI

Suture securing ETI

6-0 ETI

Cricothyroid membrane

FIG 7 • 2-0 Prolene used to secu re the ETI in p l ace a n d to c l ose the wou n d .

FIG 6 • 6-0 ETI i ntrod u ced i nto the trachea over the b o u g i e catheter.

PEARLS AND PITFALLS I n cision

•

A vertica l i ncision is p refera b l e, as a tra nsve rse/h orizonta l i n cision can tra nsect the anterior j u g u l a r ve i n s, lead i n g to s i g n ificant bleeding, a n d i m pede visu a l i zation.

Cricothyro id m e m brane entry

•

If a h e m ostat is not rea d i ly ava i l a b l e, the b l a d e of the sca l pe l can be used to i ncise the membrane a n d the handle ca n be used to open the m e m brane.

I ntubation

•

A bougie does not have to be used, but once i n p l a ce, it fac i l itates the i ntroduction of the ETI a n d m a i ntains the control of the a i rway. G iv i n g a twist to the ETI a l l ows for easier i ntrod u ction of the ETI t h r o u g h the cricothyro id m e m b ra n e . A trach eostomy t u be can be used i n stead of the ETI, but often th ese a re m o r e d iffi cult to find a n d the ETI a re usua l l y rea d i ly ava i l a b l e .

• •

POSTOPERATIVE CARE •

•

The cricothyroidotomy should be formalized to a tracheos­ tomy within the first 48 hours to minimize risk of long-term complications of tracheal stenosis as well as to establish a safer, more definitive airway. In general, the cricothyroidotomy is converted to an open tracheostomy. At the same time, the wound of the cricothy­ roidotomy is surgically cleaned and a strap muscle can be pulled down to the site of the cricothyroidotomy to aid with wound healing.

COMPLICATIONS • • •

Subglottic stenosis Wound complications Occlusion of the small ETT with blood

REFERENCE 1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult air­ way. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 1992;78:597-602.

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I

Chapter

3

Tracheostomy: Endoscopic 1----------------------------------------------------- ....

Sam

T.

Windham,

DEFINITION •

Tracheostomy is defined as a procedure creating a com­ munication between the trachea and the skin of the neck anteriorly. Tracheostomy is used as a definitive manner of airway management as opposed to translaryngeal intubation for the needs of the critically ill patient. Since the mid- 1 9 80s, percutaneous dilational tracheostomy (PDT) has gained acceptance with equivalent safety as compared to standard surgical tracheostomy, with equal or fewer complications, and decreased resource usage and costs. 1 •2

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

The history from the patient may be limited as compared to standard history and physical exams normally performed during routine evaluations for surgery; however, the history and physical exam should focus on ( 1 ) the indications for tracheostomy, (2) optimal timing for the performance of the tracheostomy, and ( 3 ) which approach will provide the safest tracheostomy for the patient. With respect to the indication for tracheostomy, the first and foremost indication should be that of the patient with a dif­ ficult airway who requires prolonged mechanical ventilator support. In these patients, loss of the airway can have devas­ tating consequences. Pertinent history might include a diffi­ cult airway at the time of surgery; prior maxillofacial trauma; presence of inflammation or edema in the mandibular, pha­ ryngeal, or base of tongue regions; prior head and neck radiation; or conditions that limit the mobility of the neck (e.g., ankylosing spondylitis, cervical trauma, or fixation). In these patients, early tracheostomy should be considered. With respect to timing of the tracheostomy, many studies have aimed to evaluate this question. When endotracheal tubes were first created, the tubes were less flexible than modern tubes with low-volume and high­ pressure cuffs that resulted in more tracheal trauma than modern endotracheal tubes. However, tracheal trauma and stenosis still occur with modern tubes, and as a result, this leads to one of the indications for timing of the tracheostomy. In order to minimize the risk of tracheal stenosis, most rec­ ommend performance of tracheostomy in patients for whom 2 weeks of mechanical ventilation is expected. Pena et aP found that 8 6 % of patients requiring laryngotracheal surgery for stenosis had a mean duration of 17 days of mechanical ventilation. So to minimize this risk, tracheostomy is usually recommended for expected duration of 14 days. Other studies have looked at the timing for when to perform tracheostomies based on outcomes for the patients. Most studies evaluating performance of tracheostomies within the first 10 days of intensive care unit (ICU) course suggest statistically significant improvement in days on ventilator, days in the ICU, need for sedation, costs, and total hospi­ tal length of stay.4-6 In busy hospitals, with increased ICU usage, early tracheostomy should be considered.

Ill

With respect to timing of the tracheostomy, a final aspect to the history to evaluate is the disease process that required the need for mechanical ventilator support. In patients with severe brain inj ury/ spinal cord inj ury associated with ineffective cough, severe multiple system organ failure, or in whom multiple-staged operations are planned, early tracheostomy should be considered. Another aspect of the history and physical exam that should be considered alters whether the patient should undergo PDT versus standard surgical tracheostomy. In the past, fre­ quently cited contraindications to PDT were altered patient anatomy, morbid obesity, coagulopathy, cervical fracture, previous tracheostomy, and high ventilator setting, all of which should be evaluated in preprocedural setting. In the setting of altered anatomy, certainly, the safer op­ tion would favor standard surgical tracheostomy with direct exposure of the trachea. With respect to morbid obesity, Byhahn et al. 8 reported greater complication rate with PDT over surgical trache­ ostomy. If an extended length tracheostomy (XLT) is an­ ticipated due to the distance between skin and trachea, then surgical tracheostomy may be a safer approach. With respect to coagulopathy, PDT can be safely per­ formed in patients with a coagulopathy as long as the risk factors are modified prior to the procedure. If the platelet count is less than 50,000/JlL, platelets should be given at the time of the procedure. 9 If the platelet count is less than 75,000/JlL and the patient has other risk factors for platelet dysfunction (i.e., azotemia, antiplatelet therapy) or abnor­ mal coagulation cascade (i.e., elevated prothrombin time or partial thromboplastin time) , platelets should be given periprocedural, as well as fresh frozen plasma if the inter­ national normalized ratio (INR) is greater than 1 . 7. With respect to cervical fixation and cervical fractures, studies have shown that PDT can be safely performed without cervi­ cal spine clearance or fixation 10 as long as cervical extension is not needed to gain adequate exposure on physical exam. In patients with prior tracheostomies, PDT has been shown to be a safe approach to tracheostomy placement.U The final consideration in preprocedural evaluation is the ventilator settings. High ventilator settings (e.g., positive end-expiratory pressure [PEEP] > 1 4 em HzO, vent rate >20 breaths per minute) are a relative contraindication to PDT due to derecruitment issues during bronchoscopy. Depending on the comfort of the surgeon, a PDT can be performed with nonbronchoscopic or a standard open surgical approach.

SURGICAL MANAGEMENT Preoperative Planning •

Probably one of the most important components for safely performing this procedure is preparation and setup. Medications for the procedure usually consist of an anxio­ lytic (Versed), a narcotic, and a neuromuscular relaxant.

15

16

P a r t 1 OPERATIVE TECH NIQUES I N THORACIC AND ESOPHAGEAL SURGERY

The bed is positioned to allow access to the head of the bed so that translaryngeal reintubation can be performed. An intubation/airway tray should be at the bedside as well as supplies for reintubation (e.g., Yankauer suction appa­ ratus, Ambu bag, free flowing intravenous fluid) . The head of the bed is positioned at approximately 30 degrees . A respiratory therapist a n d a nurse are both available a s part of the preoperative planning a n d setup portions o f the procedure. A bronchoscopy cart is set up to be used during the procedure. Periprocedural antibiotics are administered.

Positioning •

•

For most patients, if the head of bed is elevated, a pack is not needed behind the back for neck extension, as it often does not increase the number of cartilaginous rings above the sternal notch. It is helpful, however, if the working dis­ tance between the chin and sternal notch is limited, such as in those patients with a " second chin . " If the pack is used, usually one t o two rectangular-shaped towels are positioned behind the shoulder blades.

SETUP •

•

•

The vent i l ator is set to d e l iver 1 00 % fraction of i n s p i red oxyge n (Fi02) i n order to preoxyg enate the patient. The vent i l ator is a l so adjusted to d e l iver a set vo l u m e, a n d the rate is i ncreased i n o r d e r to p reventi l ate the patient. At the same t i m e of adjust i n g the venti l ator setti ngs, if the patient is conscious, the a nxio lytic is g iven . If the patient tolerates the dosing of the anxio lytic from a hem odyn a m i c sta n d p o i nt, then a na rcotic is g iven shortly thereafter. F i n a l ly, the n e u ro m uscu l a r relaxant med ication is a d m i n iste red. • The base of the neck is prep ped with c h l o rhexi d i n e f r o m the c h i n t o the n i p p l es a n d f r o m l atera l aspect of the neck to the other latera l aspect of the neck. • Three ste r i l e towe ls are used to d ra p e the latera l aspects of the surgical field a n d the ca u d a l aspect of the fi e l d . A ste r i l e sheet is then p l a ced to cover the entire body of the patient a n d is used to lay out the e q u i p m ent for the p roced u re (FIG 1 ) .

I NC I S I O N •

•

•

•

Introducer need le

Guidewire

Pretracheal dilator

Tapered dilator with gu idance catheter

Tracheostomy with loading dilator

FIG 1 • To aid with the procedu re, the equi pment is positioned on a sh eet on the patient to m i n i m ize turning away from the operative field.

Thyroid carti lage

Chin

Lidoca i n e with e p i n e p h r i n e is i nfi ltrated a l o n g l ower m i d l i n e cervical reg ion from the externa l ly p a l pated cri­ coid carti l a g e to the ste r n a l n otc h . A 1 2- to 1 5- m m length incision is made with a no. 1 5 blade sca l p e l thro u g h the dermis a l o n g the m i d l i n e . The cepha­ lad portion of the i n cision should sta rt at or j ust below the l evel of the cricoid cartilage (FIG 2) . Lidoca i n e with e p i n e p h r i n e is often used to i nfi ltrate sma l l poi nts of bleed i n g at the lower portion of the dermis and then p ress u re h e l d for 10 to 20 seco nds to ach ieve relative hem ostasis before p roceed i n g . C u rved hem ostats a re then used to perform b l u nt d i ssec­ tion a l o n g the l e n gth of the i ncision between the stra p m uscles in order to better p a l pate the trachea to dete r­ m i n e the point of entry.

FIG 2 • A 1 2- to 1 5- m m i n cision is m a d e a l ong the lower m i d l i n e portion of the neck. The incision is m a d e through the epiderm is, derm is, a n d p l atys m a .

C h a p t e r 3 TRACH E O STOMY: E ndoscop i c

•

CAN N U LATI O N OF THE TRACH EA •

If the bronchoscope is used, it is inserted down the endo­ tracheal tube at this point to the end of the endotracheal tube but sti l l i n s i d e the endotrach e a l tube so as to proteet the e n d osco pe from tra u m a (FIG 3A) . • The c u rved h e m ostat or the i ntrod ucer need l e is then used to p a l pate the trachea between cart i l a g e r ing s 2 a n d 3 (FIG 38) . • The endotracheal tube a n d bronch oscope a re with­ d rawn s l owly until they a re positioned j u st above the point of p a l pation, then the i ntrod ucer needle e nters the trachea u n d e r visu a l i zation of the bron­ ch oscope (FIG 3C) . • The g u i dewire is then passed t h ro u g h the i ntro­ d ucer need l e u n d e r visu a l i zation of the broncho­ sco pe (FIG 3D,E) .

•

If the patient has l i m ited " reserve"/re q u i red h i g h venti lator setti ngs p r i o r t o t h e proced u re, t h e bron­ ch oscope can be removed prior to the d i lation por­ tion of the p roced u re. If bronch oscope is not used fo r the procedu re, the e n d otrach e a l tube is l eft i n position, a n d the i ntroducer need l e is p l aced o n the i nterspace between ca rti l a g e ri ngs 2 a n d 3 . • The need l e is adva n ced i nto the trachea, a s p i rati n g w i t h a syri nge as the trachea is entered . M ost com­ m o n ly, air or a i rway secretion fluid is a s p i rated as the trachea is entered with the i ntrod ucer need le. The endotracheal tube is l eft down at this step to decrease the c h a n ce for a poste rior trachea l wa l l i n j u ry with t h e need le. • The g u i dewi re is adva nced through the i ntroducer need l e .

Int roducer need le

Tracheal rings

Chin

Carina

A

C

D

FIG 3 • A. I m a g e from the bronch oscope viewi ng the entire trachea. B. The needle is then used to a p p ly pressure on the anterior wa l l of the trachea. C. Need l e entry i nto the trachea under endoscopic vision. D. G u i dewi re i nsertion t h roug h the i ntroducer need l e from the exte r n a l view. (contin ued)

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P a r t 1 OPERATIVE TECH NIQUES I N THORACIC AND ESOPHAGEAL SURGERY

Introducer need le

FIG 3 • (continued) E. Guidewire insertion through the intro­ ducer need le from the endoscopic view.

E

D I LATION •

•

The short, p retracheal d i lator is then adva n ced over the g u i dewi re, ente r i n g the trachea at 90 deg rees to the tra­ chea. As the d i lator is ente r i n g i nto the trachea, a s l i g ht twist is a p p l ied to the d i lator to a i d with entry i nto the trachea (FIG 4A,B). N ext, the tapered d i l ator a n d the g u i d i n g catheter a re adva n ced as a u n it over the g u idewire. Once a g a i n , the catheters s h o u l d enter the trachea at 90-deg ree angle to

Pretracheal dilator

•

the trachea . The tapered d i l ator is advanced to d i late the trachea until the skin level mark o n the d i l ator is at the skin incision. If the bronch oscope is not used, the e n d o­ trachea l tu be is withd rawn at this point by seve ra l cen­ t i m eters as the respi ratory thera p i st, who is h o l d i n g the endotrachea l tu be, beg i n s to feel the ta pered d i lator p u l l a n d h i t t h e endotrachea l t u be (FIG 4C,D) . T h e ta pered d i l ator is rem oved from the g u i d i n g catheter and the g u i dewi re, leaving the two of these i n place.

Gu idewire

Pretracheal dilator

B FIG 4 • A. Pretrachea l d i lator being passed over g u i dewi re to perform pretracheal d i lation . B. E n d oscopic view of pretracheal d i l ator. (continued)

C h a p t e r 3 TRACH E O STOMY: E ndoscop i c

Tapered di lator

Thyroid cartilage Sternal notch

FIG 4

•

Guidewire

(contin ued) C,D. Ta pered d i l ator being passed over g u i d ewire a n d g u i da nce catheter.

I N SERTION OF TRACHEOSTOMY TUBE

•

Guiding catheter

D

c

•

Tapered di lator

F i n a l ly, the loading d i l ator a n d the tracheostomy are loaded onto the g u idewire a n d g u ida nce catheter with caution to m a ke sure the g u ida nce catheter emerges from the d i sta l end of the tracheostomy and loading d i l ator. O n ce the load i n g d i l ator is at the safety ridge of the g u i da nce catheter, the g u ida nce catheter, load i n g d i la­ tor, a n d tracheosto my tube a re advanced as a u n it i nto the trachea (FIG SA, B) .

Guidewire

Guidance catheter

Load ing catheter

Tracheostomy

•

T h e g u i d ew i re, g u i d a n c e catheter, a n d l o a d i n g d i l a t o r a re rem oved a s a u n it . T h e cuff of t h e trach eosto m y t u b e i s i nf l a t e d . T h e i n n e r ca n n u l a i s t h e n i n s e rted i nto the trach eosto m y. E n d-ti d a l c a r b o n d i o x i d e ( C 0 2 ) d etect i o n s h o u l d be assessed a s t h e p a t i e n t i s p l aced b a c k o n t h e vent i l ator o r t h e b r o n c h osco p e s h o u l d be q u i c k l y p a s s e d t h ro u g h t h e t r a c h e os­ tomy t u b e to c onfi r m a p p ro p r i ate positi o n i n g of t h e t r a c h e osto m y t u b e .

Tracheostomy

Loading dilator

Guidewire

Gu idance catheter

B A FIG S • A. Trach eosto my tube being advanced i nto trachea over the g u idewi re, g u i da nce catheter, a n d load i n g d i l ator. B. Co m p letion of i ntroduction of tracheosto my tube i nto trachea.

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P a r t 1 OPERATIVE TECH NIQUES I N THORACIC AND ESOPHAGEAL SURGERY

COMPLETION OF THE PROCE DURE •

• •

A 4 x 4 gauze s h o u l d be cut to rest between the skin a n d trach eosto my tube for 24 h o u rs, after which it is removed. The trach eostomy t u be s h o u l d be sewn to the neck with 2-0 Prolene sutu res that re m a i n i n place for 7 to 1 0 days. A Ve lcro rei nforcement co l l a r a lso provides s u p po rt to prevent accidenta l d islodgement prior to tract formati o n .

•

•

A ch est rad iograph is ro utinely obta i n e d postproce d u re to eva l u ate for a p propriate positio n i n g of the trache­ osto my tu be, rule out p n e u m otho rax, and eva l u ate for bronch i a l obstruct i o n . The stylet of the tracheosto my tube s h o u l d be t a p e d t o the wa l l a bove the patie nt's b e d to be u s e d f o r tracheos­ tomy rei nsertion s h o u l d accidenta l d islodgement occu rs.

PEARLS AND PITFALLS I n d ications

•

I n the obese patie nt, if a computed to m o g ra p h y (CT) sca n is ava i l a b l e, this can be used to measure the d ista nce between the s k i n a n d trachea if an XLT trach eosto my tube is being considered .

Incision

•

If a n anterior j u g u l a r ve i n is encou ntered i n the i ncision (eve n if n o i n j u ry is suspected), consider l i gation p roxi m a l l y a n d d i sta l ly as this is easi est to perform before the trach eosto my tube has been placed.

Ca n n u lation

•

The i ntrod u c i n g needle should be sta b i l ized with the 1 st a n d 2 n d d i g its of the l eft h a n d while the 3 rd-5th d i g its rest on the trachea to sta b i l ize it; this h e l ps p revent the needle from s l i d i n g off the l atera l wa l l of the trachea. The g u idew i re s h o u l d pass easily t h ro u g h the i ntrod ucer needle i nto the trachea.

D i lation

•

A l l catheters (p retracheal d i l ator, tapered d i l ator, a n d i ntrod u c i n g cath eter) should enter perpen d i c u l a r to the trachea as to prevent p retrachea l d i ssection or fa lse passag e .

I nsertion of trach eostomy tube

•

Confi rmation with bronchoscope s h o u l d be performed if the bronchoscope is used o r confi rmation of end-t i d a l C02 if the bronchoscope is not used .

•

POSTOPERATIVE CARE •

• •

The coagulopathic patient should be evaluated for bleeding, with platelets and/or blood products given if bleeding is present in the first 6 hours. A 4 X 4 gauze placed between the tracheostomy and skin should be removed 24 hours after placement. The initial tracheostomy tube should be exchanged between days 7 and 12 to help minimize secretions and decrease the ingrowth of granulation tissue.

COMPLICATIONS • • • •

Rate of skin infection at surgical site: 2 % to 3 % Bleeding Tracheoinnominate fistula Tracheostomy dislodgement

REFERENCES 1.

Freeman BD , Isabella K, Lin N, et al. A meta-analysis of prospective trials com paring percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000;1 1 8 : 1 4 1 2-1 4 1 8 . 2 . Freeman BD , Isabella K , Cobb JP, e t a l . A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 200 1 ;29: 926-930.

3 . Pena J , Cicero R , Marin J , et al. Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present. Otolaryngol Head Neck Surg. 200 1 ;1 2 5: 3 9 7-400 . 4 . Arabi Y , Haddad S , Shirawa N, et al. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care. 2004 ;8 : R34 7-R352. 5. Brook AD , Sherman G, Malen ], et al. Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Am J Crit Care. 2000;9 ;3 52-3 59. 6. Rumba k MJ, Newton M, Truncale T, et al. A prospective, randomized study com paring early percutaneous dilational tracheotomy to pro­ longed translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;3 2 : 1 6 8 9-1 694. 7. Teoh WH , Goh KY, Chan C . The role of early tracheostomy in criti­ cally ill neurosurgical patients. Ann Acad Med Singapore. 200 1 ;3 0 : 234-2 3 8 . 8 . Byhahn C , Lischke V , Meininger D , et a l . Peri-o perative com plications during percutaneous tracheostomy in obese patients. Anaesthesia. 2005;60 : 1 2-1 5. 9. Kluge S, Meyer A, Kuhnelt P, et al. Percutaneous tracheostomy is safe in patients with severe thrombocytopenia. Chest. 2004;126: 547-551 . 1 0 . Mayberry JC, Wu IC, Goldman RK, et al. Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients. Crit Care Med. 2000;28:3436-3440. 1 1 . Meyer M , Critchlow J , Mansharamani N, et al. Repeat bedside per­ cutaneous dilational tracheostomy is a safe procedure. Crit Care Med. 2002 ;3 0 : 9 8 6-9 8 8 .

-

I

Chapter

4

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

Tracheal Resection and Reconstruction 1-----------------------------------------------------

Alexander

DEFINITION •

Tracheal resection is usually performed for the external ex­ cision of tracheal stenosis or hypertrophic scarring of the trachea with critical obstruction of the airway. The term cri­ cotracheal resection is used when the anterior section of the cricoid cartilage requires removal due to extension of the scar near the vocal folds. Tracheal resection is performed following failure of other surgical therapy, primarily endo­ scopic excision and dilation of tracheal stenosis. A success­ ful tracheal resection allows the patient to avoid a lifelong tracheostomy tube.

T.

Hillel

•

•

•

•

Tracheal stenosis is primarily due to postintubation injury, although autoimmune disease can also cause subglottic ste­ nosis. Acquired stenosis is usually secondary to pathogenic wound healing, with the formation of permanent scar tissue in the airway. Tracheal neoplasms, including adenoid cystic and squamous cell carcinoma, or thyroid tumors with tracheal invasion are less frequent etiologies for segmental tracheal or cricotra­ cheal resection. 1

•

•

•

PATIENT IDSTORY AND PHYSICAL FINDINGS •

•

•

•

A thorough history should be performed, including past medical history, past surgical history-including previous intubations or surgery on the trachea or esophagus, medica­ tions, allergies, and a family history of autoimmune disease. Patients with an idiopathic etiology, who have not undergone intubation, or those with a history/family history of autoim­ mune disease should have an autoimmune serum panel. A detailed medical history for comorbidities that could affect recovery following resection includes diabetes, coronary artery disease, and lung disease including chronic obstructive pulmonary disease (COPD) and tracheobronchial malacia. Severe COPD and tracheobronchial malacia may necessitate the need for tracheostomy even following successful resection. Patients who had multiple previous procedures, especially open tracheostomies or cervical tracheoesophageal fistula repair, may have extratracheal fibrosis, making dissection more challenging and increasing the risk of injury to the recurrent laryngeal nerve (RLN ) .

William Grist

Thorough evaluation of vocal fold mobility is recommended to document preoperative function. Patients often have mul­ tiple levels of stenosis, and glottic narrowing due to a second stenosis at level of vocal folds (relative contraindication) may limit the efficacy of successful tracheal resection. Accurate understanding of the length of stenosis will impact the necessity of surgical release maneuvers. These are rarely required for stenosis less than 5 em. Contraindications for tracheal resection are listed in Table 1 .

IMAGING AND OTHER DIAGNOSTIC STIJDIES

DIFFERENTIAL DIAGNOSIS •

�

•

Bronchoscopy is required to accurately map out the stenosis, including its length, width, and distance from the vocal folds and carina when appropriate. Bronchoscopy is usually per­ formed in the operating room or endoscopy suite ( FIG 1 ) ; however, with appropriate topical anesthesia, in-office bron­ choscopy can provide similar results and avoid a trip to the operating room. As detailed in the preceding section, laryngoscopy or strobes­ copy, when indicated, should be performed to assess preopera­ tive vocal fold mobility and the presence of laryngeal stenosis. Computed tomography ( CT) can provide key anatomic detail of the trachea, especially of the external trachea and adjacent vasculature. Three-dimensional CT provides excellent recon­ structions of the tracheal and bronchial airways ( FIG 2 ) . I f the patient complains o f dysphagia, a modified barium swallow study may yield relevant results especially if the patient requires infra- or suprahyoid laryngeal release maneu­ vers, which will adversely affect swallowing postoperatively.

SURGICAL MANAGEMENT Preoperative Planning •

When relevant, preoperative discussion between surgical teams about the extent of the stenosis is recommended. If the otolaryngologist represents the primary surgeon and repair of the stenosis may require a sternotomy, thoracic surgery should be consulted.

Table 1 : Absolute and Relative Contraindications for Tracheal Resection 1. Active autoimmune d iseases affecti ng the a i rway (Wegener's g ra n u l o matosis, relapsing polychond ritis) 2. Stenosis extending to include the vocal folds 3. Stenosis greater than half the length of the trachea (relative contraindication) 4. Concurrent laryngeal stenosis (relative contraind ication)-tracheostomy wil l need to rem a i n i n place until laryngeal stenosis is add ressed.

FIG 1 • B ro n chosco p i c view of tracheal ste nosis taken at the level of the voca l fo lds.

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P a r t 1 OPERATIVE TECH N IQUES I N THORACIC AND ESOPHAGEAL SURGERY

•

•

•

Similarly, if it is a primary thoracic team performing surgery and the stenosis requires a suprahyoid release maneuver, pre­ operative inclusion of otolaryngology team is recommended. Use of an NIM™ RLN monitoring endotracheal tube (ETT) is recommended to allow for monitoring of the RLN during dissection. Having a second anesthesia circuit in a sterile sleeve allows for easy control of the airway when the anode tube is placed in the distal trachea following the tracheal cuts.

Positioning • •

•

FIG 2 • Th ree-d i mension a l sag itta l CT i m a g e of cervica l trachea l ste nosis with d i l ated seg ment proxi m a l to ste nosis.

•

BRONCHOSCOPY •

•

If there is exist i n g trach eostomy skin scar, the i ncision should i n c l u d e the sca r a ro u n d the tracheosto my site i n a n e l l i pse fas h i o n .

•

The a uthors a re proponents of the M ayfi e l d thyro id retractor to provide adequate expos u re.

•

This provides exposu re of the trachea, which s h o u l d be skeletonized with b l u nt d i ssection to free up the a nteri o r l i g a m e ntous attac h m ents to j u st above the ca r i n a . T h i s assists i n f o r te nsion-free a n asto m osis. Late ral d i ssection should be l i m ited to m a i nta i n the vascu l a r s u p p ly.

An i n cision is extended deep to the p l atysma, a n d i nfe­ rior and superior s u b p l atysm a l flaps s h o u l d be e l evated from the ste r n a l notch to the hyoid superio rly.

EXPOSURE OF TRACH EA •

A k e y determ ination o n bron ch oscopy is the proxim ity o f the stenosis to the voca l f o l d s . If the p roxi m a l portion is wit h i n 2 em of the superior aspect of the voca l fo lds, the cricoid will usua l ly need to be i n c l uded i n the excision, which will i nf l u ence the l ocation of the i n it i a l tracheal incision.

A low tra n sverse neck incision s h o u l d be p l aced in a neck crease below the crico i d carti l a g e exte n d i n g from the a nte rior border of the sternocleidom asto id m uscles on each side of the neck.

SKIN I NC I S I O N AND RAI S I N G OF FLAPS •

•

I n it i a l bronch oscopy is reco m mended to assess the ste no­ sis; d i l ate a n d p l ace a n ETI prior to resect io n . We encour­ age perioperative p l a cement of an ETI in patie nts with trach eosto m i es to rem ove the trach eosto my tube from the surgical f i e l d .

PLACEM E NT OF I N C I S I O N •

An inflatable shoulder roll should be inflated to provide complete neck extension and deflated prior to closure. Initial bronchoscopy may be performed with the bed rotated 90 degrees from the anesthesia team to allow the surgical team to dilate the stenosis in order to place an ETT. Following intubation, the bed should be rotated another 90 degrees to have the head 1 8 0 degrees from anesthesia. This allows for adequate room around the head and neck. If tracheostomy tube cannot be replaced with placement of an ETT following dilation, replace the tracheostomy tube with an anode tube to remove the flange from the operative field.

The sternohyoid a n d the ste rnothyro id m uscles s h o u l d be d i ssected a n d retracted latera l ly to expose the thy­ roid isth m us, which s h o u l d be tra nsected and reflected l atera l ly.

C h a p t e r 4 TRACH EAL RESECTION AND RECONSTRUCTION

SEPARATION OF COMMON PARTY WALL •

•

Fol lowi ng ske l eto n i z i n g the a nteri o r trachea, the trachea s h o u l d be d i ssected c i rcu mferentia l ly at the level of the ste nosis. During exposure of tracheoeso p h a g e a l g roove, ca re s h o u l d be taken with the d i ssection g iven p roxi mity of RLNs. G iven the g reater asce n d i n g l e n gth of the l eft RLN, it tends to run i n a more cra n i a l-ca u d a l cou rse, whereas the right may be m o re o b l i q u e in a l atera l to m e d i a l d i rect i o n . Dissection may be used with a (Cri l e) c l a m p to sepa­ rate the co m m o n pa rty wa l l , sepa rati ng the poste rior

I

•

•

m e m b ra n o u s tracheal wa l l from the anterior wa l l of the eso p h a g u s (FIG 3A). This should be done at the level of stenosis, however, not superior to the 1 st trachea l r i n g to p revent i n j u ry to the RLNs. P a l pate the t i p of the clamp on the contra latera l side to gently d i ssect through the tissue plane. Tissue b u n c h i n g u p between c l a m p t i p a n d f i n g e r suggest i n g the d i ssec­ tion is i n wrong p l a n e with the tissue is l i kely represent­ ing folded m e m b ra n o u s tracheal wa l l o r the esophagus. After the wa l l is sepa rated, p l a cement of a 1 -i n c h t h i c k Pen rose d ra i n m a i ntains control (FIG 38) .

Surgeon's fingert i p palpating clamp Clamp tips

Esophagus Clamp

cartilage Tracheal ring 1

A B FIG 3 • A. B l u nt c l a m p d i ssection sepa rati ng poste rior tracheal wa l l from eso p h a g u s . B. M ayfi eld retractor provi d i n g cra n i a l­ ca u d a l exposure of trachea after 1 -i n Pen rose p l aced betwee n trachea a n d eso p h a g u s .

TRACH EAL I NC I S I O N •

•

Prior to the trachea l i n cision, two rete ntion sutu res s h o u l d be p l aced with 2-0 Vicryl sutu res (on a CT- 1 need l e) a r o u n d one or two trachea l r in g s b e l ow the p l a n n ed i nfe rior i n cision l i n e . These a re p l aced at 1 0 o'clock and 2 o'clock positions. This provides a s u b­ sta nti a l h o l d on the trachea s h o u l d the trachea retract following the i n c i s i o n . The superior i n cision s h o u l d be made fi rst. If the s u b­ g l ottic ste nosis is h i g h, in p roxi m ity to the cricoid, the i n it i a l i ncision should be made at the inferior aspect of the cricothyroid m e m brane. A c u rved M ayo scissors is used to cut throug h a nterol atera l cricoid, a n g l i n g the cut l atera l ly i n a su peroinferior d i rection (FIG 4A) . U s u a l ly, o n ly 1 20 to 1 80 deg rees of the a nte rior crico i d req u i re excision; h owever, u p to 240 deg rees may be excised 2 (FIG 48) . If poste rior crico i d rem a i n s thickened with concern for a i rway obstruction fo l l owi n g a n asto mosis, it may be excised o r a b lated .

•

•

•

•

•

For cervica l tracheal ste nosis, enter at top portion of the stenosis as est i m ated by bronch osco py. I n it i a l ly, favor the incision toward the ste nosis so hea lthy trachea is not excised. If the ETT is i nterfe r i n g with the superior i n cision, it may be retracted by the a n esthesia team a n d s u rg e ry may cont i n u e under i nterm ittent apneic conditions. Tyi n g a 2-0 s i l k suture thro u g h the M u rp hy's eye of the ETT w i l l a l l ow f o r easy advancement l ater i n t h e proced u re . N ext, the posterior incision is made t h ro u g h the m e m ­ branous trachea. This may be i n f e r i o r to the a nterior inci­ sion, resulting i n a beve led cut. The i nfe rior i n cision is made one r i n g below the inferior aspect of ste nosis, again beve led i nferiorly i n a n a nte­ rior-posterior d i rection to m atch the superior cut. At this poi nt, a ste r i l e a n ode t u be on a seco n d a n esthesia c i rc u it is p l aced i nto the open aspect of the trachea to vent i l ate the patient (FIG 4C) . C l ose com m u n ication with the a n esthesia tea m is paramount d u r i n g p l acement and su bseq uent rem ova l of the a n ode tube.

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P a r t 1 OPERATIVE TECH N IQUES IN THORACIC AND ESOPHAGEAL SURGERY

Scissor blade Cricoid carti lage

Cricothyroid membrane Cricoid cart i lage

A

Recu rrent laryngeal nerves

B

FIG 4 • A. Cricoid cuts taken d u ri n g cri cotracheal resect i o n . B. Axi a l i m a g e o f cricoid depicti n g maxi m a l cricoid c u t a n d relati onsh i p t o RLN a n d eso p h a g us. C. An a n o d e t u be is p l aced i nto the d ista l trachea fo l lowing t h e cricoid c u t sepa rati ng the s u p e r i o r trachea .

c

ANASTOMOSIS • •

•

•

D u r i n g the a n asto mosis, the a n ode tube is i nterm ittently rem oved to p l ace the sutu res a n d re p l a ced to venti late. The poste rior m e m b ra n o u s wa l l s h o u l d be l i ned up fi rst with a 2-0 polydioxa n o n e (PDS) suture p l aced at the corner b i l atera l ly, leaving the suture knot exte r n a l to the trachea (FIG SA,B) . If a centra l trachea l resection is performed, the suture spans from the corner of the memb ra n o u s trachea i nferiorly to the poste rior aspect of the crico id superiorly. Prior to tyi n g the corner sutu res, a run­ ning 2-0 PDS is used to close the m e m branous trachea . After the corner sutu res a re tied, the r u n n i n g suture is sutu red to one side, p u l led tig ht, a n d sutu red to the con­ tra l atera l corner suture (FIG SC) . Closure conti n u es in a l atera l to a nteri o r d i rection from each corner using 3-0 Vicryl i nterrupted sutu res with the suture knots kept o utside the l u m e n (FIG SD,E). Prior to p l a c i n g the a nterior sutu res, the anode is u lti mately rem oved a n d the ETI is adva n ced past the a n asto mosis. The cuff should be adva n ced beyo nd the

• •

•

•

a n astomosis to p revent anterior sutu res from i n c l u d i n g the cuff. If there is some concern for tension, the s h o u l d e r ro l l m a y b e deflated a n d t h e head fl exed t o red u ce tensi o n . S u p e r i o r rete ntion sutu res a re p l aced through the thy­ roid carti l a g e su periorly at 1 0 o'cl ock and 2 o'clock positions and tied to the i nferior stay sutu res to release te nsion from the a n asto m osis (FIG 5F,G). 3 F i n g e r d i ssection a l o n g a nte rior trachea is usua l ly ade­ q u ate for tension release i n m ost cases ( < 5 em). If extra l e n gth is needed, s u p ra hyo id l a ryngea l release provides 1 to 2 em in l e n gth with l ess risk of i n j u ry to the i nte r­ n a l branch of the superior l a ryngeal n e rve t h a n i nfra hy­ oid release. • H i l a r release is not usua l ly perfo rmed for lengthy b e n i g n ste nosis; i n stead, the su bsta nti a l ly l ess 2 morbid Trachea l T-Tu be reconstruction is reco m m e n d e d . After thoro u g h ly i rrigating the surgical bed, the a n as­ tomosis may be tested by fi l l i n g the bed with sa l i ne, defl ating the cuff, and having a n esthesia provide posi­ tive press u re venti lation. If b u bbles a re a p p reci ated, the l e a k should be l oca l ized a n d closed .

C h a p t e r 4 TRACH EAL RESECTION AND RECONSTRUCTION

A

B

Corner sutures

Running suture

D Tied retention sutures

c

F

E

G

Anastomotic suture line

Cricoid cartilage

Thyroid cartilage

cricoid carti lage

FIG S • A. The a n asto mosis beg i n s with sutu res passed at each poste rol atera l corner of the m e m b ra n o u s trachea i nferiorly a n d the poste rior crico i d u s i n g 2 - 0 dyed P D S suture. Pa n e l (B) is a n i l l ustration o f this step . C. Closure o f m e m b ra n o u s trachea l wa l l i n itia l ly with two posterolatera l corner sutu res a n d then a r u n n i n g suture a l ong t h e m e m b ra n o u s wa l l . After a l l t h ree a re p l aced, the two corner sutu res a re tied, and then each e n d of the r u n n i n g suture is tied to the respective corner suture. All suture knots a re kept outside the l u m e n . D. After the l atera l trachea is a p p roxi m ated with interrupted Vicryl sutu res, the ETI is adva n ced (ETI no p i ct u red) a n d the anterior wa l l is cl osed . Panel (E) is a n i l l ustration of this ste p . F. Rete ntion sutu res a re tied to re l i eve te nsion off the a n asto motic suture l i n e in a trachea l resect io n . G. The a n asto mosis in a cricotracheal resection, sutu red to the thyro id anteriorly, showing the latera l presence of the cricoid, which is i n c l uded i n the a n asto mosis latera l ly (and poste riorly-not p ictu red).

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26

P a r t 1 OPERATIVE TECH N IQUES I N THORACIC AND ESOPHAGEAL SURGERY

•

CLOSURE •

After hem ostasis is verified, a Pen rose d ra i n may be p l aced deep to the stra p m uscles. We favor a Pen rose d ra i n because a negative p ress u re b u l b d ra i n may propa­ g ate a sma l l tracheal d e h i scence. The 3-0 Vicryl sutu res a re used to c l ose the ste rnohyoid and ste rnothyro id m us­ cles and to rea p p roxim ate the p l atysm a l ayer. F i n a l ly, the epidermis is cl osed with a nylon suture.

2 G r i l l o proposed a " g u a rd i a n " suture (Gri l l o stitch) passed through the skin of the submentum to the presternal skin as a rem i nder to the patient to prevent excessive neck exten­ sion and l i m it postope rative tension on the a nastomosis. The p l acement of carti l a g i nous retention sutu res creates a h i g h e r force req u i rement for tracheal a nastomotic rupture beyond native trachea l rupture. This provides support for not placing a g u a rd i a n sutu re, a l lowi ng patients to avoid the associ ated postoperative discomfort. 3• 5

PEARLS AND PITFALLS I n d ications

•

• •

A thoro u g h h i story s h o u l d be performed, i n c l u d i n g past medical, surgical, a n d fa m i ly h i sto ry a l o n g with preoperative bronch oscopy a n d i m a g i n g t o assess if t h e patient is a n a p p ropriate surgica l ca n d i date. Postintubation ste nosis represents the p r i m a ry i n d ication a l ong with tracheal neoplasms a n d , rarely, tracheoeso p h a g e a l fistu l a . Avo id operat i n g on patie nts with active a uto i m m u n e d isease.

I ncision

•

Exposu re

•

S u b p l atysmal flaps a re e l evated from the sternal notch i nfe riorly a n d su periorly to the thyroid ca rti lage for tracheal resection a n d hyoid ca rti lage for cricotrachea l resection.

•

The posterior wa l l of the trachea should be sepa rated from the esophagus with a clamp. I nferior rete ntion sutu res p revent tracheal retract i o n . I n c l u d i n g a m a r g i n of one trachea l ring, when poss i b l e, is ideal t o prevent reste nosis.

•

Excision

• •

Closure

• • •

Postoperative ca re

•

A low tra nsverse neck i ncision is usua l ly p l aced i n a neck crease j u st below the cricoid carti l age. Exist i n g trach eotomy scars s h o u l d be excised .

Absorba b l e sutu res red uce the risk of a n asto motic restenosis. Tyi n g the superior a n d i nferior retention sutu res rel axes tension on the a n a stomosis. A Pen rose d ra i n may be p l aced and a n o pt i o n a l G r i l l o stitch may be used to re m i n d the patient n o t to exte n d t h e i r neck. Extubation fo l l owi n g the proce d u re is h i g h l y reco m m e n d e d .

POSTOPERATIVE CARE •

We are proponents of immediate extubation following tra­ cheal resection. Close observation with the patient placed on proton pump inhibitors, antibiotics, and pain control is recommended. If there is no concern for esophageal inj ury, an initial soft diet may be advanced as tolerated. The patient should be instructed to limit neck extension.

OUTCOMES •

Long-term outcomes from tracheal resection are excellent with 9 5 % of patients, maintaining a patent airway and mor­ tality between 1 % and 2 % . 1 •6 Anastomotic complications occur less than 1 0 % of the time, with significant risk factors including reoperation, diabetes, lengthy resections ( > 4 em), and laryngotracheal resection. 1

COMPLICATIONS • •

Anastomotic dehiscence Anastomotic granulation tissue and restenosis

• • • • •

Infection (wound or pulmonary) Vocal fold paralysis Loss of high-pitched phonation (with sacrifice of cricothy­ roid muscles) Dysphagia ( increased with superior release maneuvers) Hemorrhage

REFERENCES 1.

2. 3.

4. 5.

6.

Wright CD , Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg. 2004;128 :73 1-73 9 . Grillo HC. Primary reconstruction o f airway after resection o f subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg. 1 9 8 2 ;33 :3-1 8 . Schilt PN, Musunuru S , Kokoska M , e t al. The effect o f cartilaginous reinforcing sutures on initial tracheal anastomotic strength: a cadaver study. Otolaryngol Head Neck Surg. 2 0 1 2 ;147:722-725. Declo HH. Surgery of the Larynx and Trachea. Philadelphia, PA: BC Decker; 1 9 9 0 . Behrend M, Kluge E, Schuttler W, e t a l . Breaking strength of native and sutured trachea. An experimental study on shee p trachea. Eur Surg Res. 200 1 ;3 3 : 2 55-263 . Herrington HC, Weber SM, Andersen PE. Modern management of laryngotracheal stenosis. Laryngoscope. 2006;1 1 6 : 1 553-1 557.

I

-

Chapter

5

Lobectomy: Open

- --------------------------------------- 1----------------------------------------------------- ....

Awad EI-Ashry

DEFINITION •

Anatomic resection of one or more of the pulmonary lobes with ligation and resection of their respective bronchus, arterial supply, and venous drainage ( FIG 1 ) .

•

PATIENT HISTORY AND PHYSICAL FINDINGS • • •

Indications •

Robert J. Cerfolio

•

Appropriately staged and selected patients with non-small cell lung cancer (NSCLC) . For the purposes of this chap­ ter, we will focus on oncologic resection of pulmonary lobe together with lymph node (LN) dissection ( FIG 2 ) . Destroyed lobe from chronic infections such a s aspergillosis or tuberculosis (TB )

• • • •

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

F I G 1 • Provides a n overview of the surgical a n atomy a n d rel ated LN stations.

Growing nodules in a smoker Chronic cough and/or hemoptysis Dyspnea Age older than 5 0 years History of smoking Family or personal history of cancer Lymphadenopathy Horner's syndrome

Chest x-ray: Plain films may show a pulmonary nodule and are also useful to evaluate for chronic lung conditions such as chronic obstructive pulmonary disease (COPD) . Historically, the pattern of calcification of the nodule has been used to dif­ ferentiate between benign and malignant lesions. However, this is not sensitive, as up to 20% of malignant nodules had benign appearance. Serial x-rays may be required to follow the lesion. Contrast-enhanced computed tomography ( CT) scan: A sol­ itary pulmonary nodule is most likely benign; however, high index of suspicion should prompt further investigation to rule out the possibility of malignancy. Typically, malig­ nant nodules enhance more than 20 Hounsfield units (HU), whereas benign nodules are usually less than 15. CT is useful to identify the location (central vs. peripheral), size, charac­ teristics, single versus multiple, presence or absence of direct

• •

Superior Mediastinal Nodes 2 Upper Paratracheal 4 Lower Paratrac heal Aortic Nodes

• • • • • •

5 S u baortic (A-P w i n d ow)

6

Para-aortic

Inferior Mediastinal Nodes 7 S u bcari nal

8

Paraesophageal

9 P u l m o nary Ligament N 1 Nodes 1 0 H i lar 1 1 I nterlobar 1 2 Lobar 1 3 Seg m e ntal 1 4 S u bsegmental

FIG 2

•

Lym p h node c l assification for l u n g cancer sta g i n g .

27

28

•

• • • •

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OPERATIVE TECH N IQUES I N THORACIC AND ESOPHAGEAL SURGERY

extension to mediastinal structures and/or chest wall, and presence or absence of suspicious LNs and their location. Positron emission tomography (PET) scan: The PET scan is less sensitive, however, more specific than CT in identify­ ing malignant lesions. A lesion with standard uptake value ( SUV) of 4.6 is associated with 9 6 % likelihood of malig­ nancy. An uptake of 0 to 2.5 is associated with 25 % likeli­ hood of malignancy. For staging purposes, PET scan helps identify the presence or absence of PET avid lymphatic and/ or systemic metastasis. Mediastinoscopy for LN biopsy and staging Endobronchial ultrasound (EBUS ) for LN status and biopsy of suspicious LNs Navigational bronchoscopy Pulmonary function test: with focus on forced expiratory volume (FEV 1 ) and diffusing capacity of the lung for carbon monoxide (DLco ) . These measures help predict the postre­ section pulmonary function. Video-assisted thoracoscopic surgery (VATS) biopsy if the diagnosis is still in doubt Brain and/or spine CT or magnetic resonance imaging (MRI) should be considered to identify possible metastasis, especially if the patient has neurologic symptoms. It was found that up to 1 8 % of NSCLC has brain metastasis at presentation, with 1 0 % asymptomatic.

SURGICAL MANAGEMENT-PULMONARY LOBECTOMY

• •

• • •

• • • •

•

•

•

Positioning and Preoperative Planning • • • • • • •

Legs are positioned with the bottom leg bent and pillow in between to stabilize patient's lateral position. Break table (kidney bend/flex) and use additional reverse Trendlenburg to position the patient's lateral chest wall almost parallel to the floor and the legs are angled toward the floor. Pad pressure points and bony prominences; appropriately secure body position. A body warmer to prevent patient hypothermia can be applied. Curvilinear posterolateral incision at the 5th intercostal space is made starting midway between the medial edge of scapula and spine ending at the anterior axillary line, passing at a point two fingerbreadths below the scapular tip. We spare the rib as well as the serratus anterior muscle dur­ ing dissection. Inject local anesthetic directly into the 5th and 6th intercos­ tals nerve roots. Apply rib spreader retractor with gradual retraction. First inspect the pleural space and explore to ensure there are no metastatic lesions on the diaphragm or the parietal or visceral pleura. The hilum is identified after the lung is retracted posteriorly and inferiorly. The dissection is carried down between the hilar structures and the phrenic nerve. Sweep phrenic nerve gently down to remove the station l OR LN, avoiding the small phrenic vein that goes to the large station lOR LN that is routinely found in this area. Divide the inferior pulmonary ligament up to the level of the inferior pulmonary vein (IPV). Resect the LNs encountered in this area (stations 8 and 9) and clean the esophagus and vagus nerve of hilar tissue ( FIG 3 ) .

Position the patient supine. Intubate with a double lumen endotracheal tube. Perform complete bronchoscopy and confirm position of the double lumen tube for single-lung ventilation. Place a Foley catheter. After intubation, place the patient in full lateral decubitus position, the operated side exposed. Arms in swimmer's position to display the axilla Shoulder higher than hip

NOTE: It is important to place the patients flank exactly over the breaking point (flex or kidney break) of the table. We use the break table/flex function to maximize rib separation.

F I G 3 • T h e inferior p u l m o n a ry l i g a ment exposed b y retract i n g the l u n g superiorly.

R I G HT UPPER LOBECTOMY •

• •

Deve l o p the bifu rcati o n between m i d d l e a n d u p p e r lobe ve i n s by b l u ntly d i ssect i n g it off of the u n derlying p u l mo­ n a ry a rtery (PA) (FIG 4). Cont i n u e en bloc d i ssection of the h i l a r tissue to clearly expose the main PA. E n c i rcle the superior p u l m o n a ry ve i n with a vessel loop a n d retract it off the PA b e h i n d it. U s i n g the vessel loop as a g u ide, the l i n ear sta p l i n g device is passed a cross the rig ht superior p u l m o n a ry ve i n a n d fi red (FIG SA-C) .

FIG 4

•

I dentification o f superior PA.

C h a p t e r 5 LOBECTOMY: Open

A

B FIG 5 •

•

•

•

•

•

•

c

Tra nsection of r i g ht superior p u l m o n a ry ve i n : (A) vessel loop p l aced, (B) vessel loop g u i d i n g sta p l e r, a n d (C) ve i n tra nsected .

N ext, the a nterior-a pica l tru n k PA branch is en circled with a vessel loop a n d tra nsected with a l i near sta p l e r in the same fash ion as the ve i n (FIG 6) . The right u p p e r lobe ( R U L) bronch us' a n atomy is ex­ posed. Its u pper aspect is easily seen com i n g off the tra­ chea. The d i ssection is conti n u ed i nferi orly to expose the i nferior edge of the RUL bronchus a n d free it from the bronchus i ntermed i u s (FIG 7). LN d i ssection (stations 1 OR a n d 1 1 R, h i l a r a n d i nterloba r) is conti nued a l o n g the r i g ht m a i n bronchus a n d the bi­ furcation between the bronchus i ntermed i u s with the upper lobe bronchus id entified (FIG 8) . E nc i rcle the R U L bronchus with a vessel loop a n d transect with a l i near sta p l e r. Ca re m ust be taken to a p p ly o n l y m i n i m a l retraction on the spec i m e n to a v o i d tea r i n g o f P A branches (FIG 9) . N ext, the posterior seg ment of the PA is expose d . The surro u n d i n g N 1 nodes can be removed a n d the poste rior a rtery can be e ncircled with a vessel loop a n d taken with a vascu l a r sta p l e r (FIG 1 0) . Prior to sta p l i n g the fissu re, the a nterior aspect of the PA is ca refu l ly i n spected to ensure there a re no PA branches

•

•

•

• •

rema i n i n g . If so, these are usua l l y q u ite sma l l a n d can be easily torn and m u st be ca refu l ly l i gated . The fissu re between the R U L a n d the r i g ht m i d d l e lobe ( R M L) is now taken with a sta p l e r (FIG 1 1 ) . This is usu a l ly taken from anterior to posterior; h owever, it can a lso be taken from the back. As d ivision of the fissu re is c o m p l eted, the main PA s h o u l d be s e e n a n d the sta pler s h o u l d be placed j u st a bove i t after ensuring t h a t a l l s m a l l P A branches to the R U L h ave been ta ken . The R M L PA bra nch ca n be easily seen a n d s h o u l d be preserved, a n d the R U L m u st be l ifted to ensure the bronchus is i n c l uded in the resected spec i m e n . T o d e l i neate the m i n o r fissu re, the upper lobe is retracted superio rly a n d the m i d d l e a n d lower lobe are pushed i nferiorly (FIG 1 2) . The m i n o r fissu re is d ivided w i t h a l i n ear sta p l e r (FIG 1 3) . The rema i n i n g LN d i ssection of stations 2 R a n d 4R s h o u l d be pe rfo rmed (FIG 1 4) .

FIG 7 • Id entification o f R U L bronch us, bronchus i nte rmedi us, and PA.

A

B FIG 6

•

A,B. Tra nsection of anterior-a p ical PA bra n c h .

FIG 8 1 1 R) .

•

Rem ova l of h i l a r a n d i nte rlobar LN stations ( 1 0 R a n d

29

30

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OPERATIVE TECH N IQUES IN THORACIC AND ESOPHAGEAL SURGERY

A

8

FIG 9 • Tra nsection of R U L bronchus: (A) vesse l loop p l aced, (B) vessel loop g u i d i n g sta p l e r, (C) sta p l e r p l aced, a n d (D) bronchus tra nsected.

D

c

FIG 1 0

•

FIG 1 2

I d e ntification of poste rior seg ment of PA.

•

M i n o r fissu re exposed for tra nsect i o n .

FIG 11

•

Tra nsection of major fissure.

FIG 13

•

Tra nsection of m i n o r fissure.

C h a p t e r 5 LOBECTOMY: Open

FIG 1 4 • Rem ova l of s u p e r i o r m e d i a st i n a l LN stat i o n s (2R a n d 4 R ) .

R I G HT M I D DLE LOBE RESECTION •

• •

• •

•

B l u ntly d i ssect a n d ide ntify the orig i n of the superior p u l ­ m o n a ry ve i n . Conti n u e the d i ssection i nferiorly t o view the R M L ve i n b ra n c h . It can be a sepa rate branch that drains i nto the l eft atri u m , but m ost com m o n ly, it j o i n s the m a i n tru n k of the s u p e r i o r p u l m o n a ry ve i n . The R M L ve i n is id entified a n d cleaned c i rcu mferenti a l ly of h i l a r tissue. The LNs l O R is rem oved . A vessel l o o p is p l aced a ro u n d the R M L ve i n , a n d then, us ing the vessel loop as a g u ide, a l i near vascu l a r sta p l i n g device is passed across t h e ve i n a n d fired. N ext, the a nterior fissu re between the R M L a n d rig ht l ower lobe (RLL) is sta p l e d . Ca re is taken to e n s u re the PA branches to the RLL a re l eft i ntact a n d the R M L bronchus is not i n j u red as the d i ssection conti n u es a nte rior to it. This will expose m u l­ t i p l e LNs ( 1 1 R a n d 1 2 R) that su rro u n d the R M L bronchus. E nc i rcle the R M L bronchus with a vessel loop a n d transect with a l i n e a r sta p l e r.

• •

•

• • •

R I G HT LOWE R LOB E RESECTION

•

•

•

•

•

•

Divide the p l e u ra enclosing the RLL a nteriorly to the level of the RML ve i n bra n c h . Conti n u e the d i ssection i n the plane between the superior a n d inferior p u l m o n a ry ve i n . Ide ntify the j u n cti on between R U L bronchus a n d bron­ c h u s i ntermed i u s a n d resect the LN that is co m m o n l y fo u n d i n this locat i o n . E nc i rcle the I PV with a vessel loop a n d , u s in g the vessel loop as a g u ide, the l i near sta p l i n g device is passed across the r i g ht I PV and fired. Conti n u e d i ssection on the i nferior side of the bronchus i ntermed i u s i nto the c a r i n a removi ng the subca r i n a l LN station 7 .

• •

•

Expose the h i l a r tissue surro u n d i n g the a rte r i a l branches to the m i d d l e lobe a n d the origin of the RML bronchus. Identify the anterior PA branch to the RLL, a n d cont i n u e d i ssection a l o n g the t o p of the P A posteriorly u n t i l t h e superior seg mental a rte ry to the RLL is recog n i zed . Dissect the h i l a r tissue (LN stations 1 0, 1 1 , a n d 1 2 R) from the i nterlobar portion of the a rte r i a l branches and then l i gate the one o r two RML PA branches. This is accom­ p l ished by fi rst remov i n g the LNs off of and between the PA branches a n d then e n c i rc l i n g them with a vessel loop. The RML fissure is sta pled; take care to avoid the RML ve i n . After the R M L is free of a l l attac h m e nts, a l l of the N2 a n d N l LNs s h o u l d t h e n be removed. Often, the LNs of stations 2 R a n d 4R have not been rem oved yet a n d s h o u l d be at this point. For com p l etion of LN d i ssection i n the s u bca r i n a l (station 7) a n d r i g ht a n d a nteri o r m e d i asti n a l tissue (stati o n 4R), the same exposu re a n d d i ssection can be perfo rmed as with the u p p e r lobe.

Identify the superior seg ment of the l ower lobe and deve l o p the su badventitial plane of the r i g ht PA. At this poi nt, a l l major vessel branches s h o u l d be identi­ fied (RML a rte ry, poste rior recu rri ng branch to the R U L, a n d the seg m enta l vessels to the RLL) . N ext, t h e major fissu re is sta pled . D i ssection is conti n u ed a l o n g the a rtery to c i rcumfer­ enti a l ly free the branches of the r i g ht PA s u p p l y i n g the lower lobe. E n c i rc l e the superior seg menta l a rtery with a vessel loop a n d tra nsect with a l i n e a r sta p l e r i n the same fash ion as the ve i n . Ta ke ca re to not i nterfere with the takeoff of the poste rior recurring branch to the R U L, beca use it can o r i g i nate from the superior seg m e nta l a rtery.

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OPERATIVE TECH N IQUES I N THORACIC AND ESOPHAGEAL SURGERY

The bifu rcation of the R M L bronchus a n d bronchus i nterm e d i u s is identified. A vessel loop can be passed a ro u n d the bronchus i ntermed i u s to ass ist w i t h expos u re. Dissect the RLL bronchus c i rcu mferenti a l ly a n d confirm co m p l ete d i ssection by p l a c i n g a vesse l loop a r o u n d it. E n s u re the R M L bronchus is seen a n d not k i n ked prior to sta p l i n g the RLL bronchus.

LEFT UPPER LOBECTOMY •

• •

•

•

•

•

Dissection is sta rted at the N2 medi asti n a l LNs. If the l u n g defl ates we l l , t h e nodes 9, 8 , a n d 7 c a n be co m p l etely removed. If the l u n g does not defl ate sufficiently, it is best to sta rt at station 7 a n d then m ove cepha lad toward the trachea and rem ove the LN 1 O L p l u s 5 and 6. Rem ova l of the LNs fi rst exposes the a n atomy a n d affords visual i nspection of the N 2 nodes. The d i ssection is conti n u ed between the h i l a r structu res a n d in between the aorta a n d PA and poste rior to the phrenic n e rve. I d e ntify the orig i n of the superior p u l m o n a ry ve i n a n d e n s u re there a re two p u l m o n a ry ve i n s a n d deve l o p t h e space between the s u p e r i o r a n d the I PV. Because the fissure may be com p l ete or i n c o m p l ete, we reco m m e n d f i n d i n g the PA poste riorly a n d then d i ssect a l o n g its s u rface to deve l o p the fissu re posteriorly. I d e ntify the poste rior seg mental PA branch a n d enc i rcle with a vessel loop. U s i n g the vesse l loop as a g u ide, the l i near sta p l i n g device is used to d ivide the vesse l . N ext, sta p l e the poste rior fissure. Somet i m es, the fissu re may need to be taken before the poste rior seg m enta l PA can be d ivided.

•

• •

•

•

•

• • •

• •

Tra n sect the RLL bronchus with a l i n ear sta p l e r. Ca re m ust be taken to a p p ly o n l y m i n i m a l retraction on the speci­ men to avo id tea r i n g of p u l m o n a ry struct u res. The d ivision of the rema i n i n g fissu re is co m p l eted with a l i near sta p l e r. Res i d u a l LN stations 7, 8R, 9 R, a n d 4R are d issected for co m p l etion of a p p ropriate h i l a r nodal resecti on.

Conti nue the dissection fol l owing the PA a nteriorly unti l a ll the branches a re ligated and finally the l i n g u l a r artery is sta­ pled in the same fash ion as the posterior seg menta l branch . S u bseq ue ntly, the a nterior fiss u re is enc i rcled by p l a c i n g a vessel loop f r o m the d ivided l i n g u l a r a rtery stu m p t o the space between the two p u l m o n a ry ve i n s a n d t h e n tra nsected w i t h a l i n e a r sta p l e r. The superior p u l m o n a ry ve i n is d i ssected off the bronchus a n d ca refu l ly encircled. Ensure the m ost superior aspect of the ve i n is d issected off of the m a i n PA so when the sta­ p l e r is passed a ro u n d the ve in, the a rtery is clearly see n . U s i n g the vessel loop as a g u ide, the l i n ear sta p l i n g device is passed across t h e ve i n a n d fi red . The only vascu l a r structu res re m a i n i n g are the a nterior a n d apical branches of the PA to the l eft u p per lobe (LU L) . Therefore, remove t h e N 1 L N s off o f the L U L bronchus a n d encircle it with a vessel l o o p . Using the vessel loop as a g u ide, the l i near sta p l i n g device is passed across the bron­ chus and fired. Care must be taken to a p p ly only m i n i m a l retraction on t h e speci men t o avoid tea ring o f PA branches. Once the LUL bronchus is tra nsected, the f i n a l re m a i n i n g branches o f t h e PA a re easily seen a n d sta pled . The re m a i n i n g LN stations are d issected .

LEFT LOWER LOBECTOMY •

• •

• •

•

Divide the inferior p u l m o n a ry l i g a ment u p to the level of the I PV. Resect the LNs encou ntered i n this a rea (LN 9 fi rst a n d then the perieso p h a g e a l LN 8). Dissect the h i l a r tissue off t h e eso p h a g u s a n d va g u s nerve (FIG 3), stay­ i n g c l ose to the pericard i u m to a p p roach the s u bca r i n a l space. Conti n u e the d i ssection toward the carina a n d rem ove s u bca r i n a l LN station 7 (FIG 1 SA, B) . N ext, the trajectory is changed a n d the l eft l ower l o be is l ifted a nteriorly a n d ce p h a l a d to expose the orig i n of the I PV (FIG 1 6) . D i ssect the I PV off the u n derlying bronchus a n d free from h i l a r tissue (FIG 1 7) . E n c i rc l e the I PV with a vessel loop a n d u s in g the vessel loop as a g u ide, the l i n ear sta p l i n g device is passed a cross the vein and fi red (FIG 1 8A-D) . Sometim es, it is best to take the vein later in the operation once the a rte ry is d i ssected out a n d the fissure co m p l eted . This may h e l p prevent the l o b e from beco m i n g edematous. The trajectory is changed back to expose the poste rior aspect of the h i l u m a n d the a rter ial struct u res (FIG 1 9) .

A

FIG 1 S • A . Expos i n g mediast i n u m f o r (B) rem ova l o f s u bca r i n a l LNs station 7 .

C h a p t e r 5 LOBECTOMY: Open

FIG 1 6

•

•

• • •

•

I d e ntification of I PV.

FIG 1 7 tissue.

Ide ntify the left PA posteriorly a n d then work a l o n g it to identify the major branches (su perior seg menta l branch bas­ i l a r PA (FIG 20) . The superior seg ment of the PA is exposed as we l l as the rema i n i n g l a rg e basi l a r PA. The surro u n d i n g N1 nodes a re rem oved from the a rte r i a l branches a l l ow i n g them to be clearly exposed (FIG 21 ) . The bronch i a l bifurcation of the upper a n d l ower lobe ca n be i d e ntified below the PA i n this l ocat i o n . The superior seg mental PA is usu a l ly taken next u s in g a vas­ c u l a r sta p l e r (FIG 22) . After the superior seg mental a rtery is sta pled, the rema i n i n g l a rg e basi l a r P A is sta pled next. N ow the I PV can be taken or the l eft lower lobe bronchus can be sta p l ed a n d the ve i n d ivided last.

•

•

•

•

•

Pee l i n g I PV off the bronchus a n d rem ova l of h i l a r

The LN d i ssection (stat ions 1 1 L a n d 1 2 L) is cont i n ­ ued a l o n g the l o w e r lobe b r o n c h u s to f r e e it c i r­ cu mferenti a l ly (FIG 23A-C) . E n c i rcle the l eft lower lobe bronchus with a vessel loop and tra nsect with a l i n ea r sta p l e r. Care m ust be taken to a p p ly o n ly m i n i m a l retraction on the speci men to avo id tea r i n g of the l i n g u l a r branch (FIG 24A-D) . N ext, the fissu re between the LU L a n d the l eft l ower l o be is exposed a n d taken with a l i near sta­ p l e r (FIG 25) . The superior mediast i n u m is exposed a n d the re­ m ova l of resi d u a l LN stations 5 and 6 is perfo rmed (FIG 26A,B) .

A B

c

D F I G 1 8 • Tra nsection o f l eft I PV: (A) vesse l l o o p p l aced, (B) vessel l o o p g u i d i n g sta p l e r, (C) sta p l e r p l aced, a n d ( D ) ve i n tra n sected.

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FIG 1 9

FIG 20

•

•

Id entifi cation of a nterior seg ment of PA.

Id entifi cation of major branches of l eft PA.

FIG 21 • Rem ova l of N 1 nodes (station 1 1 L) from the o r i g i n of the l i n g u l a r a rtery.

A

B

c

D

E

F

G

H FIG 22 • A-C. Tra nsection of superior seg m enta l PA. D-F. Tra nsection of inferior PA. G-1. Tra nsection of l ower lobe basi l a r a rte ry.

C h a p t e r 5 LOBECTOMY: Open

B

A FIG 23

•

35

c

Rem ova l of N 1 n o d e s a l o n g l ower lobe b r o n c h u s (A) LN 1 OL, (B) LN 1 1 L , a n d (C) LN 1 2 L.

B

A

FIG 24 • Tra nsection of l eft lower lobe bronchus: (A) circu mferential dissection, (B) vessel loop g u i d i n g sta pler, (C) sta pler p laced, and (D) bronchus tra nsected .

D

c

FIG 25

A

•

Tra nsection of fissure.

B FIG 26 • A. Thoracic grasper expos i n g superior mediast i n u m for (B) rem ova l of resi d u a l LN station (SL).

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•

CLOSURE A N D D RAI NAG E •

• •

The ch est is f i l led with i rrigation f l u i d a n d the rema i n i n g l u n g infl ated t o 20 em H 20 t o m a ke certa i n there is n o l e a k at the bronch i a l stu m p . If there is a l e a k, a 3 - 0 Prolene stitch o n a n R B n e e d l e i s used t o oversew the bronch i a l stu m p . Ch est t u be is e m p l oyed p e r s u rgeon's sta n d a rd routi ne .

• • •

R i b a p p roxi mation is a c h i eved by d r i l l i n g h o l es through the r i b a n d pass i n g the suture materi a l t h roug h the ho les. The m u scle faci a l edges a re a p p roxi m ated using a bsorb­ a b l e r u n n i n g suture . S k i n cl osed w i t h su bcuti c u l a r a bsorba b l e suture . The bronch i a l m a r g i n is sent for frozen section, a n d the t u m o r is sent for genetic test i n g a n d t u m o r m a rkers.

PEARLS AND PITFALLS R i g ht u p p e r l o bectomy

• • •

I nj u ri n g the right main PA while getting ci rcu mferent i a l contro l of the right superior p u l m o n a ry vein Fa i l u re to ide ntify the poste rior asce n d i n g branch to the poste rior seg ment of the R U L

•

Fa i l u re to ide ntify the RLL bronchus while obta i n i n g control of the RML bronchus I n j u ry of the poste rior seg mental vein while co m p l et i n g the fissu re between the R U L a n d the R M L

R i g ht lower l o bectomy

•

I n j u r i n g or k i n k i n g the RML bronchus while sta p l i n g the RLL bronchus

Left u p p e r l o becto my

• •

I n j u ry to the anterior a p i c a l tru n k of the LU L, with resu ltant massive bleed i n g Fa i l u re t o recog nize the l i n g u l a r a rtery

•

Fa i l u re to ide ntify the superior seg m e nta l a rtery to the left l ower lobe

R i g ht m i d d l e lobecto my

Left lower l o becto my

POSTOPERATIVE CARE •

•

Postoperative pain management Dispense pain medication per usual postoperative regimen. The patient is placed on aspiration precautions (no oral intake until fully awake and able to sit upright) . Inpatient hospital follow-up and discharge should be based on surgeon's experience and preference. Almost all patients should be extubated in the operating room. Extubated patients are transferred to the recovery room and to the appropriate hospital inpatient setting ( bed with monitoring until discharge) . N o postoperative antibiotics are used. Patients should be monitored with oximetry around-the­ clock. Chest drain removal once output is less than 450 mL per day The patient is discharged from the hospital, if stable, most commonly on postoperative day 3 or 4. Outpatient follow-up Follow-up visit 2 weeks postoperatively In cases of malignancy following pathology review, coun­ sel the patient concerning the need for additional therapy

or adj uvant chemotherapy as indicated. Adjuvant therapy, even radiotherapy, which is rarely indicated, as soon as 3 to 6 weeks postoperative, depending on patient's perfor­ mance status.

SUGGESTED READINGS 1. Sabistons and Spencer; Surgery of the chest. 2. ACS Curriculum; Pulmonary Resection. Min P. Kim, Ara Vaporciyan. 3. Fell SC, Kirby TJ. Technical aspects of lobectomy. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 4. Hood RM. Techniques in General Thoracic Surgery. 2nd ed. Philadelphia, PA: Lea & Febiger; 1 9 9 3 . 5 . Kirby T J , Fell S C . Pneumonectomy and its modifications. I n Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:470-4 8 5 . 6 . Martini N, Ginsberg RJ. Lobectomy. I n : Pearson FG, Cooper JD , Deslauriers J, et al, eds. Thoracic Surgery. 2nd ed. Philadelphia, PA: Churchill Livingstone; 2002: 9 8 1 . 7. Nesbitt J C , Wind G G . Thoracic Surgery Oncology: Exposures and Techniques. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. 8 . Waters PF. Pneumonectomy. In: Pearson FG, Cooper JD , Deslauriers J , e t al, eds. Thoracic Surgery. 2 n d e d . Philadelphia, PA: Churchill Living­ stone; 2002:974.

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·

Tyler Grenda Jules Lin

DEFINITION •

Video-assisted thoracic surgery (VATS) lobectomy is defined as an anatomic lobectomy in which bronchial and vascular ligation is performed with lymph node sampling or dissection through several small incisions while avoiding spreading of the ribs. VATS is an appealing alternative to thoracotomy but must follow the same principles with vascular ligation, resection with negative margins, and appropriate lymph node dissection.

•

IMAGING AND OTHER DIAGNOSTIC STUDIES •

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

• •

A detailed history and physical must be performed prior to any treatment including past medical and surgical history, allergies, medications, social, and family history. The patient's previous history of tobacco use as well as any chemical or asbestos exposures should be determined. Cessation of tobacco use preoperatively should be strongly encouraged for 4 weeks prior to any surgical intervention. The history should include the patient's current functional status and exercise tolerance. A complete physical examination should be performed with particular attention to auscultation of the heart and lungs and any evidence of cervical or supraclavicular lymphade­ nopathy or peripheral edema.

Routine laboratory studies including a complete blood count and basic chemistry panel should be included as part of the preoperative evaluation.

•

•

Patients typically present with abnormal chest radiograph ( FIG 1 A) or chest computed tomography ( CT) findings. If available, the findings should be compared to previous imaging to determine any interval changes. Lesions that are stable for more than 2 years are generally considered benign. Indeterminate lesions less than 1 em in size can be followed on serial imaging according to the recommendations of the Fleischner Society. 1 A chest CT ( FIG 1 8) should be obtained in all patients with a suspicious lung nodule to evaluate the size and charac­ teristics of the nodule; proximity to the chest wall, vessels, airway, and mediastinum; additional pulmonary lesions; and hilar or mediastinal lymphadenopathy. The CT should include the upper abdomen to evaluate the liver and adrenal glands for metastatic disease. A positron emission tomography (PET) scan ( FIG 1 C) pro­ vides additional information regarding the metabolic activity of the pulmonary nodule and areas of uptake that are suspicious for regional nodal or distant metastatic disease

A

c

FIG 1 • A. Chest x-ray shows a peripheral left u pper lobe nod u l e (arrowhead). B. Chest C T shows a peripheral left upper lobe nodule sus­ picious for a l u n g carci noma (arrow­ head). C. Left: This PET sca n shows a n i ntensely FDG-avid right u pper lobe mass (arrowhead). Right: There is a lso a moderately FDG-avid right h i l a r lym ph node suspicious for reg ional metastatic d isease (arrowhead).

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and should be obtained in all patients suspected of having a non-small cell lung carcinoma? In patients with abnor­ mal findings on fluorodeoxyglucose (FDG)-PET imaging, sampling of the abnormal lymph node should be performed prior to lung resection either by endobronchial ultrasound (EBUS) or mediastinoscopy. For patients with non-small cell lung carcinoma who are surgical candidates, anatomic lobectomy and mediastinal lymph node dissection for complete oncologic resection and staging is recommended. 3 Due to the low morbidity and mortality after wedge resec­ tion, our preference for nodules that are highly suspicious for lung carcinoma based on PET or serial imaging is to per­ form a VATS wedge resection for a tissue diagnosis. Needle biopsies are performed less often and are reserved for cases where the diagnosis is less clear or for central lesions that would require a lobectomy for diagnosis alone.

Table 1 : Relative Contraindications to Thoracoscopic Lobectomy Complete resection unable to be ach ieved with a lobectomy (Need for sleeve resection or pneumonectomy) A central lesion making it d ifficult to staple the bronch us or pulmonary arterial branches C h est wa l l or mediastin a l invasion (T3 or T4) Nodal d isease adherent to the vessels Neoadj uvant chemoradiation Positive N 3 disease Patient unable to tolerate single-lung ventilation

•

•

SURGICAL MANAGEMENT Preoperative Planning •

•

•

•

• •

Preoperative risk assessment determines whether a patient will tolerate pulmonary resection based on pulmonary reserve (pulmonary function tests [PFTs] ) and other comorbidities.4 Patients with significant cardiovascular risk factors or symp­ toms should undergo preoperative cardiac evaluation. Patients with a preoperative forced expiratory volume in 1 second (FEV 1 ) of more than 6 0 % predicted and diffus­ ing capacity of lung for carbon monoxide (DLCO) of more than 5 0 % predicted are candidates for lobectomy. Patients not meeting these criteria should undergo further evaluation with a quantitative ventilation perfusion scan to determine their postoperative predicted pulmonary function with a minimum postoperative value of 4 0 % predicted. Cardiopulmonary exercise testing is occasionally helpful in patients whose symptoms do not correlate with the severity of their pulmonary function results. For patients who will not tolerate an anatomic lobectomy, alternatives include a sublobar resection such as a segmen­ tectomy or wedge resection, stereotactic body radiation therapy (SBRT), radiofrequency ablation (RFA), or defini­ tive chemoradiation. These patients are best discussed in a multidisciplinary setting. Relative contraindications for VATS lobectomy are listed in Table 1 . In the preoperative area, the history and physical should be reviewed and consent should be obtained. The operative side should be appropriately marked.

Positioning •

•

•

The patient should be placed in the lateral decubitus position, tilted slightly posteriorly. The bed is flexed taking care to drop the hips out of the way of the camera port ( FIG 2) . The arms should be positioned in an arm holder in neutral position. The patient should then be secured and all pressure points padded. Following positioning, the endotracheal tube position should be confirmed again by the anesthesiologist.

FIG 2 • The patient is p l aced in the latera l decubitus posit i o n . It is i m portant to d ro p the h i p out of the w a y of the camera, which is p l aced i n the most inferior port.

PLACEM E NT OF I N C I S I O N S •

Once in the operating room, a flexible bronchoscopy should be performed to verify airway anatomy and rule out any endobronchial lesions. Single-lung ventilation is achieved with a left-sided double lumen endotracheal tube, which is generally preferable to a bronchial blocker.

Port p l acement is i m porta nt to obta i n the id eal a n g l es for sta p l e r p l acement a n d l u n g retract i o n . O u r genera l port p l acement for a VATS lobecto my is shown (FIG 3) . Port 1 is p l aced j ust below the infra m a m m a ry crease i n the 6th i nte rcosta l space i n the anterior axi l l a ry l i n e . A 5-mm, 30-degree a n g led scope is p refera b l e to decrease compression of the i nte rcosta l nerve. The re­ m a i n i n g ports can be p l aced u n d e r d i rect visual izat i o n .

•

•

•

Port 2 is p l aced poste riorly i n t h e a uscu ltatory tri a n g l e i n t h e 6th i nte rcostal space. Placing t h i s i ncision one i nter­ space lower is h e l pf u l for an u p p e r lobecto my in pass i n g the sta p l e r when d ivid i n g the s u p e r i o r p u l m o n a ry vei n . Port 3 is p l aced i n t h e 8th or 9th i nte rcosta l space i n the poste rior axi l l a ry l i ne, taking care to avoid i n j u r i n g the d i a p h ra g m . An access incision (< 1 0 e m ) is placed i n t h e 4th i ntercosta l space in the midaxi l l a ry line (d i rectly above the superior

C h a p t e r 6 LOBECTOMY: Thoracosco p i c

FIG 3 • Sta n d a rd port p l acement for a VATS l o bectomy. Port 1 is p l aced j u st below the i nfra m a m m a ry crease i n the 6th i ntercosta l space in the anterior axi l l a ry l i n e . Port 2 is p l a ced posteriorly in the a uscu ltatory tri a n g l e i n the 6th i nte rcosta l space. Port 3 is p l aced i n the 8th o r 9th i ntercosta l space i n the posterior axi l l a ry l i n e . An access i ncision (< 1 0 em) is p l aced i n the 4th i nte rcostal space in the mi da xi l l a ry l i n e . The s u rgeon operates t h ro u g h port 1 a n d the access i n cision while the assista nt retra cts the lung usi ng Foe rste r c l a m ps in port 2. The camera is p l a ced in the m ost inferior port 3 . (The arrow i n d icates t h e front o f t h e patient.)

•

pul monary vei n for a n u p per lobectomy or one space lower for a middle or l ower lobectomy) for dissection and retrieva l of the speci men. A Weitlaner retractor is used to hold the incision open to prevent suction from reexpa nding the l u n g . I n the event of bleeding, a sponge stick ca n be quickly inserted through the access incision to hold pressure. The s u rgeon operates through port 1 a n d the access i n cision w h i l e the assista nt positions the lung using Foe rster

•

•

LOCALIZATION OF THE LU NG N O D U LE •

•

The n o d u l e is loca l ized by correlating the ch est CT with the visu a l i zed a n atomy. The n o d u l e is then p a l pated with either the s u rgeon's fi nger or an i n strument (FIG 4A) . Ca re s h o u l d be t a k e n n o t to c r u s h the nodu le, w h i c h co u l d m a ke it h a rd to identify. I n a d d ition, ru ptu r i n g t h e mass risks p l e u r a l spread of d isease. As screen i n g chest CTs identify smaller nodules, preopera­ tive local ization with methylene blue or coi l/wire place­ ment by CT guida nce or super d i mensional bronchoscopy

•

c l a m ps i n port 2 . The camera is p l aced i n the m ost i nfe­ rior port 3 . Thoracoscopic exploration s h o u l d be perfo rmed l o o k i n g for any effusion, p l e u r a l l esio ns, o r u n expected nodu les i n the re m a i nder of the l u n g . If t h e l u n g is n o t adequately co l l a psed, sucti on s h o u l d b e a p p l ied t o the a p p ropriate l u m en o f the endotrachea l tube.

may be helpful in identifying g round g l ass nodu les (< 1 em), sma l l nodu les (2-3 em) Obesity (BM I >35)

Specific to transoral incisionless fundoplication I n a b i l ity to to l e rate general a nesthesia

Specific to laparoscopic LES augmentation surgery I n a b i l ity to tolerate general a nesthesia Tita n i u m , sta i n less steel, n icke l , or ferro us a l lergy Patients who may need to u n dergo an M R I (LINX considered not safe for M R I ) BMI, body mass index; LES, lower esophageal sphincter; MRI, magnetic resonance imaging.

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202

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patient's symptoms. These include recent weight loss or progressive inability to tolerate solids and liquids (malig­ nancy) , atypical symptoms associated with exertion (coro­ nary artery disease or asthma) , or diarrhea (irritable bowel syndrome ) . The presence o f abdominal surgical scars o r abdominal wall hernias is important to identify if laparoscopic LES augmen­ tation surgery is being considered as they may make access to the peritoneal cavity and the gastroesophageal ( GE) junction challenging. Laparoscopic LES augmentation surgery, which involves placement of a magnetic device around the GE junction, is considered not safe for magnetic resonance imaging (MRI ) . Patients should be aware of this contraindication prior to surgery.

•

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Establishing GERD as the etiology of the patient's symptoms is critical before proceeding with any intervention. Patients may have subjective complaints of heartburn or dysphagia that are unrelated to their reflux disease. The four diagnostic tests that are most commonly used to establish a diagnosis are upper endoscopy, barium esophagram, pH testing, and manometry. Upper endoscopy (esophagogastroduodenoscopy [EGD]) All patients undergoing an antireflux procedure should have an EGD . EGDs can identify the presence of hiatal hernias and rule our other pathology, which may be contributing to the patient's symptoms, such as peptic ulcer disease or malignancy. GERD-related complications such as esophagitis, Barrett's esophagus, and esophageal strictures can also be identified ( FIG 1 ) . Ambulatory p H testing This is considered to be the gold standard test for diagnos­ ing the presence of symptomatic GERD. Patients should typically not be taking their antireflux medications when the study is performed. pH testing can be performed via catheter-based systems (i.e., 24-hour pH probe testing) or wireless systems (i.e., 48 -hour Bravo testing) . Both catheter-based and wireless systems allow for the quantification of six variables including total/upright/

FIG 1 • The presence of B a r rett's eso p h a g u s is a contra i n d ication to T I F, ra d i ofreq uency en ergy a p p l i cation, a n d l a p a rosco p i c LES a u g m e ntation s u rgery.

•

•

supine time that the pH is less than 4, number of reflux episodes, number of episodes longer than 5 minutes, and longest episode. These variables can be combined to calculate the "DeMeester score , " which is used by many surgeons as definitive evidence for the presence of GERD . 1 Barium esophagram This is a dynamic fluoroscopic study that characterizes both anatomic and functional aspects of the esophagus. It involves multiple swallows of barium and barium­ coated solid food. The two most important things to characterize with a barium esophagram are the position of the GE junction relative to the diaphragmatic hiatus and overall esopha­ geal motility. The presence of a large hiatal hernia (FIG 2 ) or significant esophageal dysmotility is a contraindication for any of the three procedures. 2 Esophagrams can also identify the presence of reflux that is characterized by the spontaneous reflux of barium back into the esophagus. However, they are less sensitive than pH studies and thus a negative finding here does not rule out GERD . Video recording of this study is crucial because it allows the surgeon to actively assess esophageal peristalsis and the functional significance of hiatal hernias. Manometry Esophageal manometry uses pressure transducers within a transnasal catheter to provide data regarding the LES resting pressure, LES abdominal and total length, and adequacy of LES relaxation. It also characterizes esopha­ geal motility by quantifying the amplitude, duration, and propagation of each contraction. The presence of significant esophageal dysmotility is a contraindication for all three procedures. Multichannel impedance testing and gastric emptying studies are also used on occasion to identify nonacidic GERD and assess gastric functionality, respectively.

FIG 2 • A l atera l view of a b a ri u m eso p h a g ra m . A l a rge h i ata l h e r n i a is present with a s i g n ificant port i o n of the sto mach h e r n i ated i nto the ch est. A sma l l d ista l eso p h a g e a l d iverticu l u m is see n . A l l th ree p roced u res wo u l d b e contra i n d i cated i n the presence of t h i s h e rn i a .

C h a p t e r 26 T H E M I N I MALLY I N VASIVE S U RG I CAL APPROACH TO GASTROESOPHAGEAL RE FLUX D I S EASE

TRANSORAL INCISIONLESS FUNDOPLICATION •

App roved by the U . S. Food a n d Drug Ad m i n i strati o n (F DA) i n 2007, the o n ly T I F device t h a t is cu rrently ava i l ­

•

a b l e f o r u s e i n the U n ited States is t h e EsophyX device ( E n d o G astric S o l u t i o ns, Red m o n d , WA) . Esop hyX re-creates the LES by p l icat i n g the d i sta l esoph­ a g u s a n d the gastric card i a together, t h u s creat i n g an a n t i refl ux valve s i m i l a r to that of a l a p a roscop i c N i ssen

•

f u n d o p l icati o n . The device consists of a h a n d le, an 1 8- m m d i a m eter shaft, a tissue i nvag i n ator co m p osed of h o l es i n the side of the device (wh ich a re conn ected to a suct i o n device), an a rti c u l a t i n g arm, which a p p roxi m ates g astric a n d esoph­ ageal tissue a n d d e p l oys the tissue fasten e rs, a h e l i c a l screw, two styl ets, a n d 20 polypropy l e n e H -faste n e rs ( 1 0 p l i cation sets) (FIG 3) .

Preoperative Planning •

At o u r i n st i t ut i o n , g e n e r a l a n est h e s i a is a d m i n i stered and t h e proced u re i s pe rfo r m e d i n t h e o p e rat i n g roo m .

•

N asotrach e a l i n t u b a t i o n is p e rfo r m e d so the o r o p h a rynx ca n be used entirely fo r t h e Esop hyX device. A bite block i s p l a ced to p rotect t h e teeth from t h e device a n d

•

sco p e . Two phys i c i a n s perform the proced u re. O n e m a n i p u l ates the e n d oscope wh i l e the other contro ls the device.

Positioning •

• With t h e patient i n t h e left latera l decub itus position a n d a nasotra c h e a l tube prese nt, a b ite b l ock i s p l aced to fac i l itate passage of the e n d oscope and su bseq uently the EsophyX device.

FIG 4

•

which may i ncrease the risk of posto perative i nfections.

Placement of the Transoral Incisionless Fundoplication Device into the Stomach • •

After i ntu bation, the patient is p l a ced i nto the l eft latera l decu b itus position with the head e l evated s l i g htly •

(FIG 4) .

Prophyl actic a n t i b i ot i cs a re a d m i n istered before the pro­ ced u re beg i ns because tra n s l u m i n a l faste n e rs a re p l aced,

Preproced u re e n d oscopy is pe rfo rmed to verify a n at o m i c l a n d m a rks. A 56-Fr b o u g i e is i nserted i nto the eso p h a g u s and then removed to fac i l itate subsequent passage of the EsophyX device (FIG S). The Esop hyX device is l u b ri cated a n d a sta n d a rd endo­ scope is t h readed t h ro u g h the device (FIG 6) . Both a re p l a ced t h ro u g h a b ite b l ock a n d adva n ced t h ro u g h the eso p h a g u s i nto the sto m a c h .

•

The sco pe is adva nced i nto the gastric l u m e n a n d then retrofl exed to exa m i n e the G E j u n cti o n . U s i n g a sta nda rd, h i g h-flow i n s uffl ator, the sto mach is i n s uffl ated with

..

' '

·'

A Articu lating arm

\ •

B FIG 3

, _.

-

H elical retractor

• A. EsophyX device with the a rti c u l a t i n g a r m fu l ly exte n d e d . B. Art i c u l a t i n g a r m is fl exed with the H fasten e rs visi b l e between the shaft a n d the d ista l end of the a rti c u l a t i n g a r m . The h e l i c a l retractor is visi b l e as we l l ( i m a g es © 2 0 1 5 E n d o G astric Sol utions, I n c) .

FIG S • Passa ge of a l a rge B o u g i e after d i a g n ostic end oscopy fa c i l itates advancement of the EsophyX device i nto the sto m a c h and m i n i m izes the l i ke l i h ood of esophagea l i n j u ry d u ri n g passa ge of the device.

203

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A B A. The e n d oscope is passed t h ro u g h the h a n d l e of the Esop hyX device a n d can be seen exiti n g the d ista l e n d of the device (B) . The a rt i c u l at i n g a r m i s fully extended i n t h i s image. O n ce the sco pe a n d device a re adva nced i nto the sto mach, the FIG 6

•

scope i s withd rawn i nto the body of the device a n d the a rt i c u l a t i n g a r m is f l exed. The scope is advanced back i nto the stomach a n d retrofl exed to o bta i n a view of the G E j u n ct i o n .

c a r b o n d i oxide to a pressure of 1 5 m m H g via the work­

i nto the s q u a moco l u m n a r j u n ct i o n (FIG 98) . The entire

i n g c h a n n e l of the e n d oscope. Once the a rticu l a t i n g a r m

device i s then adva n ced d i sta l ly a co u p l e of cent i m ete rs a n d rotated c l ockwise on the screen . T h i s a l l ows the a rti c u l a t i n g a r m to be opened a n d the helical retractor d i se n g a g ed from the a rti c u l a t i n g a r m . The a rtic u l a t i n g a r m is then rotated back to the 6 o'clock posit i o n , p a rti a l ly cl osed, a n d p u l led back 1 to 2 em (FIG 9C) . The G E j u n ct i o n is advanced ca u d a l l y by a p p ly­ i n g tension to the h e l i c a l retractor. The sto mach is then desufflated a n d the a rticu l a t i n g a r m i s rotated toward the 1 o ' c l o c k posit i o n . T h i s m a n euver

i s visu a l i zed with i n the sto mach, the s c o p e i s withd rawn i nto the d evice, the a rtic u l a t i n g arm is flexed, and the

•

sco pe i s then adva n ced back i nto the retrofl exed positi o n with i n the gastric l u m e n (FIG 7). U s i n g the retrofl exed vi ew, the G E j u n ct i o n is envisioned as a clock face with the 12 o'clock position l ocated at the l esser c u rvatu re, the 6 o'clock posit i o n at the g reater c u rvature, and the 9 o'clock position l ocated a l o n g the poste rior gastric wa l l (FIG 8).3

•

•

rotates the f u n d u s anteriorly a r o u n d the eso p h a g u s there by i n itiating the fu n d o p l icati o n . Exte r n a l ly, the h a n ­ d l e of the device is rotated a p p roximately 1 80 d e g rees

Anterior Rotational Plication Fasteners •

The cl osed a rtic u l a t i n g a r m is p l aced at the 1 2 o'clock position (FIG 9A) . The h e l ix retractor portion of the device is a l so at the 12 o'clock position a n d advanced

FIG 7 • The a rtic u l a t i n g a r m of the device is fl exed with i n the gastric lumen. The a r m will su bse q u ently be rotated i nto the 12 o'clock position at the l esser c u rve to fac i l itate p l acement of the h e l ix retractor.

(FIG 1 0) . This has been described in the l iterature as the •

" B e l l R o l l m a n e u ve r. "3

The h e l i ca l retractor a n d a rticu l a t i n g a r m are secu red i n p l a ce a n d t h e suction i s a p p l i e d .

• U s i n g a clock f a c e to d e s c r i b e the a n atomy of the GE j u nction i n a retrofl exed vi ew, the lesser c u rvatu re i s at 1 2 o'cl ock w h i l e the g reater c u rvature i s a 6 o'clock.

FIG 8

C h a p t e r 26 T H E M I N I MALLY I N VASIVE S U RG I CAL APPROACH TO GASTROESOPHAGEAL RE FLUX D I S EASE

retractor

A

B

FIG 9 • A. With the a rticu lati ng arm at 1 2 o'cl ock, the h e l i x retractor is p l aced i nto the s q u a m oco l u m n a r j u nction. B. T h e h e l ix retracto r ca n be seen as a t h i n , horizonta l ly oriented wire entering the gastric l u me n . The device is then advanced d i sta l ly i nto the stomach a n d rotated clockwise on the screen so that the a rtic u l at i n g arm is at 6 o'clock (C) .

Articu lating ann at the 6 o'clock position

c

• •

The fi rst H -faste n e r set is then d e p l oyed . The sto mach is then reinsuffl ated to visu a l ize d e p l oy­ ment of a p a i r of H fasteners. Two sets of a d d i t i o n a l H faste ners a re su bseq u e ntly p l aced at varyi n g d i stances

•

from the GE j u n ct i o n . T h i s wi l l result in the p l acement of six faste n e rs 1 to 3 em a bove the s q u a m o co l u m n a r j u n ct i o n .

Posterior Rotational Plication Fasteners • •

FIG 1 0 • The a rti c u l a t i n g a r m is rotated cou nterclockwise back towa rd the 1 o'clock position (the tip is thus not visi b l e i n t h i s view) . The f u n d u s i s t h u s anteriorly rotated a r o u n d the eso p h a g u s . T h i s co m p l etes the a nte rior portion of t h e f u n d o p l icati o n .

•

The h e l ix retractor port i o n of the device is m a i ntai ned at the 1 2 o'clock posit i o n . The a rtic u l at i n g a r m is rotated cou nterclockwise t h ro u g h the lesser c u rve to the 8 o'clock positi o n , p a rti a l ly c l osed, and p u l led back 1 to 2 em. The GE j u n ct i o n is advanced ca uda l ly by a p p ly i n g te nsion to the h e l i c a l retractor. The " Be l l Rol l " m a n e uver is a g a i n performed, but this t i m e i n the clockwise d i rection (clockwise on the screen).

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FIG 1 1 • To perform the posterior component of the fundoplication, the articu lating arm is rotated clockwise to the 1 1 o'clock position. This m a neuver is a m i rror image of the m a neuver used to create the anterior com ponent of the fundoplication. Articu lating arm at the 6 o'clock position

The sto mach is desuffl ated a n d the a rticu lating arm is rotated clockwise to the 1 1 o'clock positio n . This m a neu­ ver rotates the fundus posteriorly around the esophagus • •

(FIG 1 1 ). The fi rst s e t of poste rior rotat i o n a l p l ication faste ners is then d e p l oyed. The process is then repeated to place two a d d i t i o n a l sets of H faste ners at vary i n g d i sta n ces from the GE j u n ct i o n .

FIG 12 • The shaft of the device has been p u l led back i nto the esophagus 3 to 4 em. This a l l ows placement of the g reater cu rve p l i cation sutu res with the a rticu lating arm near the 6 o'clock position. This m ove adds length to the a nti reflux valve.

Anterior Corner Longitudinal Plication •

To a d d ress a g a p in the a nterior co m ponent of the p l icat i o n that is often a p p reci ated o n ly after the a nterior a n d poste rior sets h a v e b e e n p l a ced, a n anterior c o r n e r p l ica­

•

•

any bleeding or i nj u ries to the esophagus and stomach. The fasteners are visual ized i n the d ista l esophagus (FIG 1 3). The f u n d o p l ication created by the EsophyX device s h o u l d h a v e a s i m i l a r e n d osco p i c a p pearance as o n e created by a l a p a rosco p i c N i ssen f u n d o p l icat i o n .

t i o n set is often p l a ced. The a rtic u l a t i n g a r m is rotated cou nterclockwise t h ro u g h the lesser c u rve toward the 1 o'clock posit i o n .

•

Te nsion is a p p l i ed to the h e l i c a l retractor ca u d a l ly a n d the a p p roxi m a t i n g a r m i s p u l led prox i m a l ly w h i l e desuf­

•

Two a d d i t i o n a l sets of H-faste ners are d e p l oyed a r o u n d the 1 o ' c l o c k posit i o n .

flating the sto m a c h .

Greater Curve Deep Plication •

•

•

•

The p u rpose of t h i s m a n e uver is to fixate the g reater c u rvatu re s l i g htly more proxi m a l ly on the eso p h a g u s . T h i s l e n gthens the a nti refl ux valve. The h e l i x retractor is d i se n g a g ed from the 1 2 o'clock po­ sition and re-e n g a g ed at the s q u a m o co l u m n a r j u n ct i o n at the 6 o ' c l o c k posit i o n . The ret i c u l a t i n g a r m is m oved i nto the 5 o'clock posit i o n a n d o n e o r t w o sets of fasten e rs a re 2 to 4 em proxi m a l t o t h e s q u a m o co l u m n a r j u nction (FIG 1 2) . The newly constructed a nti refl ux va lve s h o u l d be 200 to 300 deg rees in c i rcu mfere nce.

Esophageal lumen

Inspection of the Newly Created Antireflux Valve •

The device a n d e n d oscope a re withd rawn together a n d

•

t h e n e n d oscope is rem oved from t h e EsophyX device. The endoscope is then advanced back i nto the stomach to a l low i nspection of the a nt i refl ux valve and to assess for

FIG 13 • M u lt i p l e p u r p l e polypropylene faste ners are visua l i zed with the d i st a l eso p h a g u s afte r TIF is com p l eted. These fasten e rs a re not typ i ca l ly seen when retroflex i n g from with i n the sto m a c h .

C h a p t e r 26 T H E M I N I MALLY I N VASIVE S U RG I CAL APPROACH TO GASTROESOPHAGEAL RE FLUX D I S EASE

RADIOFREQUENCY ENERGY APPLICATION

Preoperative Planning

TO THE LOWER ESOPHAGEAL SPHINCTER

•

•

App roved by the FDA in 2000, the Stretta system (Mederi Thera peutics I n c, G reenwich, CT) is cu rrently the only device on the m a r ket that uses ra d i ofre q u e ncy en ergy fo r the treatment of G E R D.4

•

The a p p l ication of ra d i ofreq u e n cy e n e rgy to the G E

•

j u nction resu lts i n therm a l i nj u ry a n d subsequent scar­ r i n g , w h i c h red u ces LES co m p l i a nce, decreases the n u m ­ b e r o f tra nsient LES rel axations, a n d thereby decreases the i n c i d e nce of refl ux sym ptoms. T h e St retta syst e m is c o m posed of two m a i n c o m po­ n e nts: a r a d i ofreq u e n cy g e n e rator and a catheter syst e m t h a t c o n n e cts to t h e g e n e rator. T h e catheter system i s c o m posed of an o u t e r s h e a t h , a 30-Fr b o u ­ g i e t i p, a n d fo u r n i c k e l -tita n i u m 2 2 -g a u g e n e e d l e e l ectrodes s u r ro u n d i n g a b a l l oo n . T h e syst e m a l so i n ­

•

formed in the e n d oscopy su ite as o p posed to the operat­ ing roo m . O n l y o n e phys ic i a n is typ i ca l ly needed to perform the p roced u re .

Positioning •

After a d m i n istration of consc i o u s sedation m e d i cations, the patient is p l aced i nto the l eft l atera l decubitus posi­ tion a n d a b ite b l ock i s placed.

Placement of the Stretta Device into the Distal Esophagus •

c l u d e s a c h a n n e l for s u c t i o n a n d a n ot h e r for i rr i g a t i o n

(FIG 1 4) .

Conscious sedation is u s u a l l y a d e q u ate for use of the Stretta syste m . At o u r i nstitution, Stretta is usu a l ly per­

• •

A sta n d a rd end oscope is adva n ced down to the G E j u nc­ t i o n . The d ista nce from the patie nt's l i ps to the sq u a m o­ co l u m n a r j u n ction is m e a s u red. A g u i dewire is i nserted t h ro u g h the wo r k i n g c h a n n e l of the e n d oscope a n d the e n d osco pe is remove d . U n d e r f l u o rosco p i c g u id a n ce, the catheter system is then passed over the g u i dewire i nto the sto m a c h . The cath­ eter tip i s then positioned 1 em a bove the s q u a m o co l u m ­ n a r j u n ction based o n measu rements o bta i n e d from the e n d osco p i c eva l u at i o n .

Application of Radiofrequency Energy •

The b a l loon is i nfl ated to a pressure of 2 l b/i n 2 .

•

T h e e l ectrodes a re t h e n d e p l oyed t h r o u g h t h e m u cosa and i nto t h e m u sc u l a r i s p r o p ri a . Suction and i r r i g a ­ t i o n a re i n i t i ated t h r o u g h t h e i r respective work i n g

•

channels. The g e n e rator is a ctivated a n d ra d i ofre q u e n cy e n e rgy is a p p l i ed for a p p roximately 90 seconds per a p p l icati o n . D u r i n g t h i s process, the m uscu l a r i s propria is h eated to a te m p e rature of 85°C, whereas the eso p h a g e a l m u cosa

A

is m a i ntai ned b e l ow 50°C via cold water that i s i nsti l l ed through the catheter system . This creates fo u r a b lation sites that are d istri buted 90 deg rees a p a rt from each •

•

oth e r. After the 90-second i nterva l is com p l ete, the catheter system is rotated 45 deg rees and a n other cycl e of radio­ freq u e n cy e n e rgy is d e l ivered for 90 seconds. F o l l ow i n g t h i s cyc le, e i g h t l e s i o n s a p p roxi mately 45 d e g rees a p a rt a re created i n a c i rcu mferent i a l fash i o n at that leve l . The catheter system is advanced a p p roxi m ately 5 m m a n d t h e process is repeated t o create a n other 8 s ites of a b l a t io n . In tota l, t h i s p rocess is performed at six l eve ls (from 1 em p roxi m a l to the s q u a m o co l u m n a r j u nct i o n to the proxi m a l gastric cardi a), creat i n g 48 a b lation s ites

•

(FIG 1 5) . The Stretta system is then remove d .

B •

A. Schematic rep resentation of the Stretta catheter syste m . The d i sta l end is com posed of a 30-Fr b o u g i e t i p . The n i ckel-tita n i u m n e e d l e e l ectrodes can be s e e n p o i n t i n g outward surro u n d i n g the b a l l o o n . B. R a d i ofreq uency g e n e rator ( i m a ges © 20 1 5 Mederi Thera peutics I n c) . FIG 1 4

Inspection of the Gastroesophageal Junction •

The e n d oscope is adva n ced back down to the G E j u nc­ tion to a l low i nspection of the rad iofreq uency e n e rgy a p p l ication s ite (FIG 1 6) .

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FIG 1 5 • Coro n a l section t h ro u g h the eso p h a g u s with the e l ectrodes positioned 1 em prox i m a l to the s q u a m o co l u m n a r j u n ct i o n . Two e l ectrodes can be seen ente r i n g t h e m uscu l a r i s propria. After t h e tissue has been a b l ated at s i x l evels ( i n d i cated by wh ite), the GE j u n ction w i l l eventua l ly sca r down as a result of the therm a l i n j u ry ( i m ages © 2 0 1 5 Mederi Thera peutics I n c) .

• Retroflexed views o f t h e G E j u n ction i m med iately before (A} a n d after (B) use of the Stretta device.

FIG 16 A

B

•

LOWER ESOPHAGEAL SPHINCTER AUGMENTATION SURGERY •

The

o n ly co m m e rc i a l ly a va i l a b l e

s u re of the p e ri sta l s i s ove rco mes the m a g n et i c f i e l d Ja p a rosco p i c

LES

with i n the L I N X d e v i c e t h e reby a l lowi n g the d e v i c e t o o p e n a n d f o o d to enter i nto the sto m a c h . T h e m a g n et i c

a u g m e nt a t i o n d e v i c e i n t h e U n ited States i s t h e L I N X Refl ux M a n a g e m e n t Syste m (To rax M e d i c a l , S t . Pa u l ,

beads c a n a l so sepa rate w h e n i ntragast r i c pressure ex­

M N ) . T h e L I N X syst e m i s d e s i g n e d t o d e c rease refl ux of g a st r i c conte nts i nto t h e d i sta l eso p h a g u s v i a p l ace­ ment of a f l ex i b l e, expa n d a b l e device c o n s i st i n g of m u lt i p l e i nt e r l i n ked t i ta n i u m b e a d s with a m a g n e t i c •

A

With the device i n p l ace, o n ce a patient swa l l ows a n d eso p h a g e a l p e r i sta l s i s reaches the G E j u n ct i o n , the p res­

core (FIG 1 7) . When p l a ced a ro u n d the G E j u nction, it e n h a nces the a b i l ity of the LES to resi st open i n g a n d p revent refl ux i nto the eso p h a g u s .

B

ceeds the m a g n et i c stre ngth of the beads, w h i c h a l l ows t h e patient to b e l c h or v o m i t if/w h e n necessa ry.

Preoperative Planning •

G e n e r a l a n esthesia is necessa ry.

•

Preoperative prophyl actic anti b iotics a re a d m i n istered p r i o r to i n c i s i o n to reduce the c h a n ce of i nfect i o n .

FIG 1 7 • A. L I N X device fu l ly open with sutu res at each end. B. M a g n et i c beads at each e n d are b ro u g ht together. T h i s is the confi g u ration that the d e v i c e is i n when p l aced a ro u n d the G E j u n ct i o n .

C h a p t e r 26 T H E M I N I MALLY I N VASIVE S U RG I CAL APPROACH TO GASTROESOPHAGEAL RE FLUX D I S EASE

•

A 5 - m m camera is i nserted t h ro u g h the s u p ra u m b i l ica l port, w h i c h is operated by a n assista nt s u rgeon sta n d i n g o n t h e patie nt's l eft. T h e operat i n g s u rgeon sta nds between the patie nt's legs a n d uses the 5 - m m r i g ht u p p e r q u a d ra nt port a n d the 8-m m port. The o perat i n g s u rgeon u s e s a b l u nt g rasper (l eft ha nd) a n d a n u ltra­ sonic d i ssector (right hand) to enter the lesser sac v i a the p a rs flaccida. The l eft u p p e r outer 5 - m m port is used by the assista nt s u rgeon to retract the sto m a c h d ownward and latera l l y towa rd the spleen to fac i l itate d i ssection of the GE j u nct i o n .

Dissection of Gastroesophageal Junction •

is i d entified t o fac i l itate the d i ssect i o n o f the retro­ eso p h a g e a l space (FIG 1 9) . The poste rior va g a l tru n k is i d e ntified and p rese rved . The m ed i a l border of the l eft

•

A 5 - m m s u p ra u m b i l ic a l port, 8-m m left u p p e r q u a d rant port, 5 - m m l eft u p p e r o u t e r q u a d rant port, a n d 5 - m m r i g h t u p p e r q u a d rant port a re p l aced. A b l a ded 5 - m m s u bxi p h o i d port is tempora r i l y p l aced to faci l itate i nsertion of a l iver retractor. The s u rgeon sta nds between the patient's legs a n d uses the 5 - m m r i g ht u p p e r q u a d ra nt port a n d 8-mm port. The assista nt o n the patient's l eft contro ls the c a m e ra a n d retra cts the stomach i nferiorly via the 5 - m m r i g ht u p p e r o u t e r q u a d ra nt port.

FIG 1 8

The m ed i a l border of the r i g ht crus of the d i a p h ra g m

crus is then i d e ntified from the patient's l eft to further open the retroesop h a g e a l space. The b l u nt g ra s p e r i n t h e s u rg e o n 's l eft h a n d is t h e n p a ssed t h r o u g h t h e retroeso p h a g e a l p l a n e between t h e poste r i o r eso p h a g e a l wa l l and t h e p oste r i o r va g a l

•

tru n k, w h i c h i s preserved . T h e t i p of t h e g ra s p e r exits t h e retroeso p h a g e a l t u n n e l a nt e r i o r to t h e l eft c r u s of t h e d i a p h r a g m a n d i s m a i nta i ned i n t h a t locat i o n .

Positioning •

The patient can be p l aced i nto either the s u p i n e or s p l it­ leg position o n the operat i n g room ta b l e .

Device Selection and Placement •

A Pen rose is p l aced i nto the u p p e r a b d o m e n a n d p u l led through the retroeso phagea l t u n n e l . This serves as a tract for sm ooth passage of the sizer.

Port Placement and Initial Dissection •

O u r tech n i q u e i nvolves i n it i a l p l acement of a Ve ress need l e i n the l eft u p per q u a d ra nt. F o u r ports a r e s u b­ seq u e ntly p l aced i n c l u d i n g a 5 - m m s u p ra u m b i l ic a l port, 8-mm l eft u p p e r q u a d ra nt port, 5 - m m l eft u p p e r outer q u a d rant port, and 5 - m m right upper q u a d ra nt port. A 5 - m m port is tem pora r i l y p l aced in the subxi p h o i d po­

•

The s i z i n g i nstr u m e nt is p l aced i nto the a bd o m e n through the 5-mm port (su rgeon's l eft h a nd) a n d advanced through the retroeso phagea l p l a n e from the patient's right to left.

•

The wh ite port i o n of the s i z i n g i nstr u m e nt is then t i g ht­ ened a ro u n d the GE j u n ction cepha l a d to the hepatic branches of the a nterior vag a l trunk. As the c i rcu mference

sition to fac i l itate p l acement of a l iver retractor (FIG 1 8) .

Blunt g rasper posterior to the d i stal esophagus

A • A,B. A b l u nt g rasper i n the su rgeon's l eft h a n d retracts the m ed i a l border o f the r i g ht c r u s latera l l y t o open u p the retroeso p h a g e a l plane while the p roxi m a l sto m a c h is retracted i nferiorly a n d latera l ly. The vagus nerve has been m o b i l ized away from the eso p h a g u s to open up the p l a n e for the sizer to be i ntrod uced . (Photo cou rtesy of D r. Kyl e Perry, The O h i o State U n ive rsity Wexner M e d i c a l Center.)

FIG 1 9

Right d i a p h ragmatic crus

B

Proximal stomach retracted i nferiorly

209

210

P a rt 1

•

OPERATIVE TECH NIQUES IN THORACIC AND ESOPHAG EAL SURGERY

the G E j u n ction a nteriorly. T h e sutu res at e a c h end o f t h e

of the sizer a p p roaches that of the G E j u n ct i o n , the a p­ propriate L I N X device size w i l l be i n d i cated on the s i z i n g device (FIG 20) . The s i z i n g i nstr u m e n t is rem oved a n d the L I N X device is i nserted through the same p l a n e that the sizer was p l aced t h ro u g h . The L I N X device is then wra p ped a r o u n d

FIG 20 • W i t h the sizer g e n t l y wra p ped a r o u n d the G E j u n ct i o n anteriorly, the a p p ro p r i ate length of the L I N X device is est i m ated a n d the L I N X device is mod ified so that the length of the device matches t h i s d ista nce. (Photo cou rtesy of D r. Kyl e Perry, The O h i o State U n ive rsity Wexner M e d i ca l Center.)

device a r e t h e n secu red with a Ti- K n ot device or secu r­ i n g the m a g n etic c l a s p depend i n g on the vers i o n of the device e m p l oyed (FIG 21 ) . •

The a bd o m e n is desufflated, the ports a re rem oved, a n d the s k i n i n cisions a r e sutu red closed.

FIG 2 1 • The LINX device is i n p l a ce a r o u n d the GE j u nct i o n . The sutu res at each are retracted su periorly a n d i nfe riorly to i l l ustrate i d e a l positi o n i n g of the device. (Photo cou rtesy of D r. Kyl e Perry, The O h i o State U n ivers ity Wexner M e d i c a l Center.)

PEARLS AND PITFALLS Pitfall

Pearl

Transoral incisionless fundoplication •

Cervical eso p h a g e a l i nj u ry d u ri n g p l acement of the device g iven the relatively l a rge size of the device

•

•

•

Posto perative b l eed i n g d u e to h e l ix retractor p l a ce m e nt or d u ri n g faste n e r p l acement, p a rticu l a r l y a l o n g the lesser c u rve of the stomach

•

• •

•

G a stric or eso p h a g ea l perfo rat i o n rel ated to faste ner p l a ce m e nt

•

•

D i lation of the eso p h a g u s with a l a rg e b o u g i e (i.e., 56 F r) a n d g e n erous a p p l ication of l u bricant to the device w i l l m i n i m ize t h e l i ke l i hood of esophagea l i nj u ry. N a sotrachea l i ntubation w i l l h e l p c l e a r the oro p h a rynx for EsophyX device i nsert i o n . M i n i m i ze the n u m be r of t i m es t h a t the h e l ix retractor is d e p l oyed (once at the 1 2 o'clock position and once at the 6 o'clock posit i o n s h o u l d be e n o u g h ) . M i n i m i ze faste ner p l a ce m e nt a l o n g the l esser c u rvatu re. Postproce d u r a l EGD w i l l identify early b l eed i n g that may occu r d u ri n g these steps; if i d e ntified, e n d oc l i ps can be placed. Avo i d p l acement of the faste ners t h ro u g h the d i a p h ra g m at i c crura by ensu r i n g that the faste n e rs a re d e p l oyed b e l ow the p o i n t where the crura cross the esop hagea l wa l l . Ad m i n ister a n t i e m et i cs agg ressively t o avoid s i g n ificant posto pera­ tive retc h i n g which may p u l l on the faste n e rs.

Radiofrequency energy application •

I m p recise ra d i ofreq u e n cy e n e rgy a p p l ication d u e to patient movement d u r i n g the proced u re

•

Ad e q u ate a m o u nts of anxio lytic a n d na rcoti c m e d i cations wi l l h e l p m i n i m ize patient moveme nt; if necessa ry, g e n e ra l a n esthesia c a n be a d m i n iste red.

•

Overd istenti o n of the sto m a c h from excess i rrigation f l u i d

•

M o n itor the suction return c l osely to p revent the stomach from fi l l i n g up with i rriga nt; there s h o u l d be essent i a l ly a 1 : 1 correlation between i rrigation a n d suct i o n f l u i d .

•

U n even e n e rgy a p p l ication v i a the fo u r-need l e e l ectrodes d u e to asym m etry of the G E j u n ction ( i . e . , if a sm a l l h iata l h e r n i a i s p resent)

•

M o re t h a n two device rotations per level may be necessa ry to e n s u re that the ra d i ofreq uency en ergy i s a p p l i ed at n u m e rous poi nts t h ro u g hout the c i rcu mference of the eso p h a g u s .

C h a p t e r 26 T H E M I N I MALLY I N VASIVE S U RG I CAL APPROACH TO GASTROESOPHAGEAL RE FLUX D I S EASE

211

Lower esophageal augmentation surgery •

Eso p h a g e a l i nj u ry wh i l e deve l o p i n g the retroeso p h a g e a l p l a n e .

• •

M i n i m ize the u s e of the u ltraso n i c d i ssecto r n e a r the eso p h a g u s . To m i n i m ize b l eed i n g n e a r the poste rior va g a l tru n k, w h i c h may obscu re the retroeso phagea l p l a ne, ca refu l ly a n d b l u ntly d i ssect with a M a ry l a n d or b l u nt g rasper.

•

Posto perative dysp h a g i a d u e to excessive restriction from the device

•

E n s u re that there is n o tension on the sizer when measu r i n g the c i rcu mference a r o u n d the G E j u n ct i o n .

•

Device m i g ration

•

When developing the retroesophageal plane, m i n i m ize the a mount of dissection posterior to the G E j u nction. The dissection only needs to be wide enough to permit passage of the sizer.

POSTOPERATIVE CARE •

•

•

TIF-Patients are admitted postoperatively for overnight observation. A liquid diet is initiated following the proce­ dure and advanced to a soft solid diet within the next several weeks. Antiemetics are administered liberally to minimize postoperative retching. Routine postoperative imaging is not obtained. Radiofrequency energy application-Patients are discharged home on the day of the procedure. They are kept on a liquid diet for the first several weeks and are subsequently advanced to a soft solid diet. Routine postoperative imaging is not obtained. LES augmentation surgery-Patients are admitted to the hospital overnight. During our early experience, as part of a clinical trial, all patients underwent a routine chest x-ray and barium esophagram to verify correct position of the device. Routine imaging is not currently obtained. The patient may resume a normal diet immediately after the procedure.

OUTCOMES •

•

•

TIF-With the earliest case series being published in 2 0 0 8 , 5 truly long-term data regarding TIF are lacking. In 2 0 1 2 , Trad and colleagues6 published their data which in­ volved 28 patients and a median follow-up of 14 months. Eighty-two percent of patients remained off their daily antireflux medications, whereas 6 8 % were satisfied with the results of the procedure.6 Heartburn and regurgitation symptoms were eliminated in 65 % and 8 0 % of patients, respectively. Radiofrequency energy application-In the earliest mul­ ticenter trial conducted in the United States (involving 47 patients ), 87% of patients had discontinued their antire­ flux medications at 6 months while quality of life improved and esophageal exposure to acid (pH "7

.

7 "7 7

..,


4 . 0 g/dL), pancreatitis, and small stones in the gallbladder have all been forwarded as indications for IOC. Intraoperative indications would include palpating stones in the CBD, unclear biliary anatomy, or to evaluate for inad­ vertent inj ury to the biliary tree.1

IMAGING AND OTHER DIAGNOSTIC STUDIES •

Prior to proceeding with cholecystectomy with IOC, patients should have an ultrasound evaluation of their biliary tree to assess for cholelithiasis, cholecystitis, and to determine the diameter of the extrahepatic CBD. Note that abdomi­ nal ultrasound is not a sensitive indicator of choledocholi­ thiasis as CBD gallstones are often located in the distal CBD within the intrapancreatic portion and are thus obscured by

•

Da wood G. Dala ly

air in the overlying stomach and/or are beyond the depth of penetration of ultrasound. In the absence of cholangitis, but presence of ultrasound or laboratory findings suggestive of choledocholithiasis, one forwarded option is to preoperatively evaluate the biliary tree with magnetic resonance cholangiopancreatography (MRCP) to determine the cause of biliary tree obstruction. Should biliary obstruction be present, preoperative endo­ scopic retrograde cholangiopancreatography ( ERCP) is then performed to clear the duct of stones prior to cholecys­ tectomy or identify more ominous etiologies of the biliary obstruction. Alternatively, others have advocated directly proceeding to cholecystectomy with roc in this clinical setting, arguing that current modalities lack accuracy in identifying clinically significant choledocholithiasis and performance of an roc often clears the duct of small stones. As such, these surgeons argue that the presurgical probability that an ERCP is neces­ sary is low and this approach is more cost-effective by avoid­ ing unnecessary ERCP.

SURGICAL MANAGEMENT Positioning •

The patient should be placed in the supine position on the operating room table. The left arm is preferentially tucked against the torso to provide room for C-arm fluoroscopy. The table should be positioned with respect to the support­ ing pedestal so as to allow the fluoroscopy C-arm to slide underneath the operating table unobstructed ( FIG 1 ) .

• A . T h e patient is positioned s u p i n e with t h e l eft a r m tucked . A footboa rd i s p l aced . T h e C-a rm f l u o roscopy u n it is positioned to the patient's l eft, with the m o n itor rea d i ly visible to the operat i n g s u rgeon who is o n the patient's rig ht. B. The patient m ust be positioned with respect to the ped esta l of the operati n g table so that there is a d e q u ate room for the C-a r m . (continued)

FIG 1

508

C h a p t e r 5 I N TRAOPE RATIVE CHOLAN G I O G RAM

•

•

509

The C-arro fluoroscopy unit should be positioned to the patient's right with the screen monitor clearly visible to the operating surgeon. The bed should have a footboard placed and the patient should be well secured to the operating table, as reverse Trendelenburg position is required during the procedure.

Radiation Safety •

•

The surgeon must be knowledgeable in the use of fluoros­ copy. This should include successful completion of institu­ tional training including certification for use of fluoroscopy in the operating theater. All operating room personnel should don appropriate pro­ tective garments prior to scrubbing and gowning.

c • (continued) C. Photogra p h d e m o nstrating a c l e a r path beneath the abdomen of the patient for the C-a r m .

FIG 1

CHOLANG IOCATH ETER PLACEMENT •

Cysti c d uct a p p roach The g a l l b l a d d e r i nfund i b u l u m s h o u l d be m o b i l ized and d issection of C a l ot's tri a n g l e s h o u l d ide ntify the cystic d u ct a n d a rtery ente r i n g the i n fu n d i b u l u m . • Once the cystic d uct is c i rcu mferenti a l l y d i ssected, a c l i p s h o u l d be p l aced across the cystic d u ct as proxi­ mal as poss i b l e to the i nfu n d i b u l u m (FIG 2). • A d u ctoto my s h o u l d be m a d e a l o n g the cystic d u ct, l eavi n g a d e q u ate l e n gth for s u bseq uent d o u b l e c l i p l i gati o n . Ca re m ust be t a k e n to avo i d f u l l y tra nsecti ng the d u ct w i t h this m a n e u ver. An i ntact poste rior-ce p h a l a d cystic d u ct wa l l is esse nti a l to •

FIG 2

•

•

m a i nta i n exposure a n d fac i l itate p l acement of the c h o l a n g iogram catheter (FIG 3). N ote that it is typ i ­ cal fo r the d u ctoto my t o e n l a rg e w i t h the n ecessa ry late r a l retraction to provide exposure or with m a ­ n i p u lation w i t h the c h o l a n g i o g ra m catheter. F u r­ therm o re, the skeleto n i zed cystic d u ct typ i ca l ly l acks i ntrinsic stre ngth and can tea r easily with a g g ressive retraction once a d u ctoto my has been m a d e . Two tech n i q ues for p l acement of the ch o l a n g i ocatheter for l a p a rosco p i c IOC have been described: The fi rst tech n i q u e e m p l oys a 5-Fr c h o l a n g io­ cath ete r i n serted t h ro u g h a n i ntrod ucer sheath (FIG 4). This sh eath, ava i l a b l e as a co m ponent

Aher c i rcu mferentia l d i ssection of the cystic d u ct, a clip i s a p p l i ed at the j u nction with the i nfund i b u l u m .

51 0

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

A FIG 3

•

B A. A d u ctotomy is sharply i ncised . B. The d u ctotomy s h o u l d j ust be l a rg e e n o u g h to a d m it a s m a l l-ca l i be r

catheter. N ote the majority of the cystic d uct re m a i n s i ntact. of c o m m e rc i a l ly ava i l a b l e c h o l a n g i o g ra m cath­ eter k its, i s i nserted t h roug h a sepa rate i ncision a l o n g the r i g ht su bcostal m a rg i n . Placem ent of this i ncision s h o u l d be g u ided by l ocation of the d u ctotomy. I d e a l ly, the cath ete r enters the a bdomen l atera l a n d caudad to the cysti c d uct (FIG S). The catheter is then gently g u ided i nto the cys­ tic d u ct with atra u m atic tech n i q u e a n d secu red with a parti a l l y occl u d i n g c l i p p l aced j u st d i sta l to the d u ctotomy. An a ltern ative tec h n i q u e is to use an O lsen­ Red d ick c l a m p (FIG 6). This device h a s a c h a n n e l •

t h ro u g h the center of the c l a m p to accommo­ date a 5-Fr c h o l a n g i ocatheter. The clamp is ad­ va n ced t h o u g h a l atera l ly p l aced troca r. Once i ntra a bd o m i n a l , the jaws of the clamp a re opened a n d the c h o l a n g iocatheter is i nserted t h ro u g h the center c h a n n e l u n t i l the catheter tip extends beyo nd the jaws of the c l a m p . The catheter is then d i rected i nto the cysti c d u ct. Once in p l ace, the jaws of the c l a m p are c l osed a ro u n d the cyst ic d u ct and c h o l a n g i ocatheter, preventi n g leakage of contrast through the d u ctotomy (see FIG 2). This m ethod re m ove the use of c l i ps a l o n g the cystic d uct during I O C . I nfund i b u l a r a p p roach • This a p p roach is l ess tech n i c a l l y d e m a n d i n g t h a n d i ­ rect ca n n u l ation of the cyst ic d u ct. It is a lso of va l u e s h o u l d i d e ntification o f t h e cystic d u ct be d iffic u l t seco n d a ry to i nf l a m mation o r sca rring of the porta he patis; however, in t h i s c l i n i ca l setting, the cystic d u ct may be occluded, prec l u d i n g the a p p roach.

/ FIG 4 • The c h o l a n g iogram catheter is i nserted i nto the cystic d uct. The catheter d e p i cted has a n expa n d a b l e cuff that can be a p p reci ated with i n the cystic d uct.

FIG 5 • Ca n n u lation of the cysti c d u ct u s i n g a flex i b l e 5-Fr c h o l a n g iogram cath eter. A c l i p i s p l a ced across the cystic d uct j u st proxi m a l to i nfund i b u l u m of the g a l l b l a d d e r a n d a seco nd, no noccl u d i n g c l i p is p l aced a cross the cystic d uct a n d catheter t o prevent retrograde leakage o f contrast m ate ria l .

C h a p t e r 5 I N TRAOPE RATIVE CHOLAN G I O G RAM

•

"-'---___:-.,---�:----

Olsen -Reddick clamp

• An O lsen-Red d i c k c l a m p can be used to sta b i l ize a n d expose the cystic d u ct. The c l a m p has a c h a n n e l fo r passag e o f the c h o l a n g i o g r a m catheter.

FIG 6

•

The peritoneum should be incised and the i nfundib­ u l u m dissected free from the hepatic bed. Once the infu n d i b u l u m is mobil ized, a Kumar c l a m p should be inserted through a latera l ly p laced su bcosta l troca r. This c l a m p has long, atra umatic jaws, which com­ pletely occlude the infu n d i b u l u m , and a side channel for the i ntroduction of a need l e-ti pped cholang io­ catheter. The c l a m p is a p p l ied a long the lower body of the g a l l b ladder, just above H a rtmann's pouch (FIG 7). • Adva nce the K u m a r catheter thro u g h the side chan­ n e l a n d visua l i ze the need l e as H a rtm a n n 's pouch is p u n ctured. • Once the catheter is p l a ced, a s p i ration of b i l e con­ tents ensu res adequate b i l i a ry access. F u n d u s a p p roach • If neither cystic d u ct n o r i nfund i b u l a r a p p roaches a re fea s i b l e, a c h o l a n g iocatheter ca n be i n serted d i rect ly t h ro u g h the f u n d u s of the g a l l b l a d d er. This tech n i q u e is s i m i l a r to that of the cystic d uct a p p roach. D u r i n g IOC, a l a rg e r vo l u m e of contrast m u st be used as the entire g a l l b l a d d e r m u st fi l l p r i o r to visu a l i z i n g the cystic d u ct.

Jaws around H artmann's pouch Cholang iocatheter ----

FIG 7 • A K u m a r c l a m p is used when perfo r m i n g an IOC by i nject i n g the i nfu n d i b u l u m of the g a l l b l a d d e r. T h i s is the l east tech n ica l l y d e m a n d i n g a p p roach to I O C but not a n o pt i o n in the sett i n g of acute chol ecystitis.

51 1

51 2

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

Contrast-containing syringe

Butterfly needle

FIG 8 • A 25-gauge butterfly needle ca n be d i rectly i nserted i nto the CBD. When performed l a p a rosco p i ca l ly, one of the flanges of the needle can be rem oved to fac i l itate passa g e t h roug h the troca r. •

Need l e c h o l a n g iogram a p p roach I n the c l i n ical situation of acute c h o l ecystitis where i n f l a m mation is extensive a n d the p r i m a ry i n d icat i o n fo r c h o l a n g iography is defi n i n g the a n atomy of the b i l i a ry tree, the CBD ca n be d i rectly ca n n u ­ l ated w i t h a s m a l l-ga uge b utterfly n e e d l e (FIG 8). Once co m p l ete, the p u n cture s ite s h o u l d be cl osed

•

•

CHOLANG IOGRAM •

•

Prior to i nsertion, the c h o l a n g iogram catheter s h o u l d be fl ushed with sa l i n e to avo id i nject i o n of a i r b u b b l es that can easi ly be m i s i nterp reted as CBD sto nes. Once the c h o l a n g i o g ra m catheter has been successf u l l y p l aced, the cath ete r s h o u l d be g e n t l y fl ushed w i t h sa l i n e

• •

with a n i nterru pted 4-0 a bsorba b l e m o n ofi l a ment suture . Open tech n i q u e • D u r i n g open hepato b i l i a ry surgery, I O C may be per­ formed by i nsert i n g a c h o l a n g iocatheter in a s i m i l a r fash i o n u s i n g a n y o f the aforementioned l a p a ro­ sco p i c tech n i q ues.

to ensure n o leakage of contrast w i l l occ u r d u ri n g chol­ a n g i o g ra p hy. The f l u o roscopy C-a rm s h o u l d be m oved i nto position, ta k i n g ca re to m a i nta i n ste r i l ity (FIG 9). The accessory l a p a roscopic i nstrum ents a n d ca mera s h o u l d be removed.

• Operative photog raph of appropriate C-a rm positioning.

FIG 9

C h a p t e r 5 I N TRAOPE RATIVE CHOLAN G I O G RAM

A

B •

N o r m a l c h o l a n g i o g ra m . N ote visu a l ization of the entire b i l i a ry tree i n c l u d i n g the i ntra hepatic d u cts (arrow) (A) . Passage of contrast i nto the d uoden u m without fi l l i n g defects is a lso demonstrated (arrow) (B) .

FIG 1 0

• •

A test c h o l a n g i o g r a m s h o u l d be performed to verify ad­ e q u ate posit i o n i n g of the f l u o rosco p i c C-a r m . After position is verified, the IOC i s performed. Ten t o 2 5 m l of l ow osm o l a r, rad i o p a q u e contrast i s us u a l ly req u i red for visua l i zation of the entire b i l i a ry tree. The a uthors typica l ly d i l ute the water-so l u b l e contrast 1 : 1 in n o r m a l sa l i n e . An IOC is not adequate u n t i l the cysti c

•

d u ct, C B D , l eft a n d right hepatic d u cts, a n d passa g e of contrast i nto the d u o d e n u m a re a l l v i s u a l ized. T h i s may be fac i l itated by a lte r i n g patient positi o n i ng, using Tre n d e l e n b u rg, reverse Tre n d e l e n b u rg, a n d latera l rota­ tion of the patient (see FIG 6). Exa m p l es of d ista l o bstruct i o n rem ove from m a l i g n a ncy, i n fl a m m at i o n , or ca lcu l i a re shown in FIGS 1 0 to 1 2 .

• Visu a l i zation of a C B D sto ne by I O C . A fi l l i n g d efect is noted in the d ista l C B D ; there is lack of flow of contrast materi a l i nto the d u o d e n u m desp ite adequate pressure (black arrows). I ncidental fi l l i n g of the pancreatic d u ct can a lso be a p p reci ated i n this exa m p l e (white arrow).

FIG 11

51 3

51 4

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

A FIG 1 2

•

B A. B i l i a ry obstruct i o n d u e to m a l i g na n cy. B. N ote the i rreg u l a r border of the m a l i g n a nt "shelf" (arrow).

PEARLS AND PITFALLS Patient sel ect i o n

•

Routine versus sel ective a p p l ication of I O C is a s u bj ect of controve rsy.

S u rg i c a l m a n a g ement

•

Posit i o n i n g of the patient with respect to the pedesta l of the operat i n g table is essent i a l for access of the C-a rm f l u o roscopy u n it. The semicircular va lves of the cystic duct can i m pede the advancement of the cholang iogram catheter. Ca re m ust be taken to not ca use a laceration while advancing the catheter i nto the duct.

•

O p e rative decision making

•

I ntraoperative cholang iogram d u r i n g chol ecystectomy should be used whenever anatomy is confusi n g . If t h e cystic duct can not be adequately mobil ized, either t h e infu n d i b u l a r or f u n d u s approaches are acceptable a lternatives for p lacement of the cholangiocatheter.

Cholangiogram i nterpretation

•

F l ush the catheter prior to i nsert i o n to avoid the i ntrod u ction of a i r i nto the C B D . The b u b b l es that form ca n n ot be easily d iffe rentiated from sto nes. If the entire b i l i a ry tree can not i n itia l ly be visual ized during I OC, the patient should be repositioned to ensure flow of contrast is not being i n h i b ited by hyd rostatic pressure. If, after repositioni ng, the b i l i a ry tree can not be seen i n its enti rety, one should suspect an obstructive process or inadvertent d ucta l injury. If d ista l obstruction is identified, l ig ate the cystic d u ct rath e r t h a n c l i p it to red uce the risk of posto perative b i l e leak. Leave a d ra i n .

•

•

•

POSTOPERATIVE CARE

COMPLICATIONS

•

•

Postoperative care does not differ from that described for cholecystectomy.

• •

Laceration of the cystic duct or CBD Bile leak Radiation inj ury to the skin

OUTCOMES •

•

REFERENCES The selective application of IOC versus routine IOC remains a subj ect of controversy; differences in outcomes between the two approaches have not been well demonstrated.2•3 IOC with CBD exploration versus postoperative endoscopic retrograde cholangiography has been shown to be more cost-effective than routine preoperative assessment of CBD stones.4

1 . Metcalfe M5, Ong T, Bruening MH, et al. Is laparoscopic intraoperative cholangiogram a matter of routine? Am] Surg. 2004; 1 87(4) :475-4 8 1 . 2. Massarweh NN, Flum D R . Role of intraoperative cholangiography in avoiding bile duct injury. J Am Coli Surg. 2007;204(4):656-664. 3 . MacFadyen BV. Intraoperative cholangiography: past, present, and future. Surg Endosc. 2006;20(suppl 2):5436-5440. 4. Urbach DR, Khajanchee Y5, Jobe BA, et al. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retro­ grade cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 200 1 ; 1 5 ( 1 ):4-13.

I

-

Chapter

6

Percutaneous Transhepatic Biliary Imaging and Intervention ·----------------------------------------------------- ....

Brian 5. Geller

sensitive identifier of biliary pathology and typically precedes elevation of the TB. If the bile has become infected, the patient can also present with fever, leukocytosis, and sepsis. Bile leaks present with abdominal pain (secondary to a chemical perito­ nitis), fever, leukocytosis, nausea/vomiting, and jaundice.

DEFINITION •

•

•

•

Cholangiography is the term used to describe the evaluation of the biliary system by fluoroscopy after injection of radi­ opaque material (contrast) . The introduction of contrast can be performed either in a retrograde (via endoscope) or an antegrade manner. The antegrade introduction of contrast requires percutaneous transhepatic access into the biliary system. A percutaneous transhepatic cholangiogram (PTC) is commonly performed when a magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatogra­ phy (ERCP) were inconclusive or unable to be performed. When an obstruction of the biliary system cannot be managed by endoscopic means, a drainage catheter can be placed. This proce­ dure is known as percutaneous transhepatic drainage (PTHD). Numerous biliary pathologies are routinely managed by the percutaneous route: stone/debris removal, stricture dilation, long-term catheter drainage, and metallic stent placement.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

PATIENT HISTORY AND P HYSICAL FINDINGS •

•

•

A PTC is an invasive procedure and as such, non- or less invasive imaging of the biliary system should be attempted; these include MRCP and ERCP. If these options fail to make the diagnosis or cannot be performed due to the patient's anatomy, then a PTC should be performed. Indications for cholangiography include biliary stenosis or obstruction, or bile leak. The underlying pathology includes stones, malignancy, infection, inflammation, fibrosis/scarring, and iatrogenic complications. Patients with biliary obstruction or moderate- to high-grade stenosis usually present jaundice with elevations of the alkaline phosphatase (ALP) and total bilirubin (TB ) . ALP is a more

•

Ultrasound (US) or computed tomography ( CT) can be used to diagnose biliary dilation. Note: Posttransplant livers do not normally have dilated ducts when obstructed. First-line imaging of the biliary system is routinely a US. This modality is readily available, inexpensive, and uses no radiation. US is optimal for detection of biliary dilation, gallbladder pathology, and ascites. It also serves a role in the identification and characterization of hepatic masses and Doppler mode provides information regarding potential vas­ cular pathology ( FIG 1 ) . When a broader view o f the abdomen i s needed, a C T scan can be performed. Intravenous (IV) contrast is routinely administered, and due to the nature of the exam, the patient will be exposed to radiation (equivalent of - 1 0 0 chest x-rays) ( FIGS 2 and 3). MRCP can also be performed to evaluate the biliary system and surrounding liver parenchyma. Note that the nature of the magnetic resonance (MR) protocol that is required to optimally visualize, the biliary system, does not optimally assess surrounding structures, thus limiting the evaluation of nonbiliary pathology ( FIG 4) .

-�

{. ,\

t}

...

0 r-

� � FIG 1 • Axi a l US i m a g e of the l iver d e m o nstrati n g m a rked i ntra hepatic b i l i a ry d u ctal d i l at i o n .

�

e...

�� ��' .

Q �

FIG 2 • Axi a l CT i m a g e with m a rked i ntrahepatic b i l i a ry d u ctal d i lation a n d pan creatic d u ctal d i l at i o n .

51 5

51 6

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

FIG 5 • I m ages from a H I DA scan (fo u r i m ages on rig ht) of a tra u m a patient with a l iver l acerat i o n . There is tracer accu m u lation i n the reg i o n of the r i g ht hepatic l o be, w h i c h corresponds to an i n crea s i n g fluid co l l ecti o n on CT. FIG 3 • Axi a l CT i m a g e with b i l o m a a n d free fl u i d . The patient was fo l lowi n g right hepatectomy.

•

When evaluating for a bile leak, cholescintigraphy (also known as a hepatobiliary iminodiacetic acid [HIDA] or diisopropyl iminodiacetic acid [DISIDA] scan) can be performed. The radiopharmaceutical is taken up by the liver and excreted into the bile. When the tracer is seen accumulating outside of the liver, or in intrahepatic cavities, the diagnosis of leak can be confirmed (FIG 5) .

SURGICAL MANAGEMENT Preprocedure Planning •

•

•

•

Coro n a l i m a g e from M RCP d e m o nstrati ng d i l ation of the r i g ht a nte rior a n d l eft hepatic d u cts. The r i g ht posterior, co m m o n h epatic, a n d p a n creatic d u cts a re of norm a l ca l i ber.

FIG 4

All related imaging to the patient's condition should be reviewed. A PTCIPTIID can be performed either under conscious seda­ tion or with general anesthesia (preferred) . Thus, the patient ide­ ally will be nil per os for at least 6 hours prior to the procedure. For any procedure that manipulates the biliary system, there is an increased risk of septicemia and endotoxemia. The patient should receive antibiotics within 1 hour of start time. The mix of gastrointestinal flora should guide antibiotic choice (gram nega­ tives and anaerobes) . At our institution, piperacillin/tazobactam 3.375 g is routinely used. In patients who are penicillin allergic, ciprofloxacin 400 mg and metronidazole 500 mg are given. Unless the left-sided ducts are unilaterally dilated, a right­ sided approach is routinely used, as this will drain a larger portion of the liver and will decrease radiation exposure to the interventionalist.

Positioning •

PERCUTANEOUS TRANSHEPATIC

Biliary procedures are performed with the patient in the supine position, arms at the side.

•

CHOLANG IOGRAPHY Immediate Preprocedure •

The patie nt's abdomen s h o u l d be cleaned a n d prepped from the n i p p l e l i n e to the l eft m idaxi l la ry l i ne to 5 em below the u m b i l icus a n d beyo nd the r i g ht posterior axi l l a ry l i n e .

•

When rig ht-sided access is warra nted, a hemostat should be p laced at the right m idaxi l l a ry l i n e at the selected access site d u r i n g deep i n s p i ration (FIG 6). This is used to verify that the entrance site is below the g reatest d i a p h ra g m atic excursion. Access above this mark should not be attem pted as it exposes the patient to the risk of violating the pleura, resulting i n pneumothorax or b i l i a ry-p leural fist u l a . Loca l a n esthetic s h o u l d be u s e d a n d a sma l l i ncision (2 t o 3 m m ) m a d e to fac i l itate needle passag e .

C h a p t e r 6 PERCUTANEOUS TRA N S H E PATI C B I LIARY I M AG I N G A N D I NTERVE NTION

FIG 7 • F a n pattern of needle passes (solid line, i n it i a l pa ss; dashed line, s u bsequent passes) . Yellow i n d i cates m i d ax­ i l l a ry l i n e .

FIG 6

•

Placement o f hem ostat to m a r k the entrance site.

Duct Cannulation •

•

•

•

•

•

•

D u ct ca n n u l at i o n can be performed with a 1 5-cm, 2 1 o r 22-g a u g e C h i ba need l e . These need l es a re relatively sma l l (th e reby red u c i n g b l eed i n g risk) a n d ca n accept a 0 . 0 1 8-in w i re . When l eft-sided a ccess is req u i red, US is routi n e l y used to loca l ize a relatively su perfi c i a l d uct. The d u ct is then ca n n u l ated u n d e r d i rect U S g u i d a nce. D u e to the overlying ri bs, rig ht-s ided access is usu­ a l ly acco m p l ished with a " b l i n d " tech n i q ue, w h i c h ca n either be su bclassified i nto an a nteg rade or retrograde a p p roach. When u s i n g the retro g rade a p p roach, the C h i ba needle is adva n ced from the l iver margin to the m i daxi l l a ry l i ne . T h e stylet is removed, a n d u n d e r f l u o rosco py, a sma l l a m o u nt o f d i l ute contrast i s i nj ected a s t h e needle i s p u l led back. When u s i n g the a nteg rade a p p roach, the sty l et is rem oved from the C h i ba needle, a n d under f l u o rosco p i c g u i d a nce, the n e e d l e i s adva n ced w h i l e i nject i n g d i l ute contrast u n t i l reach i n g the m i dclavicu l a r l i n e . Rega rd less of a pproach, m u ltiple passes through the l iver at different obliqu ities (cra nia l-ca udal and anterior-posterior) are often req u i red before a duct is ca n n u l ated (FIG 7). The tech n ica l challenge and n u m ber of passes req u i red for successfu l ca n n u l ation is d i rectly related to the extent of i ntra hepatic b i l i a ry d i lation. This is particu la rly prob lematic i n the setting of bile d uct i nj u ry with a b i l i a ry tree that is fully decompressed i nto the peritoneal space. Peri pheral ca n n u lation is the g oa l . Ca n n u l ation of cen­ tra l ly l ocated d uct i n c reases the risk of a rte r i o b i l i a ry o r ven o b i l i a ry fist u l a a n d hemorrhage.

Cholangiogram •

It is very easy for a w e l l - p l aced n e e d l e to d islodge w h i l e the patient i s breat h i n g . To p revent t h i s from occu rring,

•

a 0 . 0 1 8-in w i re is p l aced through the C h i ba need l e a n d co i l e d with i n the b i l i a ry system . T h e n e e d l e i s exchanged for the inner port i o n of a n AccuStick catheter. A Tu ohy­ B o rst sidearm i ntroducer is then p l a ced over the w i re a n d attached t o the catheter, a l lowing f o r contrast i nject i o n w i t h o u t l oss of w i re access. W h i l e i nject i n g d i l ute contrast, either a n a n g i o g ra p h i c run o r static i m ages a r e o bta i n e d i n m u lt i p l e o b l i q u ities

(FIG 8). •

Once adequate i m ages are o bta i n ed, the catheter a n d w i re a re removed .

• PTC in a patient fo l l owi ng l iver tra n s p l a nt with h i story of hepaticoj ej u n ostomy stricture. C h o l a n g iogram demonstrates n o evidence of strict u re . I ntra hepatic d u cts were n o r m a l on other i m a g e s (not shown).

FIG 8

51 7

51 8

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

PERCUTANEOUS TRAN SHEPATI C DRAI N •

If d u rable access to the b i l i a ry tree is indicated, once a O.D1 8in wire is coi l ed with i n the b i l i a ry system, a fully assem bled AccuStick is advanced and the inner meta l l i c ca n n u l a and 4-Fr catheter are removed . A hydro p h i l i c wire and hockey­ stick catheter are then used to ca n n u late the sma l l bowe l .

•

•

•

• I nterna l/exter n a l b i l i a ry d r a i n a g e cath eters i n both the r i g ht anterior and poste rior d u cts.

FIG 9

The hydro p h i l i c w i re is removed a n d exchanged for a stiff wire thro u g h the hockey-stick cath eter. The tract is d i l ated to acco m m odate a b i l i a ry drainage catheter, which is po­ sitioned so the proxi m a l side holes a re d ra i n i n g the i ntra­ hepatic d u cts and the d ista l pigta i l is i n the bowel (FIG 9). The catheter s h o u l d then be sutured to the s k i n a n d p l a ced t o exte r n a l d r a i n a g e f o r 24 t o 48 h o u rs, after which it can be capped. If the a rea of ste nosis ca n n ot be crossed, a n exte r n a l d ra i n can be p l aced w i t h the p i gta i l coiled with i n the i ntrahepatic b i l i a ry d u cts (FIG 1 0). This catheter m ust be kept to g ravity bag d r a i n a g e .

FIG 1 0 • D i g ital s u btract i o n a n g iography (DSA) i m a g e of a n 8-Fr exte r n a l d r a i n a g e catheter with i n the m a i n hepatic d u ct.

•

Dilations

If the c h o l a n g i o g r a m shows that the a rea of ste nosis i s patent, a n exter n a l d ra i n a g e catheter i s p l aced w i t h the pigta i l peripheral to the a rea i n q u esti o n a n d capped

•

(FIG 1 0).

BALLOON D I LATION

•

•

• •

Postsurgical or foca l i n fl a m m ato ry sca rring can routi nely be treated with seria l ba l l oo n d i lation. With a stiff w i re in p l a ce, serial d i l atio ns, sta rti n g with ba l l oons 1 to 2 m m s m a l l e r than the a rea of stenosis a n d then 2 to 3 m m l a rg e r t h a n n o r m a l d u cts, a re performed. The l e n gth of the balloon can be either 2 o r 4 em i n l e n gth, depe n d i n g on the a rea o f ste nosis. When a reg u l a r b a l loon is not a d e q u ate, a sco r i n g b a l loon o r a cutt i n g balloon can be used i n ce rta i n circumstances, w h i c h a re dependent o n the a n at o m i c relationsh i p of the stricture to the hepatic vascu lature (FIG 1 1). After d i l ation, the same size or l a rger i nterna l/exte r n a l b i l i a ry d ra i n is re placed. D i l ations are pe rfo rmed eve ry 2 to 3 wee ks, for a tota l of t h ree d i lations.

Challenge •

When the patient returns 2 to 3 weeks after the t h i rd d i lation, a TB is d rawn preoperative ly.

Success or Failure • •

•

•

•

The patient returns in 1 to 2 weeks afte r c h a l l e n g e . A TB i s d rawn preoperative ly. A c h o l a n g iogram is pe rfo rmed t h roug h the exist i n g catheter. If the a rea i n q u estion rem a i n s patent a n d the b i l i ru b i n i s n o r m a l , the catheter i s removed. If either the c h o l a n g i o g r a m is a b n o r m a l or the b i l i ru b i n i s e l evated, t h e exter n a l d r a i n a g e catheter is rep l a ced with a n i nterna l/exte r n a l catheter (FIG 1 2). U nti l defi n itive s u r g i c a l m a n a g e m ent, the patient w i l l req u i re rout i n e (every 3 m o nths) c h a nges of this catheter. Alternative ly, if a n ato m i ca l ly fea s i b l e, an e n d osco p i ­ ca l l y retrieva b l e ste nt can be p l aced u n t i l defi n itive surgical m a n a g e m ent (see fo l l ow i n g d i scussion of " Stent Placement").

C h a p t e r 6 PERCUTANEOUS TRA N S H E PATI C B I LIARY I M AG I N G A N D I NTERVE NTION

A

• A. Sta n d a rd n o n co m p l i a nt b a l l o o n . B. A mod ified b a l loon a l l ows for the sco r i n g of the d u ctal wa l ls, w h i c h has s h o w n to i n c rease the c h a n ces of su ccessfu l d i lation. C. A cutt i n g b a l l o o n for extrem e l y d iffi cult ste noses. D u e to the r i s k of perforation, g reat ca re s h o u l d be t a k e n w h e n using this balloon.

FIG 1 1

.. -f-....:ucnu

c

• Arrow i n d i cates res i d u a l h i g h-grade a nastom otic strict u re after c h a l lenge. Patient req u i red replacement of the i nterna l/exter n a l d ra i n ag e cath eter.

FIG 1 2

STENT PLACEMENT Evaluation •

O n ly u n t i l rece ntly, m eta l l i c stents were permanent a n d reserved f o r th ose patients w i t h a I i f e expectancy o f l ess t h a n 6 months, as there is a 5 0 % occ l u s i o n rate a t t h i s i nterva l . ' W i t h i ntrod u ct i o n of the covered m eta l stents that can be end osco p i ca l ly exc h a n ged, patients with l o n g e r l ife expecta ncies can ben efit from i ndwe l l ­ i n g m eta l l i c stents (FIG 1 3). H owever, i n patients wh ose

•

•

b i l i a ry syste ms a re not endosco p i ca l ly access i ble, these stents ca n n ot be c h a n g e d . Once a PTH D has b e e n performed a n d the b i l i a ry system has had time to d ra i n (24 to 72 h o u rs), a form a l c h o l a n ­ g i o g r a m i s performed. There m ust be a n adequate l a n d i n g zone (p roxi m a l ly a n d d i sta l ly) for a m etal stent to be used . Add i t i o n a l ly, each a rea of ste nosis w i l l usu a l ly req u i re a ste nt. In m ost situations, a s i n g l e centra l a rea of stenosis of either the rig ht, l eft, a n d/o r main hepatic d u cts a re a m e n d a b l e

51 9

520

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

• C h o l a n g iogram d e m on strati n g m u lt i p l e centra l i ntra hepatic b i l i a ry strictu res as we l l as a l o n g -seg ment stricture of the peripheral com m o n bile d u ct consistent with a Klats k i n t u m o r. Due to the n u m ber of strictu res, this patient was not a ste nt ca n d i date.

FIG 1 4

FIG 1 3

•

A covered, se lf-exp a n d i n g m eta l b i l i a ry ste nt.

to stent p l acement. Patients with Klats k i n t u m o rs, who present with m u lt i p l e a reas of ste nosis, are typ i ca l ly not ca n d i d ates (FIG 1 4).

Placement • •

•

Over a stiff w i re, a properly sized ste nt is adva n ced a n d d e p l oyed (FIG 1 S). If the ste nosis i nvolves the d i stal co m m o n b i l e d u ct, a short seg ment of stent (1 to 2 m m ) s h o u l d extend i nto the sma l l bowe l . When there is an associated d u o d e n a l stricture that a l so req u i res ste nting, a l o n g e r seg ment o f the b i l i a ry ste nt s h o u l d exte n d i nto the bowe l, a l ongside the d u o d e n a l stent. A sma l l catheter s h o u l d re m a i n across the ste nt for 24 to 72 h o u rs.

Follow-up •

•

The patient s h o u l d return fo r a c h o l a n g i o g ra m in 24 to 72 h o u rs to d eterm i n e if the ste nt rem a i n s patent. If the ste nt is pate nt, the catheter ca n be removed . If the ste nt is occl uded, an i nterna l/exte r n a l catheter s h o u l d be placed. The patient s h o u l d return for ro uti ne catheter c h a n g es every 3 months.

FIG 1 S • With sheaths a n d w i res t h ro u g h both the right a n d l eft b i l i a ry d u cts, self-expa n d i n g stents were d e p l oyed. I n each ste nt i s a n a n g i o p l asty ba l l oon, w h i c h will be i nflated s i m u lta neously to p revent one from crush i n g the oth er.

C h a p t e r 6 PERCUTANEOUS TRA N S H E PATI C B I LIARY I M AG I N G A N D I NTERVE NTION

M ISCELLANEOUS BILIARY I NTERVENTIONS

•

Brushings/Biopsy •

•

Once a PTH D has been performed, the a rea of stenosis crossed and the b i l iary system has had time to d ra i n, and any associated blood that is i nvariably present after the i n itial access proced u re had cleared, biopsies ca n be performed. Both brushings and a forceps biopsy a re routi nely per­ formed to increase i n the l i kelihood of diagnosis (FIG 1 6). To obta i n brush i n gs, a sheath m u st be p l aced across the ste nosis, through w h i c h the brush system is adva n ced . The sheath is p u l led back to expose the brush syste m . T h e brush is adva n ced o u t o f its catheter m u lt i p l e times to co l l ect the ce l ls. The brush is removed a n d p l a ced in cyto logy so l uti o n .

When perfo r m i n g a forceps b i o psy, the sheath is p l aced j u st prox i m a l to the lesion and two to three s a m p l e s a re obta i n ed a n d p l a ced in form a l i n .

Stone and Debris •

•

•

After a d e q u ate d ra i na g e, a sheath is p l aced t h ro u g h w h i c h a n o n co m p l i a nt a n g i o p l asty b a l loon is adva n ced to d i late any c o m m o n b i l e d u ct strictu re, if present. U s i n g a co m p l i ant b a l loon, debris a n d sma l l sto nes a re swept i nto the co m m o n d u ct a n d then pushed i nto the bowe l . When the sto ne is too l a rg e to be pushed i nto the bowe l, a sto ne-crush i n g basket can be used to brea k the sto ne i nto smaller p i eces.

FIG 16

•

A. B i l i a ry brush. B. B i l i a ry i ntrod ucer force ps.

PEARLS AND PITFALLS Patient h i story a n d physica l f i n d i n g s O p e rative tech n i q u e

•

B i l i a ry d i lation does not n o rm a l ly occ u r in posttra n s p l a nt l ivers.

•

Defi n i n g maxi m u m i n s p i ration is i m po rtant to p revent p l e u r a l tra nsg ress i o n . To prevent septice m i a a n d e n d otoxe m i a, d i l ated b i l i a ry system s s h o u l d be d ra i ned f o r 24 t o 72 h o u rs after catheter p l acement. F u rther i nterve ntion s h o u l d be d e l ayed . Cross i n g the m id c l avicu l a r l i n e d u ri n g d uct ca n n u lation i n c reases the risk of a left-s ided ca n n u l ation as we l l as travers i n g centra l vessels i n the porta hepatis. M i n i m iz i n g the d u ctal entry angle a l l ows for a proper force vector when d i lating the tract and adva n c i n g the catheter. Each p u ncture of the l iver caps u l e i ncreases the risk of bleed i n g . When red i rect i n g the needle, care s h o u l d be m a d e not to rem ove it com p l etely from the l iver.

• • • •

Postoperative ca re

•

U pper endoscopy s h o u l d not be perfo rmed for u p to 6 weeks after PTH D to p reve nt l et h a l a i r e m b o l u s from poss i b l e b i l i a ry t o hepatic ve i n fistu l a .

521

522

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

POSTOPERATIVE CARE • •

•

•

Drainage catheters should be flushed twice a day with 10 mL of sterile 0 . 9 % saline. Patients with internallexternal biliary catheters that are capped should be instructed to uncap the catheter and place it to gravity bag drainage if they experience abdominal pain, fevers, leakage, or pruritus. They should be evaluated in the next 24 to 4 8 hours. During the process of a " challenge," it is not uncommon for there to be some leakage around the biliary catheter; this should resolve in a few days. If it does not resolve, it may indicate a challenge failure. When a patient is draining externally, the possibility of dehy­ dration and electrolyte loss must be taken into consideration. Patients should replace the amount of bile loss with an oral fluid that contains electrolyte replacement.

•

Average patency of metallic stents for malignant strictures is about 6 months. 1

COMPLICATIONS •

The risk of all complications is < 3 % 7 and include: Hemorrhage Bile leak Bile peritonitis Sepsis Pancreatitis Pleural transgression Contrast reaction Death

REFERENCES 1.

OUTCOMES •

•

•

•

For a PTC, the success rate is linked to whether the ducts are dilated. For a dilated system, the success rate nears 1 0 0 % , however, i n a non-obstructed system the success rate is con­ siderably lower ( 65 % ) .2 The success rate for all biliary interventions is dependent on the technical success of cannulating the biliary tree. The success rate for a dilated system is significantly higher than for a nondilated system (including transplants) , 9 9 % and 74 % , respectively.2•3 Once cannulated, internalization of the catheter is success­ ful in 78 % of native livers but only 5 9 % in transplanted livers .4 Technical and clinical success rates for balloon dilation of benign strictures are 9 3 % to 1 0 0 % and 75 % to 94%, respectively.5 However, there is a wide variation based on the location of stenosis. 6

2.

3.

4.

5.

6. 7.

Gordon RL, Ring EJ, LaBerge JM, et a!. Malignant biliary obstruction: treatment with expandable metallic scents-follow-up of 5 0 consecu­ tive patients. Radiology. 1 992; 1 82:697-70 1 . Jander HP, Galbraith J , Aldrete J S . Percutaneous transhepatic chol­ angiography using the Chiba needle: comparison with retrograde pancreatocholecystography. Southern Med ]. 1 9 8 0; 7 3 ( 4 ) : 4 1 5-42 1 . Mueller PR, Harbin WP, Ferrucci JT Jr, e t a!. Fine-needle transhepatic cholangiography: reflections after 450 cases. A1R Am 1 Roentgenol. 1 9 8 1 ; 1 36 : 8 5-90. Morita S, Kitanosono T, Lee D, et a!. Comparison of technical success and complications of percutaneous transhepatic cholangiography and biliary drainage between patients with and without transplanted liver. A1R Am 1 Roentgenol. 2012; 1 9 9 ( 5 ) : 1 1 49-1 152. Kucukay F, Okten RS, Yurdakul M, et al. Long-term results of percu­ taneous biliary balloon dilation treatment for benign hepaticojejunos­ tomy strictures: are repeated balloon dilations necessary? 1 Vase Interv Radial. 2012;23 : 1 347- 1 3 5 5 . Citron SJ, Martin L G . Benign biliary strictures: treatment with percu­ taneous cholangioplasty. Radiology. 1 9 9 1 ; 1 78 : 3 3 9-34 1 . Saad WEA, Wallace MJ, Woj ak JC, e t al. Quality improvement guide­ lines for percutaneous transhepatic cholangiography, biliary drainage, and cholecystostomy. 1 Vase Interv Radial. 2 0 1 0 ;2 1 : 78 9-795.

I

-

Chapter

7

Surgically Assisted Endoscopic Retrograde Cholangiopancreatoscopy ·----------------------------------------------------- ....

Kfir Ben-Da vid

•

DEFINITION •

•

•

•

•

Surgical assistance to successfully perform endoscopic retrograde cholangiopancreatoscopy (ERCP) is necessary when intestinal continuity has been surgically modified such that the ampulla of Vater cannot be accessed via the mouth. Previous gastric bypass with a long Roux-en-Y limb is the surgical procedure that leads to the need for surgically as­ sisted ERCP. The presence of a gastric remnant is essential to the perfor­ mance of surgically assisted endoscopic retrograde cholan­ giopancreatoscopy ( SA-ERCP) . Rarely, a clinical scenario may arise where surgical access to a gastric remnant may be indicated to facilitate endoscopic ultrasound (EUS ) . A s magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive means to assess the pancreatico­ biliary duct systems in most patients, ERCP is generally not indicated merely as a diagnostic modality-therapeutic in­ tent is the indication for ERCP; this concept must be empha­ sized when considering SA-ERCP.

DIFFERENTIAL DIAGNOSIS • •

Ste ven J. Hughes

• •

B

Ampulla of Vater pathology Intraductal papillary mucinous neoplasm (IPMN) Chronic pancreatitis Disrupted pancreatic duct syndrome

PATIENT HISTORY AND P HYSICAL FINDINGS •

•

•

•

Choledocholithiasis Sphincter of Oddi dysfunction

A

•

Historically, the most common indication for SA-ERCP was for the diagnosis and treatment of sphincter of Oddi dysfunction (SOD )-a condition thought to be elicited by gastric bypass surgery. However, results from a recent study have led to serious concerns about the value of therapeutic intervention for symptoms attributed to SOD . 1 A history of prior cholecystectomy must b e obtained. I f the gallbladder is in situ, a cholecystectomy is likely warranted as part of the SA-ERCP. The gastric bypass operative note must be reviewed. The lo­ cation of the Roux limb with respect to the gastric remnant and transverse colon must be known preoperatively and this information factored into the counseling the patient as to the risks of the procedure-an antegastric and/or an antecolic Roux limb will increase the technical complexity and thus risk { FIG 1 ) . Specifically review any potential allergy t o iodinated con­ trast agents. Medical preparation to mitigate an allergic re­ action may be indicated.

c

FIG 1 • Anato m i c re lationsh i p s of the Roux l i m b fo l l owi n g g astric bypass (A) retroco l i c, retrogastric; (B) a nteco l ic, a ntegastric; a n d (C) retroco l ic, a nteg astric.

523

524

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

SURGICAL MANAGEMENT

Positioning

Preoperative Planning

•

•

•

•

The potential need for serial ERCP procedures should be determined. A gastrostomy tube ( G-tube) can be placed at the index procedure to facilitate subsequent endoscopic in­ terventions. Potentially affected patients should be prepared for this possibility. These operations require significant coordination between multidisciplinary teams. The authors highly recommend that these procedures be scheduled as the first case of the day. The procedure needs to be scheduled in a room that can accommodate two teams, a C-arm fluoroscopy unit, and a mobile endoscopy cart.

• •

•

The operative table should be configured so that C-arm fluoros­ copy can be readily performed of the upper abdomen ( FIG 2). After induction of general anesthesia, a urinary bladder catheter is placed. An orogastric tube is rarely necessary. The patient is positioned supine, ideally with both arms tucked to facilitate access for both C-arm fluoroscopy and the endoscopy team. A footboard is placed. A fixed liver retractor can be positioned on either side of the patient if needed. Venous thromboembolism prophylaxis ( both mechanical and pharmacologic) should be used. Antibiotics are admin­ istered within the guidelines of Surgical Care Improvement Program (SCIP) criteria for a clean-contaminated procedure.

Endoscopy cart

C-arm fluoroscopy

I

fluoroscopy

FIG 2 • The C-a rm f l u o roscopy u n it is positioned o n the patie nt's rig ht, a n d the m o b i l e d u odenoscopy eq u i p m e nt o n the patie nt's l eft.

B

A

TROCAR PLACEMENT •

Trocar p l acement is d e p i cted in FIG 3. F o u r trocars w i l l b e req u i red f o r p l a cement o f stay sutu res i n t h e sto mach, a n d one of these can be su bseq uently used fo r c l a m p i n g o f the sma l l bowe l . A subxiphoid, tra nsg astric troca r is a lso necessa ry.

•

•

I n it i a l troca r p l acement is performed in the l eft m i dcla­ vicu l a r l i ne at the level of the u m b i l icus fo l l owi n g i n s uf­ flation of the abdomen with a Ve ress need l e . The a uthors p refer the use of a n optica l sepa rator a n d a 30-deg ree scope. S u bseq uent trocars are p l aced under d i rect vision .

• Trocar p l acement for SA-ERCP. P n e u m o perito n e u m is esta b l ished via a l eft m i d a bd o m i n a l i n cision (alternatively, a peri u m b i l ical a pproach). The fa r r i g ht abdom i n a l 5-mm troca r is used for g ra s p i n g a n d the bowel clamp. The rig ht, m i d c l avicu l a r l i n e port (1 2 m m ) is used for suture a n d sta p l e r p l acement. The l eft a bdom i n a l 5- to 1 2- m m trocar is used for the camera and l eft port (5 mm) is used for g rasp i n g . T h e s u bxi p h o i d troca r (X) i s p l aced transgastrica l ly to provi de access for the duode noscope. It m ust be at l east 1 5 mm in d i a m eter.

FIG 3

C h a p t e r 7 S U R G I CALLY ASSISTED E N DOSCOPIC RETROGRADE CHOLA N G I O PANCREATOSCOPY

GASTRIC PEXY •

•

The patient is p l aced in reverse Tre n d e l e n b u rg position a n d the l ocati o n of the transgastric troca r p l acement dete r m i ned a n d m a rked . I d e a l ly, the troca r w i l l enter the a nterior g astric wa l l at the j u n ct i o n of the body a n d the a ntrum of the stomach at the m i d po i n t between t h e mesentery of the g reater a n d lesser c u rves. Determ i n e the re lationsh i p of an a ntegastric Roux l i m b a n d t h e associated m esentery t o t h e i d e a l ta rget f o r the tra nsg astric trocar. D i ssect i o n of the Roux l i m b o r m esen­ te ry should be taken with g reat ca ution; i n j u ry to o r vas­ c u l a r co m p rom ise of the Roux l i m b can be catastro p h i c . It i s better to accept a m o re l atera l target, i n c l u d i n g one that may req u i re ta k i n g down some of the g reater c u rve mesentery, t h a n to engage in a s i g n ificant d i ssect i o n of the Roux l i m b from the sto m a c h .

• •

F o u r sta b wo u n d s a re p l a ced a r o u n d the p l a n ned site of the tra nsgastric troca r. Sta rt i n g with the cra n i a l sutu re, fou r stay sutu res a re deeply p l a ced in the g astric wa l l a n d sna red u s i n g a Ca rter-Th omason device d e p l oyed t h ro u g h the a p p ro­ priate sta b wo u n d . If a G-tube i s p l a n ned, the Ca rte r­ Thomason s h o u l d not be passed t h ro u g h the same tract so that the stay suture can u lt i m ately be used to secu re the gastric wa l l to the a nterior a b d o m i n a l wa l l (Sta m m tec h n i q ue). Tag each suture without a p p lyi n g tension. The tension that will be su bseq uently a p p l ied to these sutu res is s i g n ificant and the risk of these sutu res l a cer­ ati ng the stomach u n d e r t h i s tension m ust not be u n ­ de resti mated . These sutu res s h o u l d be positi o n ed i n t h e stomach to create a 3 em x 3 em ta rget f o r the tra nsgas­ tric troca r (FIG 4).

A B A. Stay sutu res are passed i n a l l fo u r q u a d ra nts to secu re the stomach d u r i n g p l acement of the tra nsgastric troca r, fac i l itate closure of the gastrosto my, or serve as secu r i n g poi nts for a Sta m m gastrosto my. B. C l ose u p of the s u bxi p h o i d , FIG 4

•

tra n sg astric t r o c a r site, a n d the associated sta b wounds u s e d for passage of the stay sutu res.

PLACEMENT OF THE TRANSGASTRIC TROCAR •

Adva nce a 1 5- m m troca r t h r o u g h the a b d o m i n a l wa l l (FIG 5). T h i s l a rg e r t roca r i s a bsol utely necessa ry t o ac­ co m m odate the s i d e-vi ewi ng d u od e n oscope. Wh i l e a p p l y i n g gentle tract i o n t o t h e stay sutu res, u s e a n e l ectrocautery device passed t h r o u g h t h e 1 5- m m troca r to create a s m a l l , a nterior g a stroto my i n the center of the ta rget. T h i s m a n euver w i l l fac i l itate fa l l i n g away of the poste r i o r g astric wa l l, thus m itigati n g the risk

•

of i n a dvertent troca r i nj u ry to the poste r i o r wa l l of the sto m a c h . Adva nce the 1 5- m m troca r i nto t h e gastric l u m e n . T h i s can be perfo rmed u n d e r d i rect v i s i o n t h r o u g h t h e troca r; a lternative ly, t h i s m a n e uver ca n be visu a l l y s u p e rvised from t h e u m b i l i c a l troca r. I ntussu scept the troca r d e e p l y i nto t h e sto mach, d i rect i n g it towa rd the pylorus w h i l e a p p l y i n g t e n s i o n to the stay sutu res. Con­ f i r m i ntra l u m i n a l l ocati o n by passi n g the l a pa roscope i nto t h e l u m e n of t h e sto m a c h v i a t h e troca r. Ta g the stay sutu res.

52 5

526

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

FIG 5 • The tra nsgastric troca r is fi rst adva n ced across the a bdom i n a l wa l l . E l ectroca utery throug h t h i s trocar esta b l ishes a n a nte rior gastrosto my, centered i n a 3 em x 3 em target zone, p r i o r to adva n c i n g the troca r across the a nterior gastric wa l l . This fac i l itates hem ostasis a n d a l l ows the poste rior gastric wa l l to fa l l away, t h u s red u c i n g the risk of posterior g astric wa l l i n j u ry as the troca r is adva nced through the anterior wa l l .

ATRAUMATICALLY CLAMP THE PAN CREATICOBI LIARY LIMB •

•

•

•

E l evate the omentum a n d tra nsverse colon to expose the l i g ament of Tre itz. The reco nstruct i o n a n atomy can d ra­ m atica l ly i m pact the ease of t h i s ste p . I d e ntify the pancreatico b i l i a ry l i m b a n d place an atra u­ matic bowe l c l a m p t h roug h a rig ht abdom i n a l troca r to occ l u d e the l u men and p revent gaseous d i stention of the sma l l bowel (FIG 6). The a uthors routi n e l y use a table-mou nted fixed retrac­ tor that can sta b i l ize this bowe l c l a m p d u ri n g the endos­ copy p h ase of the proce d u re . Once t h i s c l a m p is p l aced, tra nsfer C0 2 i nsufflation to the transgastric troca r a n d confi rm an a i rt i g ht seal by the bowel c l a m p . T h i s i ns uffl ation strategy can be m a i n ­ tai ned throug h the ERCP; it assists the e n d osco p i st.

DRAPE THE OPERATIVE FIELD AND PERFORM EN DOSCOPIC RETROGRADE

FIG 6 • The pancreatico b i l i a ry l i m b is atra u m atica l ly c l a m ped to p revent d i stention of the sma l l bowe l from i nsuffl ation req u i red d u ri n g the E RCP.

• •

CHOLANG I OPANCREATOSCOPY •

We prefer to cut a s m a l l h o l e in the center of a l a rg e l a p a roto my sh eet a n d d ra p e t h i s o v e r the e n t i r e patient so that o n ly the 1 5- m m troca r is visi b l e .

GASTROSTOMY CLOSURE OR TUBE PLACEMENT •

• •

The two l atera l stay sutu res a re cut a n d removed, l eavi ng the cephalad a n d caudad stay sutu res i n p l a ce to faci l i ­ tate E n d o G I A sta p l e r closure o f the gastrosto my. Alternative l y, a l l stay sutu res a re l eft i n p l a ce a n d used to secu re t h e sto m a c h to t h e a nte r i o r gastric wa l l . If i n d icated, a l a rge-ca l i b e r G-tube with a n i nflata b l e b a l l o o n i s adva n ced t h ro u g h t h e a b d o m i n a l wa l l a n d

•

ERCP then proceeds. We advise that the surgical tea m re­ m a i n in the room d u r i n g t h i s portion of the proce d u re . At comp letion of the ERCP, desufflate the stomach via the transgastric troca r a n d m ove the i n suffl ation to o n e of the re m a i n i n g a b d o m i n a l trocars. The d u odenosco pe and the 1 5- m m troca r (no l o n g e r steri le) are rem oved be­ fore the seco n d s u rg i ca l d ra p e is removed.

i nto the l u m e n of the sto m a c h (FIG 7). The b a l l o o n is i n fl ated a n d the stay s u t u res secured u n d e r d i rect v i ­ s i o n if poss i b l e . Occasi o n a l ly, t h e p n e u m o pe r i to n e u m w i l l l e a d to excess ive t e n s i o n of these sutu res a n d se­ c u r i n g t h e m s h o u l d be deferred u n t i l p n e u m o pe r ito­ n e u m i s re l e a s e d . C o n s i d e r p l a c i n g a p u rse-st r i n g a r o u n d t h e g a stros­ t o m y u s i n g m o n of i l a m e n t s u t u r e . This w i l l a l l o w t h e ca l i b e r of t h e g a st rosto m y to e q u a l t h a t of t h e G -t u b e .

C h a p t e r 7 S U R G I CALLY ASSISTED E N DOSCOPIC RETROGRADE CHOLA N G I O PANCREATOSCOPY

FIG 7

527

A B A,B. Operative photog ra phs of the l a p a rosco p i c p l acement of a G-tube. I nfl ate the b a l loon, release the

•

p n e u m operito n e u m , a n d then tie the stay sutures.

PEARLS AND PITFALLS Patient h i story a n d physica l f i n d i n g s

S u rg ical m a n a g e m ent

• •

• • •

Postoperative ca re

•

You m ust know the reconstructive a n atomy prior to s u rg e ry. An a ntegastric (a n d then potent i a l l y a nteco l i c) R o u x l i m b i m pacts the co m p l exity a n d thus r i s k o f the proce d u re . Therapeutic m a n ag e m e nt of SOD is now very controvers i a l . H ave c l e a r therapeutic g o a l s f o r the proce d u re before embarking on SA-ERCP. Ta ke l a rge, deep b ites of the sto mach with the stay sutu res. The sto mach is prone to l aceration by the sutu res g iven the s i g n ificant te nsion that is typica l l y a p p l i ed d u ri n g this p roced u re . A d uodenoscope w i l l not p a s s through a 1 2- m m troca r. Use a 1 5- m m troca r. If you do not effectively occ l u d e the pancreatico b i l i a ry l i m b with a bowe l c l a m p, you w i l l not be a b l e to see a nyth i n g once the ERCP is c o m p l eted. The bowel w i l l be d iste nded with gas. If m u lt i p l e ERCP sessions a re p l a n ned, leave a l a rge-ca l i ber, bal loon-t i p ped, G-tube.

POSTOPERATIVE CARE

OUTCOMES

•

•

• •

Patients should be monitored overnight for evidence of complications. A liquid diet can usually be initiated the evening of surgery. If a G-tube has been placed, it should be left to gravity drain­ age overnight and can be clamped the morning of the first postoperative day prior to discharge.

•

SA-ERCP should be successfully completed in a very high percentage of cases.2 The supine position can be challenging for even experienced endoscopists. Outcomes should be equivalent to those reported for ERCP without the need for surgical access to a gastric remnant.

REFERENCES COMPLICATIONS • • • •

Devascularization or laceration to the Roux limb Posterior gastric wall inj ury Pancreatitis Other complications of ERCP (i.e., retroduodenal perforation)

1. Wilcox CM. Endoscopic therapy for sphincter of Oddi dysfunction in idiopathic pancreatitis: from empiric to scientific. Gastroenterology. 2012;143 ( 6 ) : 1423-1426. 2. Saleem A, Levy MJ, Petersen BT, et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg. 2012; 1 6 ( 1 ) :203-2 0 8 .

-

Chapter

8

Roux-en-Y Choledochojejunostomy

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

t

Sha wn n Nich ols

DEFINITION •

•

Choledochojejunostomy involves the anastomosis of the common bile duct ( CBD) to the jej unum, thereby reestab­ lishing continuity of biliary flow ( FIG 1 ) . It may be used for repair of biliary strictures, after traumatic or iatrogenic CBD injury, or following for surgical resection for benign or malignant disease of the distal CBD. It may also be incor­ porated in resection of duodenal, ampullary, or pancreatic tumors, such as in pancreaticoduodenectomy. Our discussion here is limited solely to choledochojejunostomy.

•

•

DIFFERENTIAL DIAGNOSIS • • • • • •

Choledochal cyst excision (type I, II, or III) Repair of CBD strictures Repair after traumatic or iatrogenic injury of the CBD Diversion of biliary flow in the presence of distal obstruction or pending obstruction for palliation Orthotopic liver transplantation Reestablishing biliary continuity after resection of benign or malignant disease, including biliary, ampullary, duodenal, or pancreatic head neoplasms

PATIENT HISTORY AND P HYSICAL FINDINGS •

A thorough medical history and physical exam is important in determining the possible etiology causing the need for reestablishing biliary continuity. The overall health of the patient must be considered in determining whether the patient

..

Ma rk 8/oomston

is a surgical candidate. Past surgical history is essential to identifying those patients at risk of iatrogenic strictures. Symptoms of easy bruising, pruritus, acholic stools, nausea, vomiting, right upper quadrant pain, fevers, chills, mental status changes, and weight loss are important indicators of hepatic dysfunction and biliary obstruction. Physical exam findings of abdominal mass, abdominal pain, abdominal surgical scars, jaundice, and scleral icterus should be sought. Additionally, indicators of cholangitis should be identified and rapidly treated: Charcot's triad (right upper quadrant abdominal pain, jaundice, and fever) or Reynolds' pentad (Charcot's triad findings plus mental confusion and sep­ tic shock) indicate the need for preoperative biliary drainage.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

Hilar anatomy must be evaluated prior to surgery, identify­ ing any aberrant biliary or arterial anatomy and elucidating the possible etiology, site of injury, extent of obstruction, and planned surgical approach needed. Contrast-enhanced computed tomography ( CT) or magnetic resonance imaging (MRI) should be used to properly identify the anatomy and assess for potential vascular involvement in neoplastic processes or injury in iatrogenic biliary injuries. Magnetic resonance cholangiopancreatography (MRCP) is particularly useful to elucidate the biliary and pancreatic ductal anatomy and adj acent structures ( FIG 2 ) . Imaging is useful and often helpful in predicting the etiology of be­ nign or malignant neoplasms. Image-guided percutaneous

Remnant bile duct

FIG 2 FIG 1

528

•

I l l ustrati o n of a Ro ux-en-Y c h o l edochojej u n osto my.

•

M RCP i m a g e dep ict i n g normal b i l i a ry a n atomy. 5, stomach;

D, duodenum; GB, g a l l b l adder; arrowheads, pancreatic duct; thin arrow, confluence of the right a n d left hepatic ducts; thick arrow, CBD; star, cystic duct; white circle, accesso ry pancreati c duct.

C h a p t e r 8 ROUX-EN-Y CHOLEDOCHOJ EJUNOSTOMY

FIG 3 • E RCP i m a g e reve a l s d i l ated i ntrahepatic and extra hepatic d u cts, with the C B D d i l ated at 17 m m a n d n a rrow i n g of the d ista l port i o n at the a m p u l l a in an a m p u l l a ry cancer.

•

approaches with ultrasound or CT guidance may enable tis­ sue biopsy of suspicious lesions. Evaluation with endoscopic ultrasound (EUS) or with endo­ scopic retrograde cholangiopancreatography (ERCP) offers another method to assess the anatomy and for tissue biopsy

( FIG 3 ) . •

•

I n cases o f cholangitis o r biliary obstruction, biliary decom­ pression by ERCP or percutaneous transhepatic cholangiogra­ phy (PTC) may be warranted prior to surgical repair. It should be noted that biliary stenting in the face of asymptomatic mild to moderate hyperbilirubinemia, prior to elective surgery, may increase the postoperative risk of infection.1 A previously obtained intraoperative cholangiogram (IOC) may be available and prove beneficial. Many cases of iat­ rogenic injuries occurring during laparoscopic cholecystec­ tomy (LC) are identified by this technique ( FIG 4) .

• I O C i m a g e with i d e ntification of a n iatrog e n i c d uct i nj u ry occu rring d u ri n g an atte m pted LC for acute c h o l ecystitis. S u rg ical c l i ps are noted. Contrast is seen with a ntegrade flow i nto the d u o d e n u m , but no retrograde flow is a p p reci ated, i n d icat i n g iatrog e n i c occ l u s i o n of the p roxi m a l b i l e d uct.

FIG 4

• • •

•

•

SURGICAL MANAGEMENT •

Indications include: Bypass of distal or ampullary strictures. Reconstruction after traumatic or iatrogenic inj uries. Reconstruction following Choledochal cyst excision (type I, II, or III ) . Benign or malignant disease: biliary, ampullary, duodenal, or pancreatic head neoplasms. It can be included for palliative diversion or following resection. Reconstruction during Orthotopic Liver transplantation.

Preoperative Planning •

Standard optimization of comorbidities should be managed as permitted; for example, diabetes, hypertension, and car­ diopulmonary status.

529

•

Coagulation disorders, if present, should be corrected with vitamin K as required. In the appropriately selected j aundiced patient, preoperative stenting via ERCP and/or PTC may be necessary. Cholangitis, if present, should be treated with appropriate drainage and antibiotics. Common biliary pathogens include Escherichia coli, Klebsiella spp, Enterococcus spp, strepto­ cocci, Enterobacter spp, and Pseudomonas aeruginosa. In the absence of cholangitis, preoperative antibiotics should be given, and expanded in the presence of biliary stenting due to the increased risk of biliary contamination, even in asymptomatic patients. In malnourished patients, nutritional support may be con­ sidered preoperatively and continued into the postoperative period to minimize postoperative complications. Adequate nutrient absorption may be hindered preoperatively due to biliary blockage or diversion. In the face of malignant disease, preoperative workup should also be tailored to the assessment of the type and extent of disease present. Surgical resectability is of primary concern in malignant processes; however, choledochojejunostomy may be undertaken as a palliative biliary diversion in unre­ sectable malignancies.

Positioning •

•

Patient is placed in supine position with both arms at 90 degrees, ensuring pressure points are protected and padded ( FIG S ) . We use a bilateral post, framed retractor system (FIG 6 ) to maximize exposure via a bilateral subcostal incision.

530

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

FIG 6 • B i l atera l su bcosta l i ncision with a b i l atera l post retractor system in p l ace to m a x i m i z e exposure.

• Proper patient positioning with arms at 90 deg rees and placement of an a i rflow warm i n g device over the patient's upper body to prevent hypotherm ia. Solid line denotes the costa l marg i n . Dotted line depicts planned placement o f bilatera l su bcosta l i ncision.

FIG 5

PLACEM E NT OF INCISION AND

•

OPERATIVE EXPOSURE •

•

• • •

•

A b i l atera l su bcosta l i ncision provides opti m a l exposure. Once the perito n e u m is entered, a d h esions are c l e a red if p resent, a n d the fa l ciform l i g a ment is d ivided between ties o r with an e n e rgy device. This further exposes the operative field a n d perm its retractor p l acement (FIG 6). The abdomen is explored and a l l peritoneal surfaces a re pal­ pated if m a l i g n a ncy is suspected . The root of the mesentery is pal pated early to assess for foreshortening due to tumor infi ltration, inflam mation, or previous surgery, which may i m pact the a b i l ity to develop a Roux limb for reconstruction. Exposure of the porta he pat is is beg u n by m o b i l i z i n g the hepatic flexu re of the colon, as necessa ry. Koch erization of the d u o d e n u m provides o pt i m a l expo­ s u re of the d i sta l C B D . The g a l l b ladder, if p rese nt, is removed in a top-down fash i o n . If the porta hepatis is i nvolved i n acute a n d/o r c h ro n i c i nf l a m m ation, the cystic d uct s h o u l d be traced to l ocate the co m m o n hepatic d u ct (CHD) a n d the C B D . M eticu lous d i ssect i o n of the porta hepatis is n ecessa ry to ide ntify essent i a l struct u res to p reve nt i n advertent i nj u ry. Ca re s h o u l d be taken to sea rch fo r a n d p revent i n j u ry to a berrant or rep l a ced a n ato m i c variations. A re p l a ced rig ht hepatic a rte ry a r i s i n g from the superior mesenteric a rtery w i l l lie to the r i g ht a n d deep to the C B D a n d can be i nj u red d u ri n g C B D tra nsection if not antici pated. The r i g ht hepatic a rtery co m m o n l y cou rses b e h i n d the CHD but on occasion the a rtery may lie a nterior to the CHD. B i l i a ry a n ato m i c va riations should a lso be expected (see Part 3, C h a pter 1 5, FIG 1 7) . The a bsence of a berrant a n atomy o n preoperative i m a g i n g should not usurp ca ref u l d i ssect i o n with a ntici pation of variance.

•

•

D i ssection a n d exposure of the C B D may be d ifficult i n t h e face o f i n fl a m m atory changes res u l t i n g from prior s u rgeri es, ra d i ation exposu re, a n d/o r preo perative p l ace­ ment of a b i l i a ry ste nt. At t i m es, i ntraoperative u ltra­ sound may be h e l pf u l in proper i d e ntification of the structu res with i n the porta hepatis. Another method to i d e ntify the C B D w h e n d i ssect i o n is d iffic u lt i s to use a s m a l l-gauge need l e a n d aspi rate l o o k i n g for b i l e . W i t h p r o p e r i d e ntification a n d d i ssect i o n of the C B D, the site of tra nsection is selected proxi m a l to the loca­ tion of i nj u ry o r o bstruct i o n . It s h o u l d be n oted that the a rte r i a l s u p p l y to the bile d u ct runs a l o n g the l atera l a n d m ed i a l aspects o f the C B D a n d C H D , a n d c a r e s h o u l d b e taken t o avoid exten sive d i ssect i o n or m o b i l i zation that may compro m ise this b l ood s u p p ly. When tra nsect i o n of the b i l e d u ct with end-to-si d e reco nstruction i s p l a n n ed, the pred o m i n a nt blood s u p p l y w i l l come from the r i g ht hepatic a rtery near the l iver h i l u m . Thus, a h ig h e r point of tra nsection is desi red to o pt i m ize b l ood s u p p l y to the a n asto m osis. The margin of resect i o n s h o u l d be path o l o g i ca l ly assessed i ntraoperatively i n the face of m a l i g n a n cy. With the transection site sel ected, the C B D can be d i ­ v i d e d s h a r p l y o r w i t h e l ectrocautery i n c u t mode t o m i n i m i ze therm a l d a m a g e . If a ste nt has b e e n p l aced preoperative ly, it is rem oved at this poi nt. C u l t u res of the b i l e f l u i d may be wa rra nted . The proxi m a l d uct s h o u l d be probed to ensure patency a n d confi rm d u ctal a n atomy­ The probe s h o u l d be g u ided up both the l eft a n d r i g ht hepatic d u cts. C h o l a n g ioscopy can be u n d e rtaken if there is concern for proxi m a l obstruction o r hepato l i ­ t h i asis. To control b i l e s p i l l a g e a n d fac i l itate hem ostasis, the prox i m a l stu m p is tem pora r i ly c l osed with a vascu l a r b u l l dog c l a m p .

C h a p t e r 8 ROUX-EN-Y CHOLEDOCHOJ EJUNOSTOMY

the mesentery and at a point where the vascular arcade ca n be preserved to both l i m bs as determi ned by tra nsi l l u m i na­ tion of the mesentery. A gastroi ntestinal a nastomosis (GIA) stapler is used to d ivide the jej u n u m at this point. The mes­ entery is then d ivided down to its base using ligatures for hemostasis. Care m ust be taken to m a i nta i n proxi m a l and d ista l orientation of the d ivided jej u n u m . A defect is created in the tra nsverse mesocolon, to the right of the middle co lic vessels, and the Roux l i m b is brought u p i n a retrocolic ori­ entation to serve as the defunctional ized b i l i a ry-enteric l i m b and placed without tension n e a r t h e d ivided C B D .

CREATION OF THE ROUX LIMB •

Although choledochoduodenostomy or choledochojej u­ nostomy using a loop of jej u n u m a re reconstructive options that may be appropriate i n the c l i n ical setting of a short l ife expectancy or a particularly hostile abdomen due to adhesions, a defu nctionalized seg ment of jej u n u m using a Roux-en-Y tech nique is preferred due to superior outcomes. Beg i n n i n g at the liga ment of Treitz, the jej u n u m is exa m i ned to the fi rst point at which a loop can easily be brought up to the d ivided CBD without tension based on the length of

CHOLEDOCHOJ EJ UNOSTOMY

•

ANASTOMOSIS •

• •

•

The c h o l edochoj ej u n osto my is created in a s i n g l e-layer, i nterru pted fash i o n u s i n g no. 4-0 or n o . 5-0 polyd i oxa­ none m o n ofi l a ment a bsorba b l e suture. If n o n a bsorba b l e suture i s used, a l l k n ots m ust rest outside of the a n asto­ mosis to p revent stone format i o n . Stenting across the a n asto mosis is not routi nely u n d e r­ taken, even in the case of a n o r m a l -sized d u ct. An end-to-side anastomosis provides for ease of exposure during the reconstruction. E lectrocautery is used to create an enterotomy on the a nti mesenteric side of the Roux l i m b a pproxi mately 3 t o 4 em from t h e sta pled e n d . T h e enter­ otomy is sized smaller than the transected CBD width, in an­ ticipation of "enterotomy stretch " that occu rs with sutu ring. The C B D is reopened, b i l e flow is a g a i n confirmed, a n d the d u ct clea red as necessa ry. The d u ct is trimmed as needed with Potts scissors, a l l ow i n g for maxi m a l d i a m eter; sha rp, crisp edges; and identification of good vascu larity.

•

Creation of the choledochojej u n ostomy a nastomosis. Corner sutu res p laced to permit latera l traction and orientation of the posterior and a nterior rows. Posterior row of monofi lament sutu res are p laced i n such a way that the knots w i l l lay with i n the lumen.

FIG 7

•

•

T h e jej u n u m is p l aced near the C B D stu m p, positioned so as to l i m it red u n d a ncy a n d k i n k i n g of the jej u n u m . Latera l traction sutu res a re p l aced fu l l thickness o ut-to-in on the j ej u n u m a n d i n-to-out on the b i l e d u ct, l eft u ntied, a n d p l aced o n hem ostats under gentle l atera l tract i o n . T h e posterior row sutu res are placed a pproxi mately every 2 to 3 mm apart, ta king ful l-th ickness bites of the duct and je­ j u n u m, working from one latera l corner to the other. Be cer­ ta i n that the jej u n a l mucosa is i ncorporated i nto the stitch . Sutu res a r e placed i n-to-out on t h e jej u n u m and out-to-i n on t h e duct, such that when tied t h e knot w i l l b e with i n t h e l u m e n (FIG 7). Gentle upward traction on t h e a nterior wa l l of the bile duct provides n ice exposure of the l u men to ensure proper suture placement through the posterior wa l l . The sutures a re tagged and left u ntied t o a l low t h e Roux l i m b to be m a n i p u l ated freely to maxim ize exposure. G reat ca re is taken to m a i nta i n ori entat i o n of the suture so that it does not become twi ste d . Suture order m u st be prese rved to p reve nt ove r l a p i n g , a n d t h u s n a rrow i n g of the a n asto mosis when the poster i o r r o w is co m p l ete and the kn ots tied. S m a l l hem ostats s h o u l d be used to tag each suture and place them in the proper orientation a n d order o n a sponge forceps, thus making t h i s task l ess c u m berso me a n d more effi cient (FIG 8).

FIG 8 • Sutu res p l aced d u r i n g creati o n of the poste rior a n d anterior rows are l eft untied, tagged with h e mostats, a n d t h e i r ori entation a n d order m a i nta i n e d by arra n g i n g t h e m o n a sponge forceps c l a m ped t o a l a p a roto my sponge. This is p l aced above the retracto r system on the d ra pes a n d opti m i zes effi ciency when tyi n g the sutu res.

531

532

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

•

•

•

Once a l l of the poste rior row sutu res are p l aced, we beg i n tyi n g each suture in order from o n e corner to the oth e r, ca refu l l y laying the knots to ensure opti m a l in­ te rva ls along the way. If a n i nterva l is dete r m i n e d to be too large (>3 to 4 m m), a n a d d i t i o n a l suture is p l aced, tied, and then the re m a i nder of the row sutu res are tied (FIG 9). The corner sutu res are l eft u ntied to a l low m o b i l ­ ity a n d maxi m u m exposure of the entire b a c k r o w w h i l e p l a c i n g the a nterior row o f sutures. Suture ta i l s a re then cut short a n d the a nterior row i s add ressed . The anterior row sutu res a re p l aced in an out-to-in fash i o n o n the jej u n u m a n d a n i n -to-out fash i o n on the d uct so that the k n ots will be on the outside when tied (FIG 1 0). Aga in, i nterva ls are assessed a n d a d d i t i o n a l sutu res p l aced as needed. O n ce com p l ete, the a n asto mosis is i n s pected for evidence of a b i l e l e a k (FIG 1 1). Absence of tension on the a n as­ tomosis is co nfirmed. The s u rg i ca l field is d ried, e n s u r i n g good h em ostasis a n d a clean, wh ite surgical sponge is ca refu l ly packed around the a n astomosis, a n d atte ntion is turned to creating the jej u n ojej u n a l a n asto mosis.

FIG 1 0 • T h e anterior r o w of sutu res h a v e b e e n p l a ced. Visu a l i nspect i o n confi rms proper i nte rva l p l acement of the sutu res. The sutu res a re ready to be tied to co m p l ete the c h o l edochojej u n osto my a n asto mosis.

• The chol edochojej u nostomy posterior row sutu res have been tied and the row i nspected. The previously placed l atera l traction sutu res are l eft u ntied in preparation for p lacement of the anterior row sutures. Gentle downward traction on the Roux l i m b e n h a n ces exposure as shown i n the picture.

FIG 11 • The a nterior row sutu res have been tied, a n d the choledochojej u n ostomy anastomosis is ca refu lly i nspected for any b i l e leak. A sma l l, clean, wh ite ga uze (not pictured) is p laced posterior to the a nastomosis to aid in eva l uation of a b i l i a ry leak.

JEJUNOJ EJUNAL ANASTOMOSIS

•

FIG 9

•

I ntest i n a l conti n u ity is reesta b l ished by a Roux-e n-Y a n asto mosis. The proxi m a l b i l iopa ncreatic l i m b is a n asto­ mosed to the b i l i a ry-e nteric Roux l i m b a pp roxi m ately 45 t o 65 em downstre a m from t h e choledochoj ej u n osto my a n asto mosis to m i n i m i ze enteric refl ux. We p refer to create a sid e-to-s i d e, functi o n a l end-to-e n d a n astomosis u s i n g a l i n ear sta p l i n g device, then closing the common ente roto my with a s i n g l e row of i nte rrupted n o . 3-0 s i l k sutu res u s i n g a mod ified G a m b e e tech n i q u e .

•

The sma l l bowe l mesenteric defect is closed at the Ro ux­ en-Y a n astomosis. If a retroco l i c posit i o n fo r t h e b i l i a ry-ente r i c l i m b was used, a n y red u n d a ncy l a y i n g in t h e s u b h e patic bed i s re­ d u ced without p l a c i n g t e n s i o n o n t h e a n asto m o s i s . The m esoco l i c d efect i s c l osed, i n corporati n g a sero m uscu l a r bite o f t h e pass i n g j ej u n u m , w i t h n o . 3 - 0 s i l k sutu res to prevent the possi b i l ity of l i m b m i g ra t i o n a n d/or i nter­ n a l h e r n i a t i o n . Every atte m pt s h o u l d be m a d e to e n s u re that t h i s c l o s u re does not i m p i n g e u p o n t h e bowe l .

C h a p t e r 8 ROUX-EN-Y CHOLEDOCHOJ EJUNOSTOMY

a n y b i l e sta i n i n g . If prese nt, further i nspection of the a n asto mosis is warra nted a n d a d d i t i o n a l sutu res a re p l aced as needed.

PREPARI NG FOR CLOSURE •

Retu r n i n g to the choledochojej u n osto my, the previously p l aced sponge is ca refu l ly rem oved a n d i n spected for

•

CLOSURE •

We rout i n e l y place a s i n g l e fl uted surgical d ra i n on cl osed sucti on poste rior to the chol edochoj ej u nostomy a n asto­ mosis and down i nto M o rrison's pouch, then out through a sepa rate sta b i ncision on the right side of the a b d o m e n . The d ra i n is a p p ropriately secured w i t h sutu re at the s k i n .

533

•

The a b d o m i n a l fascia i s c l osed i n two layers (poste rior fascia a n d anterior fascia) with n o . 1 a bsorba b l e synthetic m o n ofi l a m ent. The skin is rea p p roxi m ated with bu ried, deep d e r m a l , i n ­ terru pted, no. 3 - 0 a bsorba b l e b r a i d e d sutures. The s k i n is cl osed with surgical g l u e .

PEARLS AND PITFALLS I n d ications

•

A thoro u g h h i story a n d physical ( H & P) exa m with good preoperative i m a g i n g i s i m portant in a nticipating the extent of the proce d u re .

D i ssection

•

Antici pate a berrant a n d accessory a n atomy with i n the porta hepatis.

Excision

•

Send C B D margins for frozen section a n a lysis when considering m a l i g n a nt d isease.

C h o l edochoj ej u n ostomy

•

M eticu lous suture tech n i q u e i s critica l . There s h o u l d be n o concerns with the poste rior row p r i o r to p roceed i n g with the anterior row. Avo i d the u rg e to p l ace too m a n y sutu res. Proper suture orientat i o n is i m po rtant as any cross i n g of suture k n ots w i l l lead to isch e m i a of the i nterposed tissue. E n s u re there is n o te nsion on the a n astomosis.

•

• •

POSTOPERATIVE CARE

COMPLICATIONS

•

•

•

•

•

We typically remove the nasogastric tube ( NGT) early ( i . e . , 1 to 2 days postoperative ) , unless ileus is anticipated ( e . g . , emergency surgery, active cholangitis, extensive enterolysis ) , and start a clear liquid diet. The patient is encouraged to begin ambulating on postop­ erative day (POD) 1. Appropriate postoperative thrombo­ embolism prophylaxis is started on POD 1 . Drain output i s assessed and followed for the presence of bile. If present, the drain will be kept until bile output has cleared, as it almost always will do so on its own. If drain output is serous, then the drains can be pulled with little concern for volume of output. Drains are pulled after the patient is tolerating a diet and usually prior to discharge. Postoperative laboratory studies are followed on a daily basis to include a complete blood count, serum chemistry, and liver function tests.

OUTCOMES •

Long-term survival rates after choledochojejunostomy are dependent on the underlying indication for the procedure.

•

Complications occur in up to 4 0 % of cases2 and include the following: Wound infection Biloma--can usually be managed with percutaneous drainage Anastomotic leak ( biliary and/or enteric)-may require operative drainage but often can be managed with the surgically placed drain or by radiologically placed percu­ taneous drains Cholangitis-generally indicates reflux from ileus; it can be managed with NGT decompression and antibiotics; PTC may be used to decompress Roux limb specifically if NGT ineffective. Biliary stricture (can occur up to 1 0 or more years after surgery)-heralded by rising alkaline phosphatase; often can be treated with PTC and balloon dilation but may require surgical revision of the anastomosis

REFERENCES 1.

Morris-Stiff G, Tamijmarane A, Tan YM, et al. Pre-operative stenting is associated with a higher prevalence of post-operative complications following pancreatoduodenectomy. lnt ] Surg. 20 1 1 ;9 ( 2 ) : 145-149. doi: 1 0 . 1 0 1 6/j .ijsu.20 1 0 . 1 0 . 0 0 8 . 2 . Sicklick JK, Camp MS, Lillemoe KD, e t a l . Surgical management o f bile duct injuries sustained during laparoscopic cholecystectomy: periop­ erative results in 200 patients. Ann Surg. 2005;24 1 :786-792.

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Chapter

9

Minimally Invasive Choledochojejunostomy

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t

Ja n a k Parikh

C. Max Sch m idt

DEFINITION •

Hepaticojejunostomy is the operative formation of an anasto­ mosis between the biliary tree and a Roux limb of the jejunum to manage biliary obstruction secondary to benign or malig­ nant strictures, or to reconstruct continuity following resection of the extrahepatic biliary tree or pancreaticoduodenectomy.

DIFFERENTIAL DIAGNOSIS •

•

Benign Traumatic or iatrogenic bile duct inj ury Chronic pancreatitis Choledochal cyst Mirizzi's syndrome Malignant Extrahepatic cholangiocarcinoma (palliative or after resection) Periampullary tumors (palliative or after resection) Portal lymphadenopathy (palliative)

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

History-The following features may be obtained: Weight loss (malignancy vs. malabsorption) Fevers/chills (cholangitis) Yellow eyes/skin ( obstructive j aundice) Tea-colored urine (obstructive j aundice) Acholic stools (obstructive j aundice) Right upper quadrant pain ( distended gallbladder, may suggest a process distal to the cystic duct confluence) Physical examination Temporal wasting (cachexia) Scleral icterus Jaundiced skin Right upper quadrant tenderness Courvoisier's sign-painless, palpable gallbladder with j aundice

Preoperative Planning •

•

STUDIES

•

Ultrasonography-preferred initial evaluations as it is read­ ily available and inexpensive. Findings may include the fol­ lowing: Gallbladder Stones Cholecystitis Biliary tree Extrahepatic duct dilatation Intrahepatic duct dilatation Cross-sectional imaging Computed tomography abdomen/pelvis ( CT AlP) with in­ travenous (IV) contrast-Triple-phase CT AlP is warranted in most cases of obstructive jaundice as part of determining

534

the probable etiology and defining surgical anatomy. This includes the following: Determine location of hepatic arteries and potential anomalous anatomy Compression, invasion, or thrombosis of portal, splenic, and/or superior mesenteric veins Magnetic resonance imaging/magnetic resonance chol­ angiopancreatography (MRI/MRCP) with IV contrast is preferred by some institutions. It is superior to ultrasound (US) and CT in identifying the location of biliary strictures. Cholangiography Endoscopic retrograde cholangiopancreatography (ERCP) is the "gold standard" when biopsy or other therapeutic intent is warranted. Provides superior diagnostic information by identifying level of obstruction/anatomy Allows for sampling of tissues at the level of obstruction via brushings for cytology Is therapeutic by placement of biliary endoprosthesis to decompress biliary tree Percutaneous transhepatic cholangiography (PTC) is re­ served for therapeutic intervention when ERCP is techni­ cally not feasible, that is, following gastric bypass or in the clinical setting of concomitant gastric outlet obstruction. Second option-Palliation is less effective as the patient will have pain from the PTC site and will need to per­ form daily care to the catheter.

SURGICAL MANAGEMENT

IMAGING AND OTHER DIAGNOSTIC

•

..

Euge n e P. Ceppa

•

Underlying cardiopulmonary disease must be evaluated when considering the laparoscopic approach; affected pa­ tients may not tolerate reduced venous return or clear in­ creased concentrations of carbon dioxide resultant from the pneumoperitoneum. An extensive past abdominal surgical history or previous peritonitis may impact the ability to perform the hepatica­ jejunostomy laparoscopically due to extensive adhesions. Prior abdominal surgery may also impact the approach of initial peritoneal access and subsequent port placement (i.e., avoiding abdominal wall defects ) , or mandate modification of the formation or routing of the reconstructive Roux limb. Morbid obesity can preclude adequate laparoscopic visual­ ization, but these patients have the greatest potential benefit of a minimally invasive approach due to the reduced wound morbidity. Obesity mandates several considerations: Distinct, longer instrumentation may be required to reach the right upper quadrant and level mechanics, thus may impact fine motor movements limitations with suturing and intracorporeal knot tying. Mobilization of the hepatic flexure and a Kocher maneu­ ver are made more difficult when the transverse mesocolon

C h a p t e r 9 M I N I MALLY I NVASIVE CHOLEDOCHOJEJUNOSTOMY

and omentum contain more fat and organs are larger in size overall. Large, friable livers as a result of fatty liver disease and are prone to lacerations (hemorrhage within the operative field significantly impairs image brightness ) .

LAPAROSCOPIC CHOLEDOCHOJ EJ UNOSTOMY • •

•

•

Port p l a ce m e nt a n d ro l e of each in the proced u re is de­ p i cted i n FIG 1 . To fi rst create the Roux l i m b, e l evate a n d retract the omentum a n d tra nsverse colon to the u p p e r a b d o m e n . The l i g a ment of Treitz i s i d e ntified at the b a s e of t h e tra nsverse m esoco l o n . Reve rse Tre n d e l e n b u rg positioning may fac i l itate visua l i zation by d r o p p i n g the s m a l l bowel i nto t h e lower a b d o m e n . A point for d ivision of the proxi m a l jej u n u m is i d e ntified d i sta l e n o u g h from the l i g a m ent of Tre itz to fac i l itate the j ej u n ojej u n osto my and such that the m esentery w i l l have a d e q u ate l e n gth t o reach t h e r i g ht u p p e r q u a d ra nt without te nsion on the b l ood s u p p ly. At t h i s l ocati on, the sma l l bowel is d ivided u s i n g a l a p a rosco p i c sta p l e r with a 2 . 5- m m sta p l e load after a w i ndow is created between the vasa rectae of the sma l l bowe l . Use b i p o l a r e n ergy device or a vascu l a r sta p l e l o a d to d iv i d e t h e mesentery towa rd t h e base. Use care not to e n croach o n t h e a rte r i a l a rca d e o n either side of the d iv i d ed bowe l . T h i s m a n euver w i l l g ive a d d i t i o n a l l e n gt h of t h e m esentery necess a ry to reach t h e b i l e

•

Positioning • • •

The patient is positioned supine with both arms abducted on arm board extensions of the operating table. A nasogastric tube and Foley catheter are placed. Use a footboard.

d u ct w i t h o u t p u tt i n g the a n asto m o s i s u n d e r u n d u e tens i o n . T h e bowel proxi m a l to t h e sta p l e l i n e i s t h e a l i m e nta ry l i m b; a n a d d i t i o n a l 4 0 t o 60 em o f s m a l l bowel d i sta l t o t h e sta p l e l i n e i s m e a s u red a n d refe rred to as t h e R o u x l i m b . A s i d e-to-side j ej u n oj ej u n ostomy is fash i o n e d . Two 3-0 stay sutu res a re p l aced 6 to 10 em a p a rt. S m a l l , adjacent ente roto m i es are created i n each l i m b of the jej u n u m with t h e caute ry. An a rti c u l at i n g 60- m m l o n g , 2 . 5 - m m sta p l e load is i ntroduced i nto the bowe l via the enter­ oto m ies. Ca re m ust be taken to ensure that the mesen­ tery is outside the sta p l e load. The a nastomosis between the a l i m enta ry and Roux l i m bs i s created with the sta p l e r. The c o m m o n ente rostomy is oversewed with a 3-0 a b­ sorba b l e r u n n i n g suture. Alternatively, t h i s c o m m o n de­ fect ca n be cl osed with a n a d d i t i o n a l firing of the sta p l e r. The jej u n ojej u n osto my mesenteric defect is cl osed with a r u n n i n g 2-0 nona bsorba b l e suture to p revent futu re i n ­ tern a l h e r n i a s . Avo i d f u l l -t h i c kness b ites a cross the bowe l mesenteric edge that was previously sea led with an en­ ergy devi ce; t h i s can lead to u n n ecessa ry h e m o rrhage, isch e m i a , o r h e m ato m a near your a n asto m osis resu lti n g i n b l eed i n g , perforation, or obstruct i o n postoperative ly. Solely suture the perito n e u m superfi c i a l l y togeth er.

X 5 mm •

T

�

"j\� �.\� /

5 mm

e c,, 5 mm

· ··--..-· Ruq Luq C 12 mm 5-1 2 mm 12 mm

53 5

Rsc

=

Right subcostal port

Ruq

=

Right upper quadrant port

Luq

=

Left upper quadrant port

Lsc

=

Left subcostal port

C

=

Camera port

X

=

Liver retractor port

T = Target --

5 mm in d i a m eter), a r u n n i n g suture tech n i q u e is a p p ropriate. T i e two sepa rate, 1 5- to 20-cm long, 4-0 a bsorba b l e sutu res togeth er to create a d o u b le-armed suture. For sma l l b i l e d u cts, i nterru pted 4-0 a bsorba b l e sutu res a re used for the posterior and anterior rows. • An enteroto my is m a d e in the a n t i m esenteric bor­ der of the Roux l i m b . Keep t h i s e nte roto my shorter than the d i a m eter of the b i l e d u ct-it w i l l stretch . • A stay suture is p l aced at 1 2 o'clock position on the bile d u ct for retraction of the a nterior wa l l d u r i n g creation o f the poste rior row (opt i o n a l ) . • The " d o u b l e-a rmed " suture that was c reated is i n ­ troduced i nto the perito n e u m ; one a r m i s passed " o utside- i n " on the bowel and the oth e r outside-in on the bile d uct (sta rti n g at 3 o'clock position). Thus, both needles a re " i n s i d e " a n d the knot is " o utsi d e " •

(FIG 2A,B). •

•

• •

•

• •

•

The poste rior row is created fi rst by ta k i n g the su­ ture i n s i d e the bile d uct a n d going " i nside-out" o n the bowe l, then outside-in o n the b i l e d u ct, a n d s o forth, adva n c i n g 2 to 3 m m w i t h e a c h passag e of t h e suture across entire poste r i o r row. U pon co m p l et i o n of the poste rior row, tension m ust be m a i ntai ned on the poster i o r suture. A b u l ldog clamp o r equ iva lent i n stru ment is p l a ced o n the pos­ te r i o r row stitch to m a i nta i n this te nsion (FIG 3A,B). The o pt i o n a l l y p l aced 1 2 o'clock stay suture s h o u l d be rem oved n o w to p revent confu s i o n . Stenting the b i l i a ry-e nteric a nasto mosis wo u l d occu r either n o w or m i dway t h ro u g h com p l et i n g the anterior row. S i m i l a rly, the anterior row is com p l eted by ta k i n g the suture i ns i d e the bowe l a n d g o i n g i n s i de-out o n the b i l e d u ct, then outside-in on the bowe l, a n d t h e n end-ove r-e n d across entire a nterior r o w (FIG 4A,B). The a n asto mosis is co m p l eted by tyi ng the two su­ tu res on the outside at the 9 o'clock posit i o n . After com pletion of the a nastomosis, the red u ndant Roux l i m b is p u l led back through the mesocolon defect toward the jejunojej u nostomy; it is i m portant to m i n i­ m ize the risk of an afferent l i m b obstruction or b i l i a ry stasis in the Roux l i m b. The l i m b is secu red d i rectly to the peritoneum at the mesenteric defect with 3-0 non­ a bsorba ble suture to prevent future herniation. S u r g i ca l d r a i n a g e of the a nastomosis is by s u rgeon preference.

C h a p t e r 9 M I N I MALLY I NVASIVE CHOLEDOCHOJEJUNOSTOMY

A B A. The i n it i a l suture is p l aced in the 3 o'cl ock position, such that the knot used to form the d o u b l e-armed sutu re is exte r n a l to the p l a n ned a n astomosis. B. Intraoperative p h otog ra p h of the 3 o'clock suture.

FIG 2

•

B A A. Artist's re nd ition of the posterior suture l i n e . N ote that the f i n a l suture w i l l be on the jej u n a l side (outside the bowe l) to fac i l itate tyi n g this arm to the a nterior suture row arm. B. I ntrao perative photog ra ph of the a n astomosis at the com p l etion of FIG 3

•

the posterior suture l i ne.

537

538

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

FIG 4

•

A B A. Artist's re n d ition of the com p l ete a nastomosis prior to tyi n g the two arms of suture. B. I ntraoperative p h otog ra p h

of the a n asto mosis at the co m p l et i o n of the a nterior suture l i n e . T h i s a r m of the suture w i l l f i n i s h o n the outside of the b i l e d u ct.

ROBOTIC CHOLEDOCHOJEJUNOSTOMY •

Overa l l tech n i q u e is s i m i l a r to that of the l a p a rosco p i c c h o l edochoj ej u n osto my.

First Step •

•

Port p l a ce m e nt fo r robotic choledochojej u n osto my as seen i n FIG 5. • Port p l acement is set further away from the ta rg et of d i ssection d u e to the l o n g robotic i n stru m e nts a n d i n a b i l ity of the robot to opti m a l ly a rt i c u l ate when the a r m s a p p roach g reater t h a n o r e q u a l to 90-deg ree a n g l e to the patient. • Additi o n a l ly, the robotic ports should be p l aced wider than the l a p a rosco p i c ports. This h e l ps avo i d " confl i ct " o r co l l isions between the robotic a r m s . M o b i l i zation o f the hepatic fl exu re, creat i o n of the Roux l i m b, creation of the jej u n oj ej u n osto my, a n d i ntrod u c-

• •

•

t i o n of the Roux l i m b t h ro u g h the tra n sverse m esoco lon a re perfo rmed with conventi o n a l l a p a roscopy before docking the robot. The patient is p l a ced in a stee p reverse Tre n d e l e n b u rg position with the rig ht s i d e ti lted s l i g htly u p . T h e robot is docked as fo l l ows: • Robot is positioned over the patie nt's r i g ht s h o u l d e r. • Place a foa m pad over the patient's arm a n d face . • Position the robot correctly in terms of both m a i n ­ ta i n i n g it centered i n its " sweet spot" (the a rrow m u st p o i nt to the a rea with i n the b l u e stripe vis i b l e on the front o f the robot) as we l l as creati n g suf­ ficient d i stance betwee n the robotic a rms. • The function of the robotic a r m s is o pt i m a l when the a r m n u m ber is fac i n g d i rectly out. The b i l i a ry enteric a n astomosis i s perfo rmed robotica l ly as described p revi ously.

C h a p t e r 9 M I N I MALLY I NVASIVE CHOLEDOCHOJEJUNOSTOMY

R1 = Robotic operative port (horizontal)

/ \�

R2 = Robotic operative port (horizontal)

T

R3 = Robotic retraction port (horizontal) A = Assistant port (horizontal) C = Camera port (vertical) T = Target

---

m

R1 "-. 8 m m "-. R1

() /c , -,/1. 2-

....

•

•

A 1 2 mm A

mm

8 mm

539

R3

R2

8-cm width (handbreadth) Instru ment length and d i rection Gray letters shown if distance between xiphoid and umbilicus

c

is 1 .5 em) ; multiple CBD stones; and primary, recurrent, or recalcitrant choledocholithiasis.

•

•

•

•

Right upper quadrant ultrasound is the frontline test for biliary obstruction, visualized as dilated intrahepatic and extrahepatic biliary ducts. It is highly sensitive, noninvasive, inexpensive, readily available, and requires no radiation.

540

Contrast-enhanced computed tomography ( CT) is a use­ ful modality to evaluate abdominal pain. CT will demon­ strate a dilated biliary tree and can help in the evaluation for causative-associated pathology including choledocholithia­ sis, chronic pancreatitis, and periampullary malignancy. Magnetic resonance cholangiopancreatography (MRCP) can give detailed information about biliopancreatic ductal anatomy and pathology (T2 weighted images) and soft tis­ sue abnormalities related to pancreatitis or neoplasm (Tl weighted images) . MRCP is an important tool for assess­ ment of biliary obstruction because of the advanced ductal imaging capability. Endoscopic retrograde cholangiopancreatography ( ERCP) is the primary initial therapeutic approach to biliary obstruc­ tion in the current era. ERCP can be both diagnostic and therapeutic in the management of biliary obstruction. It can be used to identify stones and apply a variety of maneuvers that facilitate stone clearance: Sphincterotomy Balloon cholangioplasty and sweeping Basket retrieval Lithotripsy Strictures can be dilated and stented endoscopically. Even with alternative strategies (metal stents, multiple plastic stents) , endoscopic stenting lacks durability in the man­ agement of chronic, longer segment CBD strictures due to chronic pancreatitis and stone disease and CDD is often employed in these cases. Endoscopic ultrasound (EUS) can be helpful in the careful evaluation of the terminal biliary tree for the diagnosis or exclusion of malignant obstruction and the assessment for occult cholelithiasis. EUS has also been more recently used for an endoscopic-directed choledochoduodenal stent. Percutaneous transhepatic cholangiography (PTC) is under­ taken to study the biliary tree and allow for biliary drain­ age in cases where endoscopic transampullary access is not possible. Maturation and dilation of the tract after PTC can allow for percutaneous instrumentation to be used under radiographic guidance to clear stones from the biliary tree.

SURGICAL MANAGEMENT •

•

IMAGING AND OTHER DIAGNOSTIC STUDIES

Da vid B. A dams

•

•

CDD is indicated in patients with a benign terminal bili­ ary stricture, with an associated dilated CBD ( > 1 .5 em diameter) , most commonly due to chronic pancreatitis or choledocholithiasis. CDD has been effectively used in the management of malignant biliary obstruction. When planning a biliary bypass procedure, a neoplastic cause for biliary obstruction should be sought out and recognized, as a malignant (or potentially malignant) process may call for a divergent operative approach. When biliary bypass is indicated in unresectable periampul­ lary malignancy, CDD may be selected as an alternative to hepaticojejunostomy. Classically, the CDD anastomosis is performed in a side­ to-side fashion but may also be performed with an end

C h a p t e r 10 CHOLEDOCHODUODEN OSTOMY

•

( bile duct) to side ( duodenum) technique, particularly when using a laparoscopic approach. Both methods are presented. Preoperative Planning •

•

•

CDD is best undertaken in an elective setting. Acute pancre­ atitis should be allowed to settle and cholangitis should be properly treated. Often, endoscopic stenting can be helpful to temporize patients and allow for medical optimization. Particular attention should be taken to the nutritional sta­ tus of the patient, as patients with chronic inflammation are often malnourished. Enteral or parenteral supplementation may be appropriate to condition the patient for surgery.

•

Hepatic function should also be assessed prior to surgery, as it may be compromised in patients with long-standing bili­ ary obstruction. Vitamin K supplementation, in particular, may be useful. Patients with terminal biliary stenosis due to chronic pan­ creatitis may have associated duodenal stenosis, pancre­ atic ductal obstruction and dilation, or splanchnic venous obstruction, which may require operative management and should be confirmed with preoperative evaluation. Patients with terminal biliary stenosis and cavernous trans­ formation of the portal vein may undergo CDD safely, al­ though additional emotional and physical work is demanded in the conduct of the procedure.

CHOLEDOCHODUODENOSTOMY, SIDE-TO-SI D E Incision and Exposure •

•

•

• •

An u p p e r m i d l i n e i ncision or a r i g ht su bcosta l i ncision may be used for t h i s operation (FIG 1 ). The a b d o m e n i s exp l o red for u n expected f i n d i n g s i n c l u d i n g evidence for d ista nt m a l i g n a ncy. C a u d a l m o b i l ization of the hepatic fl exu re of the colon i s u n d e rtaken to a i d i n adequate d u o d e n a l expos u re. Use of self-reta i n i n g retractors fac i l itates exposu re of the term i n a l bile d u ct a n d the fi rst a n d seco n d portions of the d u oden u m (FIG 2). An exte nsive Kocher m a n euver is performed to opti m a l ly m o b i l ize the d u oden u m . This m o b i l i zation is a critica l step for the success of a tension-free a nastomosis. The pancreatic head a n d term i n a l bile d u ct a re p a l pated a n d exa m i ned t o assess f o r extent o f d i sease a n d u n expected f i n d i ngs. If the g a l l b l a d d e r re m a i n s in p l ace, a c h o l ecystectomy i s perfo rmed (FIG 3). The porta hepatis is exa m i n e d a n d the C B D clearly i d e nti­ fied for the cou rse of g reater t h a n 3 em along its a nterior wa l l . I n cases w i t h s i g n ificant i n f l a m mation a n d f i b rosis, the a n atomy can be d i storte d . Pa l pation of the hepatic a rte ry can be h e l pf u l i n ori entation, as can p a l pation of

•

an i ntra d u cta l b i l i a ry ste nt or a s p i ration of b i l e with a f i n e need l e a n d syr i n g e . I ncision of the perito n e u m at the ce p h a l a d aspect of the fi rst portion of the d u o d e n u m can fac i l itate the esta b­ l is h m e nt of a p l a n e between the poste rior wa l l of the

• When p rese nt, retrograde d i ssection of the g a l l ­ b l a d d e r fac i l itates i d entificat i o n o f the cystic d uct confl uence a n d d ista l C B D .

FIG 3 FIG 1

•

The a uthors favo r a r i g ht su bcosta l i n c i s i o n .

541

542

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

A FIG 4 • A. After ca u d a l m o b i l ization of the d u o d e n u m , stay sutu res are p l aced in the d i stal C B D (fi ne m o n ofi l a ment sutu res) a n d the d u oden u m ( l a rger braided sutu res) to fa c i l itate exposu re . B. Add i t i o n a l view from the patie nt's r i g ht further demonstrates how t h i s m o b i l ization fa c i l itates a n a n asto mosis free of tens i o n . P l a n ned d u ctoto my a n d d u odenotomy (white lines). d u o d e n u m a n d the a nte rior wa l l of the C B D , p rovi d i n g a d d i t i o n a l l e n gth a n d i m p rovi ng t h e p roxi m ity o f the p l a n ned d u ctotomy a n d d u odenotomy sites, thus red u c­ i n g potent i a l te nsion on the a n astomosis (FIG 4).

te n s i o n . A d u o d e n ot o m y i s t h e n m a d e with e l ectroc a u ­ te ry, with cutt i n g c u rrent i n t h e postb u l ba r d u o d e n u m . T h e a n g l e o f t h e d u od e n otomy w i l l vary from patient to patie nt, d e p e n d i n g o n t h e u n d e r l y i n g d i s o r d e r a n d v a r i a t i o n f r o m n o r m a l a n atomy. I n p a n creatitis, t h e m o b i l ity of t h e d u o d e n u m va r i e s w i t h t h e u n d e r l y i n g p e r i p a ncreatic fi b ro s i s so t h e l o c a t i o n of t h e d u ode­ notomy w i l l va ry accord i n g ly. The d u o d e n otomy is u s u ­ a l l y a n o b l i q u e i n c i s i o n , with t h e g o a l of a comforta b l e a n asto m o s i s w i t h o u t d i stort i o n o f t h e d u o d e n a l fl ow. The d u o d e n otomy s h o u l d be cut at a l e ngth of a bout 1 . 0 e m a s it w i l l a l ways stretch m o re than expected

Choledochoduodenal Anastomosis • •

•

•

•

I d e ntification of the C B D is confirmed by aspi ration with a 2 1 -gauge need l e . An anterior d u ctoto my is m a d e sharply, typica l ly with a no. 1 1 b l a d e at the site of the need l e aspi ration, l a rg e e n o u g h to p e r m i t entrance i nto the d u ct w i t h the t i p o f a f i n e hem ostat. An a nterior l o n g itud i n a l choledochot­ omy is then extended with scissors or e l ectroca utery for 1 . 5 em in length. The d u ctoto my is m a d e on the d i sta l C B D as close as safe ly poss i b l e to the d u oden u m . Arte r i a l bleed i n g on the d ista l d u ctoto my means "far enoug h . " The d i sta l C B D a n d c o m m o n hepatic d u ct s h o u l d be i rrigated with an 8-Fr catheter to c l e a r the d u ct of sto nes a n d s l u d g e . If d u cta l l ithiasis i s prese nt, c h o l edochoscopy s h o u l d be u n d e rtaken to confi rm clearance of the d uct of sto nes. Resid u a l sto nes may req u i re ba l l oon catheter o r basket extract i o n . When cavernous tra nsformation of the porta l ve i n is prese nt, the venous netwo rk surro u n d i n g the co m m o n d uct w i l l req u i re a co m b i n at i o n o f suture l igation, co­ a ptive e l ectroca utery, and a rgon beam coa g u lation to a c h i eve hem ostasis. T h e m o b i l ity of d u o d e n u m is assessed to determ i n e w h e re a n a n asto m o s i s w i l l m ost s u it a b l y l i e w i t h o u t

•

•

•

(FIG 5). If a preoperative prograde or retrograde ste nt has been p l a ced, it may be prudent to leave it i n place to se rve as a postoperative stent, part i c u l a r l y i n the d iffi cult a n as­ tomosis in the presence of severe peri pan creatic f i b rosis, recog n i z i n g the risk of ste nt- i n d uced postope rative b i l i ­ a ry sepsis rel ated to the s i a l o m u c i n stent b i ofi l m ha rbor­ i n g g ra m - n eg ative bacte r i a . A s i n g l e l a y e r of i nterru pted sutu res w i t h f i n e 4 - 0 or 5-0 m o n ofi l a ment a bsorba b l e suture i s used for t h i s a n a sto­ mosis. F u l l-thickness corner sutu res a re p l a ced through the d u o d e n u m a n d then the b i l e d uct at either e n d of the a n asto mosis such that the ta i l s are outside the l u m e n . They a re m a rked w i t h a hem ostat a n d act f o r exposure and for conceptu a l p l a n n i n g (FIG 6). The poste r i o r row of sutu res is p l aced with the ta i l s o n the i ns i d e of the l u m en, beg i n n i n g w i t h the m i d d l e s u ­ t u re to a i d i n spat i a l p l a n n i n g . T h i s s u t u r e w i l l be at the

C h a p t e r 1 0 CHOLEDOCHODUODEN OSTOMY

• An anterior c h o l edochotomy is performed i n a n o b l i q u e m a n n er, at least 1 . 5 em i n length. An o b l i q u e d u odenotomy i s m a d e i n a confi g u ration that will a l low fo r a te nsion-free a n astomosis without d i stortion of the duodenum, a p p roximately 1 .0 em i n l e n gth as it will stretch .

FIG 5

•

A

e n d of the choledochotomy a n d at the m i d d l e of the d u o d e n otomy. The i n d iv i d u a l sutu res a re tagged and t h e n tied down at the co m p l et i o n of the poste r i o r row, except the corner stitch es, w h i c h rema i n u ntied to a i d i n exposure (FIG 7). The a nterior row of sutu res is then p l a ced, beg i n n i n g with t h e m i d d l e sutu re, with t h e ta i l s o n the outside of

B

a

•

a

)

b

iii c ..o::oiiiiiil� d

c

•

t h e a n a stomotic l u m e n . A l l re m a i n i n g sutu res a re then tied securely i n place (FIG 8). When the a n atomy is favora b l e, p a rticu l a r l y with a t h i ck­ ened b i l e d u ct, a l a rg e a n a stomosis, and easy d u o d e n a l m o b i l ity, the a n asto mosis can be constructed w i t h con­ t i n u o u s sutures. A cl osed suct i o n d ra i n i s p l aced nea r the a nastomosis.

a

c ..o::oiiiiiil� d iii

/

FIG 6 • Schematic d ra w i n g of how the two osto m ies a re ori ented for the a n asto mosis. A. D e p i ct i o n of the osto m i es as they l i e perpen d i c u l a r to one a n other. B. Stay sutu res a re p l aced on both sides of the m i d po i nt of the choledochotomy (ha lfway between a and b). C. These stay sutu res a re then used to take f u l l-th ickness b ites of the d uoden u m at the ends of the d uodenotomy. This a l i g ns the structu res for p lacement of the poste r i o r sutu re l i n e .

• Anato m i c dep i ct i o n of the c o r n e r sutu res t h a t a r e p l aced with ta i l s o u t s i d e the l u m e n a n d ta gged to a i d f o r exposu re a n d spat i a l p l a n n i n g . The back r o w of sutu res is perfo rmed i n a n i nterru pted fas h i o n , with ta i l s o n the i n s i d e .

FIG 7

543

544

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

A

FIG 8 • A. The a nterior row of sutu res is then p l aced i n a n i nterru pted fas h i o n , with ta i l s o n t h e outs i d e o f the l u men, a n d tied i n turn to com p l ete the a n asto m osis. B. Schematic d ra w i n g of the co m p l eted a n asto mosis.

B

CHOLEDOCHODUODENOSTOMV,

Choledochoduodenal Anastomosis, End-to-Side

EN D-TO-S I D E

•

Incision and Exposure Including Portal Dissection •

The i n c i s i o n a n d exposure a re s i m i l a r to that for the sid e-to-si d e tech n i q ue, i nc l u d i n g a n exte nsive Kocher m a n euver to m o b i l ize the d u oden u m . I n the end-toside tech n i q ue, however, c i rcu mferent i a l d i ssect i o n of t h e C B D i s n ecessa ry. I n cases with severe i nfl a m mation a n d fibrosis of the porta he patis, a sid e-to-side tech n i q u e may be prudent t o avo i d vascu l a r i nj u ry. M e d i a l t o latera l d i ssect i o n of the poster i o r C B D away from the hepatic a rtery a n d porta l ve i n is the safest tech n i q u e . Once the C B D has been e n c i rcled, it i s d ivided as d ista l ly as possible, with attention to precise control of the ra d i a l blood supply of the d u ct, avo i d i n g excess ive use of ca ute ry. The d i sta l e n d of the d ivided bile d uct is then oversewn in a r u n n i n g fash i o n u s i n g a n a bsorba b l e suture.

•

•

A l o n g itud i n a l i n c i s i o n is m a d e in the seco nd port i o n of the d u o d e n u m near where the d ivided b i l e d uct i s l ocated . A s i n g l e l a y e r of f i n e (4-0) a bsorba b l e suture is a lso used for t h i s a n asto mosis. F u l l -thickness corner su­ tures fi rst through the bowel, then t h ro u g h the bile d u ct, a n d a re p l aced at either e n d of the a n astomosis for expos u re and spat i a l p l a n n i n g . If an a n asto mosis with i nterrupted suture is p l a n ned, the conduct of the a n asto mosis is i d e ntica l to that of the s i d e-to-si d e tech n i q u e . If a n a n asto mosis with a run­ ning suture is p l a n ned, the corner sutu res a re tied and l eft l o n g with need l e i n place. O n one end, the needle i s passed to the i n s i d e a n d r u n a l o n g the posterior wa l l i n s i d e t h e l u m e n a n d tied t o t h e oth e r corne r's ta i l . The oth er suture is then run a l o n g the anterior wa l l and tied to the oth e r corne r's ta i l . A c l osed suction d ra i n is p l aced near the a n asto m osis.

LAPAROSCOPIC

Initial Dissection

CHOLEDOCHODUODENOSTOMY

•

Patient Positioning and Port Placement • •

The patient is positioned s u p i n e a n d in reverse Tre n­ d e l e n b u rg with a l eft side down ti lt. Lapa rosco p i c port s ites are p l aced in an a rc a bove the level of the u m b i l icus with a rig ht-s ided b i a s . Port site p l acement s i m i l a r to a l a p a rosco p i c cholecystectomy.

The c o n d uct of t h e o p e r a t i o n is s i m i l a r to that for t h e o p e n tech n i q ue, i n c l u d i n g m o b i l i z a t i o n of t h e h e p a t i c flexu re of t h e c o l o n a n d a n ext e n s ive K o c h e r m a n e u ­ ver to m o b i l ize t h e d u o d e n u m . A l a p a rosco p i c l iver retractor i s n ecessa ry to expose t h e p o rta hepatis. Por­ ta l d i ssect i o n is c a r r i e d o u t with ca re u s i n g t h e h o o k e l ectroca ute ry.

C h a p t e r 1 0 CHOLEDOCHODUODEN OSTOMY

Choledochoduodenal Anastomosis •

When possible, an end-to-side tech nique is favored laparo­ scopical ly, as this anastomosis without tension is often tech­ nically easier to perform. In cases with severe inflam mation and fibrosis of the porta hepatis, however, circu mferentia l bile duct dissection m a y b e treacherous and a side-to-side tech nique is favored.

•

•

545

A f i n e a bsorba b l e suture i s used for the a n asto mosis . The a nastomosis is beg u n with corner sutu res p l aced a n d t i e d without cutt i n g the need l e . T h e poste rior r o w i s r u n f r o m m ed i a l to latera l a n d t i e d to the ta i l of the oth er corner suture. The anterior row is then s i m i l a r l y run, now l atera l to m ed i a l a n d tied to the oth er corne r's ta i l . A cl osed suct i o n d ra i n i s p l aced near t h e a n astomosis .

PEARLS AND PITFALLS I n d ications

•

A thoro u g h preoperative eva l u ation of the cause for b i l i a ry obstruct i o n is i m po rta nt, specifica l ly recog n iz i n g neoplasia if present to a l low for proper ope rative decision m a k i n g .

Preoperative p l a n n i n g

•

I n f l a m mation associated w i t h acute pan creatitis a n d i n fection a n d i n f l a m mation rel ated to c h o l a n g itis on p resentation s h o u l d be properly treated and a l l owed to resolve prior to p roceed i n g w i t h t h i s e l ective o perat i o n . Patient n utriti o n a l status s h o u l d be opti m ized p r i o r to s u rgery to m i n i m ize morbid ity.

•

I ncision a n d exposure

•

An exte nsive Kocher m a n e uver s h o u l d be perfo rmed to m o b i l ize the d u o d e n u m and m i n i m i ze ten­ sion potent i a l l y lead i n g to a n a stomotic fa i l u re .

C h o l edochod u o d e n a l a n astomosis

•

The choledochotomy a n d d u odenotomy should be confi g u red i n a way so as to m i n i m ize a n asto­ m otic tension and d u o d e n a l d istort i o n . Ca refu l i ntrao perative p l a n n i n g and an o b l i q u e b i a s to the i ncisions a re usefu l . T h e a n astomosis s h o u l d b e g reater t h a n 1 . 5 em i n l e n gth t o avoid ste nosis resu lti n g i n c h o l a n g itis, hepatic a bscess, sto nes, and potentia l ly s u m p synd ro m e .

•

POSTOPERATIVE CARE

COMPLICATIONS

•

•

•

Nasogastric decompression should be undertaken in the initial postoperative period. The closed suction drain is removed once diet is tolerated and there is no evidence of anastomotic leak.

• • •

OUTCOMES •

•

Outcomes following CDD are limited to small, retrospec­ tive, single institution case series, including both open and laparoscopic approaches. Postoperative morbidity fol­ lowing CDD is reported as 9 . 8 % to 2 8 % , with the most common complications being wound infection and anas­ tomotic leak. A phenomenon known as "sump syndrome " has been de­ scribed following CDD where food debris or stones accumu­ late in the terminal portion of the CBD, resulting in episodes of abdominal pain, fever, and cholangitis. The incidence of sump syndrome after CDD appears to be relatively uncom­ mon, reported as 0% to 9% in case series, and presents in a delayed fashion, typically years after the procedure. Anastomotic stenosis has been implicated as the cause for sump syndrome as well as for the rare occurrence of recur­ rent stones, cholangitis, and hepatic abscess, and therefore, generous anastomotic girth is encouraged to prevent these complications.

• • •

Intraoperative hemorrhage from portal vein or proper hepatic artery Anastomotic leak, duodenal fistula Anastomotic stricture Cholangitis Hepatic abscess Choledocholithiasis or intrahepatic ductal stones Sump syndrome

SUGGESTED READINGS 1. 2.

3.

4. 5.

6. 7.

Blankenstein J, Terpstra 0. Early and late results following choledocho­ duodenostomy and choledochojejunostomy. HPB Surg. 1 990;2 : 1 5 1-158. Escudero-Fabre A, Escallon A Jr, Sack ], et al. Choledochoduode­ nostomy: analysis of 71 cases followed for 5 to 15 years. Ann Surg. 1 9 9 1 ; 2 1 3 : 635-642. Khajanchee TS, Cassera MA, Hammill CW, et a!. Outcomes following laparoscopic choledochoduodenostomy in the management of benign biliary obstruction. I Gastrointest Surg. 2012; 1 6 : 8 0 1-805. Leppard WM, Shary TM, Adams DB, et a!. Choledochoduodenos­ tomy: is it really so bad? I Gastrointest Surg. 201 1 ; 1 5 : 754-75 7. de Almeida AC, dos Santos NM, Aldeia FJ. Choledochoduodenostomy in the management of common duct stones or associated pathology­ an obsolete method? HPB Surg. 1 9 9 6 ; 1 0 :27-3 3 . Pitt HA, Kaufman SL, Coleman J , e t a l . Benign postoperative biliary strictures: operate or dilate ? Ann Surg. 1 9 8 9;4:4 1 7-425 . Stuart M , K e o T, Hermann RE, e t a ! . Palliation of malignant obstruc­ tion of the common bile duct by side to side choledochoduodenos­ tomy. Am I Surg. 1 9 7 1 ; 1 2 1 :505-509.

-

Chapter

11

Resection of Hilar Cholangiocarcinoma ·----------------------------------------------------- ....

t

Ryan T. Groesch l

PATIENT HISTORY AND P HYSICAL

DEFINITION •

Hilar cholangiocarcinoma (HC), also referred to as Klatskin's tumor, is an extrahepatic cancer of biliary epithelial ori­ gin near the confluence of the right and left hepatic ducts. The hepatic artery and portal vein are in close proximity to the bile duct, and vascular involvement is common. Given the limited effectiveness of other therapies, margin-negative resection is the optimal treatment. Although multimodal therapy combined with transplantation is also a potential approach to HC,l this chapter focuses on the resection tech­ nique for this biliary disease.

FINDINGS •

•

DIFFERENTIAL DIAGNOSIS •

Growth patterns for HC may be exophytic, infiltrative, pol­ ypoid, or any combination thereof ( FIG 1 ) . The differential diagnosis includes pathologies that may mimic any of these appearances. Papilloma-composed of vascular connective tissue and covered with columnar epithelium; low-grade malignant potential Adenoma-glandular tissue surrounded by fibrous stroma; low-grade malignant potential Benign biliary stricture from recurrent pyogenic cholan­ gitis, primary sclerosing cholangitis, choledocholithiasis, Mirizzi's syndrome, previous surgery, or trauma.

•

•

IMAGING AND OTHER DIAGNOSTIC

•

Exophytic

I nfi ltrative

•

P o l ypo id •

Va rious c h o l a n g ioca rci n o m a .

546

1

Combi ned

g rowth

patte rns

of

extra hepatic

Successful hepatectomy must maintain an adequately healthy liver remnant. Initial assessment of the patient must not only focus on the malignancy itself but also on general liver func­ tion. Underlying liver dysfunction ( due to chronic alcohol exposure, viral hepatitis, fatty liver disease, etc . ) may alter operative planning and the minimum remnant required. History Symptoms: j aundice, itching, unintentional weight loss, abdominal pain Broader aspects of patient history: gallstones, cholangitis, primary sclerosing cholangitis, ulcerative colitis, previous surgery or trauma, viral hepatitis, cirrhosis, alcohol con­ sumption, international travel, obesity, diabetes, hyperlip­ idemia, bruising, immune deficiency Physical exam Jaundice or scleral icterus; muscle wasting may be present. If disease occludes cystic duct, gallbladder may be palpa­ ble ( Courvoisier's sign ) . Assess for stigmata o f cirrhosis, portal vein thrombosis, o r portal hypertension: ascites, encephalopathy, spider angio­ mata, skin telangiectasias, palmar erythema, bruising.

STUDIES •

FIG

T. Clark Ga mblin

Transabdominal ultrasound May identify duct dilation and large hilar tumors, but pri­ marily functions as a screening tool Doppler may identify narrowing or thrombosis of the hepatic artery or portal vein. Cross-sectional imaging: computed tomography and magnetic resonance Good visualization of mass lesions and ductal dilation Staging: may identify intraabdominal lymphadenopathy and/or metastases Contrast enhancement allows assessment of vascular in­ volvement and identification of anomalous hepatic inflow, which are critical to operative planning. Signs of cirrhosis or portal hypertension may be present: irregular hepatic capsule, caudate hypertrophy, cavernous transformation, hypersplenism, ascites, recanalized um­ bilical vein. Cholangiography Magnetic resonance cholangiopancreatography Noninvasive; allows visualization and three-dimen­ sional reconstruction of ductal anatomy Does not provide opportunity to sample tissue Endoscopic retrograde cholangiography Allows visualization of ductal anatomy, provides opportunity for brushing or biopsy, and allows stenting in case of biliary obstruction Invasive; risk of procedure-induced pancreatitis

C h a pt e r 1 1

•

•

•

Cholangiography via percutaneous catheters If percutaneous biliary drainage catheters have been placed, contrast can be used to delineate ductal anat­ omy and also allow brushings. Ideally, such catheters are placed in the future remnant liver or bilaterally. Endoscopic ultrasound Allows evaluation of the duct and regional lymph nodes, which may also be sampled with fine needle aspiration or core biopsy when available ( 1 9 gauge to 22 gauge) Intraductal fiberoptic direct visualization (with biopsy) and intraductal ultrasonography are available at some centers. Positron emission tomography Fluorodeoxyglucose (FDG) avidity is typically limited to mass lesions greater than 1 em but provides poor qual­ ity for identifying cancers with infiltrative growth; hence, limited use beyond standard cross-sectional imaging for assessing primary tumor. May identify occult metastatic disease Laboratory evaluation Cholestasis may be indicated by elevated bilirubin, alka­ line phosphatase, and gamma-glutamyltransferase levels. Albumin and prothrombin time evaluate synthetic function. Aspartate and alanine aminotransferase levels are often normal. Low platelet levels may reflect hypersplenism due to por­ tal hypertension. Elevations in carbohydrate antigen 1 9-9 ( CA 1 9-9) or carcinoembryonic antigen may be elevated in patients with HC. CA 1 9-9 may be spuriously elevated in the setting of j aundice. When workup reveals tumor marker elevation, these levels may be followed after resection to assess for dis­ ease recurrence.

RESECTION OF H I LAR CHOLAN G I OCARC I N OMA

Table 1 : Liver-Specific Criteria for Unresectable Klatskin Tumors Tumor extension to bilateral secondary branches of hilar structures Portal vein Hepatic artery Bile duct In patients with normal background liver Future remnant liver < 2 5 % Inability t o preserve two adjacent segments In cirrhotic patients If resection is considered, preservation of a large remnant is essential to prevent postoperative liver failure. These patients can be considered for transplantation in the context of an established multimodal treatment protocol or clinical trial.

• •

• •

•

• •

SURGICAL MANAGEMENT Preoperative Planning • •

•

•

Patients with jaundice should be drained either endoscopi­ cally or percutaneously to optimize liver remnant function. Operations for HC involve the dissection of critical struc­ tures, biliary and vascular reconstruction, and adaptation to intraoperative findings. Expertise in hepatobiliary anat­ omy and surgical technique is essential. In particular, fa­ miliarity with common patterns of anomalous ductal and arterial hilar anatomy ( FIG 2 ) will prevent inj ury to unin­ tended structures. Features of unresectability are shown in Table 1 . When a diminutive liver remnant i s anticipated, preoperative angioembolization of the contralateral (tumor-supplying) portal vein should be pursued in an attempt to hypertrophy the potential remnant. The Bismuth-Corlette classification is used to describe the extent of right and left duct involvement ( FIG 3 ) . Care­ ful review of cholangiography and cross-sectional imaging will identify resectable patients and aid in operative planning.

547

•

Right hepatectomy or trisectionectomy is generally indicated for types II and Ilia tumors. Left hepatectomy, and especially left trisectionectomy, is uncommonly performed and often carries a higher compli­ cation rate. This type of resection is usually reserved for type Illb tumors, or those cases where the future left-sided rem­ nant would be inadequate for type II tumors. Type IV tumors are unresectable unless a full sectoral branch is uninvolved and free of tumor. Type I HC may occasionally be amenable to local biliary re­ section alone; however, RO rate and thus survival have been directly linked to the use of hepatic resection. 2 Apparent invasion of the portal vein or vena cava does not preclude resection. Large tumors can narrow adj acent ves­ sels on imaging; however, this may be mass effect and not necessarily represent invasion. Contraindications to resection include distant metastatic disease and bilobar liver involvement. Although enthusiasm has grown for laparoscopic liver sur­ gery, the dissection and reconstruction required for resec­ tion of HC currently requires laparotomy in most cases. However, a preliminary laparoscopy (performed immedi­ ately before planned resection) will identify occult disease in at least half of unresectable patients, who are then spared laparotomy.3 Intraoperative ultrasound should be used liberally through­ out the operation to assess extent of disease, location of ducts, and location/patency of vessels.

Positioning • •

•

• •

Supine position with arms perpendicular to body axis ( FIG 4) Sterile skin preparation extends cranially beyond the nipple line, caudally to the groins, and laterally to the posterior axillary lines (particularly on the right side ) . I f the need for portal vein reconstruction with autologous internal jugular vein is suspected, a sterile field is also pre­ pared at the neck. If preoperative biliary catheters were placed, they are prepped into the field. Both groins are prepped if venovenous bypass is an antici­ pated strategy.

548

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

M i d d l e hepatic artery

Type 1 - 55%

Left hepatic artery

Proper hepatic artery

Common

bile d u ct

Common

Gastro d u odenal artery

hepatic artery

Right gastric artery

Type 1 1 - 1 0%

Type 1 1 1 - 1 0 % M i d d l e hepatic artery

Left hepatic artery

Right

R i g ht hepatic

hepatic artery

artery

��,rl

------

Cystic artery

Proper hepatic artery

--'1•

----

---"""">"'MW"\'\11•

Cystic artery

Left

Superior

gastric

mesenteric

artery

Common

artery

hepatic artery

Right hepatic artery

•

Com m o n va riations of h i l a r a rte r i a l a n atomy. Alth o u g h the u s u a l cou rse of the r i g ht hepatic a rte ry is from the c o m m o n hepatic a rtery a n d cross i n g l atera l ly poste rior to the bile d u ct confl u e n ce, a rep l a ced (or accesso ry) r i g ht a rtery may orig i n ate from the superior mesenteric a rte ry. A re p l a ced (or accessory) l eft a rte ry may be fo u n d i n the gastroco l i c l i g a ment o r i g i nating from the l eft g astric a rte ry.

FIG 2

Type I

Type I I

Type lila

Type lllb

Type IV

FIG 3

•

t u m o rs.

B ism uth-Corl ette classification of Klats k i n

C h a pt e r 1 1

RESECTION OF H I LAR CHOLAN G I OCARC I N OMA

549

FIG 4 • Proper positi o n i n g of the patient in the s u p i n e position with a rms perpend i c u l a r to the body axis. The r i g ht su bcostal i ncision with s u bxi p h o i d exte nsion i s a l so shown.

PRELIMI NARY LAPAROSCOPY •

•

Using the Hasson method, a 1 0- to 1 2-mm peri u m b i l ica l port is placed . A 1 0-mm 30-deg ree lapa roscope is used to i nspect the abdomen for evidence of metastases: peritoneal cavity, l iver surface, porta hepatis, gastrohepatic l i g a ment. If n ecessa ry, an a d d i t i o n a l 5-mm port is p l aced u n d e r d i rect visua l i zation i n the s u bxi p h o i d m i d l i n e (to b e i n c l uded i n the potent i a l l a pa roto my i ncision).

• • •

•

LAPAROTOMY Incision and Abdominal Inspection • •

•

•

The a bdomen is entered with a r i g ht su bcostal i ncision with subxi p h o i d exte nsion (FIG 4). The l i g a mentum teres hepatis (ro u n d l i g a m ent) is d ivided a n d fa lciform l i g a ment taken down from the a nte rior a b d o m i n a l wa l l . The abdomen is i n spected thoro u g h ly to confirm a bsence of d ista nt d i sease. The l iver is i n spected with b i m a n u a l p a l pation a n d i ntraoperative u ltrasonography. Along with control of the h i l a r vesse ls, c i rcu mferenti a l control o f t h e s u p ra- a n d i nfra hepatic vena cava with a tape can be used sel ectively, which a l l ows for nearly co m p l ete vascu l a r control of the l iver s h o u l d venovenous bypass be necessa ry.

Paraaortic Node Assessment and Biliary Dissection • • • •

The omentum is freed from the tra nsverse colon, a l l ow­ i n g access to the o m enta l b u rsa. The hepatic flexure of the colon is m o b i l ized a n d rotated m ed i a l ly until the duodenum and vena cava a re identified . A Kocher m a n e uver is perfo rmed, retract i n g the d uode­ num to the l eft until the aortocava l g roove is exposed . F i r m or e n l a rged paraa ortic nodes a re sa m p l ed for i m ­ m e d i ate path o l o g i c exa m i nati o n . • If nodes are g rossly positive, the operation i s term i n ated.

Potenti a l m etastases should be b i o psied for i m m ed iate path o l o g i c a n a lysis. If d ista nt m etastatic d i sease or b i l o b a r l iver d i sease i s n oted, the operation i s term i n ated. If there are n o s i g n s of u n resecta b i l ity, proceed to l a p a roto my.

• •

If nodes show m icrosco p i c d i sease, a l l exposed paraa o rtic fib rofatty a n d nodal tissue is resected . • If nodes a re negative, no further para aortic dissection. The g a l l b l a d d e r is d issected from the l iver a n d l eft attached to the spec i m e n via the cysti c d uct. Seg ment 4b is l i fted to expose the h i l a r p l ate. Connective tissue i nvest i n g the b i l e duct, hepatic a rtery, a n d porta l vein in this area is a d d itio n a l ly covered by a tissue conflu­ ence from G l i sson's capsu l e on the l iver surface. Fine scissor d issection here w i l l expose h i l a r structures and clear fasc i a l a n d lymphatic tissue f r o m the field (FIG S). A " no-touch " a p p roach is recom mended for h a n d l i n g the tumor a n d h i l a r vesse ls. I nstead, m a n u a l m a n i p u lation should ta rget periadventit i a l and other noncritica l con nective tissues. • The hepatic a rtery is i d e ntified prox i m a l ly. Its b i ­ fu rcati o n typ i ca l ly i s ca u d a l to the b i l e d u ct a n d porta l ve i n confl u e n ces. T h e r i g ht hepatic a rtery most often cou rses poste rior to the proxi m a l com­ m o n bile d uct. C a refu l exa m i nation of h i g h-q u a l ity cross-sect i o n a l i m a g i n g s h o u l d a l low the s u rgeon to a ntici pate the cou rse of the a rte ry a n d p rotect it. • Repl aced or accessory a rteries may o r i g i nate from the l eft gastric a rtery t h ro u g h the gastro hepatic l i g a ment (l esser o m e ntum) o n the l eft or from the superior mesenteric a rtery poste rior to the common bile d u ct on the r i g ht. • Although the m i d d l e hepatic a rtery most often a rises from the left hepatic artery and crosses a nterior to the left duct, its origin and orientation a re h i g h ly variable.

550

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

•

•

•

• D issection of the h i l a r p late beg i n s with proxi m a l identification o f the b i l e duct a n d hepatic a rtery, w h i c h l i e a nterior t o t h e porta l ve i n . T h e g a l l b ladder h a s been rem oved from the base of the l iver and is used for retract i o n . A no-to uch tech n i q ue should be observed when d i ssect i n g near the tumor.

FIG 5

•

•

The proxi m a l extent of tumor is determi ned by caudal re­ traction of the b i l e duct and g a l l b ladder. This step is critica l as it w i l l determ i n e whether right or left hepatectomy is underta ken. Some l iver parenchyma may need to be tra n­ sected to adequately assess either duct. D ivid ing con nective tissue between the base of seg ment 4 and the bile duct con­ fl uence (tumor) w i l l often fac i l itate loweri ng the h i l a r plate. • To a d e q u ately i n spect the l eft hepatic d u ct, the n a r­ row bridge of l iver parenchyma u n d e r the u m b i l i ca l fissu re ca n be d ivided. The l eft d u ct has a l o n g e r ex­ trahepatic cou rse a n d l i es perpend i c u l a r to the comm o n d u ct before enteri ng the l iver parenchyma at the base of the u m b i l ica l fiss u re . The l e n gth of the extra hepatic portion of the l eft d uct is the p r i m a ry reason that a r i g ht l iver resection is m ost often performed in p u rs u it of an RO resect i o n . • The extra hepatic right h e p a t i c d uct is typica l l y shorter a n d ra p i d ly ascends l atera l ly i nto t h e parenchym a . I n nearly o n e-fou rth of patie nts, a right segm e nta l d u ct will cross Cantlie's line to join the m a i n l eft hepatic d u ct. D u e t o its short l e n gth a n d orientation, the r i g ht d u ct is prone to i n a dvertent i nj u ry. I ntrao pe rative c h o l a n g i o g ra m serves as a va l u a b l e t o o l t o cla rify the a n atomy. • If g ross d isease extends to a l l fo u r hepatic secti o n a l d u cts, the t u m o r is u n resecta b l e a n d further o perative exploration is not wa rra nted . The r i g ht g astric a rtery is l i g ated a n d d ivided at its o r i g i n f r o m the c o m m o n hepatic a rte ry.

•

The poste rior superior pan creaticod uodenal a rtery (PSPD) crosses the c o m m o n b i l e d uct n e a r the superior aspect of the pancreatic h e a d . The co m m o n bile d uct w i l l b e l i g ated a n d transected i n t h i s a re a : • If no t u m o r i nvolve m e nt nearby, the PSPD may be l eft i n situ. • If a d h e rent to t u m o r, the PSPD s h o u l d be l i g ated and resected e n bloc with t u m o r speci m e n . • If t u m o r extends i nto p a n creatic head but the PSPD is not i nvolved, then the PSPD i s d ivided and retracted to a l low d i ssection of t u m o r i nferiorly i nto pancreatic parenchy m a . I n rare cases of H C, a pancreaticod uodenecto my may be n ecessa ry for m a rg i n -neg ative resect i o n . The d i stal c o m m o n b i l e d u ct i s tra nsected j u st a bove the pan creas a n d a d i stal m a rg i n sent for i m med iate patho­ logic assessment. • The d ista l peripa ncreatic stu m p is oversewn with r u n n i n g 5-0 Prolene. • If b i l i a ry drainage catheters a re in p l ace, they are re­ tracted i nto the hepatic parenchyma, a l lowing for the proxi m a l duct to be tied off and retracted superio rly. Caudate resection is reco m mended .4•5 Explorati o n com­ m e n ces by expo s i n g the i nfe rior vena cava (IV C) poste rior to the l i ve r. The m ost i nfer i o r hepatic ve i n s a re l i g ated and d ivided to a l l ow poster i o r exposure of the cau date. • Ve i n s less t h a n 5 m m in d i a m eter ca n be d ivided with sta n d a rd suture l igation o r c l i ps. • Co m m o n ly, there w i l l be at least one ve i n g reater than 5 mm in d i a m eter b e h i n d the cau date. Such ve i n s shou l d be contro l led with a Sat i n s ky c l a m p on the v e n a cava, tie l i g ated at the caudate aspect, d ivided, a n d the cava l stu m p oversewn with r u n n i n g 5 - 0 Pro l e n e suture (FIG 6). • F i g u re-of-e i g ht stay sutu res p l aced in the caud ate a re a usef u l means of retract i n g the ca u d ate off the vena cava (FIG 7). • The l eft aspect of the he patocava l l i g a ment may have to be d ivided to a l l ow visua l i zati o n . Porta l ve i n i nvolve m e nt is assessed b y retra ct i n g the b i l e d u ct a nte r i o r a n d cra n i a l .

5 mm

FIG 6 • Tec h n i q u e of d iv i d i n g short hepatic ve i n s from seg ment 1, 4, 5, o r 8.

C h a pt e r 1 1

RESECTION OF H I LAR CHOLAN G I OCARC I N OMA

FIG 7 • To assist with caudate retraction, fig u re-of-e i g h t stay sutu res can be p l aced in the ca u d ate parenchyma a n d gently retracted. FIG 8 •

•

•

Caudate prese rvati o n is o n l y poss i b l e if sufficient b i l i a ry outflow can be spared. Alth o u g h va r i a b i l ity exists, the caudate w i l l typica l ly have at least two d u cts, w h i c h m ost often d ra i n to the m a i n l eft d u ct, the m a i n right d u ct, o r the r i g ht poste rior sect i o n a l bra n c h . If caudate resection is perfo rmed, then sma l l porta l ve i n branches (poste r i o r aspect of both r i g ht a n d l eft m a i n porta l ve i n s) m u st be l i g ated a n d d ivided. Caudate m o b i l ization is assisted by a p p roach i n g from both the r i g ht side and l eft side of the ve n a cava .

•

•

Hepatectomy

• •

As previously described, the choice of he patecto my is d i rect ly rel ated to the extent of d u ctal, porta l ve nous, a n d hepatic a rte r i a l i nvolve m e nt. • R i g ht hepatectomy is described in Part 3, Chapter 23. • left he patecto my is described in Part 3, C h a pter 2 5 . • R i g ht trise g m entecto my is described in Part 3, C h a pter 30. • left trise g m e ntectomy is described i n Part 3, C h a pter 3 1 . Porta l ve i n considerations are u n i q u e d u ri n g hepatec­ tomy for H C, howeve r, and described here. E n bloc hepatic a rte r i a l resection a n d reco nstruction is rarely needed, as t h i s extent of t u m o r is g e n era l ly deemed u n resecta b l e .

•

• •

•

Biliary Resection and Reconstruction • •

The d uct is cut s h a r p l y without ca utery a rtifact. Periductal bleed i n g is contro l led with d i g ita l p ressure. Frozen section pat h o l o g i c a n a lysis g u ides the exte nt of b i l i a ry resection i nto the rem n a nt l i ver. Stay sutu res (5-0 Pro l e n e) in the d u ct a l low further retract i o n a n d d is­ section if a more p roxi m a l m a rg i n is necessa ry.

H e paticojej u n osto my.

A Ro ux-en-Y j ej u n a l l i m b is broug ht t h ro u g h the co­ l o n i c m esentery to the rig ht of the m i d d l e co l o n i c ves­ sels (retroco l i c), with sufficient m o b i l ization to a l l ow for tension-free he paticojej u n ostomy. An e nte roto my i s created o n the a n t i mesente ric border of the Roux l i m b, size-m atched to t h e ta rget hepatic d u ct. When p racti c a l , m u lt i p l e adjacent d u cta l branches ca n be i n corporated en m asse to the a n asto mosis (FIG

8). •

•

•

•

•

I nterru pted, d o u b le-armed 5-0 Pro l e n e sutu res a re i n i ­ tia l ly p l a ced i n t h e anterior wa l l o f t h e d uct a n d gently retracted with shods to fac i l itate exposu re . An asto mosis beg i n s a l o n g the poster i o r wa l l , where a s i n g l e layer of 5-0 Prolene sutu res i ncorporate the f u l l ­ thick ness wa l l o f both d u ct a n d R o u x l i m b . Knots are tied once a l l poste rior sutu res are su ccessfu l ly p l a ce d . If a l ready present, percuta neous transhepatic stents a re a d ­ vanced and left i n p l a c e across t h e b i l ioenteric a nastomosis. As an a ltern ative, a 4- to 6-Fr tra nsanastomotic tu be ca n be p l a ced through the a n t i m esenteric wa l l of the Roux l i m b with the Witzel tech n i q ue, p l a ced prox i m a l ly i nto the rem n a nt b i l i a ry tree, b ro u g ht out t h ro u g h the a b d o m i n a l wa l l , a n d conn ected to a d r a i n a g e b a g . This a l l ows a ccess to the b i l i a ry tree without p l a c i n g retro­ g rade b i l i a ry catheters t h ro u g h the l iver (FIG 9). The previously shod-retracted anterior d u cta l 5-0 Prolene sutu res a re i n corporated i nto the bowe l wa l l a n d tied to com p l ete the a n asto mosis. The final h i l a r m a rg i n should be m a rked with c l i ps (or g o l d f i d u c i a l m a rke rs) to g u i d e su bse q u ent needs for exte r n a l beam ra d i a ti o n . Cl osed suct i o n d r a i n s a re p l a ced adjacent t o the b i l ioen­ teric a n asto mosis a n d u n d e r the r i g ht d i a p h ra g m before a b d o m i n a l closure .

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

FIG 9

•

Alternative p l acement of tra nsanastomotic tube.

•

Division of Portal Vein • •

•

FIG 10 • Va rious a pproaches to porta l ve i n resect i o n . When co m p l ete tumor resect i o n en croaches o n the porta l ve i n confl ue nce, closure s h o u l d be performed i n a tra nsverse fas h i o n , as l o n g itud i n a l suture l i n es may cause ste nosis of the rem a i n i n g vesse l .

If the porta l ve i n is free of t u m o r, then the porta l vein is d ivided i n sta n d a rd fash i o n as for ro utine hepatectomy. If the r i g ht or left porta l ve i n transection p l a n e encroaches i nto the confl uence d u e to tumor i nvolvement (FIG 1 0) • C l a m p the m a i n a n d contra l atera l porta l ve i n branch separately a n d tra nsect t h e v e i n as necessa ry to a c h i eve t u m o r-free m a r g i n s . • Cl ose the porta l d efect in a tra nsverse orientat i o n w i t h ru n n i n g 6 - 0 Pro l e n e . Longitu d i n a l c l o s u r e re­ su lts in u n n ecessa ry n a rrow i n g and skew i n g of the re m a i n i n g porta l ve i n . If t u m o r i nvolves the porta l confl ue nce, vein resect i o n a n d reco nstruct i o n is performed l a t e r i n the operation (afte r l iver parenchyma has been fully tra nsected a n d l eft hepatic d u ct d i ssected).

•

Porta l ve i n resections of u p to 3 em can be repa i red p r i m a r i ly. C l a m p the m a i n a n d contra l atera l porta l ve in, a n d excise the porta l ve i n e n bloc with t u m o r. H e p a r i n is a d m i n istered syste m i ca l ly prior to c l a m p i n g the m a i n porta l vein a n d is reve rsed at the c o m p letion of the operati o n . After e n s u r i n g proper m o b i l i zation o f rem a i n ­ i n g vei n, r u n n i n g 6 - 0 Prolene sutu re i s used to a p p roxi m ate ends. Porta l ve i n resect i o n s g reater t h a n 3 em in l e n gth typica l l y req u i re i nterposit i o n a utog raft (th e a u t h o rs prefer e i t h e r l eft re n a l ve i n o r i nte r n a l j u g u l a r ve i n ) .

PEARLS AND PITFALLS I n d ications

•

M u ltidetecto r cross-sect i o n a l i m a g i n g s h o u l d accu rate ly stag e m ost patie nts a n d w i l l often reve a l a n o m a l o u s h i l a r vascu l a r a natomy. Ca refu l preoperative review of th ese i m a g e s is essentia l .

Skeleto n i z i n g the he patod uodena l l i g a ment

•

•

Observe a n o-touch tech n i q u e when m o b i l i z i n g t h e t u m o r, d u cts, a n d a rteries. G ra s p i n g adjacent connective tissue (such as peri adventit i u m o r neural p l exus) w i l l avoid i atro­ g e n i c i n j u ry and t u m o r capsu l e v i o l a t i o n .

Va r i a b l e a n atomy

•

Co m p l exity of d u cta l a n d vascu l a r d i ssection i n creases w i t h the presence of t u m o r b u l k a n d i n f i l ­ trati o n i n the h i l u m . Review o f i m a g i n g a n d knowledge o f co m m o n a n atomic varia nts w i l l exped ite a safe operat i o n .

•

Caudate resect i o n

• •

S h o u l d be routi nely perfo rmed a n d can be a p p roached f r o m e i t h e r side The caudate a n d r i g ht poste rior sect i o n s h o u l d be d ivided by parenchy m a l tra nsection toward the r i g ht cava l edge.

C h a pt e r 1 1

RESECTION OF H I LAR CHOLAN G I OCARC I N OMA

POSTOPERATIVE CARE

COMPLICATIONS

•

•

• • • •

•

Standard thromboprophylaxis should be given immediately. Early ambulation and pulmonary toilet are mandatory. Early ultrasound is a vital tool for any suspected insult to the remnant liver. High-volume ascites may signify postoperative hepatic fail­ ure and is an early sign of portal thrombosis. Bilious drain output may indicate a disconnected biliary duct in the remnant or an anastomotic leak. This should be evaluated with cholangiogram and cross-sectional imaging. Closed suction drains are typically removed after biliary tree catheters are clamped, provided there is no substantial bile leak or ascites. This typically occurs prior to discharge.

• • • • •

Bile leak Bilioenteric anastomotic stricture Torsion of liver remnant Thrombosis of portal vein, hepatic vein, hepatic artery, or vena cava Cholangitis or abscess Liver failure

REFERENCES 1.

2.

OUTCOMES • • • • •

After curative intent resection for HC, 5-year survival IS 2 5 % to 3 0 % . 6 Rate of RO resection is typically 64% to 71 % . Postoperative morbidity and mortality rates range up to 5 0 % and 1 0 % , respectively. Bile leaks may occur in up to 2 0 % of resected patients. Left liver resection (particularly left trisectionectomy) is as­ sociated with greater morbidity and a higher rate of positive margins.

553

3.

4.

5.

6.

Heimbach JK, Gores GJ, Haddock MG, et al. Liver transplantation for unresectable perihilar cholangiocarcinoma. Semin Liver Dis. 2004; 24(2) :20 1-207. Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg. 2001 ;234(4 ) : 507-5 1 7; discussion 5 1 7-5 1 9 . Weber SM, DeMatteo RP, Fong Y, e t a l . Staging laparoscopy i n pa­ tients with extrahepatic biliary carcinoma: analysis of 100 patients. Ann Surg. 2002;2 3 5 ( 3 ) : 3 92-3 9 9 . Endo I , Matsuyama R, Taniguchi K, e t a l . Right hepatectomy with resection of caudate lobe and extrahepatic bile duct for hilar cholan­ giocarcinoma. ] Hepatobiliary Pancreat Sci. 2012; 1 9 ( 3 ) : 2 1 6-224. Uesaka K. Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarci­ noma (with video ) . ] Hepatobiliary Pancreat Sci. 20 12; 1 9 ( 3 ): 1 9 5-202. Friman S. Cholangiocarcinoma---75% of hepatic lobe o r >3 C o u i n a u d's segments i n a s i n g l e lobe Juxta hepatic venous inju ries

VI

Vascu l a r Hepatic avulsion Adva nce one g rade for m u ltiple inju ries up to g rade Ill.

From Moore EE, Cogbill TH, Jurkovich GJ, et a/. Organ injury scaling: spleen and liver (1994 Revision) J Trauma. 1995;38:323-324.

608

FIG 1 • CT sca n i m a g e of a grade IV l iver i nj u ry. Desp ite the exte nsive i nj u ry to the l i ver, n ote the rel ative pau city of b l ood surro u n d i n g the l i ve r. This i s a pitfa l l of FAST u ltrasonography, as it detects p r i m a r i ly free f l u i d . It a lso speaks to the lack of sensitivity of FAST for i n d iv i d u a l org a n i n j u ries. It d etects b l ood but not the sou rce of the bleed i n g .

C h a p t e r 1 8 S U R G I CAL MANAG E M E N T OF H E PATI C TRAUMA

•

•

•

for abdominal trauma (e.g., a patient with severe traumatic brain inj ury following motor vehicle crash) . Specific to liver laceration, the identification of intravenous contrast extrav­ asation warrants treatment rather than observation. Arteriography with embolization can be selectively employed as a primary treatment or as an adj unct to surgical manage­ ment of liver lacerations with arterial hemorrhage. This may be employed more frequently in centers with hybrid operat­ ing room (OR)/interventional radiology (IR) suites. Cholangiography is sometimes useful to determine whether there is biliary injury and ongoing bile leak. This is generally performed later in the postinj ury course. The presence of a biliary injury and bile leak generally calls for intervention either surgical or endoscopic. Magnetic resonance imaging has little role in the manage­ ment of liver trauma.

SURGICAL MANAGEMENT •

Severe abdominal pain or tenderness, peritonitis, evisceration, or shock with a presumed abdominal injury warrant LAP.

SKIN I NCISION •

Exploratory LAP fo r tra u m a s h o u l d be perfo rmed through a g e nerous m i d l i n e ab d o m i n a l i n c i s i o n . Alth o u g h it may not i n itia l ly extend from the xiphoid to p u b is, as is clas­ sica l ly sugg ested, once a major l iver i n j u ry is identified, exte nsion u p to the x i p h o i d p rocess is reco m m ended to afford opti m a l exposu re. Some e l ective l iver s u rg e ry is perfo rmed t h roug h r i g ht o r b i l atera l su bcosta l i ncisio ns,

ABDO M I NAL EXPLORATION •

The i n it i a l o bj ective of tra u m a LAP is to dete r m i n e if there is exsa n g u i nating hemorrhage a n d from where it e m a n ates. B l ood m u st be evacu ated a n d the sou rce

MANUAL COMPRESSION •

The fi rst ste p in hepatic hemorrhage control is m a n u a l comp ression (FIG 2) . This s h o u l d be a b l e to control the vast majority of l iver bleed i n g . The i m po rtance of s i m u ltaneous a g g ressive resuscitation ca n n ot be overem­ phasized. Restorati o n of b l ood vo l u m e and m a i ntena nce of tissue perfusion, correction of coa g u l o pathy, a n d active wa r m i n g of the patient a re critica l to avo i d t h e " b l oody v i c i o u s cyc l e " t h a t can lead to e a r l y m o rtal ity.

FIG 2 • M a n u a l compression of the l iver is pe rfo rmed to restore the normal a n ato m i c conto u r of the l iver a n d tam ponade b l eed i n g . T h i s m a n e uver can control hemorrhage while p l a n n i n g pack i n g o r defi n itive i nterventions.

•

609

Following stab wounds, the presence of shock, evisceration, or peritonitis is a clear indication for LAP. Gunshot wound to the abdomen, given its high association with significant injury, is an indication for LAP regardless of the initial physi­ cal findings.

Preoperative Planning •

Prior to taking the patient to the OR, the surgeon should communicate with the OR team regarding the suspected di­ agnoses and planned interventions, anticipated blood loss and transfusion requirements, positioning and incisions, extent of skin preparation, the need for imaging, and any special equipment needs.

Positioning •

The patient should be positioned supine. There is no advan­ tage to tucking the arms. In the setting of trauma, it is best to leave both arms out to allow the anesthesiologist's access for venous and arterial catheterization and sampling.

with or without ceph a l a d extension in the m i d l i n e . This may be ch osen if the operation i s perfo rmed l ater i n the patient's c l i n ical cou rse for co m p l ications of l iver inju ry, typica l ly b i l e leak. H owever, t h i s may l i m it access to the lower a bd o m e n i n the eve nt there are m u lt i p l e i nj u ries. If a m i d l i ne i n cision has been made, the s u rgeon s h o u l d n o t hesitate to extend the i ncision to the r i g ht if nec­ essa ry. Adequate exposu re i s critica l to repa i r i n g major hepatic i nj u ries.

identified. Pri m a ry c u l prits a re so l i d orga ns, retro peri­ tonea l vessels, a n d mesentery. The surgeon should be a b l e to ra p i d ly assess the l iver for major l acerations, by i nspect i n g it a n d p a l pati ng its surface.

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

PERI HEPATIC PACKING •

Pe r i h e patic pack i n g s h o u l d be performed in such a m a n ner to m a i nta i n hem ostatic compression on the l iver (FIG 3) . The s u p po rt i n g l i g a m e nts of the l iver a re l eft i n ­ tact at t h i s sta ge, as t h e y may p rovi de t a m p o n a d e of ve­ nous b l eed i n g . H owever, s h o u l d the patient have ste l l ate

lacerations or extens ive su bcapsu l a r i nj u ry, one s h o u l d n o t hesitate to m o b i l ize the suspensory l i g a ment o f t h e fa l ciform o r the right a n d l eft tri a n g u l a r l i g a m e nts t o a l l ow better expos u re . Pac k i n g s h o u l d be pe rfo rmed i n a syste matic fas h i o n , p l a c i n g packs between t h e l iver a n d the a bdom i n a l wa l l , d i a p h ra g m , a n d retroperito neum.

Laparotomy pad

B

A

FIG 3 • The l iver is packed with LAP pads to provide com pression a g a i nst the a bdom i n a l wa l l , d i a p h ra g m , a n d retro perito n e u m . A. I n the sag itta l view, packs a re p resent between the l iver and the d i a p h ra g m a n d a bdom i n a l wa l l . B. I n the photog raph, the right lobe is comp ressed by packs.

TOPICAL HEMOSTASI S •

G rades I a n d I I l acerations (see Ta b l e 1 ) may sto p b l eed­ ing spontaneously o r after a short period of packi n g (FIG 4). O n g o i n g hemorrhage c a n usu a l ly be contro l l ed with e l ectroca utery or a rgon beam coa g u l ation, with or without a p p l ication of top ica l hem ostati c agents such as m icrocrysta l l i n e collagen, f i b r i n g l u e, o r oth e r a g ents

(FIG 5).

FIG 4 • Low-g rade lacerations (arro w) may often stop b l eed i n g sponta neously or fo l l owing a brief period o f com p ression or packi n g .

C h a p t e r 1 8 S U R G I CAL MANAG E M E N T OF H E PATI C TRAUMA

A

B

DAMAG E CONTROL •

In the physiologica l ly comprom ised patient, the decision to p u rsue damage control m ust be made early i n order to opti m ize the patient's chance of surviva l . Ti me-consu m i n g efforts t o stop relatively m i nor bleed i n g s h o u l d n o t distract

FIG 5 • Low-grade i n j u ries with per­ sistent b l eed i n g may be treated by to pi ca l hem ostati c tech n i q ues such as a rgon beam coa g u lation (A) o r m icrocrysta l l i n e co l l agen a p p l ication (B).

the surgeon from the primary objective. The l iver should be packed q u ickly a n d oth er damage control m a neuvers com p l eted prior to a tempora ry abdom i n a l closure. I n order t o facil itate l ater pack rem ova l without d isrupting clot, a nonadherent p lastic d rape may be spread over the liver su rface, with the packs p laced on top of the plastic.

If the patient's condition a l l ows, the l iver s h o u l d be ex­ a m i ned to determ i n e the extent of the i n j u ry. G rades II a n d I l l lacerati ons s h o u l d be i n spected to dete r m i n e whether a d i screte vesse l may be l i g ated (FIG 6) . B l eed­ ing can g e n e ra l ly be contro l l ed by packi n g the wou nd with a n omental ped icle or a plug of to p ic al hem ostatic

a gents such as a bsorba b l e gelatin sponge wra p ped in oxi d i zed reg enerated ce l l u lose (FIG 7) . Suture he pator­ rha phy is an option, but one m ust avoid l eavi ng a l a rg e dead s p a c e a n d avo i d devita l i z i n g t i s s u e o r l acerat i n g vessels or b i l e d u cts. Extens ive lacerations may n e e d t o be exp lored to control m a j o r vesse ls. The finger fracture tec h n i q u e a l l ows one to reach major vessels for l i gation (FIG 8) . Sta p l i n g devices can a lso be usef u l i n dividing the hepatic parenchyma to reach deep vessels (FIG 9).

FIG 6 • The l aceration s h o u l d be exp l o red to identify d i screte vesse ls to l i g ate.

FIG 7 • Omental ped i c l e packi n g may p rovi de hem ostasis for deeper inju ries.

DEEP PARENCHYMAL HEMORRHAG E CONTROL •

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P a r t 3 OPERATIVE TECH NIQUES I N HEPATO-PANCREATO-BI LIARY SURGERY

B

FIG 8 • F i n g e r fracture of l iver p a renchyma (A) can provi de exposure for c l i p p i n g o r suture l i gation of lacerated vesse ls (B) .

A

• S u rg ical sta p l ers may be used to d ivide l iver parenchyma to reach b l eed i n g vessels.

FIG 9

BALLOON TAMPONADE •

Tra nshepatic penetrating wounds may leave a long i ntra­ cavita ry defect that is d ifficult to access for vascu l a r con­ tro l . B a l loon ta mponade may be acco m p l ished by a device orig i n a l ly described by Poggetti and co l leagues.5 This may be fashioned by l igating a 1-in Pen rose d ra i n at one end. A red rubber catheter is i nserted i nto the open end and secu red with a seco nd l i g ature. The Pen rose d ra i n is p u l led through the wound, with the red rubber catheter and d ra i n exiting the abdom i n a l wa l l . The b a l l oon is i nfl ated with sa l i n e to ach ieve tamponade (FIG 1 0).

• B a l loon tamponade i s a n effective means of hemorrhage control for penetrat i n g wounds t h ro u g h the m i d d l e of the l i ve r.

FIG 1 0

C h a p t e r 1 8 S U R G I CAL MANAG E M E N T OF H E PATI C TRAUMA

PRI N G LE MANEUVER •

B l eed i n g that persists despite packi ng may be a rterial i n orig i n . T h e Pri ngle maneuver-that i s , control of the hepa­ tod uode n a l l i g a ment with a Rumel tourniq uet or vascu­ lar c l a m p-sho u l d be e m p loyed (FIG 1 1) . If this controls hemorrhage, it is l i kely that the bleed i n g is from either a hepatic a rterial branch or major branch of the portal

vei n . This ca n n ot be left i n p lace for a prolonged period. I nterm ittent u n c l a m p i n g decreases the deg ree of ischemia/ reperfusion injury. Defin itive maneuvers m ust be under­ taken and the c l a m p should be released with i n 60 m i n utes if possi ble. Ligation of the right or l eft hepatic a rtery may contro l the bleed i n g . Alternatively, in the appropri ate set­ ting, the patient may u ndergo a rterioembol ization.

FIG 11 • The Pringle m a n e u ver. A vascu l a r c l a m p is a p p l ied to the he patod u o d e n a l l i g a m ent, pass i n g the poste rior blade through the fora men of Winsl ow, g u ided by the i n d ex f i n g e r.

HEPATI C RESECTION •

Resection of d evita l i zed tissue may be perfo rmed at the i n it i a l operation; i n the damage control sett i n g , how­ ever, t h i s is reserved for su bseq u ent LAP. The extent of devita l ized tissue i s genera l ly rea d i ly a p p a rent (FIG 1 2) . Resection may be necessa ry to control m a j o r vascu l a r o r b i l i a ry struct u res. Ag a i n , i n the patient who is seve rely comprom ised physiological ly, this i s best done after resuscitation.

FIG 1 2 • H e patic necrosis may result from major i n j u ry o r vascu l a r l i gation to control bleed i n g .

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

HEPATIC VASCULAR ISOLATION •

B l ee d i n g that persists desp ite the Pri n g l e m a n e uver i s l i kely f r o m the h e p a t i c ve i n s . H e patic vascu l a r isolation with or without venovenous bypass should be considered (FIG 1 3).6 This enta i l s control of the suprare n a l IVC, the su prahepatic IVC, and a Pri n g l e m a n euver. If the i nter­ ruption of venous return resu lts in card i ovascu l a r col­ l a pse, the aorta may need to be cross-c l a m ped wh i l e venovenous bypass is esta b l ished. T h e suprahepatic c l a m p may be p l a ced below the d i a p h ra g m , but t h i s is not i d ea l . The c l a m p opti m a l l y s h o u l d be p l a ced with i n the perica rd i u m . T h i s c a n be acco m p l i shed from with i n the a bdomen, but the exposure i s m a rkedly i m p roved by m e d i a n ste rnotomy (FIG 1 4) .

To internal

Suprahepatic inferior

Pringle

Pump

Suprarenal inferior

vena cava via femoral vein or greater saphenous vein • H e patic vascu l a r isolation a n d venovenous bypass is pe rfo rmed by c l a m p i n g the suprare n a l IVC, the s u p ra h epatic IVC, a n d a Pringle m a n e u ver. Ve nous ca n n u l a e a re positioned i n the fe moral ve i n a n d superior mesenteric vein, a n d b l ood i s s h u nted i nto the i ntern a l j u g u l a r ve i n .

FIG 1 3

FIG 14 • Com b i n i n g a med i a n ste rnotomy with a m i d l i n e LAP i ncision provides exposu re to the hepatic ve i n s a n d retro hepatic v e n a cava wh i l e avo i d i n g i n j u ry to the p h r e n i c nerves. The pericard i u m a n d d i a p h ra g m can be d ivided down the center toward the IV C.

C h a p t e r 1 8 S U R G I CAL MANAG E M E N T OF H E PATI C TRAUMA

CLOSURE •

If the l iver is to re m a i n packed, a temporary ab d o m i n a l closure s h o u l d be performed. G o a l s are r a p i d closu re, conta i n ment of ab d o m i n a l viscera, p revent bowe l from a d h e r i n g to fasci a l edg es, a l l ow room for swe l l i n g of ab dom i n a l viscera, p rovi de a means for eg ress of ascites, m a i nta i n ste r i l ity of the a bdom i n a l cavity, avo i d d a m ­ age to fascia a n d s k i n edg es, a n d m i n i m i ze cost. T h e "Vac-Pack" d ress i n g satisfies a l l o f t h e s e req u i rements

61 5

(FIG 1 S) . A p l astic sh eet is d ra ped over the bowe l a n d exte nded t o the p a raco l i c g utters to k e e p the bowel from a d h e r i n g to wound edges. S l its are cut in the sheet to a l l ow eg ress of ascites. A towe l is p l aced over the sh eet to p reve nt suction d r a i n s from a d h e r i n g to bowe l through the sl its. D r a i n s a re p l aced on top of the towe l . An a d h esive d ra p e is p l aced over t h e entire wo u n d . Defi n itive closure m a y be a c h i eved by s i m p l e ru n n i n g fasc i a l suture (e . g . , no. 2 nylon) a n d s k i n sta p l es.

• Tem porary closure of the a bdomen enta i ls cove r i n g the bowel with a fen estrated plastic d ra p e (A), p l a cement of cl osed suction d r a i n s a n d a b l u e towel (B), fo l l owed by an a d h esive occ l usive d ress i n g (C) .

FIG 15

PEARLS AND PITFALLS I n d i cation for LAP

•

U nsta b l e patie nts s h o u l d g o to the OR promptly. P u rsu i n g a n g i o e m b o l ization in an u n sta b l e patient is not advisa b l e a n d may prove d i sastro us.

I ncision

•

A m i d l i n e i n cision is the best choice i n a n u nsta b l e tra u m a patient. The surgeon s h o u l d not hes itate to extend the i n cision rig htwa rd or i nto the ch est in order to g a i n exposu re and contro l . M e d i a n ste rnotomy m a rkedly i m p roves exposure f o r retro hepatic v e n o u s repa i rs.

D a m a g e control

•

The decision to pack the l iver s h o u l d be made very q u ickly, as s h o u l d the decision to a d o pt a " d a m a g e contro l " strategy.

Resuscitati o n

•

O n g o i n g resuscitati o n is critica l d u r i n g the operative phase.

Defi n itive p roced u res

•

Avo i d major defi n itive procedu res at the fi rst operation, if the patie nt's co n d ition warra nts d a m a g e contro l .

On the other hand, if the patient is physiologically compro­ mised, it is prudent to return to the OR to control surgical hemorrhage while resuscitating the patient.

POSTOPERATIVE CARE •

Trauma patients should be monitored for response to resus­ citation. Once resuscitated, postoperative care is routine for abdominal surgery, with provision of diet as tolerated and early ambulation.

Abdominal Compartment Syndrome •

OUTCOMES •

Severe liver injuries may be associated with high morbidity and mortality rates. However, patients who survive without significant complications should be expected to have normal life span and functional status vis-a-vis the liver injury.

COMPLICATIONS

The abdominal compartment syndrome refers to intraabdom­ inal hypertension that is associated with organ dysfunction (see Part 3, Chapter 2 6 ) . It is often seen in association with damage control surgery in the presence of liver packing. The accumulation of ascites and retroperitoneal edema, coupled with bowel swelling, lead to a progressive rise in abdominal pressure. Patients may develop the abdominal compartment syndrome in spite of an open abdomen, so the intraabdominal pressure and organ function should be monitored.

Hemorrhage •

Postoperative bleeding is not common outside of the damage control setting. Bleeding may continue despite liver packing. In this case, depending on the patient's condition, angioem­ bolization may be reasonable to control arterial hemorrhage.

Bile Leak •

This is the most common major complication of liver injury. Leaks may come from any biliary repair or anastomosis. They may also originate from peripheral biliary radicals. If a

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

bile duct repair has leaked, it may be managed via endo­ scopic means (e.g., stenting) . Peripheral leaks usually spon­ taneously seal, but occasionally, leakage persists. This may be managed by endoscopic stenting. Bile collections should be drained. Hemobilia •

Generally caused by injuries to an adjacent hepatic artery and bile duct, hemobilia is heralded by right upper quadrant pain, j aundice, and falling hemoglobin level. A more dramatic pre­ sentation may be upper gastrointestinal hemorrhage, as blood enters the duodenum via the common bile duct. Endoscopy can make the diagnosis, as blood is seen exiting from the ampulla of Vater. Angioembolization of the involved artery may be definitive treatment, but occasionally, drainage and/ or debridement of a large hematoma/biloma cavity is needed.

Bilhemia •

Bilhemia results from a biliovenous fistula. Bilirubin levels can rise dramatically. Endoscopic biliary stenting may facili­ tate resolution, but hepatic resection may be required.

Hepatic Necrosis •

Although this may result from the initial injury, ligation or embolization of major vascular branches may also result in hepatic necrosis. This generally requires operative debride­ ment or resection.

REFERENCES 1. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling: spleen and liver (1994 Revision). I Trauma. 1995;38:323-324. 2. Kozar RA, Feliciano DV, Moore EE, et al. Western Trauma Associa­ tion critical decisions in trauma: operative management of adult blunt hepatic trauma. I Trauma. 2011;71:1-5. 3. Pachter HL. Prometheus bound: evolution in the management of hepatic trauma-from myth to reality. I Trauma. 2012;72:321-329. 4. Peitzman AB, Marsh JW. Advanced operative techniques in the man­ agement of complex liver injury. I Trauma Acute Care Surg. 2012;73: 765-770. 5. Poggetti RS, Moore EE, Moore FA, et al. Balloon tamponade for bilobar transfixing hepatic gunshot wounds. ] Trauma. 1992;33: 694-697. 6. Biffl WL, Moore EE, Franciose RJ. Venovenous bypass and hepatic vascular isolation as adjuncts in the repair of destructive wounds to the retrohepatic inferior vena cava. I Trauma. 1998;45:400-403.

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Chapter

19

Hepatic Neoplasm Ablation and Related Technology 1-----------------------------------------------------

/do Na ch many

Ra vit Geva

DEFINITION •

Hepatic ablation represents the use of chemical or physical means to destroy a neoplastic lesion and surrounding nor­ mal tissues as an alternative to resection.

INTRODUCTION • •

•

•

• •

•

•

•

•

•

The liver is one of the most common sites for development of malignancy-either primary or metastatic disease. As a general concept, the main curative option for liver tumors is surgical resection via partial hepatectomy or whole liver replacement. A variety of clinical situations preclude this approach; ablation is an attractive and viable option in some of these clinical situations. The most common indications for liver resection are colorec­ tal cancer liver metastases ( CLM), primary liver cancer (mainly HCC and CCA ) . I n the case of CLM, about 5 0 % of patients will ultimately develop liver metastases. Only about 1 5 % to 2 0 % are resectable at presentation. 1 Oncologic benefit o f liver resection has been shown only when complete clearance of metastatic disease is achieved. Factors limiting resection include extent of tumor involve­ ment, volume of the postresection liver remnant, anatomic proximity to essential intrahepatic structures, underlying liver disease, and comorbidities. HCC is the only universally accepted oncologic indication for liver transplantation (OLT ) . Only a small subset of patients is suitable for OLT, mainly due to stringent cri­ teria influenced by the limited organ availability and infe­ rior long-term survival in patients with locally advanced disease. For patients with unresectable liver tumors or those beyond criteria for OLT, life prolongation and control of symptoms are the major goals. This can be achieved by systemic ther­ apy or by different locoregional modalities, grouped under two major categories: tumor ablation and transarterial treat­ ment (chemotherapy infusion, embolization, combination of the two and irradiation ) . Ablation can be achieved b y direct application of thermal energy ( by cooling: cryoablation; heating: radiofrequency ablation [RFA] or microwave ablation [MWA] ) , chemical ablation: percutaneous acetic acid (PAl) or percutaneous ethanol injection (PEl), or newer techniques: irreversible electroporation (IRE ) . The most commonly applied modality is thermal ablation using RFA technique. In recent years, MWA has also been rapidly gaining acceptance. Based on accumulating data supporting the clinical benefit of ablation techniques, there had been an expansion of the indications. Ablation is now introduced in combination

�

• • •

•

with liver resection and, in limited cases, as a replacement of resection with curative intent. Ablation can be performed percutaneously, laparoscopically, or via laparotomy. The main advantage of a percutaneous approach is the mini­ mal invasiveness of the procedure. The advantages of using ablative modalities in surgery are the ability to reach any territory of the liver, the ability to combine ablation with resection, and the control of inflow and outflow. This may counteract the cooling effect of blood flow in maj or vessels (referred to as the " heat sink " effect) . Laparoscopic ablation may combine the benefits o f surgery with those of minimally invasive treatment. Studying the long-term effectiveness of ablative modalities has been challenging; in part, this is due to the rapid evolu­ tion of ablative tools (probes and energy sources) , thus the field is in constant development. Also, the results of most studies are limited by sample size, methodology, and follow­ up time.

INDICATIONS •

HCC The vast maj ority of patients with HCC have background chronic liver disease. The management of these patients takes into account the primary liver disease ( synthetic dysfunction and portal hypertension) as well as the extent of the tumor. The most commonly used algorithm outside of the United States for HCC management is the Barcelona Clinic for Liver Cancer (BCLC) staging and treatment strategy.2 Other criteria (Milan and University of California, San Francisco [UCSF] ) have also been forwarded. Based on the BCLC algorithm, patients suitable for cura­ tive treatment are those with very early and early stages (stages 0 and A ) . Curative options include resection, liver transplantation, and, in some cases, ablation. The choice between the different options is based on the extent of liver disease, tumor stage, tumor location, and patient comorbidities. There are three subsets of patients specifically suitable for ablation: Patients with unresectable HCC beyond transplant crite­ ria. Tumor ablation is usually combined with other treat­ ment modalities, such as transarterial chemoembolization (TACE). These patients are not considered curable. Patients with very early stage HCC (stage 0-single, up to 2 em tumor with Child A cirrhosis, and in good performance status) are usually considered resection candidates. Recent data suggest that they can also be managed by ablative modalities. The main potential benefit of resection over ablation is the availability of

617

618

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P a r t 3 OPERATIVE TECHNIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

the pathologic specimen. The presence of microvascu­ lar invasion or microsatellites in the specimen, which are maj or risk factors for recurrence, is considered by some an indication for " salvage OLT. "3 Therefore, if the patient is a transplant candidate, resection is preferred over ablation. On the other hand, ablation offers a less invasive procedure and may be attractive alternative to patients. Patients with early stage HCC (stage A-up to 3 lesions, largest ,;:;3 em, with Child A-B cirrhosis, and in good performance status) are best treated by OLT unless they have significant comorbidities. In such cases, ablation may be an alternative. Colorectal liver metastases The only curative option for patients with CLM is re­ section, but unfortunately, this is possible in only about 1 5 % to 2 0 % of cases. Some patients may become resect­ able with neoadjuvant chemotherapy or with anticipated liver remnant volume manipulation such as portal vein embolization.4 The advantages of RFA include low complication rates, fast recovery, and good safety profile in patients with mar­ ginal liver reserve. The main disadvantages are the higher local recurrence rates and limitations in treating large or multiple lesions. Tumor ablation is a valid option for Patients with limited disease that cannot achieve RO resection with surgery

•

•

Patients who are not surgical candidates due to systemic conditions or because of multiple previous operations on the liver Some authors consider ablation an alternative in pa­ tients with resectable metastases. There are currently no studies to support this approach.5 In the future, with improving devices and technique, the equiva­ lence of ablation and resection may eventually be demonstrated. Ablation can also be used in combination with resection of other metastases. This is usually done for relatively small and deeply seated lesions for which resection would dramatically increase the morbidity of the procedure. CONTRAINDICATIONS • •

•

C h e m i c a l a b l a t i o n with i nject i o n (usu a l l y percuta n e­ o u s l y) of eth a n o l or acet i c a c i d was used m a i n ly for H CC, because this tumor i s soft and a cce pts t h e fl u i d i nj ected wel l . Cu rrently, u s e o f c h e m i c a l a b l a t i o n i s n o t c o m m o n m a i n ly d u e to i nfe r i o r effi ca cy, as com­ pa red to t h e rm a l a b l a t i o n and t h e need fo r repeated treatments. 6 RFA • R FA uses a lternat i n g e l ectric f iel d d e l ivered t h ro u g h a n e e d l e o r m u lt i p l e n e e d l e e l ectrodes. It can b e i nserted percutaneously, l a p a rosco p i c a l ly, or at l a pa­ roto my (FIGS 1 a n d 2) .

There are very few contraindications for ablative therapy. An absolute contraindication for thermal ablation is abut­ ment of hilar structures, mainly the bile ducts and gallblad­ der, due to the high risk of thermal injury. This may not apply for IRE. The vicinity of major blood vessels (specifically hepatic veins and large portal branches) is associated with significantly reduced efficacy due to the heat sink effect and is a risk fac­ tor for local recurrence. This can be overcome surgically to some degree by flow manipulation such as the Pringle maneuver or outflow obstruction and thus is not considered an absolute contraindication.

•

•

Ions in the tissue fo l l ow the d i rection of the ra p i d ly c h a n g i n g cu rrent. This causes frict i o n a l e n e rgy to prod uce heat a n d coa g u l ative necrosis. • As te m p e ratu res a p p roach 1 00°C, c h a n g es in the physica l properties of the tissue i n crease i m pedance a n d l i m it the flow of cu rrent (tissue desiccati o n d u e to eva poration o f tissue f l u id, charring, a n d the for­ mation of e l ectrica l ly i n s u l at i n g gas betwee n the e l ectrode a n d the tissue d u e to boi l i n g). This l i m its treatment of l a rg e r t u m o rs. MWA7 • MWA uses e l ectro m a g n etic radiation, m u c h h i g h e r o n the spectrum of e l ectro m a g n etic ra d i ation t h a n

Radiofrequency needles

FIG 1

•

Th ree R F needles l iver i nsert i o n .

C h a p t e r 1 9 H E PATI C N E O P LASM ABLAT I O N A N D RE LATED TECH N O LOGY

A

FIG 2 • Laparosco pic u ltraso u n d (U S)-g u i ded R FA of a periphera l HCC. A. B efore a b lati o n . B. Les i o n measurements. C. D u r i n g a b l at i o n . D. I m med iate posta blation. N ote the typ ic al a rtifacts created by the gas formed b y tissue boi l i n g . R FA (usu a l ly i n t h e ra n g e o f 9 0 0 to 2,450 M H z)

(FIGS 3 a n d 4) . •

•

•

• •

Pola r molecules in the e l ectro m a g n etic field (ma i n l y water) try t o a l i g n i n the d i rection of the cu rrent. As the d i rection changes consta ntly, conti n u o u s rea l i g n ment causes friction a n d heat i n g effect. L i ke R FA, the heat causes ce l l death by coag u l ative necrosis. U n l i ke R FA, MW causes osc i l lation of water m o l ­ ecu les i n the e n t i r e field, so h e a t is u n ifo r mly d istri b uted i n the MW f iel d throughout the activa­ t i o n . This ach i eves i m med iate and homogeneous heati ng a n d therefore faster tissue destruct i o n . H eat is conducted outside of that field, so the u lti­ m ate a b lation size is the s u m of the m icrowave field a n d the co n d u ctive heat zone. The size of the m icrowave field is determ ined by the wave length a n d the a nte n n a desi g n . With i n the m i crowave field, heat s i n k a n d cu rrent s i n k effects a re not present. Outside the m icrowave

• • •

fi eld (in the conduction zone) there w i l l be a heat s i n k effect, s i m i l a r to RFA.8 MWA does not req u i re poi nt-to-p o i nt cu rrents. No cu rrent fl ows through the patient a n d no g rou n d i n g pads are req u i red.

I R E9 • •

• •

I R E is a new tech n i q ue, based on nontherm a l tissue destruct i o n . I R E is pe rfo rmed by p l a c i n g e l ectrodes i nto the tis­ sue and del ive r i n g m u lt i p l e h i g h-vo ltag e e l ectrical p u lses to i n d uce po res i n the l i p i d b i layer of ce l l m e m b r a n e . T h i s sta rts a p rocess that leads t o ce l l death. I R E is not i n f l u e n ced by the heat s i n k effect. Because the l ocation of I R E activity is the ce l l m e m ­ brane, acel l u l a r structu res a re p rese rved . Because h i l a r structu res are wrapped i n a fibrous sh eet, they a re protected . This a l l ows for a p p l ication of IRE to lesions in the vicin ity of i ntrahepatic vita l structu res, u n l i ke therm a l a b lati o n . 1 0

61 9

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P a r t 3 OPERATIVE TECHNIQUES I N HEPATO-PANCREATO-BI LIARY SURGERY

FIG 3

•

Th ree m icrowave a nte n n a s a rrayed to a b late a l a rge

lesion.

A

B

• A-C. Laparoscopic a blation of a n HCC using m u ltiple deployments of a m icrowave probe.

FIG 4 c

C h a p t e r 1 9 H E PATI C N E O P LASM ABLAT I O N A N D RE LATED TECH N O LOGY

621

PEARLS AND PITFALLS I n d icati ons

• • • •

Tech n i q u e

• • •

Resection is not a n o pt i o n . The lesion is n o t t o o b i g . The l e s i o n is n o t adjacent to a h e a t s i n k or vita l structure. U ltraso u n d i n ci rrhotic l ivers is tec h n i c a l l y c h a l l e n g i n g . Confi rm a p p ropriate probe placement with u ltraso u n d-Record the i m a g es. Confi rm co m p l ete d estruction of the lesion by u ltraso u n d-Record the i m a ges. Preco a g u lation prior to parenchym a l tra nsection (FIG 5)

FIG 5 • MWA as a p recoa g u l a nt strategy prior to parenchy m a l tra nsect i o n .

OUTCOMES •

•

•

•

Factors influencing outcome include the following: Tumor size. Best results are achieved for the treatment of small tumors less than 3 em for RFA. MWA achieves effec­ tive results in somewhat larger lesions but is also limited by lesion sizeY Ablation margin. In order to minimize the chance for local recurrence, it is advised to leave a rim of 1 em of ablated tissue beyond the tumor margin. Vicinity to major vascular structures, mainly large veins, due to the heat sink effect Mode of application. Surgical application usually achieves better outcome than percutaneous. Ablation is operator dependent and therefore experience plays a major role. Assessing the isolated effect of ablation is difficult. In most cases, ablation is not considered curative; therefore, it is usually combined with other treatment modalities. Also, there are no high-quality randomized studies, the follow­ up is usually short, and the devices used are in constant evolution. The most representative benchmark of ablation efficacy is local recurrence at the ablation site. This is widely variable, and in the case of RFA, runs from 2% to 6 0 % Y HCC In a large study on nearly 3,000 RFA treatments done on more than 1 ,000 patients, the 5- and 1 0-year survival rates were 60.2% and 27.3 % , respectively, and the 5- and 1 0-year local progression rates were both 3 . 2 % _ 13 Complete pathologic response for HCC smaller than 3 em is as high as 6 5 % with RFA and similar results had been shown with MWA.14-16 Combining eight studies and more than 1 ,000 patients, Giacomo et al.6 found that RFA was superior to PAl or

•

PEl with regard to survival, complete tumor necrosis, and local recurrence. CLM During the past decade, RFA has superseded other ablative therapies, due to its low morbidity, mortality, safety, and patient acceptability. In the near future, MWA may be­ come the leading modality due to some benefits over RFA. Multiple studies have compared RFA to liver resection as a radical approach to CLM. These studies demon­ strated higher local recurrence of RFA as compared to resection.11'17-19 A recent Cochrane analysis comparing RFA to hepatic resection concluded that the current data is insufficient to consider RFA to be as effective as surgery.5 In the case of nonresectable CLM, the addition of ablation to systemic chemotherapy probably increases the progres­ sion-free survival, although it was not found to have sig­ nificant effect on the overall survival. 20

COMPLICATIONS •

• •

•

Morbidity and mortality are relatively low. Complications include bleeding, vascular thrombosis, abscess formation, and injury to intrahepatic structures (mainly bile ducts and gallbladder) and extrahepatic organs (colon, duodenum, etc . ) . I n the case of RFA, morbidity h a d been reported i n about 1 0 % of cases and mortality is very rare. U For MWA, Martin e t al.21 reported a n overall 90-day mor­ tality and morbidity rate of 0% and 2 9 % , respectively, from a cohort of 1 0 0 patients treated with a total of 270 abla­ tions. Only 1 patient developed hepatic abscess ( FIG 6) , and there were no bleeding complications. Needle track seeding is extremely rare. For percutaneous MWA, it was found to be 0.47% per tumor and 0 . 75 % per patient.22

622

P a r t 3 OPERATIVE TECHNIQUES I N HEPATO-PANCREATO-BI LIARY SURGERY

FIG 6

•

A l iver a bscess in an RFA site.

REFERENCES 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59(4):225-249. 2. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53:1020-1022. 3. Sala M, Fuster ], Llovet JM, et al. High pathological risk of recurrence after surgical resection for hepatocellular carcinoma: an indication for salvage liver transplantation. Liver Transpl. 2004;10:1294-1300. 4. Adam R, Delvart V, Pascal G, et al. Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg. 2004;240:644-657. 5. Cirocchi R, Trastulli S, Boselli C, et al. Radiofrequency ablation in the treatment of liver metastases from colorectal cancer. Cochrane Data­ base Syst Rev. 2012;(6):CD006317. 6. Germani G, Pleguezuelo M, Gurusamy K, et al. Clinical outcomes of radiofrequency ablation, percutaneous alcohol and acetic acid injection for hepatocellular carcinoma: a meta-analysis. J Hepatol. 2010;52(3):380-388. 7. Sindram D, Lau KN, Martinie JB, et al. Hepatic tumor ablation. Surg Clin North Am. 2010;90:863-876. 8. Yu NC, Raman SS, Kim YJ, et al. Microwave liver ablation: influence of hepatic vein size on heat-sink effect in a porcine model. ] Vase Interv Radio/. 2008;19(7):1087-1092.

9. Charpentier KP. Irreversible electroporation for the ablation of liver tumors: are we there yet? Arch Surg. 2012;147(11):1053-1061. 10. Charpentier KP, Wolf F, Noble L, et al. Irreversible electroporation of the liver and liver hilum in swine. HPB (Oxford). 2011;13(3): 168-173. 11. Hur H, Ko YT, Min BS, et al. Comparative study of resection and radiofrequency ablation in the treatment of solitary colorectal liver metastases. Am J Surg. 2009;197(6):728-736. 12. Mulier S, Ni Y, Jamart J, et al. Local recurrence after hepatic radio­ frequency coagulation: multivariate meta-analysis and review of con­ tributing factors. Ann Surg. 2005;242:158-171. 13. Shiina S, Tateishi R, Arano T, et al. Radiofrequency ablation for hepa­ tocellular carcinoma: 10-year outcome and prognostic factors. Am 1 Gastroenterol. 2012;107(4):569-577. 14. Pompili M, Mirante V G, Rondinara G, et al. Percutaneous ablation procedures in cirrhotic patients with hepatocellular carcinoma submit­ ted to liver transplantation: assessment of efficacy at explant analysis and of safety for tumor recurrence. Liver Transpl. 2005;11:11171126. 15. Mazzaferro V, Battiston C, P errone S, et al. Radiofrequency abla­ tion of small hepatocellular carcinoma in cirrhotic patients await­ ing liver transplantation: a prospective study. Ann Surg. 2004;240: 900-909. 16. Shibata T, Iimuro Y, Yamamoto Y, et al. Small hepatocellular carcinoma: comparison of radiofrequency ablation and percutaneous microwave coagulation therapy. Radiology. 2002;223:331-337. 17. Aloia TA, Vauthey JN, Loyer EM, et al. Solitary colorectal liver metas­ tasis: resection determines outcome. Arch Surg. 2006;141:460-467. 18. Schiffman SC, Bower M, Brown RE, et al. Hepatectomy is superior to thermal ablation for patients with a solitary colorectal liver metastasis. J Gastrointest Surg. 2010;14:1881-1886. 19. W hite RR, Avital I, Sofocleous CT, et al. Rates and patterns of recurrence for percutaneous radiofrequency ablation and open wedge resection for solitary colorectal liver metastasis. J Gastrointest Surg. 2007;11:256-263. 20. Ruers T, Punt CJ, van Coevorden F, et al. Final results of the EORTC intergroup randomized study 40004 (CLOCC) evaluating the benefit of radiofrequency ablation (RFA) combined with chemotherapy for unresectable colorectal liver metastases. 1 Clin Oneal. 2010;28. 21. Martin RC, Scoggins CR, McMasters KM. Microwave hepatic ablation: initial experience of safety and efficacy. J Surg Oneal. 2007;96:481-486. 22. Yu J, Liang P, Yu XL. Needle track seeding after percutaneous micro­ wave ablation of malignant liver tumors under ultrasound guidance: analysis of 14-year experience with 1462 patients at a single center. Eur 1 Radio/. 2012;81:2495-2499.

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20

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Catheter-Based Treatment of Hepatic Neoplasms -1

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DEFINITION

SURGICAL MANAGEMENT

•

Preoperative Planning

Catheter-based treatment of hepatic neoplasms is a percuta­ neous, minimally invasive, image-guided therapy in which the anticancer regimen is delivered to the arterial supply of the tumor. The most common therapies are transarterial chemoembolization (TACE) and radioembolization using yttrium 90 (90Y ) .

• • •

DIFFERENTIAL DIAGNOSIS •

•

Differential diagnosis of the different types of hepatic neo­ plasms is made by using tissue biopsies, tumor markers, and imaging characteristics. Dynamic computed tomogra­ phy ( CT)/magnetic resonance imaging (MRI) demonstrat­ ing intense arterial uptake followed by venous or delayed phase "washout" of contrast is considered to be diagnostic of hepatocellular carcinoma (HCC ) . 1 TACE and radioembolization are usually performed i n patients with liver-dominant disease. These tumors may b e primary liver malignancies o r metastatic disease where the liver is the dominant site of the disease.

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PATIENT IDSTORY AND PHYSICAL FINDINGS •

•

•

·

Da rren W. Postoak

A thorough history should be obtained prior to treatment including a past medical history, medications, and allergies. Prior therapy should be evaluated, especially if radioemboli­ zation is being considered and the patient has previously had external beam radiation to the liver. Performance status (ECOG [Eastern Conference Oncology Group] or Karnofsky) must be evaluated. Patients with poor performance status may not be suitable candidates for intra­ arterial therapy. Arterial pulse examination is needed for planning of the arterial access site. Typically, the puncture site is the com­ mon femoral artery, but this may need to be adjusted if the patient has severe iliofemoral atherosclerotic disease.

Patients need to be well hydrated, typically with 1 5 0 to 300 mL per hour of normal saline prior to and during the procedure. Preprocedure medications may include antiemetics and steroids. Antibiotics are administered as needed. This is important in patients without an intact sphincter of Oddi due to sphinc­ terotomy, biliary stent or catheter placement, and surgical biliary-enteric anastomosis. The regimen is 2 weeks in total, beginning 2 days prior to the embolization procedure.2•3 Radioembolization is a multistep procedure with a need for arterial embolization of vessels leading to the GI tract and a simulation of the procedural inj ection prior to the actual injection of 9 0 Y particles. This will be discussed in more depth in the "Techniques" section. Proton pump inhibitors are started about 2 weeks prior to radioembolization. Octreotide pretreatment is indicated in patients with meta­ static carcinoid to help prevent a carcinoid crisis. Typically, 250 ).Lg is administered intravenously about 1 hour prior to the procedure.

Positioning •

The patient is placed supine with both groins prepped and draped ( FIG 1 ) . If there are iliac arterial occlusions or other technical problems, then brachial artery access is the next choice with the left arm being preferred. For brachial access, the arm is extended 45 to 9 0 degrees away from the body.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

•

All patients should have a preprocedural multiphase CT or MRI examination. A positron emission tomography/CT may be helpful in some instances. Imaging should be evaluated for tumor number, tumor vol­ ume, and portal vein invasion/thrombosis. The vascular anatomy should be evaluated for vascular disease and ana­ tomic variants as this may change the treatment plan. Laboratory evaluation should include a complete blood count, coagulation profile, creatinine, albumin, and liver function studies. Exclusionary criteria include immediate life-threatening extrahepatic disease, tumor volume greater than 5 0 % to 70 % , uncorrectable flow to the gastrointestinal ( GI) tract, and significant hepatopulmonary shunting.

FIG 1 • The patient is s u p i n e with both g r o i n s prep ped a n d d ra ped. T h e C-arm f l u o rosco p i c u n it a n d m o n itors a r e i n position to visu a l ize the p u n cture site i n the common femora l a rtery a n d the entire a b d o m e n .

623

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

TRANSARTERIAL CHEMOEMBOLIZATION Superior Mesenteric Arteriogram with Venous Phase Imaging •

•

A 4- or 5-Fr catheter is used to sel ectively catheterize the superior mesenteric a rtery (SMA). The a rte r i a l p h ase (FIG 2) is i n spected for a n a to m i c va r i a nts such as a re­ p l a ced r i g h t hepatic a rtery (FIG 3) o r oth er a n ato m i c va r i a nts. T h e potent i a l f o r " p a rasitized " b l ood flow re­ cru ited from the SMA to the l iver m ust a lso be assesse d . The ve nous phase (FIG 4) is i n spected to eva l u ate patency of the porta l ve i n a n d to eva l u ate for hepatofu g a l fl ow. TACE can be perfo rmed in ci rrhotic patie nts with hepa­ tofu g a l porta l fl ow, but a s m a l l e r vo l u m e of l iver s h o u l d be e m b o l i z e d e a c h t i m e .

Celiac and Common Hepatic Arteriograms •

•

•

The 4- or 5-Fr catheter is used to sel ectively cath ete rize these vesse ls. The a rteriograms (FIG 5) a re eva l u ated for a n ato m i c va r i a nts such as a re p l a ced o r accessory l eft hepatic a rtery a r i s i n g from a gastrohepatic tru n k (FIG 6) a n d p h r e n i c a rteri es, which may arise at the o r i g i n of the celiac. If the ce l i a c a rtery is occ l u ded, the occlusion can often be crossed a n d poss i b ly ste nted to a l l ow access or the pro­ ced u re may be perfo rmed from the superior mesenteric a rtery i n a retrograde a p p roach via the pancreaticoduo­ denal a rcade (FIG 7) . Eva l u ate where t h e a rte r i a l supply t o t h e t u m o rs is aris­ ing. Try to l i m it e m b o l ization of branches that do not supply the t u m o rs.

FIG 2 • A s u p e r i o r mesenteric a rteriogram i s o bta i ned to eva l u ate for a n ato m i c varia nts. The patient i s positi o n ed to v i s u a l ize t h e porta l v e i n d u r i n g the ve n o u s p h ase of the exa m .

• T h e re p l aced r i g ht hepatic a rtery is o n e o f the a n ato m i c va ria nts more co m m o n ly see n . The rep l a ced r i g ht hepatic a rtery arises as a branch of the superior mesenteric a rte ry.

FIG 3

Advancement of the Catheter to Point of Embolization • •

•

Common ly, t h i s w i l l be perfo rmed u s i n g a coaxi a l m i crocath ete r. Adva nce the cath eter as sel ectively as poss i b l e; h owever, a l o b a r e m b o l ization may be req u i red if the t u m o rs a re scatte red throug h out the l i ver. In patients with i ntact g a l l b ladders, eva l u ate where the cystic a rtery o r i g i nates (FIG 8) . I dea l ly, e m b o l i zation

FIG 4 • Venous phase fo l l owi n g a superior mesenteric a rteriogram demonstrates patency of the superior m esenteric and porta l ve i n s (sa m e patient as FIG 2) . PV, porta l ve i n ; SMV, superior mesenteric ve i n .

C h a p t e r 2 0 CATH ETER-BAS E D TREAT M E N T OF H E PATI C N E O P LASMS

• Ce l i a c a rte riogram demo nstrati ng typ ical ce l i a c a n d hepatic a rte r i a l a n atomy. LGA, l eft gastric a rte ry; SA, s p l e n i c a rtery; G DA, gastrod uodena l a rte ry; C H A, common hepatic a rtery.

FIG S

FIG 6 • The catheter t i p is in a gastroh epatic tru n k a r i s i n g f r o m the ce l i a c a rte ry. The re p l a ced l eft h e p a t i c a rtery s u p p l ies the l eft hepatic l o be, whereas the rem a i n i n g l eft gastric a rtery branches supply the fundus of the sto m a c h . When e m b o l i z i n g the re p l aced l eft hepatic a rte ry, the catheter m u st be d i stal t o the l eft g astric a rtery branches. G HT, gastrohepatic tru n k; R L H , re p l aced l eft h e patic a rte ry; LGA, l eft gastric a rtery branches.

A

c

B

FIG 7 • I n a patient with an occ l u ded celiac a rtery, the superior mesenteric a rte riogram demonstrates flow to the hepatic a rteries via co l l atera l s u p p l y (A). The pa ncreaticod u o d e n a l a rcade a n d gastrod uodena l a rteries are crossed i n a retrograde fash i o n (B) with the m icrocatheter t i p eve ntu a l ly p l aced i n the l eft hepatic a rtery (C) for treatment of l eft l oba r t u m o r. SMA, superior mesenteric a rte ry; G DA, g astrod uodenal a rte ry; P H A, proper hepatic a rtery; LHA, l eft hepatic a rte ry.

625

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

Left hepatic artery

Catheter tip distal to

Gallbladder

hepatic artery Gastrod uodenal artery

FIG 9 • Fluoroscopic image fol lowi ng o i ly chemoembolization shows the Eth iodol m ixtu re with i n the tumor.

FIG 8 • The catheter t i p is p l aced d i stal to the o n g m of the cystic a rtery p r io r to chemoembol ization to p revent a chemical chol ecystitis.

•

should be performed d ista l to the cystic a rte ry. Treatment prox i m a l to the cystic a rtery ca n cause a chemical cholecystitis with a m o r e severe poste m b o l ization syndrome. Arte riogram to eva l u ate sel ective ca n n u lation of the feed i n g vessel (s) a n d to assess for a rterioven o u s s h u n t i n g

Embolization Using the Embolic Material •

O i l y chemoembol izati o n Eth iodol is a poppy seed o i l-based contrast. The Eth iodol veh icle is m ixed, m ost com m o n ly with a com­ b i n ation of cisplatin, doxoru bicin, a n d m itomycin-C. The Eth iodol acts as a carrier a n d the chemotherapy is released slowly from the m ixtu re. The Eth iodol is reta i ned with i n the tumor a n d the neovasculature of the tumor (FIG 9). This is fo l l owed by particu late embol ization of the target vessels. Drug-eluting m icros p h eres • LC beads a re a polyvinyl a l cohol-based m i crosphere a n d Q u a d raSpheres a re a copolymer m i crosphere. • 50 to 75 mg of doxo r u b i c i n is loaded i nto each v i a l of m i crospheres w i t h a maxi m u m of two v i a l s b e i n g u s e d per p roced u re . 1 00 to 3 0 0 m i cron LC beadsTM and 50 to 1 00 m i cron Q u a d ra S p h eresrM a re com­ m o n ly used . The particles a re then i nj ected (FIG 1 0) u n t i l there is s i g n ificant slowi n g of flow with i n the ta rg et vesse ls. • l r i n oteca n has been used, i n stead of doxo rubi ci n, i n treati n g patients w it h colorecta l cancer that has m etastasized to the I iver. Transarterial embol ization (TAE), also known as b la nd em­ bol ization, has a lso been performed. TAE uses Eth iodol e m b o l i zation, particulate e m b o l i zation, or a com b i nation •

•

•

of both without the add ition of a ny chemothera peutic agent.

Removal of the Catheters and Sheath •

The pu nctu re s ite is cl osed u s i n g m a n u a l p ress u re or a n a rte r i a l closure device.

Follow-up • • •

Labs in a bout 4 weeks to eva l u ate l iver fu nction Repeat i m a g i n g if needed . Repeat e m b o l ization, if needed, i n a bout 4 to 6 weeks .

Liver

-......-- - Catheter in hepatic artery

Tumor •

Drug-e l ut i n g m icrospheres b l ock the a rte r i a l s u p p l y to the t u m o r a n d then the chemotherapy d r u g is s l owly released d i rectly to the t u m o r.

FIG 10

C h a p t e r 2 0 CATHETER-BASED TREAT M E N T OF H E PATI C N E O P LASMS

RAD IOEMBOLIZATION Sir-Spheres™ o r TheraSphere™ •

90Y b i n d s to particles that a re l ess than 35 m icrons i n size. S i r-Spheres•M a re res i n-based particles, whereas the TheraSph ere•M p a rticles are n o n b iodegra d a b l e g l ass mi­ crospheres.

Superior Mesenteric, Celiac, and Common Hepatic Arteriograms •

The i n it i a l steps a re s i m i l a r to TAC E . The a rteriog ra ms a re eva l u ated for vessel patency a n d a n ato m i c varia nts.

Arteriograms of the Gastroduodenal, Right, and Left Hepatic Arteries •

•

Eva l uation of a natomy is performed with spec i a l atte ntion p a i d to branches t h a t lead to the G l tract such as the rig ht gastric a n d s u p raduodena l a rteries (FIG 1 1 ) . B ra nches connect i n g to the G l tract, such as the gastro­ d u o d e n a l a rtery (G DA), a re e m b o l ized (FIG 1 2) . Th ese branches m ust be e m b o l ized as 90Y particles in the G l tract can cause severe, s l ow-hea l i n g u l cers.

Lobar Injection of Technetium-99m ( Tc 99m) Macroaggregated Albumin •

•

The Tc 99m macroagg regated a l b u m i n (MAA) p a rticles a re used to s i m u l ate the 90Y p a rticles. Nuclear i m a g i n g is t h e n pe rfo rmed t o eva l u ate f o r activity i n the G l tract a n d the a m o u nt of s h u n t i n g to the l u ngs (FIG 1 3) . If there is a ct ivity in the G l tract fo l l owi n g MAA i njection, with no obvious feed i n g vesse l that can be e m b o l ized, 90Y therapy s h o u l d not be a d m i n i ste red .

FIG 1 2 • An A m p l atzer p l u g has been used to e m bol ize the G D A with m icroco i l s wit h i n the r i g ht g astric a rtery (RGA) a n d supraduodenal a rteries (S DA) . The m i crocatheter wou l d then be p l aced d i stal to the cyst ic a rte ry o r i g i n f o r r i g ht l o b a r Tc-99m M AA a n d 90Y i njections (asterisk) .

• •

• •

in the same position as d u r i n g the Tc-99m MAA i nject i o n . The catheter position i s s i m i l a r to F I G 8 when perform i n g rig ht l o b a r e m b o l izat i o n . The 90Y p a rticles are i nj ected w i t h extreme c a r e to pre­ vent s p i l l a g e of ra dioactive particles (FIG 1 4) . If there is 1 0 % t o 1 5 % hepato p u l m o n a ry s h u n t i n g o n the M AA study, then the S i r-Spheres•M d o s e is decreased by 20 % . If the s h u nt i n g i s 1 5 % to 20%, then the dose is decreased by 40 % . I f h e pato p u l m o n a ry s h u nt i n g i s g reater t h a n 2 0 % , then S i r-Spheres•M a re not a d m i n istered. When using Thera S p h e re•M, the l i m itati o n of what can be a d m i n istered to the l u ngs is based o n the c u m u l ative dose, i rrespective of the l u n g s h u nt.

Return for Injection of Yttrium 90 Particles •

This is perfo rmed su bsequent to the i n it i a l assessment of a natomy, a p p ropriate e m b o l ization of vessels feed i n g the G l tract, a n d M AA eva l u a t i o n . T h e catheter is p l a ced

FIG 1 1 • Common hepatic a rte riogram demonstrates the a n atomy p r ior to Tc-99m MAA particle i nject i o n . B ranches l e a d i n g to the G l tract w i l l need to be e m b o l i zed to p reve nt 90Y p a rticle reflux to these branches with su bseq uent i n j u ry. G DA, gastrod uode n a l a rte ry; SDA, s u p raduodena l a rte ry; RGA, r i g ht g astric a rte ry; CA, cystic a rtery.

Removal of the Catheters and Sheath •

The p u n cture site is cl osed u s i n g m a n u a l p ress u re or a n a rte r i a l closure device.

FIG 13 • N u c l e a r i m a g i n g fo l l ow i n g Tc-99m M AA a d m i n i strati o n d e m o n strates no activity with i n the G l tract a n d 1 3 .4% s h u n t i n g to the l u ngs. The dose of S i r-Spheres•M to be g iven would be reduced by 20% due to the d e g ree of s h u nt i n g .

627

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P a r t 3 OPERATIVE TECH NIQUES I N HEPATO-PANCREATO-BI LIARY SURGERY

Follow-up • • •

Labs in a bout 4 weeks to eva l u ate l iver fu nction Repeat i m a g i n g if n ecessa ry. Wo rkup for the secon d l o b a r i njection is beg u n a bout 4 to 6 weeks after the i n it i a l side if l a bs and i m a g i n g a re adequate. T h e patient wi l l n e e d a n a rteriogram a n d repeat Tc-99 m M A A i njection as well, prior to ra d i oem­ b o l ization of the seco nd l o be, if needed.

FIG 1 4 • The S i r-Sph eres'M particles a re connected to the catheter via a speci a l del ivery system to p revent s p i l l a g e of radioactive m ate ria l .

PEARLS AND PITFALLS Patient h i story a n d physica l f i n d i ngs.

•

I m a g i n g a n d oth e r d i a g n ostic stud ies

•

•

•

•

S u rg ical tech n i q u e (TACE)

• • •

Surgical tech n i q u e (90Y)

•

Patie nts without an i ntact s p h i ncter of O d d i a re at m u c h h i g h e r risk of a bscess formation a n d need extended a n t i b i otic prophylaxis. Do not overtreat i n patients with borderl i n e hepatic function. The proced u re can a l ways be repeated at a later time. C-a rm CT sca n may be h e l pf u l to verify that the cath eter is i n the correct a rte r i a l branch as it may be d iffic u lt to te l l with lesions that a re not we l l visual ized. (FIG 1 S) . H e patic t u m o rs may be s u p p l ied b y n o n h e patic vesse ls, especi a l ly su bcapsu l a r lesions. Parasitized flow from the i nferior p h ren ic, i nte r n a l m a m m a ry, a n d i ntercosta ls a rteries may need to be e m b o l ized (FIG 1 6) . It may be d iffic u lt to te l l if there i s a rteri a l t u m o r e n h a ncement on a contrasted C T sca n with Eth iodol in p l ace. A nonco ntrast sca n (FIG 1 7) is needed for compa rison or a n M R I c a n be o bta i n e d . Arte r i a l -porta l s h u nts ca n be e m b o l i zed w i t h l a rg e particles or coils prior to TAC E . There a re more postembol ization syndrome sym ptoms with o i ly chemoembolization t h a n with d rug-eluting m icrospheres. Embol ization of dome lesions may cause right shoulder pain or h iccups. Steroids (Medrol Dosepak) may be helpfu l . E v e n t h o u g h the G OA a n d r i g ht gastric a rteries a re e m b o l ized, d o n o t i nj ect 9 0 Y via the common o r proper he patic a rteries.

C h a p t e r 2 0 CATHETER-BASED TREAT M E N T OF H E PATI C N E O P LASMS

FIG 1 S • C-a rm CT sh ows t u m o r a l e n h a ncement d e m onstrati n g t h a t the m icrocatheter i s with i n the correct a rte r i a l branch prior to chemoembol izat i o n . The t u m o r a l e n h a ncement was not a p p reci ated by convent i o n a l a rteriography.

629

FIG 16 • R i g h t i nferior p h r e n i c a rte riogram demonstrates t u m o r e n h a ncement i n the d o m e of the l iver s u p p l ied by the d ista l p h r e n i c branches. These branches were then e m b o l i ze d .

FIG 1 7 • C T sca n demonstrates resi d u a l Eth i o d o l with i n a t u m o r on a nonco ntrast exa m i nati o n . A noncontrast exa m m u st b e o bta ined prior to the contrast-enha nced exa m to d e m o nstrate the d ifference between contrast e n h a ncement and resi d u a l Eth i o d o l .

POSTOPERATIVE CARE • Pain medications • Antiemetics • Proton pump inhibitor (radioembolization) • Steroids (Medrol Dosepak) • Antibiotics (as indicated) • Hospitalization for TACE is typically overnight for micro­ sphere embolization and up to several days for oily chemo­ embolization. Patients that receive radioembolization can typically be discharged the same day. • Repeat labs and imaging are typically obtained. Protocols are institution-specific and not typically driven by data. • Further embolization procedures as needed. Imaging after TACE is about 4 to 6 weeks after the completion of embolization. If there is tumor identified on repeat imaging, then embolization is again performed. If no further tumor is identified, then imag­ ing is performed every 3 months (FIG 1 8).

•

Imaging after radioembolization is performed 2 to 3 months after the last lobe is embolized as it can take longer to see the effects.

OUTCOMES •

•

•

In 2002, two separate studies demonstrated that TACE for HCC had a statistically significant survival advantage over the best supportive care that was available.4•5 Since then, other studies have confirmed these findings in patients with well-compensated cirrhosis. In patients with limited hepatic reserve or decreased perfor­ mance status, there have been better outcomes with drug-eluting microspheres as compared to oily chemoembolization.6 In addi­ tion, the treatment was better tolerated by the patients. Treatment using drug-eluting microspheres loaded with doxo­ rubicin demonstrated a statistically longer time to progression and fewer recurrences when compared to bland embolization. 7

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

A

B A. I n it i a l CT scan demo nstrates a l a rge, contrast-e n h a n c i n g HCC in the r i g ht lobe of the l iver prior to treatment. B. A fo l l ow-u p CT 5 weeks after treatment u s i n g doxoru bici n-loaded LC beads shows that FIG 1 8

•

the t u m o r is s l i g htly s m a l ler a n d there is n o further contrast e n h a ncement. Repeat imaging would then be performed a bout 3 months l ater.

•

•

Patients with HCC and Child-Pugh A disease survive signifi­ cantly longer following 90Y radioembolization than do those patients with Child-Pugh B disease, 1 7. 7 versus 7. 7 months, respectively. 8 In a study of patients with unresectable, chemoresistant liver metastases treated with 90Y radioembolization, the median survival for patients was 1 5 . 2 months for those with colorectal tumors, 2 5 . 9 months for those with neuroendo­ crine tumors, and 6.9 months for those with noncolorectal, non-neuroendocrine tumors. 9

COMPLICATIONS • • • •

• • •

Groin hematoma/pseudoaneurysm Liver insufficiency Severe postembolization syndrome Routine postembolization syndrome is not an unexpected event. Postembolization syndrome includes pain, fever, and nausea/vomiting. Severe postembolization syndrome would necessitate an extended hospital stay or readmission. Hepatic abscess Cholecystitis Nontarget embolization with GI tract ulceration

REFERENCES 1. Bruix J, Sherman M; American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53:1020-1022.

2. Geschwind JF, Kaushik S, Ramsey, et a!. Influence of a new pro­ phylactic antibiotic therapy on the incidence of liver abscesses after chemoembolization treatment of liver tumors. ] Vase Interv Radio/. 2002;13:1163-1166. 3. Patel S, Tuite CM, Mondschein JI, et a!. Effectiveness of an aggressive antibiotic regimen for chemoembolization in patients with previous biliary intervention. J Vase Interv Radio/. 2006;17:1931-1934. 4. Lo CM, Ngan H, Tso W K, et a!. Randomized controlled trial of tran­ sarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002;35:1164-1171. 5. Llovet JM, Real MI, Montana X, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomized controlled trial. Lancet. 2002;359:1734-1739. 6. Lammer J, Malagari K, Vogl T, et a!. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepa­ tocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radio/. 2010;33:41-52. 7. Malagari K, Pomoni M, Kelekis A, et a!. Prospective randomized comparison of chemoembolization with doxorubicin-eluting beads and bland embolization with BeadBlock for hepatocellular carcinoma. Cardiovasc lntervent Radio/. 2010;33:541-551. 8. Salem R, Lewandowski RJ, Mulcahy MF, et a!. Radioemboliza­ tion for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 2010;138:52-64. 9. Sato KT, Lewandowski RJ, Mulcahy MF, et a!. Unresectable chemore­ fractory liver metastases: radioembolization with 90Y microspheres­ safety, efficacy, and survival. Radiology. 2008;247:507-515.

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Chapter

21

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I

�

Segmental Hepatectomy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Neil H. Bhaya n i

Eric T. Kim chi

DEFINITION

IMAGING AND OTHER DIAGNOSTIC

•

STUDIES

•

•

A segmental hepatectomy consists of surgical resection of one or more functional anatomic segments of the liver, as originally classified by Couinaud ( FIG 1 ) . Nomenclature for liver resections was standardized in the Brisbane conference. 1 The most common anatomic segmental resections are ( 1 ) right posterior sectionectomy (segments 6 and 7), (2) left lateral sectionectomy (segments 2 and 3 ) , and ( 3 ) caudate lobe resec­ tion (segment 1 ) . Smaller resections o f a single segment o r nonanatomic sub­ segmental resections will not be covered in this chapter. Usually, these involve simple excisions without formal in­ flow or outflow occlusion or delineation of the segmental vascular or biliary anatomy.

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS • • •

•

• •

Patients should be good medical candidates for major surgery. Preoperative planning requires a thorough history of previ­ ous abdominal surgeries. If performing a metastasectomy, there should be a thorough evaluation of extrahepatic disease. The presence of extrahe­ patic disease should be considered in conj unction with the tumor type and extent of resection to determine if the patient will benefit from surgical intervention involving the liver or extrahepatic sites. Episodes of j aundice, hepatitis exposure, alcohol, illicit drug abuse, and treatment with chemotherapy should be elicited to ascertain the health of the liver parenchyma. A complete viral hepatitis panel should be obtained as part of screening surgical candidates. Liver function can be assessed by the Child-Pugh classifica­ tion and/or the Model for End-Stage Liver Disease (MELD ) . Neither metric has been definitively shown t o b e superior in determining a patient's ability to tolerate surgery.2

•

•

•

..

Niraj J. Gusa n i

Multiphase, contrast-enhanced cross-sectional imaging with either computed tomography ( CT) or magnetic resonance imaging (MRI) is necessary for planning surgery. Both im­ aging modalities are of similar sensitivity and may often be used interchangeably or in combination to better define cer­ tain pathologic processes. In a normal, healthy liver, a future (postresection) hepatic remnant composed of at least two contiguous segments with adequate inflow and outflow and measuring 2 5 % of the complete liver volume is sufficient functional liver to allow for full hepatic recovery. However, in a damaged or cirrhotic liver, a remnant of greater than 40% is often recommended, although the percentage of viable remnant liver may need to be greater, depending on the amount of damage/dysfunc­ tion of the liver. Segmental hepatic resections rarely induce hepatic insufficiency unless the remnant liver is severely diseased. Concern for significant hepatic dysfunction should be in­ vestigated by obj ective testing of the liver. Transjugular measurement of the portal pressure gradient (normal < 5 t o 8 mmHg) , routine serum liver function tests, and biopsy (to evaluate steatosis or cirrhosis ) are the most common mo­ dalities to evaluate the extent of hepatic disease. In Asia, indocyanine green clearance testing is often per­ formed to quantify liver health. This is rarely performed in the United States. In patients with evidence of decompensated cirrhosis ( Child's B and C) and pathologic conditions that have demonstrated benefit from transplantation (hepatocellular cancer, neuroen­ docrine malignancies, and some hilar cholangiocarcinomas ), surgeons should consider a referral for transplantation.

SURGICAL MANAGEMENT • •

The indications for hepatectomy include diagnostic uncer­ tainty, symptomatic benign lesions, and malignancy (Table 1 ) . The strongest evidence for hepatic metastasectomy shows that RO resection prolongs survival and is potentially cura­ tive for colorectal carcinomas and neuroendocrine tumors.

Table 1: I n d i cations for Hepatectomy Diagnosis Foca l n o d u l a r hyperplasia vs. hepatoce l l u l a r adenoma

Pre m a l ig nant d isease Hepatoce l l u l a r adenoma B i l i a ry cystadenoma

Symptoms He m a n g i o m a

M a l ign a n cy Metastasis Hepatoce l l u l a r carci noma Cho l a n g i ocarci n o m a

Simple cysts B e n ign d isease Refractory abscesses/cho l a n g itis Severe hepatol ithiasis

FIG 1

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Couinaud segments with vascular anatomy.

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

Preoperative Planning •

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Ideally, preoperative cross-sectional imaging should be dis­ cussed with skilled radiologists before surgery and be avail­ able throughout the procedure. Vascular, particularly hilar, arterial anomalies are common. Inadvertent inj ury at surgery may be prevented by thorough multiplanar analysis of preoperative imaging. 3-D reconstruction is not mandatory, but understanding of all the lesions and their relation to hepatic and portal ve­ nous structures is imperative. This should be combined with intraoperative ultrasound. For postoperative pain control, we employ epidural cath­ eters, administered by a dedicated pain service, placed preoperatively. Low central venous pressure ( CVP) anesthesia is a corner­ stone in reducing blood loss in hepatic surgeries. To main­ tain low CVP (5 to 8 mmHg) , good communication with the preoperative nursing and anesthesia teams is critical.

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Patients receive appropriate prophylactic antibiotics due to transection of the biliary tree (clean-contaminated surgery) . We consider cases with an indwelling biliary device as contami­ nated procedures secondary to colonization of the biliary tract. Most patients undergoing hepatectomy are at high risk for venous thromboembolic (VTE) disease due to age, presence of malignancy, and complex and long major abdominal sur­ gery. Unfractionated heparin is given subcutaneously prior to induction and redosed every 8 hours as needed. Patients undergoing hepatectomy for malignant diagnoses are usu­ ally sent home on a 3 0-day course of low-molecular-weight heparin for VTE prophylaxis.

Positioning •

RIGHT POSTERIOR SECTION ECTOMY (SEGMENTS 6 AND 7)

Supine with arms abducted. Laparoscopic resections may be facilitated by use of the modified lithotomy position or of a split-leg table. For extreme lateral right liver lesions, full lateral positioning may be used.

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Exposure • •

A su bcosta l, ch evron, or m i d l i n e i n cision ca n be used . It i s o u r p reference to ope rate t h ro u g h a m i d l i n e i n c i s i o n . A fixed traction system is e m p l oyed . Retraction of the costal m a r g i n is critica l .

Mobilization •

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The ro u n d l i g a ment is l i g ated but kept l o n g to a l low its use for cou ntertraction and expos u re . The fa l ciform l i g ament is d ivided close to the l iver, thus m i n i m i z i n g i nterfe rence from t h i s struct u re d u r i n g i ntraoperative u ltraso n o g raphy ( I O U S) . D i ssection of the a pex of the r i g ht tri a n g u l a r l i g a ment proceeds from m ed i a l to latera l . The perito n e u m and a re olar tissue surro u n d i n g the anterior a n d latera l aspects of the rig ht hepatic ve i n (RHV) is cleared. To con­ tinue latera l l y a n d i nferiorly, the l iver can be retracted m ed i a l ly a n d compressed poste riorly. If cava l com p ression i n d uces hypote nsion, tempora ry release of retraction may be a l l that is req u i red . Alter­ natively, ra i s i n g the i nfe rolatera l edge of the r i g ht l iver wi l l expose the f i n a l attachme nts of the right tri a n g u l a r l i g a ment. Com p l ete m o b i l ization of the right l iver req u i res extensive exposure of the lateral a n d a nterior su rface of the i nferior vena cava (IVC). M ed i a l retraction a n d ce phalad rotation of the i nferol atera l edge raises the l iver off the IVC. A va r i a b l e n u m ber of short hepatic ve i n branches d ra i n t h e r i g ht hepatic l o b e d i rectly i nto t h e IVC. These s h o u l d be ca refu l l y l i g ated u s i n g 4 - 0 ties a n d c l i ps. W e a v o i d use of c l i ps o n the hepatic side of these sma l l vesse ls as they may i nte rfe re with p a renchy m a l tra nsection a n d rese rve t h e i r use for the branches on the cava l side.

At the p roxi m a l a n d l atera l aspect of the IVC, there is a l i g a mentous b a n d/parenchym a l bridge, which extends from seg ment 7 to the retro peritonea l tissue behind the IVC. Release of this band is critica l i n the exposure and safe d i ssection of the RHV. This b a n d can be vascu l a r and tra nsection s h o u l d be perfo rmed by l i gation, sta p l i ng , or use of bipolar tra nsection of t h i s tissue.

Hilar Dissection and Vascular Control • • •

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Anterior a n d cra n i a l fixation of the fa l ciform l i g a ment exposes the h i l u m . Anteg rade chol ecystectomy i s perfo rmed t o expose the r i g ht l atera l h i l a r p l ate. IOUS s h o u l d be used rout i n e l y to exa m i n e the hepatic pa renchyma for known and occu lt lesions. IOUS confi rms vascu l a r a n ato my, i d e ntifies major vascu l a r bran ches, a n d m a ps the p roxi m ity o f hepatic a n d porta l ve i n branches near the lesions. After creat i n g a n apert u re through the gastrohepatic l i g a m e nt, a n u m b i l ical tape is p l aced a ro u n d the porta hepatis. Creation of a l oose R u m m e l tourniq uet perm its a ra p i d P r i n g l e m a n e uver in the event of b l eed i n g . D i ssection beg i n s at t h e rig ht l atera l e d g e o f t h e hepatic p l ate. D i ssection o n the contra l atera l side should be avoided to p revent i n a dvertent i nj u ry a n d to m i n i m ize sca rring i n case subsequent h epatecto my i s req u i red. I n the r i g ht h i l u m , the r i g ht hepatic a rtery (RHA) is su per­ f i c i a l a n d is accord i n g ly d i ssected fi rst. The RHA typ ica l ly bifu rcates as it e nters the right l i ve r. Both the a nte rior a n d posterior branches s h o u l d be identified. A vascu l a r loop fac i l itates g e n t l e traction, a n d a b u l ldog c l a m p i s then p l aced on the r i g ht posterior a rtery (FIG 2) . Perfusion i n the rig ht a nte rior a n d proper hepatic a rtery ( i n the porta he patis) as we l l as the l eft hepatic a rtery (LHA) s h o u l d now be confi rmed. M a n u a l p a l pation or D o p p l e r exa ms a re suffi cient. IOUS i n the h i l u m o r of the pa renchyma ca n be used fo r confi rmati o n .

C h a pt e r 21

Anterior hepatic artery Posterior portal vein (taped)

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Gall bladder fossa

S E G M E N TAL H E PATECTOMY

safe ly l i gate the d u ct d ista l to the b ifu rcati o n a n d avoids u n n ecessa ry hilar d i ssection, which can devasc u l a rize or i nj u re the b i l i a ry syste m . The poste rior section s h o u l d beg i n to d e m a rcate. Inflow occlusion is now co m p l ete. The RHV is not routi n e l y isolated for posterior sectionec­ tomy, but branches are l i g ated i ntra hepatica l ly d u ri n g p a renchy m a l tra nsect i o n .

Parenchymal Transection •

Right hepatic artery Posterior hepatic artery (taped)

FIG 2 • The r i g ht porta l ped icle is exposed, a n d the anterior a n d poste rior branches are visua l i zed prior to l i gation of the r i g ht poste rior hepatic a rtery o r porta l ve i n .

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If no deficit is noted, then the c l a m p may be removed and the posterior branch of the RHA can be d ivided between 2-0 s i l k l i g atu res a n d 3-0 suture l i g atu res. Division s h o u l d expose the right porta l ve i n (R PV) posteriorly a n d c e p h a l a d to the R H A . T h e RPV d i ssection s h o u l d identify anterior a n d poste rior branches a n d a l so the RPV or l eft porta l ve i n (LPV) bifu rcat i o n . Correct i d e ntificat i o n of the bifurcation of the RPV a n d LPV is i m perative to avoid l i gating o r narrow­ i n g the m a i n porta l tru n k or the ta keoff of the LPV. D u r­ i n g t h i s exposu re, poste rior branches of the RPV to the caudate (seg ment 1) can easily be avulsed. These s h o u l d be pree m ptively l i g ated or avoided as the d i ssection pro­ ceeds to avo i d u n n ecessa ry b l eed i n g . F u rther d i ssection along the c i rcu mference of the RPV s h o u l d a l l ow identificati o n a n d isolation of the right a nterior a n d r i g ht poste rior branches. In some c i rc u m stances, a short seg ment hepatoto my of seg ment 6 may be used to access the pos­ te rior porta l ve i n . Isolation of the poste rior branch may be confirmed by I O U S . The poste rior branch of the R PV is e n c i rcled with a vessel loop or a 14-in Pen rose d ra i n to a l low gentle tract i o n . W e routi nely tra nsect the posterior porta l ve i n w i t h a vasc u l a r sta p l e r. An a rti culating sta p l e r i s u sefu l in obta i n i n g the opti m a l a n g l e for tra nsect i o n . Extreme care is taken d u r i n g passage of the jaws of the sta p l e r to avoid d isruption of nea rby vascu l a r branches. If d iffi culty is e n co u n tered, ofte n, the na rrow jaw can be i nserted i nto the open i n g of the Pen rose d ra i n and gentle withd rawa l of the Pen rose g u ides the sta p l e r i n the a p p ropriate p l a n e . W e do n o t rout i n e l y perform extra hepatic d ivision of t h e rig ht poste rior he patic d uct. Rather, w e prefer to l i gate a n d d ivide it i ntra p a renchym a l ly d u ri n g the p a renchym a l tra nsection with t h e sta p l e r. This tech n i q u e a l l ows us to

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To beg i n tra nsection, we use ca utery to d i s r u pt G l isso n 's capsu l e a n d m a r k the l i n e of tra nsect i o n . This p rocess is cont i n ued c i rcu mferent i a l ly. J O U S may be h e l pf u l to identify the extent of the lesion and to m a r k a n a p p ro­ priate m ed i a l m a rg i n . This c i rcu mferent i a l g roove w i l l se rve as a g u i de for the co m p l etion of the hepatic tra nsect i o n with sta p l ers. The i m porta nce of creat i n g a fu l ly c i rcu mferent i a l g roove (especi a l ly poste rio rly) in order to provide tact i l e and vi­ s u a l g u i de for sta p l i n g ca n n ot be overstated. The next 1 to 2 em of l i ver parenchyma can be tra n­ sected with a n e n e rgy source. B i po l a r, ra d i ofreq uency, o r u ltraso n ic-g e n e rated heat e n e rgy can be used at the s u rgeons' prefe rence. We find superior h e m ostasis with sa l i n e-rad iofreq uency devices, which sea l vasc u l at u re a n d b i l e d u cts a l i ke . A Pringle m a neuver may be a pp l ied at this point to occlude col l atera l flow thro u g h the l iver rem n a nt. This prevents u nexpected b leed i n g d u r i n g parenchym a l tra nsection. Sta p l i n g of the re m a i n i n g hepatic parenchyma is o u r pre­ ferred means of com p l et i n g the tra nsect i o n . H a v i n g two sta p l e rs perm its the use of o n e wh i l e the oth e r is b e i n g reloaded, a l lowi ng f o r ra p i d tra nsect i o n . The t h i n (meta l) end of the sta p l e r is t u n n e led b l u ntly i nto the hepatic parenchyma. Alternatively, a g roove for i nsertion of this end can be created by gentle passage of a cl osed cu rved c l a m p . Closure of the sta p l e r is a n a logous to crush i n g the hepatic p a renchyma with a m eta l clamp d u r i n g the cl assical crush-cl a m p hepatic tra nsect i o n . T h e sta pler s h o u l d be passed t h r o u g h the parenchyma without resista nce. Resista nce may i n d icate that the sta pler is encountering the sidewa l l of a vesse l . Forci ng the sta pler through these branches may cause s i g n ificant bleed i n g . S m a l l e r bites with the sta p l e r resu lts i n s l ow, seq uenti a l p a renchym a l com p ression a n d avo ids tea r i n g o f vesse ls. Push i n g out excess tissue a l l ows superior sta p l e forma­ tion, m i n i m i z i n g the chance of b l eed i n g or bile leak. D i fficu lty i n closing or firing the sta p l e r may be encoun­ tered when (1) too m u ch tissue i s between the jaws or (2) the r i g ht hepatic d u ct ( R H D) is l i g ated a n d d ivided. With the l eft h a n d h o l d i n g the right l iver, the line of tra nsection can be contro l l e d . With the f i n g e rs i n the poste rior g roove, the IVC is p rotected and the e n d po i nt of the tra nsection is known at a l l ti mes. The entire tra n­ section conti n u es with repeated f i r i n g s of the sta p l e r. For a co m p l ete or fo r m a l r i g ht posterior section ecto my, the p l a n e of tra nsection s h o u l d p a ra l l e l the latera l aspect of the RHV (FIG 3) .

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

Completion •

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• For a com p l ete or form a l right poste rior sectio­ nectomy, the plane of tra nsection should para l l e l the l atera l aspect of the RHV.

FIG 3

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After the p a renchyma is d ivided, the spec i m e n is rem oved from the f i e l d . We ro utinely work with the path o l o g i sts to orient the speci men, i n k the a p propriate m a r g i ns, a n d assess g ross m a rg i ns i ntraoperatively. H e m ostasis is a c h i eved at the cut edge of the l i ver. We p refer the b i p o l a r, sa l i n e-perfused ra d i ofreque ncy a b l a ­ tion (RFA) device, which is effective i n sea l i n g sm a l l ves­ sels and b i l e d u cts. Care s h o u l d be taken to avo i d coa g u lating major b i l i a ry branches, as this may lead to su bseq uent stricture. Any a rea of b i l e leak, which m i g ht be near a l a rger b i l e d u ct, can a lso be l i g ated with a bsorba b l e monofi l a m ent suture. For a reas of bleed i ng near the h i l u m , where e n e rgy devices may risk d a m a g e to cru c i a l structu res, we e m p l oy m a n u a l pressure a n d/o r to pi ca l hem ostatic agents a n d precise sutu r i n g w h e n necessa ry. A l a rge, cl osed suction d ra i n may be p l aced adjacent to the tra nsected pa renchyma at the s u rgeon's p refe rence. We rea p p roxim ate the fa l ciform l i g a m e nt to p revent l at­ era l rotati o n of the re m n a nt that may resu lt in k i n k i n g a n d poss i b l e occlusion o r t h ro m bosis o f the hepatic ve i n s .

LEFT LATERAL SECTIONECTOMY (SEG M ENTS 2 AND 3) Mobilization •

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D i ssection of the a pex of the l eft tria n g u l a r l i g a ment pro­ ceeds from l atera l to m ed i a l . It may be h e l pf u l to p l ace a l a p a roto my pad posterior to the l eft tria n g u l a r l i g a ment to help p rotect the g astric card ia a n d g astroeso p h a g e a l j u ncti o n . The perito n e u m a n d a reo l a r tissue surro u n d i n g the lat­ eral aspect of the l eft he patic ve i n (LHV) is cleared. Ante­ rior retraction may aid i n d o i n g this safe ly.

Hilar Dissection and Vascular Control •

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I O U S is used to l ocate a n d m a r k the caps u l e where the LHV wi l l be encou ntered d u r i n g tra nsect i o n . This visu a l re m i n d e r can be usefu l d u ri n g parenchym a l d ivision. The gastro h e patic l i g a ment i s d ivided, including any a b­ errant LHA. An u m b i l ical tape can now be p l a ced around the porta hepatis i n preparation for a ra p i d Pri n g l e m a n euver i n the event o f b l eed i n g . D i ssection beg i n s at the l eft l atera l e d g e o f t h e round l i g a m e nt, pass i n g i nto the u m b i l ical fissure. D i ssection on the main porta hepatis o r the contra latera l side should be avoided to prevent i n advertent i nj u ry a n d to m i n i m ize sca rring i n case su bseq uent he patecto my is req u i red . The b r a n c h es of t h e LHA a n d LPV s u p p l y i n g t h e l eft lateral sect i o n can be i n d ivid u a l ly i so l ated a n d l i g ated on the l eft s i d e of the ro u n d l i g a m e nt. M o re p roxi m a l d i ssect i o n on the m a i n LHA a n d LPV is not n ecessa ry. Vascu l a r contro l can be o bta i n ed by P r i n g le, if needed

(FIG 4) .

FIG 4 • T h e LPV is s h o w n i n the u m b i l ical fissure. The l eft­ sided branches to segm ents 2 a n d 3 req u i re l i g at i o n .

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The LHV is not isol ated extra he patica l ly for a l eft l atera l sectionectomy but is l i g ated i ntra hepatica l ly d u r i n g tra n­ sect i o n . Tu m o r location may req u i re extra hepatic liga­ tion of the LHV.

Parenchymal Transection and Completion • •

As described a bove A t t h e m ost cra n i a l p a rt of the pa renchym a l tra nsection, the LHV will be encou ntered. This i s best l i g ated with a vascu l a r sta p l e r; it is u s u a l l y l a rg e r t h a n reco m mended for e n e rgy-sea l i n g device (FIG S) .

C h a p t e r 21

Falciform ligament

S E G M E N TAL H E PATECTOMY

Left hepatic

Tumor

Seg ments 2 and 3 portal vein branches

FIG 5

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The LHV is l i g ated i ntraparenchyma l ly with a sta p l e r.

CAUDATE LOBE RESECTI ON (SEGMENT 1) I nferior vena cava

Mobilization •

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D i ssection of the a pex of the l eft tri a n g u l a r l i ga ment proceeds from m ed i a l to l atera l . The l eft tri a n g u l a r l i g a ­ ment s h o u l d be d ivided as described e a r l i er. For l a rger t u m o rs or t u m o rs that are c l ose or i nvolve the caudate ist h m us, co m p l ete m o b i l ization of the r i g ht l iver is a l so necessa ry. This req u i res l i g ation of the short he­ patic branches between the poste rior l iver and the IVC. The perito n e u m and a reo l a r tissue surro u n d i n g the lat­ era l aspect of the LHV is cleared. Anterior retraction may aid i n d o i n g this safe ly. The gastrohepatic l i g a ment is d ivided. If an a berrant LHA i s p resent, there should be a n atte m pt to p rese rve it. H owever, d ivision of the LHA may be necessa ry for ad­ equate expos u re . After t h i s m o b i l izati o n is co m p l ete, the l eft l iver ca n be rotated a nteromed i a l l y to visu a l ize the caudate lobe (FIG 6) . I O U S exa m i nes the l iver f o r k n o w n a n d occ u lt l e s i o n s. The a rte r i a l a n d porta l ve nous i nflow a rises as s m a l l e r poste rior branches off the m a i n or l eft h i l a r structu res. The caud ate branches to the h i l a r vesse ls and b i l e d u ct a re identified on the a nterior surface of the caudate. Th ese can be l i g ated using energy devices, l i g atu res, or c l i ps. D i ssection beg i n s by d i v i d i n g the p a renchyma, some­ t i m es ca l l ed the "cau date i sth m u s . " This bridge of tissue crosses a nterior to the IVC and fuses with seg ment 6 at the l eft l atera l edge of the l i g a mentum teres pass i n g i nto the u m b i l ical fissure. Sequenti a l sea l i n g of this bridge ca n be perfo rmed with m o n o p o l a r, ra d i ofreq uency, b i p o l a r, or sta p l e rs. Altern ative ly, a rig ht-a n g l ed c l a m p can be used to isol ate sma l l packets of parenchyma, which a re then I i gated between 3-0 ties. Caudate outflow i s via sma l l ve i n s d i rectly i nto the IVC a n d the RPV. These should be l i g ated i n d iv i d u a l ly, as de­ scribed a bove.

Middle hepatic vein Left hepatic vein

Ligamentum venosum Caudate lobe

Right portal vein

I nferior vena cava

Left portal vein

FIG 6 • With rotation of the l eft l iver, the caudate lobe is seen in re lation to the LHV, l i g a mentum ve nosum, the IVC, a n d a major branch from the LPV.

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The poste rior s u rface of confl uence of the hepatic vei ns, p a rticu la rly the m i d d l e and LHVs, ove r l i es the cephalad most aspect of the caudate lobe (FIG 7) . Safe d i ssection h e re req u i res good m o b i l ity of the rig ht a n d l eft l o bes of the l i ver.

Parenchymal Transection and Completion •

As described a bove

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

Middle hepatic vein

Left hepatic vein

Right hepatic vein

Paracaval portion Spiegel lobe

Caudate process • The u p p e r p o l e of the ca ud ate lobe l ies between the IVC a n d the confl uence of the m i d d l e a n d l eft hepatic ve ins.

FIG 7

IVC

PEARLS AND PITFALLS Patient h i story

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S u g g esti o n of hepatic insufficie ncy or d a m a g e s h o u l d be a g g ressively eva l u ated to reduce postre­ section h e patic fa i l u re .

I m a g i n g a n d test i n g

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H i g h -q u a l ity i m a g i n g a n d a thoro u g h u n d e rsta n d i n g of hepatic a n atomy is essent i a l f o r proper surgica l p l a n n i n g . Libera l u s e o f vo l u m etry i s warra nted . Vasc u l a r a b n o rm a l ities s h o u l d be deta i l ed on preoperative i m a g i n g .

Vascu l a r isolation

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Avo i d u n n ecessa ry d i ssection i n order to m i n i m ize the risk of contra l atera l i nj u ry.

Parenchym a l tra nsection

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Low CVP a n esthesia i s essenti a l to m i n i m ize i ntraoperative b l ood l oss d u ri n g hepatic tra nsect i o n . Sta p l i n g q u ickly d ivides the hepatic p a renchyma, vascu l atu re, a n d b i l e d u cts, m i n i m iz i n g b l ood l oss a n d b i l e l e a ks. Small venous b l eeders encou ntered d u ri n g d i ssection ca n be s i m p l y tam ponaded, sea led with a n e l ectrosurgical d evice, o r on occasion, sutured o r c l i pped.

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H e m ostasis

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Use of en ergy near major b i l i a ry or h i l a r structu res s h o u l d be avo i d e d .

POSTOPERATIVE CARE

OUTCOMES

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VTE prophylaxis is continued, including doses on the day of surgery as appropriate to the dosing schedule. Antibiotics are only continued to complete less than 24 hours of prophylaxis. All patients are given supplemental magnesium ( 6 g/IV once ) , phosphate ( sodium phosphate, 30 mmol!IV TID ) , a n d vitamin K (phytonadione, 5 mg/SC q 8 h ) t o a i d in liver regeneration and production of normal levels of vitamin K-dependent factors . This is given regardless of serum levels . Drains are checked for bilirubin o n postoperative day 3 . If the level i s less than o r equal t o serum levels and the out­ put is less than 1 0 0 mL per day, the drain is removed.

• •

In experienced centers, mortality is now less than 3 % and morbidity is approximately 2 0 % .3 Overall and disease-specific survival at 5 years can reach 69% and 72 % , respectively, varying with the underlying pathology.4 Neoadjuvant or adjuvant systemic treatment, a total of 6 months of perioperative therapy, is recommended.5

COMPLICATIONS • •

Volume-outcomes relationships are prominent in hepatic resection. Outcomes specific to hepatectomy include bile leaks ( 5 . 9 % ) , perihepatic abscesses ( 3 . 7 % ) , hemorrhage ( 0 . 9 % ) , and hepatic insufficiency ( 3 . 1 % ) . 6

C h a pt e r 21

•

Bile leaks can be managed by percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy to facilitate internal drainage.

REFERENCES 1. Strasberg SM. Terminology of liver anatomy and resections: The Brisbane 2000 terminology. In: Clavien PA, Sarr M, Fong Y. Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery. New York, NY: Springer; 2007: 3 1 3-3 17. 2. Teh SH, Nagorney OM, Stevens SR, et a ! . Risk factors for mor­ tality after surgery in patients with cirrhosis. Gastroenterology. 2007; 132(4 ) : 126 1-1269. 3 . Hamed OH, Bhayani NH, Ortenzi G, et a!. Simultaneous colorec­ tal and hepatic procedures for colorectal cancer result in increased

S E G M E N TAL H E PATECTOMY

637

morbidity but equivalent mortality compared with colorectal or he­ patic procedures alone: outcomes from the National Surgical Quality Improvement Program. HPB (Oxford) . 2 0 1 3 ; 1 5 ( 9 ) :695-702. 4. Nikfarjam M, Shereef S, Kimchi ET, et a!. Survival outcomes of pa­ tients with colorectal liver metastases following hepatic resection or ablation in the era of effective chemotherapy. Ann Surg Oneal.

2009; 1 6 ( 7) : 1 8 60-1 867 0 5. NCCN clinical practice guidelines: colon cancer. National Compre­ hensive Cancer Network. http://www.nccn.org/professionals/physi­ cian_gls/PDF/colon.pdf. Published 2 0 1 3 . Accessed September 2, 20 1 3 . 6. Zimmitti G , Roses RE, Andreou A , e t a!. Greater complexity of liver surgery is not associated with an increased incidence of liver­ related complications except for bile leak: an experience with 2,628 consecutive resections. ] Gastrointest Surg. 20 1 3 ; 1 7( 1 ) :57-64; discussion 64-65.

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22

Chapter

Minimally Invasive Sectional and Segmental Hepatic Resection · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ....

Kevin T. Nguyen

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DEFINITION •

The International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane 2000 terminology of liver anatomy and resections1 defines a segmental hepatic resection as a liver resection of one of nine anatomic Couinaud's segments and a sectional hepatic resection as a liver resection of anatomic sections or sectors (right posterior section [Couinaud's seg­ ments 6 and 7] , right anterior section [Couinaud's segments 5 and 8 ] , left anterior section [Couinaud's segment 4], or left lateral section [Couinaud's segments 2 and 3 ] ) .

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

scan of the abdomen are virtually equivalent for assessment of disease. They can be complementary in characterizing le­ sions and determining the probable pathology. Localize the tumor(s) with respect to the portal structures and hepatic veins to evaluate for resectability. Can an RO liver re­ section be performed with curative intent, namely obtaining adequate margins, while leaving a sufficient functional liver remnant with preserved vascular inflow and outflow? Pay attention to anatomic variants (i.e., replaced/accessory left hepatic artery, replaced/accessory right hepatic artery, trifurcation of the main portal vein, takeoff of the right an­ terior or right posterior portal vein from the left portal vein, the presence of large inferior hepatic veins, etc . ) .

SURGICAL MANAGEMENT

The indications for liver resection include primary or meta­ static malignant liver lesions or symptomatic benign liver lesions in patients who are surgical candidates. Patients who are candidates for an open liver resection should be consid­ ered for a possible minimally invasive approach.

Preoperative planning • •

IMAGING AND OTHER DIAGNOSTIC

Where is the transection plane to achieve a negative margin and preserve adequate functional liver reserve ? Where should the port positions be to provide optimal triangulation?

STUDIES

Positioning

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•

Eovist™-enhanced liver magnetic resonance imaging (MRI) or triphasic, contrast-enhanced computed tomography ( CT)

Port Placement

LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY •

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Left latera l sector he patoce l l u l a r ca rc i n o m a .

I n it i a l trochar p l a cement: open H asso n a p p roach at a peri u m b i l ical position, Ve ress needle a p proach in l eft u p p e r q u a d ra nt, or o ptica l sepa rator a p p roach in the l eft u p p e r q u a d ra nt FIG 2 sh ows the suggested port positions for a p u rely l a p­ a roscopic l eft l atera l sectionectomy. A 1 2- m m port at the peri u m b i l ical i ncision, a 1 2-mm port i n l eft upper quad­ rant m idclavicu l a r line for l a pa rosco pic u ltraso u n d and E n do G IA sta pler, a 5-mm port i n l eft upper q u a d rant mid­ clavicu l a r l i ne, a n d a 5-mm l eft su bcosta l/l eft flank port.

Mobilization o f the Left Lateral Segment .

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A p u rely l a p a rosco pic l eft latera l sect io n ectomy can be attem pted for hepatic lesions l ocated with i n seg m e nts 2 a n d/or 3 of the l iver (FIG 1 ) .

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Supine with arms abducted. Split-leg positioning is an option preferred by some liver surgeons.

.

•

U s i n g a therm a l en ergy device of choice thro u g h the r i g ht upper q u a d rant 1 2- m m port, d ivide the ro u n d l i g a ment a t the a bdom i n a l wa l l . The assista nt provides cou ntertension throug h the l eft-sided 5-mm ports. U s i n g hook ca utery through the right u p p e r q u a d ra nt 1 2- m m port, d ivide the fa l ciform l i g a ment towa rd the i nsertion of hepatic ve i n s i nto the i nfe rior vena cava (IVC). The assista nt provides cou ntertension throug h the

C h a p t e r 22 M I N I MALLY I N VASIVE SECTIONAL A N D S E G M E NTAL H E PATI C RESECTION

•

Rarely, obta i n i n g an adequate m a r g i n w i l l d i ctate extra­ p a renchy m a l d i ssection of the portal structu res s u p p l y i n g seg ments 2 a n d 3 . The a uthor's favored a p p roach is t o identify the l eft he patic a rtery near the porta hepatis a n d d i ssect it d i sta l ly to identify a n d d ivide the seg m e n ­ tal branches of a l l of the porta l structu res.

Parenchymal Transection of the Liver •

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Port positi ons for p u rely l a p a rosco p i c l eft l atera l section ectomy.

FIG 2

•

•

l eft-sided 5-mm ports by compress i n g the l iver posteriorly a n d inferiorly. The avascu l a r adventitia p rotect i n g the hepatic ve i n s should be d ivided to fu l ly expose the a nte­ rior aspect of the co m m o n tru n k of the m i d d l e and l eft hepatic ve i n . U s i n g t h e h o o k cautery t h ro u g h t h e l eft u p p e r q u a d ra nt 5-mm port, d ivide the l eft tria n g u l a r l i g a m e nt. O pti o n a l : Protect the sto mach a n d s p l e e n with a 4 x 4 g a uze between the l eft tria n g u l a r l i g a ment and stomach. U s i n g the hook ca utery t h ro u g h the l eft-sided ports, d ivide the h epatogastric l i g a m ent, a n d i d e ntify any re­ p l aced o r accessory l eft hepatic a rtery. The assista nt l i fts the l eft latera l section t h ro u g h the r i g ht u p p e r q u a d ra nt 1 2- m m port. C l i p a n d l ig ate any replaced/accessory l eft hepatic a rte ry.

•

•

U ltraso u n d the l iver a n d ensure that the l iver m ass(es) is/a re loca l i zed o n ly in the l eft latera l secto r of the l iver and that the tra nsection p l a n e ach i eves a n adequate on­ co l o g i c m a rg i n (2: 1 em). M a rk the tra nsection p l a n e j ust to the left of falciform l i g a ment with the hook ca utery. The fi rst 2 em of p a renchym a l d e pth can be d ivided safely with a n e n e rgy device of cho ice (FIG 3) . The op­ t i m a l traj ectory for the l iver p a renchym a l tra nsection is through the r i g ht u p pe r q u a d ra nt 1 2- m m port hea d i n g toward t h e i nsertion of the l eft hepatic ve i n . T h e cam­ era is at the peri u m b i l i ca l port a n d the assistant uses an atra u m atic g rasper a n d suctio n/i rrig ator from the l eft­ sided 5-m m ports. As the d i ssect i o n prog resses deeper i nto t h e p a re n ­ c h y m a , expect to encou nter t h e cross i n g seg m e nts 2 a n d 3 p o rta l vei ns, b i l i a ry b r a n ch es, a n d hepatic ve i n b r a n c h es . U s i n g a flat, b l u nt i n stru ment (e . g . , l a p a ro­ sco p i c bowel g rasper), create a t u n n e l in t h e l iver pa­ renchyma below t h ese cross i n g branches (FIG 4) . The t u n n e l s creates an easy path for t h e E n d o GIA sta p l e r (2 . 5 - m m vascu l a r l o a d s a re p referred) (FIG 5) . The b l u nt i n str u m e nt a n d l ower b l a d e of t h e sta p l e r s h o u l d e a s i l y s l i d e t h ro u g h l iver pa renchym a . If t h e i n stru m e n t m eets resista nce, it s u g g ests a cross i n g vascu l a r o r b i l i a ry b r a n c h a l o n g that path a n d t h e i n stru m e n t needs to be redi rected . The l a st d iv i s i o n to free the l iver sect i o n is t h e d iv i s i o n of t h e l eft hepatic ve i n a p p roxi m ately 2 em from t h e i n sert i o n i nto t h e IVC with Endo G IA vascu l a r load. A 4 x 4 gauze can be used to d ry the cut s u rface of the l i ver to identify any a reas of b l eed i n g or b i l e lea k .

FIG 3 • Superficial parenchyma l tra nsection with Harmonic sca l pe l .

639

640

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-BI LIARY SURGERY

FIG 4 • Creat i n g a t u n n e l t h r o u g h the l iver parenchyma u s i n g a flat l a p a roscopic b l u nt g rasper. The l a p a rosco p i c en ergy sou rce is then used to control any sma l l b l eeders or ooz i n g . (The a uthor advi ses a g a i n st u s i n g the l a p a rosco pic argon beam d u e to the risk of argon e m b o l ism.) Any large vesse l s or b i l e l e a ks s h o u l d be contro l l ed w i t h sutures.

• •

Place a specimen retrieva l bag through a Pfa n n enstiel or a n e n l a rged peri u m b i l ica l incision to extract the speci m e n . I ncisions l a rger t h a n 1 2 m m a re c l osed w i t h the 0 Vicryl u s i n g the Ca rter-Thom pson device o r with a sta n d a rd open closing tec h n i q u e .

FIG 5 • Sta p l i n g a n d cross i n g l a rg e vascu l a r branches w i t h the E n d o G I A vascu l a r l o a d sta p l e r.

q u a d rant m i dclavicu l a r l i n e a n d 2 em a bove the level of the u m b i l icus for l a p a rosco pic u ltraso u n d a n d E n d o G IA sta p l e r, a 5 - m m port in r i g ht f l a n k, a 5 - m m port in the l eft u p p e r q u a d ra nt!m idcl avicu l a r l i ne, a n d a 5-mm port in the subxi phoi d/e p i g astric reg i o n .

LAPAROSCOPIC RIGHT POSTERIOR SECTION ECTOMY •

A p u rely l a p a rosco pic r i g ht poste rior sectionectomy can be atte m pted for hepatic lesions l ocated with i n seg­ m e nts 6 a n d/o r 7 of the l iver (FIG 6) .

Port Placement •

FIG 7 shows the sugg ested port porti ons for a p u rely l a p­ a rosco pic r i g ht poste rior sect io n ecto my: a 1 2- m m port at the peri u m b i l ical i n cision, a 1 2- m m port in right u p p e r

Mobilization of the Right Lobe of the Liver •

U s i n g a therm a l en ergy device of choice, through the r i g ht u p p e r q u a d rant 1 2- m m port, d ivide ro u n d l i g a ment from the a bdom i n a l wa l l .

C h a p t e r 22 M I N I MALLY I N VASIVE SECTIONAL A N D S E G M E NTAL H E PATI C RESECTION

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•

FIG 6

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Colorecta l m etastasis to the r i g ht poste rior secto r o f

the l i ver. •

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•

U s i n g the hook ca utery, d ivide the fa l ciform l i g a ment towa rd the i n sertion of hepatic ve i n s i nto the IVC. The avascu l a r adventitia protect i n g the hepatic ve i n s s h o u l d be d ivided to fu l ly expose the a nterior aspect of the r i g ht hepatic ve i n . This can be m o re easily reached through the e p i gastric 5-m m port. M o b i l ize the rig ht lobe of the l iver off the retroperitoneum . The assista nt on the left uses a nontra u m atic, expa n d i n g retractor through t h e left u p p e r quadrant 5-mm port to l ift the right lobe of the liver. This w i l l expose the plane by placing tension on the posterior peritoneum attach­ ments to the liver. The surgeon is on the right side with the suction/i rrigator on the left hand through the right f l a nk 5-mm port and hook ca utery i n the right hand through the

•

Parenchymal Transection of the Liver •

•

•

5 mm

o

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1 2 mm

5 mm

•._.:

1 2 mm •

Port positions for p u rely l a p a rosco pic right poste rior section ectomy.

FIG 7

right u p per quadrant 1 2-mm port. Divide the peritoneum close to but not on the l iver and enter the avascu l a r plane. The assistant conti n u a l ly lifts the right lobe of the l iver a nteriorly and toward the left to further expose the dissec­ tion plane. The right kidney and adren a l g l a n d should be swept posterior by the surgeon using the suction/i rrigator i n the left ha nd. D issect su periorly toward the d i a p h ra g m and right tri a n g u l a r l i g a ment and toward t h e IVC. U s i n g the hook cautery t h ro u g h the r i g ht f l a n k 5 - m m port, d ivide the r i g ht tria n g u l a r l i g a ment a n d the d i a­ p h ra g matic atta chment of the rig ht lobe towa rd the r i g ht hepatic ve i n . Additi o n a l m o b i l i zation can be a c h i eved when n ecessa ry by isolating a n d d iv i d i n g the short ve i n s from the ca u­ date lobe enteri ng the vena cava . M ost can be safe ly con­ tro l led with bipolar e l ectroca utery or u ltraso n i c shears. Some w i l l req u i re c l i p p i n g . An accessory r i g ht hepatic ve i n s h o u l d be expecte d . This vessel is best contro l led a n d d ivided with a vascu l a r sta p l e load (2 . 5 mm). Perform a laparoscopic cholecystectomy in sta ndard fash ion. U ltraso u n d the l iver a n d confirm the lesion(s) a re in the r i g ht poste rior section (Cou i n a u d 's seg ments 6 a n d 7). If a r i g ht posterior section ecto my is p l a n ned, then m a r k l iver u s i n g the hook ca utery a l o n g a n i m a g i n a ry l i n e from the r i g ht of the g a l l b l a d d e r fossa to 2 to 3 em to the r i g ht of the r i g ht hepatic ve i n . This i m a g i n a ry l i ne of tra nsection s h o u l d be para l l e l but l atera l to Cantl ie's line of tra nsi­ tion for a n a nato m i c rig ht o r l eft hepatectomy.

• •

The fi rst 2 em of pa renchym a l depth can be d ivided with a n en ergy device of choice. This can a lso be perfo rmed a l o n g the poste rior s u rface of the l iver along the p l a n ned tra nsection plane. The l a p a rosco p i c en ergy device can be used to d ry the cut su rface of the l iver periodical ly. As the d i ssection p roceeds, repeat perfo r m a n ce of u l ­ traso u n d eva l u ation c a n assist i n t h e i ntra p a renchy m a l identification of the seg ments 6 a n d 7 porta l vei ns, b i l i ­ a ry b ra n ches, a n d hepatic ve i n branches. U s e a fl at, b l u nt i nstr u m ent (e. g . , l a p a rosco pic bowe l g rasper) to create a t u n n e l below these cross i n g branches to a p p l y the E n d o G I A sta p l e r (vascu l a r l o a d s [ 2 . 5 m m ] a re p referred). T h e i nstr u m ent s h o u l d easily s l i d e t h r o u g h the l iver paren­ chym a . If the i nstrument meets resi sta nce, it suggests a cross i n g vascu l a r or b i l i a ry branch a n d the i nstru m ent s h o u l d be red i rected . The last d ivision to free the l iver section i s the d ivision of the right hepatic ve i n a p p roxi­ mately 2 to 3 em from the i nsertion i nto the IVC with Endo GIA vasc u l a r loa d. A 4 x 4 g a uze can be used to d ry the cut s u rface of the l iver to identify any a reas of b l eed i n g o r bile leak. The l a p a rosco p i c en ergy device i s used to control a ny sma l l b l eeders o r ooz i n g . Any l a rger vessels o r b i l e l e a ks s h o u l d be contro l l ed w i t h sutures. Place spec i m e n retri eva l bag thro u g h a Pfa n n e nst i e l or e n l a rged peri u m b i l i cal i n cision to extract the spec i m e n . I ncisions l a rg e r than 1 2 m m a re cl osed w i t h the 0 Vicryl u s i n g the Carter-Thom pson device o r with a sta n d a rd open closing tech n i q u e .

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P a r t 3 OPERATIVE TECH NIQUES I N HEPATO-PANCREATO-BI LIARY SURGERY

LAPAROSCOPIC SEGMENT 6 SEGME NTECTOMY •

A p u rely l a p a rosco p i c seg ment 6 seg m e ntecto my can be attem pted for hepatic lesions l ocated with i n seg ment 6 of the l iver (FIG 8) .

Port Placement •

FIG 9 shows the sugg ested port porti ons for a p u rely l a p a rosco pic seg ment 6 seg m e ntectomy. A 1 2- m m port at the peri u m b i l i ca l i ncision, a 5-mm port in r i g ht u p p e r q u a d rant m i dclavicu l a r l i n e a n d 1 em a bove the l e v e l o f the u m b i l icus, a 5 - m m port i n r i g ht f l a n k, a n d a 1 2- m m port su bcosta l/m idclavicu l a r l i n e .

Mobilization o f the Right Lobe o f the Liver • • •

M o b i l i ze the right lobe of the l iver off the retro perito­ n e u m as described e a r l i e r. Perform a laparoscopic cholecystectomy in sta ndard fash ion . U ltraso u n d the l iver a n d confi rm the lesion is in seg ment 6 of the l iver. If a seg ment 6 seg m e ntectomy i s p l a n ned, then mark the l iver su rfa ce that is a p p roximately 2 em around the lesion(s) . Confi rm the tra n section p l a n by

5 mm

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FIG 9 • Port positions for p u rely l a p a rosco pic seg ment 6 seg m entecto my.

u ltrasonography of the shadow from the m a rked cau­ terized s u rface of the l iver. This l i n e sta rts along the tra nsection plane of a r i g ht poste rior section ecto my but then ta kes a sharp l eft turn toward the l atera l s u rface of the right lobe of the l iver as confirmed by u ltraso u n d to a c h i eve a m a r g i n of at least 1 to 2 em b y u ltraso u n d a l o n g e a c h tra nsection p l a n e .

Parenchymal Transection o f the Liver •

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FIG 8

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Seg m e nt 6 ped uncu l ated hepatic a d e n o m a .

REFERENCE 1. Belgihiti J, Clavien PA, Gadzijev E, et al. The Brisbane 2000 terminology of liver anatomy and resections. HPB. 2000;2:333-339.

This s h o u l d be performed a l ong the anterior a n d poste­ rior su rface of the l iver a l o n g the p l a n ned tra nsection p l a n e . The l a p a rosco p i c en ergy device can be used to d ry the cut s u rface of the l iver periodica l ly. To control the seg ment 6 porta l veins, b i l i a ry branches, a n d hepatic ve i n branch es, a vascu l a r sta p l e r is a p p l ied as e a r l i e r. In contrast to e a r l i e r, t h i s load is typica l ly i nserted tra n sversely via the subxi phoi d port.

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Chapter

23

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Right Hepatectomy

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Neil H. Bhaya n i

DEFINITION •

A right hepatectomy (or hemihepatectomy) consists of surgi­ cal resection of the right liver, consisting of Couinaud seg­ ments 5 to 8 (FIG 1 ). Nomenclature for liver resections was standardized in the Brisbane conference. 1

PATIENT HISTORY AND PHYSICAL FINDINGS • •

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Medical evaluation and suitability for major abdominal sur­ gery is tantamount. Health of the liver can be ascertained by questions regarding episodes of j aundice, hepatitis exposure, alcohol, illicit drug abuse, and treatment with chemotherapy. In addition to standard preoperative laboratories, it is our practice to obtain a complete viral hepatitis panel on all po­ tential surgical candidates. Regardless of the metric or risk scoring system employed, thorough assessment of the health of the remnant liver is mandatory. Previous history of abdominal surgery, especially abdominal foreign bodies (e.g., mesh) , may alter the approach. Physical exam findings of chronic liver disease or hepatic insufficiency should prompt more invasive testing if the pa­ tient remains a surgical candidate. If performing a metastasectomy, there should be a thorough evaluation for extrahepatic disease. Computed tomography ( CT) is considered standard of care; a positron emission to­ mography (PET) scan is currently considered optional but used commonly by the authors. Findings of extrahepatic dis­ ease should prompt reconsideration of hepatectomy or plan­ ning for multiple staged procedures. In appropriate, medically operable patients, resectability is now only limited by the need to preserve adequate func­ tional hepatic reserve.

Niraj J . Gusa n i

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Kevin Staveley-O'Carro/1

Liver function can be assessed by the Child-Pugh classifica­ tion or Model for End-Stage Liver Disease (MELD } . Neither metric has been definitively shown to be superior.2•3 Specific biochemical testing of liver function is more preva­ lent in Asia but rarely performed in the United States.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

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•

•

Noncontrast, arterial, and venous contrast cross-sectional imaging is essential in diagnosis and evaluation of suitability for surgery. CT and magnetic resonance imaging (MRI) are of similar sensitivity. In a normal, healthy liver, a remnant measuring 2 5 % of a complete liver volume should constitute sufficient functional liver. However, in a damaged or cirrhotic liver, a remnant of greater than 40% is recommended. When performing a right hepatectomy, the remnant hemiliver is usually of adequate size in a healthy liver. In most cases, this does not require formal volumetric analysis; however, liberal use of volum­ etry should decrease the risk of postoperative hepatic insuf­ ficiency ( FIG 2 ) . In the event of marginal remnant volume, preoperative portal vein embolization on the side of resec­ tion can induce hypertrophy of the planned liver remnant. Hepatic steatosis can be evaluated by comparison of the densities of liver and spleen on noncontrast images. Alterna­ tively, biopsy of the liver can provide quantitative assessment of fat content. Significant steatosis can suggest a liver rem­ nant at risk of postoperative failure. Current practice would advocate strategies for preoperative hypertrophy to ensure a remnant that is at least 3 0 % of the native volume of the liver. Patients with history, laboratory, or radiographic findings concerning for significant hepatic injury or dysfunction are referred for invasive testing of the liver, such as transj ugular measurement of the portal pressure gradient (normal 4 5 minutes), CBD dilatation greater than 1 .2 em, and elevated alkaline phosphatase or serum glutamic oxaloacetic transaminase ( SGOT) (greater than two times the upper limit of normal) have excellent response to endoscopic sphincter­ otomy alone without other diagnostic maneuvers. Patients who meet some but not all of these criteria benefit from further diagnostic testing with manometry, and those patients in whom manometry is abnormal may benefit from sphincterotomy. Patient with biliary pain but without any of the aforemen­ tioned abnormalities may undergo manometry but have gen­ erally lower rates of success following sphincterotomy even in the presence of abnormal manometry. Although this has not been validated prospectively, one small study suggested that HIDA scan with morphine as an adjunct has the advantage of a noninvasive test that, when positive, correlates well with a positive surgical outcome. 1 0 MRCP with secretin stimulation is another modality that has been used to demonstrate SOD dysfunction in patients with prior Roux-en-Y gastric bypass for morbid obesity. 8 Sphincter manometry is performed via a miniaturized pres­ sure catheter that is placed in the sphincter of Oddi using a side-viewing endoscope. Four categories of manometric abnormalities are defined and include the following: Papillary stenosis, which is defined as persistently el­ evated resting pressures within the sphincter of Oddi that are unresponsive to pharmacologic means of sphincter relaxation Dyskinesia, in which the response to pharmacologic relaxation is preserved within the context of elevated rest­ ing pressures

C h a p t e r 44 AM PU LLECTOMY A N D TRAN S D U O D E N A L S P H I N CTEROPLASTY

•

Tachyoddia, in which there is an increased frequency of spontaneous contractions of the sphincter and physiologi­ cally abnormal (paradoxical) response to cholecystokinin.1 1 Paradoxical sphincter response, in which an increase in sphincter tone is observed in response to cholecystokinin administration Endoscopy with secretin stimulation test may also be used in the stratification of patients with pancreas divisum who are likely to benefit from surgical sphincteroplasty. Briefly, EUS may be used to visualize the minor pancreatic duct. After administration of secretin, increase in ductal dilatation gives evidence to an obstructive papillary stenosis. The absence of this dilatation should prompt consideration of further trials of nonsurgical therapy.

•

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829

of unfractionated heparin are given in the preoperative hold­ ing area as deep venous thrombosis (DVT) prophylaxis. Preoperative antibiotics are administered within 1 hour of incision. Appropriate antibiotics should cover for skin flora as well as for gram-negative enterics and anaerobes. Our practice is to extend the left arm and tuck the right arm and place the Bookwalter (or similar) retractor on the patient's right side . A right subcostal (Kocher) inci­ sion with extension a short distance across the midline is used ( FIG 3 ) .

SURGICAL MANAGEMENT

Preoperative Planning •

•

•

Biliary tract decompression, that is, by percutaneous trans­ hepatic biliary drain placement or ERCP, may be required if the patient has presenting symptoms of biliary obstruction. Preoperative placement of an epidural catheter for pain control is a useful adj unct for a planned open operation and limits postoperative dependence on narcotic pain medication. General strategies to optimize patients for major surgery should be employed as indicated. These may include optimi­ zation of nutritional status as well as smoking and alcohol cessation.

Positioning •

The patient is positioned supine on the operating table. Sequential compression device boots are placed. Unless there is a contraindication to heparin administration, 5,000 units

INCISION AND EXPOSURE •

A right su bcostal (Kocher) i n cision is made with exten­ sion a cross the m i d l i n e to fac i l itate expos u re. The i n ci­ sion should be made a p p roxi m ately two f i n g e rbreadths i nfe rior to the costal m a rg i n . Adequ ate exposure i s faci l i ­ tated b y the p l acement of a fixed retractor s u c h as t h e Bookwalter o r Thompso n . If the g a l l b l a d d e r i s p resent,

KOCHER M ANEUVER •

The seco nd portion of the d u o d e n u m is g rasped a n d re­ tracted m ed i a l ly so as to e n a b l e d ivision of the perito n e u m at i t s l atera l border. An avascu l a r p l a n e is deve l o ped, with exte nsion towa rd the m i d l i n e to completely m o b i l ize the d u o d e n u m through the t h i rd portion (FIG 4) . The loca­ tion of the a m p u l l a is typica l ly at the d ista l aspect of the seco nd portion of the d u o d e n u m; he nce, wide m o b i l i ­ zation o f t h e d u o d e n u m w i t h a Kocher m a n euver that

FIG 3 • The patient i s positi o n ed i n the s u p i n e posit i o n . The r i g ht a r m i s tucked a n d a Bookwalter retracto r is typ ica l ly p l aced o n the right side. A rig ht-sided su bcostal i n cision with extension a cross the m i d l i n e is used .

a cholecystectomy is typ ica l ly performed. We suggest leaving a l o n g cystic d u ct stu m p to faci l itate p l a cement of tra nscystic d uct stu m p b i l i a ry catheter to g u i de i den­ tification of the a m p u l l a ry ori fi ce. This m a n e uver can o pt i m ize the location of the su bseq uent d u odenotomy. The l iver is retracted su periorly a n d the hepatic flexure i s co m p letely m o b i l ized such t h a t it can be safe ly retracted i nferiorly out of the operative f i e l d .

extends i nfe riorly a n d m ed i a l ly towa rd the m i d l i n e with f u l l m o b i l i zation of the hepatic flexure to expose the t h i rd portion of the d u o d e n u m i s essent i a l to provide ad­ equate exposu re and a tensio n-free closure. This m o b i l i ­ zation a lso a l l ows the d u o d e n u m t o be retracted u p i nto the field where it may be m a i ntained with stay sutu res for su bseq uent ste ps of the operati o n . The p l acement of l a p a roto my pads posterior to the d u o d e n u m to further e l evate it i nto the i ncision is reco m mended.

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

FIG 4 • A Kocher m a n euver is perfo rmed by i n cision of the latera l attac h m ents of the d u o d e n u m a n d exte nsion to the t h i rd portion of the d u o d e n u m , expos i n g the j u nction of the m i d d l e co l i c a n d the superior mesenteric vessels.

D UODENOTOMY AND EXPOSURE OF T HE AMP U L L A •

B i m a n u a l ly p a l pate the seco n d portion of the d u ode­ num to i d e ntify the lesion. If it ca n n ot be p a l pated, p l ace a b i l i a ry catheter via the cyst ic d u ct stu m p, i nflate the ba l l oon, and withdraw it u nt i l you m eet resi sta nce-the b a l l oo n wi l l be p a l p a b l e at the a m p u l l a . An a n t i m esen­ teric d u o d e n otomy is then m a d e to expose the l u m i n a l orifice o f t h e a m p u l l a (FIG S) . T h e d u o d e n otomy may be m a d e either i n a l o n g itud i n a l o r a so-ca l l ed l azy 5

c u rvi l i n e a r i nc i s i o n . We typ ica l ly favor a l o n g itud i n a l i ncision, w h i c h a l l ows f o r exte nsion o f t h e i n c i s i o n i f a w i d e r f i e l d o f exposure i s needed. Alternatively, if a w i d e exposure is req u i red to rem ove a l a rge a d e n o m a , a cu rvi l i n e a r i ncision offe rs the broad est operative f i e l d . The d u o d e n u m w i l l stretch, so u s e ca re n ot to m a ke a n u n necessa r i l y l a rge i n c i s i o n . A 5-cm l o n g itud i n a l i ncision wi l l usua l ly faci l itate a d e q u ate exposu re. Stay sutu res a re p l aced a ro u n d the edges of the d u o d e n otomy to m a i nta i n the operative f i e l d , t h u s expos i n g the l u men of the d u o d e n u m .

F I G 5 • A d u odenotomy i s performed. T h e p l acement o f the i ncision may be l o n g i tu d i n a l o r i n a l azy 5 confi g u rati o n . Pal pation of the a m p u l l a thro u g h the d u o d e n a l wa l l or p a l pation of a b i l i a ry catheter t h readed through the cystic d u ct stu m p across the a m p u l l a faci l itates p l acement o f t h e i n c i s i o n . T h e dashed line rep resents the a p p roxi m ated l ocation of the a m p u l l a r structu res. Pal pation of the structu res (and any preoperatively p l aced b i l i a ry stents) should g u i de the p l a cement of the i n c i s i o n .

C h a p t e r 44 AM PU LLECTOMY A N D TRAN S D U O D E N A L S P H I N CTEROPLASTY

IDENTIFICATION OF T HE M AJOR AND

•

MINOR PAPILLA •

The major a n d m i n o r (if p rese nt) p a p i l l a e a re identified. Ad enomas are rea d i l y a p p a rent. Altern ative ly, the b i l i a ry catheter wi l l i d entify the major pa p i l l a .

The m i n o r p a p i l l a is typ ica l l y l ocated 2 em ce p h a l a d to the major orifice. Its identificati o n may be fac i l itated, if needed, by i ntraoperative secret i n i njection (75 U/kg) to sti m u l ate pancreatic secretions.

P REPARATION FOR T HE EXTIRPATIVE P HASE •

•

At t h i s poi nt, it is advantageous to prepare the field for excision of the a m p u l l a (FIG 6) . The m a n e uvers used w i l l be dependent on t h e g o a l s o f t h e operation specific to the i n d iv i d u a l patient. If a mass i s to be excised, p l ace­ ment of a traction suture (2-0 s i l k) i nto the m ass a l l ows it to be e l evated, retracted, and excised.' From with i n the l u m en of the d u oden u m, f u l l -thickness, circumferent i a l stay sutu res a re p laced to dema rcate 1 .0-cm borders a ro u n d the p l a n ned resection a rea (i.e., 1 .0 em from the a m p u l l a or obvious borders of the mass itse lf), which w i l l a lso fac i l itate d e l ivery of the a m p u l l a i nto a n o pti m a l position f o r resect i o n . These sutu res a l so sta b i l ize the red u n d a nt d u o d e n a l m u cosa .

FIG 6 • C i rcu mferent i a l ca utery a ro u n d the a m p u l l a resu lts in the exposu re of the b i l i a ry a n d p a ncreatic d ucta l orifices. If d ifficu lty i s encou ntered identify i n g the pa ncreatic orifice, i ntraoperative secret i n a d m i n i strati o n may be used, with a resu ltant clear eff l uent o bserved in the operative field from the pancreatic orifice. The loca l ization of the b i l i a ry d u ct i s e n a b l e d by the p l acement of a d i rected b i l i a ry catheter via the cystic d u ct stu m p .

PERFORM ANCE OF T HE EXTIRPATIVE

•

P HASE •

•

•

Retracting the mass i nferiorly, needle tip el ectroca utery is used to d ivide the posterior duodenal mucosa until the bile duct is reached. At that poi nt, sutu res are placed to a pproxi m ate the (fu l l -thickness) CBD a n d the medial d uo­ denum (5-0 a bsorbable monofi lament). The dissection then conti n u es circumferentia l ly i n a cra n i a l to ca udal fash ion. The b i l i a ry catheter, when present, is withd rawn . Need l e­ t i p ped e l ectroca utery is used to i n c i se the m ed i a l (deep) wa l l of the C B D . This transaction p o i nt can be u p to 3 em proxi m a l to the d u o d e n a l orifice a n d sti l l acco m m odate a d u cto p l a sty. As the d i ssection prog resses ci rcumferent i a l ly, 4-0 or 5-0 a bsorba b l e monofi l a ment sutu res are p l a ced fu l l ­ th ickness through t h e C B D a n d t h e n the d u o d e n a l wa l l a n d tied. Hence, the reco nstruction occu rs a s the d i ssec­ tion is performed. This a p p roach p rovides o pt i m a l identi­ fication of the edge of the i ncised bile d u ct a n d prevents catastrop h i c retraction of the CBD out of the field of vi ew.

•

•

•

Alternative ly, delaying reco nstruction u n t i l both pan­ creatic d ucts a n d CBDs have been excised se rves two p u r poses. F i rst, i ntraoperative froze n section of the co m p l etely excised speci men may be perfo rmed a n d ad­ d i t i o n a l d u cta l m a rg i n s ( u p to 1 em) taken as needed. Second, the reconstruction with orientation of the pan­ creatic a n d CBDs may be o pt i m ized. For t h i s a p p roach, sutu res should be p l aced i n the b i l e a n d pa ncreatic d u cts as t h e d issection p roceeds a n d the need l es l eft i n p l a ce. Opposing b ites of d u o d e n u m w i l l be taken later t o a p p roxi m ate these struct u res afte r the resection i s co m p l ete. The pancreatic d ucta l orifice i s encou ntered at a bout the 2 o'clock posit i o n . S i m i l a r to the CBD, stay sutu res (5-0 polydioxa n o n e [PDS] o r s i m i l a r) a re p l aced fu l l th ick­ ness t h ro u g h the pa ncreatic d uct and u lt i m ately a re secu red to the d u oden u m . T h e d i ssection is carried c i rcu mferent i a l l y with sutu res p l aced through the d u o d e n a l wa l l u n t i l the entire a m ­ p u l l a ry co m p lex has b e e n excised.

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INTRAOPERATIVE FROZEN SECTION •

•

If the operation is performed for an adenomatous lesion, i ntraoperative frozen section should be used. M a l i g nancy found on i ntraoperative frozen section should warrant consideration of conversion to pancreaticod uodenectomy.

RECONSTRUCTIVE P HASE •

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•

Reconstruction p roceeds with creation of a septu m by a p­ position of the C B D a n d pancreatic d u cts. F u l l-th ickness i nterrupted sutu res u s in g 5-0 monofi l a m ent, a bsorba b l e sutu res are p l a ced through each d u ct such that they can be t i e d on the l u m e n side (FIG 7) . The pa ncreatic d u cts a n d CBDs a re then a p p roxim ated to the duodenal wa l l by ta king the previ ously p l aced sutu res thro u g h the d u cts and placing fu l l -thickness suture b ites thro u g h the d uodenum, exiti n g in the d u odena l m ucosa. This is carried out i n a circu mferenti a l fash ion u nt i l a duo­ d e n a l defect re m a i n s at the i nferior portion of the reco n­ struction, which is then closed by rea pproximation (FIG 8). O u r p ra ctice is to cl ose the d u odenotomy in a tra ns­ verse fash i o n when t h i s can be acco m p l ished in a ten­ sio n-free m a n n e r (typica l ly dependent on the size of the d u odenotomy). Altern ative ly, we use a l o n g itud i n a l

F I G 7 • A com p l eted reconstruction of the a m p u l l a ry structures. The CBD is identified by the dashed green line, whereas the pa ncreatic duct is identified by the dashed blue line.

•

Between 25 % a n d 4 5 % of patie nts with path o l o g i c T1 peria m p u l l a ry lesions will h ave positive lym p h node m etastases. Thus, pancreaticod uodenecto my is the pre­ ferred m a nagement strategy for m a l i g n a n cy. I ntraopera­ tive a n a lysis of the resected adenoma is essenti a l 4• 1 0• 1 2

clos u re using sero m u scu l a r 3-0 s i l k sutu res. Oversew i n g i s avoided i n o r d e r to p revent stricture a n d to m a i nta i n maxi m a l d u o d e n a l patency. I n some cases, when a l o n g i ­ tu d i n a l closure provides a bette r p r i m a ry clos u re but n a r­ rows the l u men, we a lso perform a gastrojej u n ostomy. A c l osed suction d ra i n may be l eft in close proxim ity to the d uodenotomy at the s u rgeon's d i scretion, a n d the abdomen is cl osed i n a sta n d a rd fash i o n .

FIG 8 • Rea pprox i m ation of the d u cta l struct u res. The rea p p roxim ated d u cts are a lways s m a l l e r than the excised a m p u l la; he nce, the a d d i t i o n a l defect may be cl osed with s i m p l e d u o d e n a l stitches.

PEARLS AND PITFALLS S p h i ncte r m a n o m etry

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Avo i d u s e of antich o l i n e rg i cs or o p i o i d s s u c h as m o r p h i ne, which a lter s p h i ncter of O d d i p ressu res.

Postoperative p n e u m o b i l i a

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Expected; i n d i cative of patency of the rep a i r

Del ayed reco nstruction of pa ncreatic a n d C B D

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Faci l itates opti m i zation of the orientation of the d u cts to the d u o d e n u m a n d e n a b les a d d i ­ t i o n a l m a r g i n s to be t a k e n if needed

Bariatric su rgery patie nts with pa ncreato b i l i a ry-type p a i n

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S O D a n d a m p u l l a ry ste nosis should be i n the d ifferenti a l and may be a m e n a b l e to surgica l i nterventi o n . M o re recently, d a t a has emerged q u esti o n i n g the va l u e of endosco pic m a nagement of S O D . The exte nsion of t h i s f i n d i n g to surgica l m a nagement is u n known.

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C h a p t e r 44 AM PU LLECTOMY A N D TRAN S D U O D E N A L S P H I N CTEROPLASTY

Preope rative ERCP and E U S

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Both a re cru c i a l m o d a l ities t o d e m onstrate the fea s i b i l ity o f a m p u l l ectomy.

Duode notomy

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The d u ode notomy w i l l stretch . Alth o u g h it m u st be of sufficient size so as to afford a p p ropri­ ate exposu re, sta rt sma l l a n d extend as needed.

Closure of the d u odenotomy

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If tra nsverse closure i s not poss i b l e to acco m p l ish i n a tension-free m a n n e r, a l o n g i tu d i n a l clo­ s u re may be used, with a gastroj ej u nostomy if concern exists that the d u o d e n a l lumen is thus na rrowed.

Id entificati o n of the a m p u l l a

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A b i l i a ry Fog a rty catheter m a y be passed v i a t h e cystic d u ct i n order t o fac i l itate identificati o n of the a m p u l l a .

POSTOPER ATIVE CARE •

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Routine postoperative care includes pain control, strict re­ cording of urine output via a Foley catheter, gastric decom­ pression via a nasogastric tube, and monitoring output of a closed suction drain. Patient-controlled analgesia or an epidural is typically used. Patients are transitioned to oral pain medication once toler­ able of clear liquids. Our practice per the clinical pathway is to draw routine full set of labs on the first postoperative day and then the fourth postoperative day but otherwise only when clinical suspicion raises concern. In sphincteroplasty patients, it is prudent to include total bilirubin and serum amylase and li­ pase and to delay advancement of diet if pancreatic enzymes remain elevated postoperatively. Sequential compression stockings and unfractionated heparin (5,000 units three times a day) are used routinely. Addition­ ally, pantoprazole (40 mg intravenously daily) is continued in the postoperative period. The nasogastric tube is typically discontinued on the third postoperative day. The epidural and Foley catheter are typically discontinued on the third postoperative day. In the absence of an epidural, the Foley catheter is removed once postoperative urine out­ put is satisfactory, typically on postoperative day 1 or 2 . The drain output is continuously monitored. The drain i s left in place until the patient can tolerate a regular diet. The drain is then removed unless the character or volume of out­ put is of concern for a leak at the duodenal closure site.

OUTCOMES •

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833

When performed for SOD, patient satisfaction and symp­ tom relief has been noted to vary with SOD subclass. In one series, patients with type I SOD reported good outcomes in nearly 1 00 % of patients. However, results were not as favor­ able in type III and type II dysfunction with 5 8 % and 6 1 % favorable outcomes, respectively. I n multivariate analysis, patients with good outcomes tended to be older (47 years old vs. 33 years old), whereas patients with poor outcomes tended to suffer from chronic pancreatitis.9 Surgical sphincteroplasty is associated with a 3 0 % compli­ cation rate. Complications after ampullectomy occur at half the frequency of complications of pancreaticoduodenectomy and with a lesser degree of severity. 10 When performed for minor papillary stenosis, success rates vary with patient characteristics. Success is lowest in pa­ tients with pancreatic-type pain without clinical evidence of

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pancreatitis, intermediate in patients with chronic pancre­ atitis, and highest ( 7 5 % to 9 0 % ) when undertaken after a single episode of acute pancreatitis. When performed for SOD, a retrospective review indicated that the success rate of transduodenal sphincteroplasty was low in patients with concomitant chronic pancreatitis but relatively high in patients who had undergone prior bariatric surgery.9 In patients who had undergone prior Roux-en-Y gastric by­ pass and subsequently underwent operation for SOD, one relatively small case series demonstrated that the maj ority of patients had pain improvement after surgery.8 When performed for malignancy, retrospective analysis in­ dicates significant disadvantages to transduodenal resection versus pancreaticoduodenectomy including increased inci­ dence of local recurrence and decreased survival. However, the only prospective series comparing the two techniques is relatively small and demonstrates that in selected patients outcomes may be equivalent. U

COMPLICATIONS •

•

In one series of patients comparing surgical ampullectomy to endoscopic ampullectomy, a 42% morbidity rate was ob­ served among the surgical ampullectomy group versus the 1 8 % in the endoscopic ampullectomy group. Complica­ tions after endoscopic ampullectomy included hemorrhage, pancreatitis, and intractable nausea, in decreasing order of frequency. After surgical ampullectomy, the most frequent complications included dehydration, symptomatic pancre­ atitis, wound infection, and intraabdominal abscess. Maj or complications are rare but include leakage at the du­ odenotomy leading to pancreaticobiliary fistula or intraab­ dominal abscess and sepsis. Cholangitis is also reported with a frequency of 6% in one series.14

R EFERENCES 1.

Ruo L, Coit DG, Brennan MF, Guillem JG. Long-term follow-up of patients with familial adenomatous polyposis undergoing pancreati­ coduodenal surgery. J Gastrointest Surg. 2002;6 ( 5 ) :671-675. 2 . Pare Y, Mabrut JY, Shields C. Surgical management of the duodenal manifestations of familial adenomatous polyposis. Br ] Surg. 2 0 1 1 ; 9 8 ( 4 ) :4 8 0-484. 3 . Roggin KK, Yeh JJ, Ferrone CR, et al. Limitations of ampullectomy in the treatment of nonfamilial ampullary neoplasms. Ann Surg Oneal. 2005; 1 2 ( 1 2 ) :971-9 80. 4. Beger H G , Treitschke F, Gansauge F, et a l. Tumor of the ampulla o f Vater: experience with local or radical resection in 1 7 1 consecutively treated patients. Arch Surg. 1 9 9 9 ; 1 3 4 ( 5 ) : 526-532.

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7.

8.

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Winter JM, Cameron JL, Olino K, et al. Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis. I Gastrointest Surg. 2 0 1 0 ; 1 4 ( 2 ) : 3 79-3 87. Ceppa EP, Burbridge RA, Rialon KL, et al. Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg. 2 0 1 3;257(2 ) : 3 1 5-322. Hornick JR, Johnston FM, Simon PO, Younkin M, et al. A single-in­ stitution review of 1 5 7 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes. Surgery. 2 0 1 1 ; 1 50 (2 ) : 1 69-176. Morgan KA, Glenn JB, Byrne TK, et al. Sphincter of Oddi dysfunc­ tion after Raux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5 ( 5 ) : 571-575. Morgan KA, Romagnuolo J, Adams DB. Transduodenal sphinc­ teroplasty in the management of sphincter of Oddi dysfunction and pancreas divisum in the modern era. I Am Col/ Surg. 2008;20 6 ( 5 ) : 908-9 14; discussion 14-17.

10. Roberts KJ, Ismail A, Coldham C, et al. Long-term symptomatic relief following surgical sphincteroplasty for sphincter of Oddi dysfunction. Dig Surg. 2 0 1 1;28(4):304-3 0 8 . 1 1 . Hazey J , Ellison C, Melvin WS, e t a l . Current application of endo­ scopic sphincterotomy, application of endoscopic sphincterotomy, lat­ eral choledochoduodenostomy, and transduodenal sphincteroplasty. In: Fischer JE, Bland KI, Callery MP, et al, eds. Mastery of Surgery. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 1 143-1 152. 12. Grobmyer SR, Stasik CN, Draganov P, et al. Contemporary results with ampullectomy for 29 " benign" neoplasms of the ampulla. I Am Col/ Surg. 2008;206(3 ):466--4 7 1 . 1 3 . Lagoudianakis EE, Tsekouras D, Koronakis N , e t a l . A prospective comparison of ampullectomy with pancreaticoduodenectomy for the treatment of periampullary cancer. I B UON. 2 0 0 8 ; 1 3 ( 4 ) :569-572. 14. Miccini M, Amore Bonapasta S, Gregori M, et al. Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy. Am I Surg. 201 0;200(2) :247-2 5 1 .

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Enucleation of Pancreatic Neuroendocrine Tumor 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ...

Mega n B. Anderson

DEFINITION •

•

Pancreatic neuroendocrine tumors (PNETs) are a diverse group of neoplasms that can arise from mature endocrine cells of the pancreas ( o. , �' 8, and -y cells ) and multipotent cells, which have the ability to differentiate into endocrine and exocrine cells. PNETs were previously known as islet cell tumors. PNETs can be subdivided into functional and nonfuctional based on their production of specific pancreatic endocrine hor­ mones. Functional PNETs can produce insulin, gastrin, gluca­ gon, vasoactive intestinal polypeptide (VIP), and somatostatin.

IMAGING AND OTHER DIAGNOSTIC

•

•

•

Functional PNETs amenable for enucleation are the following: Insulinoma Selected gastrinoma Selected somatostatinoma Selected nonfunctional PNETs amenable for enucleation are typically less than 2 em but this is an area of controversy.

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

A thorough history and physical must be obtained to assess for signs of functional tumors, symptoms of mass effect, or evidence of metastatic disease. Physical exam should focus on abdominal masses, organomegaly, signs of biliary obstruction or liver dysfunction, and lymphadenopathy. Although most PNETs are sporadic, 1 0 % can be associated with predisposing syndromes such as multiple endocrine neoplasia type 1 (MEN- 1 ) , von Hippel-Lindau (VHL) dis­ ease, neurofibromatosis type 1 (NF 1 ) , and tuberous sclerosis complex (TS C ) . Nonfunctional PNETs are typically slow growing and occur in the head of the pancreas. These lesions usually present sim­ ilarly to pancreatic adenocarcinoma due to the mass effect of the tumor: jaundice, abdominal pain, and weight loss. Functional PNETs Insulinoma: Whipple's triad-symptoms of hypoglyce­ mia, generally when fasting, at night, or during exercise; hypoglycemia documented at the time of symptoms; and symptom relief with glucose administration. Supervised 72-hour fast with a plasma glucose of less than 45 mg/dL Increased C peptide more than 1 0 0 pmol/L Negative sulfonylurea screen in urine Negative insulin antibodies Gastrinoma: Zollinger-Ellison syndrome-refractory pep­ tic ulcer disease and secretory diarrhea Serum gastrin of more than 500 pg/mL Gastric pH less than 3 Positive secretin or calcium stimulation test

Barish H. Edit

STUDIES

DIFFERENTIAL DIAGNOSIS •

Christopher D. Raeburn

•

•

Imaging: Computerized tomography (CT), magnetic reso­ nance imaging (MRI ) , endoscopic ultrasonograph with fine needle aspiration (EUS/FNA) , somatostatin receptor scin­ tigraphy (SRS), percutaneous transhepatic portal venous sampling (PTPVS ) , and arterial stimulation with venous sampling (ASVS ) all may play a role in localization of a PNET and preoperative planning. FIG 1 shows a CT scan of an insulinoma at the level of the head of the pancreas. These lesions are typically best visualized on arterial phase CT. CT scanning is unfortunately only 67% sensitive in localizing PNET and these other adjunctive measures may be required. As a part of EUS evaluation, tattoo small lesions or lesions that are deep within the parenchyma of the pancreas to make localization easier at the time of operation. Based on the data collected from laboratory tests and imag­ ing studies, only select PNETs are amenable to enucleation. Low-grade tumors such as insulinomas are most amenable to enucleation.

SURGICAL MANAGEMENT

Preoperative Planning •

Because most ( > 9 0 % ) insulinomas are benign, enucleation is usually preferred. A formal pancreatic resection should be considered if there is evidence of invasion, lymphadenopa­ thy, or if the tumor is in close proximity to the pancreatic

FIG 1 • CT sca n of a b d o m e n showing an insu l i n o m a in the head of the pancreas. It i s we l l c i rcu mscribed, consistent with a b e n i g n P N ET. It is presented as it is u n us u a l ; it does not e n h a nce o n the a rte r i a l phase of i m a g i n g . Arrow poi nts to an exo phytic i n su l i n o m a at the head of the pancreas.

83 5

836

•

•

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

duct or maj or vessels. It is possible to perform an enucleation through traditional open technique or laparoscopically. For lesions where the pancreatic duct may be at risk for injury, some have advocated preoperative placement of a pancreatic duct stent. There is not clinical data that supports or con­ demns this approach. Contraindications would include recent pancreatitis, un­ controlled coagulopathy, comorbidities that would limit life

expectancy, and signs of malignancy, which include enlarged lymph nodes or distant metastases.

Positioning •

The patient should be placed supine on the operating room table. The entire abdomen should be sterilely prepped and draped.

P LACEMENT OF INCISION •

•

O p e n : An u p p e r m i d l i ne i ncision s h o u l d be m a d e to enter the a b d o m e n . Lapa roscopic: An i nfra u m b i l i ca l 1 0-mm port s h o u l d be p l aced to g a i n access to the a b d o m e n . From there, a n ­ oth e r two 1 0- m m ports w i l l be p l aced i n the l eft u p p e r q u a d rant a n d right l o w e r q u a d ra nt, a n d two 5-mm ports wi l l be p l aced in the r i g ht upper q u a d rant a n d l eft l ower q u a d rant as shown i n FIG 2.

(

l

1--FIG 2 • I l l ustration of port s ite p l acement fo r l a p a rosco pic en ucleation of P N ET. It i s best to b r i n g the d ra i n (s) out t h ro u g h the l eft upper q u a d ra nt a n d/o r right upper q u a d ra nt port sites. I l l ustrati o n by Fra n k Corl.

P N ETs m ost co m m o n ly m etastasize to the l i ver; th us, thorough exa m i nation of the l iver is critica l and i ntraop­ erative u ltraso u n d ( I O U S) is the m ost sensitive i m a g i n g m o d a l ity f o r detecting m etastases.

ABDOMINAL EXPLORATION •

A thoro u g h exa m i nation of the a b d o m e n s h o u l d be per­ formed p r ior to proceed i n g with en ucleation to exc l u d e adva nced locoreg i o n a l d isease o r m etastatic d i sease.

PANCREATIC DISSECTION •

•

If the lesion l ies in the head of the pancreas, t h i s a rea is m o b i l ized by fi rst d i ssect i n g the omentum from the hepatic flexure. A Kocher m a n euver a l l ows you to fur­ ther m o b i l ize the head of the pan creas. D ivision of the r i g ht gastroe p i p l o i c vessels on the a nterior s u rface of the pan creatic head will a l l ow for fu l l expos u re. W h i l e m o b i l iz i n g m e d i a l ly, the s u p e r i o r mesenteric vein (SMV) wi l l be encou ntered a n d care m u st be taken to avoid a vascu l a r i nj u ry. The gastro e p i p l o i c ve i n may need to be d ivided to pro­ vide adequate exposu re to the pan creatic neck.

•

•

•

•

If the t u m o r is l ocated in the neck, the p l a n e below the neck a n d a nterior to the porta l vei n/S MV m ight need to be developed. If the lesion is i n the ta i l of the pancreas, m o b i l i z i n g the splenic bed may expose t h i s a rea. This req u i res d ivision of the gastrosp l e n i c l i gament (conta i n i n g gastroe p i p l o ic vesse ls) a n d a lso the short gastric vesse ls. O bta i n access to the lesser sac by d iv i d i n g the gastroco l i c l i g a ment from l eft to rig ht. Retract the sto mach more superio rly, a l o n g with the omentum to adequately visu­ a l ize the pa ncreas. At this poi nt, i nspection of the pa ncreas is done. If the tumor i s easily i d e ntified, further d i ssection may be

C h a p t e r 45 E N U CLEAT I O N OF PAN C REAT I C N E U R O E N D O C R I N E T U M O R

•

•

•

•

avoided u n l ess patient has a n i n he rited syn d ro m e o r i f there are c l i n ical concerns of m u lticentric d isease. D i ssect i n g out the superior a n d i nfe rior borders of the pancreas us ing b l u nt a n d sharp tec h n i q u e may further help d e l i n eate the l ocation of the lesion a n d a l l ows ac­ cess to the poste rior pan creas if n ecessa ry for tumor ide ntificat i o n . Once the pancreas is vis ib le, p a l pate the mass u s in g yo u r finger o r a l a p a roscop i c i nstr u m ent. I n open cases, a wide Kocher m a n e uver a n d splenic m o b i l ization fac i l itates bi­ manual p a l pation of the pan creatic head a n d body/neck, respectively. If the t u m o r is s m a l l , I O U S is a lso u sefu l i n loca l iz i n g t h e m ass as we l l as t o bette r eva l u ate t h e p rox­ i m ity to the pancreatic d uct a n d vascu l a r structures. Once the mass is l ocated, care m ust be taken to avoid any major surro u n d i n g vascu l a r struct u res. Once the pancreas has been sufficiently m o b i l ized a n d exce l l ent exposure has b e e n o bta i n ed, o n e s h o u l d b e a b l e to vis u a l ize the m ass u s in g the aforementioned tech n i q ues. P l ease see FIG 3 to a p p reciate how exposu re of the pancreas provides v i s u a l ization of the mass.

FIG 3 • I ntrao perative p h otog ra ph o f a n i n s u l i n o m a . T h i s photo shows the we l l -encapsu l ated mass t h a t exte nds outside the parenchyma of the pan creas being d i ssected u s i n g a n u ltraso n i c energy device. T h i s a nato m i c re lationsh i p o f a P N ET to the parenchyma of the pan creas, co u p l ed with the pseud oca psule, m a ke t h i s lesion idea l for e n u cleation.

DISSECTING T H E M ASS •

•

•

•

•

•

PN ETs, espec i a l ly i n su l i nom as, a re typ ica l ly we l l c i rcu m­ scribed a n d we l l encapsu l ated, a n d a d i ssection p l a n e s h o u l d be evident. F I G 4 demonstrates a we l l -encapsu­ l ated i n su l i n o m a a n d a d i ssection p l a n e, which ca n be fo l l owed with electroca ute ry. O n ce the a p p ropriate tissue p l a n e has been identified, it may be further d issected out using d i fferent type of energy devices. Constant gentle e l evation a n d traction a l l ows for v i s u a l ization of the plane of d i ssection a n d feed i n g vessels. The a uthors advocate the use of surgica l c l i ps on any bridg i n g structure g reater t h a n 1 m m . A f i g u re-of-e i g ht suture p l aced in the mass can serve as a va l u a b l e retraction p o i nt and fac i l itate deve l o pment of the tissue p l a n e a l o n g the pse u doca psu l e of a PN ET. Once the m ass is rem oved, ca re s h o u l d be taken to en­ s u re exce l l ent hem ostasis. I n add ition, IOUS can be used to demo n strate the i nteg rity of the pan creatic d uct. In the case of gastr i n o m a , some a dvocate for routi ne d u ode notomy as there is a h i g h er risk of m u lt i p l e t u m o rs, which can be sma l l a n d oth e rwise d iffi cult to detect.

CLOSURE AND D R AIN P L ACEM ENT •

•

When closing the 1 0-mm ports, the fasci a is i d ea l ly cl osed to p reve nt i n c i s i o n a l h e r n i a in the future. A d ra i n should be p laced along the a rea that has been enucl eated; this wi l l aid in m o n itoring for and contro l l i n g

FIG 4 • Schematic demonstration of adequate exposure of the pancreas. This f i g u re e m p h asizes the i m porta nce of retract i n g the sto mach o n prov i d i n g adequate exposu re . The inset demonstrates how the lesion s h o u l d be easily d i ssect i b l e f r o m the pancreatic parenchyma.

any postoperative leaks. The drains a re m ost easily brought out through the left upper quadra nt or right upper quad­ rant i ncisions, as demonstrated i n FIG 5.

837

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

FIG S • A p h otog ra p h of the cl osed a bd o m en; the d r a i n s a re most easily brought out t h ro u g h the right u p p e r q u a d rant o r l eft u p p e r q u a d ra nt port sites.

PEARLS AND PITFALLS E U S with tatto o i n g of the lesion

•

A tattoo that loca l i zes very sma l l P N ETs is i n va l u a b l e to g u i de the operati o n . As m ost a re n ow a p p roached l a p a rosco p i c a l ly, t h i s fac i l itates identification of the neoplasm without the a b i l ity of pa l pati o n .

D e e p d iffi cu lt P N ETs

•

If e n u c l eation is d ifficult for body/ta i l t u m o rs or violation of the pancreatic d u ct is suspected, perform either l a p a roscop i c o r open d i sta l pancreatectomy, with preservati o n of the spleen when possi b l e .

Tech n i q u e

•

G ra s p i n g a P N ET wi l l often l e a d t o l acerat i o n . T h e neoplasm s h o u l d n o t be g rasped; rathe r, use an i nstr u m ent to push the lesion to provide expos ure. A suture through the lesion serves as a n exce l l ent retraction tool when exposure is cha l le n g i n g .

IOUS

•

A very usef u l t o o l i n d eterm i n i n g d u ct relati onsh i p w i t h t u m o r t o p l a n en ucleation versus resection early in the operat i o n .

D ra i n

•

T h e vast majo rity o f pancreatic s u rgeons p l ace a d ra i n fo l l owi n g e n ucleati o n . T h e fist u l a rate i s very h i g h .

•

POSTOPER ATIVE CAR E •

Postoperatively, the patient may have their diet advanced as tolerated. If an insulinoma is removed, plasma glucose should be monitored every 15 minutes until stabilized. The drains should be monitored for the quantity and quality of the output. Once patient is taking adequate oral intake, the drains should be sent for amylase levels to rule out a leak before the drains are removed.

•

Wound or intraabdominal infection Bleeding Late complications Chronic pancreatic leak resulting in a cutaneous fistula, ascites, or pseudocyst Recurrent PNET

SUGGESTED R EADINGS 1.

OUTCOMES •

If the PNET is an insulinoma, enucleation should be cura­ tive. If a nonfunctional PNET is elected for enucleation, the patient should be placed in a surveillance program and for PNETs that are large or potentially malignant, the operation should be a formal resection with lymphadenectomy.

COMPLICATIONS •

Early complications include the following: Pancreatic leak Acute pancreatitis

2. 3. 4.

5.

6.

Burns WR, Edil BH. Neuroendocrine pancreatic tumors: guidelines for management and update. Curr Treat Options Oncol. 201 2; 1 3 ( 1 ) : 24-34. Zhou C, Zhang J, Zheng Y, et al. Pancreatic neuroendocrine tumors: a comprehensive review. Int J Cancer. 2012; 1 3 1 ( 5 ) : 1 0 1 3-1 022. O'Grady HL, Conlon KC. Pancreatic neuroendocrine tumours. Eur J Surg Oncol. 2008;34 ( 3 ) :324-3 32. Newman NA, Lennon AM, Edil BH, et al. Preoperative endoscopic tat­ tooing of pancreatic body and tail lesions decreases operative time for laparoscopic distal pancreatectomy. Surgery. 201 0; 1 4 8( 2) :371-3 77. Haugvik SP, Labori KJ, Edwin B, et al. Surgical treatment of sporadic pancreatic neuroendocrine tumors: a state of the art review. Scientific World ]. 2009;1-9. Grant CS. Surgical management of insulinoma. Oper Tech Gen Surg. 2002;4(2 ) : 1 75-1 86.

-

I

Chapter

46

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

Operative Treatment of Gastrinoma 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ....

Jason A. Castellan os

gastrinomas, patients with MEN-1 also develop parathyroid adenomas, pituitary adenomas, and other neuroendocrine tumors.4

DEFINITION •

Zollinger-Ellison syndrome is a rare etiology of ulcer disease that is caused by gastrin secretion of neuroendocrine tumors (gastrinomas ) typically found in the duodenum and pancreas. These tumors may be sporadic or associated with multiple endocrine neoplasia type 1 (MEN- 1 ) . Although the gastrin­ mediated gastric acid hypersecretion can be controlled with modern antacid and proton pump inhibitor medications, the potentially malignant nature of the gastrinoma is the main determinant of patient survival. Therefore, surgical manage­ ment remains critical in the care of patients with gastrinomas.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

DIFFERENTIAL DIAGNOSIS •

Table 1 summarizes the potential etiologies of hypergas­ trinemia.

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

Patients with gastrinomas typically have nonspecific symp­ toms, and this has historically led to delayed diagnosis from 3 to 9 years after initial onset of symptoms. Although pre­ sentation may occur anytime from childhood to old age, patients typically present with a male predominance ( 3 : 2 ) in the fifth decade of life with sporadic gastrinomas and in the fourth decade of life with MEN- 1-related gastrinomas.1 The most common symptoms are abdominal pain, diarrhea, and gastroesophageal reflux disease ( GERD ) (Table 2 ) . Typi­ cally, patients have a small, solitary ulcer ( < 1 em in diame­ ter) in the first portion of the duodenum, although they may also have a history of recurrent ulcers in atypical locations such as the jejunum ( 1 1 % ) and distal duodenum ( 1 4 % ) .2•3 The most common complications are due to ulcer perfora­ tion, although up to 2 0 % of patients do not have an ulcer on presentation. Gastrinomas arise sporadically in a maj ority of cases ( 75 % to 8 0 % ), whereas the remainder are due to MEN- 1 . It is impor­ tant to differentiate the etiology as this dictates the clinical and surgical management of these patients. In addition to

Table 1 : D ifferential D i agnosis of Hypergastrinemia

Elevated Gastric Acid Secretion

Helicobacter pylori infection Reta ined gastric antrum Gastrinoma Antral G-ce l l hyperp lasia R e n a l fa i l u re S h o rt bowel syndrome

Normal/Decreased Gastric Acid Secretion Pe rnicious a n e m i a Atro p h i c gastritis Proton pump i n h i bitor o r H 2 b locker use Postva gotomy

Nipun B. Merch a n t

•

If a gastrinoma is suspected, then a serum fasting gastrin level should be obtained. Prior to this test, the patient should be instructed to hold antacid medication (proton pump in­ hibitors held for 7 days; histamine receptor blockers held for at least 30 hours) . A n elevated gastrin level greater than 1 0 times the upper limit of normal ( > 1 ,000 pg/mL) should be followed by a gastric pH probe in order to rule out achlorhydria. A gastric pH of 4.0 or greater confirms the diagnosis of gastrinoma if other etiologies (e.g., retained antrum after Billroth II resec­ tion) have been ruled out. A gastrin level that is elevated but less than 10 times the upper limit of normal should be followed by a secretin stimulation test. Although normal G cell gastrin secretion is inhibited by secretin, gastrin release by gastrinoma cells is actually increased. Secretin is infused intravenously over 1 minute after baseline gastrin measurements are obtained; gastrin is then measured at 2, 5, 1 0 , 1 5 , and 20 minutes after infusion. A positive test, typically defined by a rise in serum gastrin of 200 pg/mL or greater, confirms diagnosis of gastrinoma.

Table 2: Signs and Symptoms of Gastri noma

Abdo m i n a l pain (75%) D i a rrhea (73%) Peptic u l cers (>90%) Refl ux esophagitis (44%) N a usea (33%) E m e s i s (25%) Weight l o s s ( 1 7 % ) C o m p l ications o f hyperacid ity B l e e d i n g (25%) Perfo ratio n Obstruction Strictu re (pylorus. d u o d e n u m , esophagus) Physica l findings Hypertro p h i c gastric rugal folds (94%) M u ltiple u l cers U n u s u a l u l ce r locations Dista l duodenum ( 1 4%) J ej u n u m ( 1 1 %) Pa ncreatic mass

(< 1 0%)

From Maze// E, Stenzel P, Woltering EA, et a/. Functional endocrine tumors of the pancreas: clinical presentation, diagnosis, and treatment. C u rr Pro b l Surg. 1 990;27:301-386; Roy PK, Venzon OJ, Shojamanesh H, et a/. Zollinger-EIIison syndrome. Clinical presentation in 261 patients. M e d i c i n e . 2000;79:379-4 1 1; Meko 18, Norton JA. Management of patients with Zollinger-EIIison syndrome. A n n u Rev Med.

1 995;46:395-4 1 1 .

839

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

Suggestive symptoms/findings •Abdominal pai n , diarrhea, weight loss •Multiple peptic u lcers •U lcers i n atypical locations •Refractory diarrhea without diagnosis

F I G 1 • D i a g nosis o f suspected gastri n o m a . U LN , u p p e r l i m it of norma l . PPI, proton p u m p i n h i b ito r; M E N - 1 , m u lt i p l e endocri n e neoplasia; P U D , peptic u l cer d isease.

•Large gastric rugal folds •Personal or family history of M E N - 1 •RecurrenVrefractory P U D .Concu rrent hypercalcemia/nephrolithiasis •Pancreatic mass

•

•

•

Negative for gastri noma

Additional testin g :

Further workup/reassess

Calciu m i nfusion study

as needed

Serum chromogranin A

If these tests do not confirm the diagnosis but a high clinical suspicion remains, then additional tests may be used. The calcium infusion study consists of a continuous intravenous infusion of 5 mglkg 1 0 % calcium gluconate over a 3 -hour period. Serum gastrin and calcium are measured prior at baseline and at 3 0-minute intervals for 3 hours after the test begins.5 A positive result is typically defined as an eleva­ tion in serum gastrin by 395 pglmL or greater, but multiple criteria exist.6 Serum chromogranin A levels have also been found to be elevated in patients with gastrinomas, and this test rnay be used to confirm diagnosis in carefully selected cases7 (FIG 1 ) . After obtaining a biochemical diagnosis o f gastrinoma, attention is turned to preoperative localization and stag­ ing. Up to 9 0 % of gastrinomas can be located in the area bounded by the j unctions of the cystic and common bile ducts, second and third portions of the duodenum, and neck and body of the pancreas-the so-called gastrinoma triangle ( FIG 2 ) . Initial localization studies include contrast-enhanced triple­ phase protocol computed tomography ( CT) or magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS ) . The decision to use CT versus MRI should be deter­ mined by the clinician based on institutional expertise and availability. Although the accuracy of these modalities con­ tinues to improve, the sensitivity for detection of tumors less

Pancreas

I , I , .

FIG 2 • The gastrinoma t r i a n g l e . Up to 90% of gastrinomas are l ocated i n this reg i o n .

C h a p t e r 46 O P E RATIVE TREAT M E N T OF GASTR I N O M A

841

Follow-up

Postoperative: Serum fasting gastrin Secretin stimulation test Annual follow-up: Serum fasting gastrin Secretin stimulation test Triple-phase CT or MRI

L___---.1

•Duodenotomy •Intraoperative US · � � 0 � ft or •Periduodenal (PD) node dissection

;��� �=��� � ��

Options: Antacid medication (PPI) Biotherapy (Octreotide) Chemotherapy Chemoembolization Radiofrequency ablation Cytoreductive surgery Observation

Considerations Patient in good health overall Large tumor not amenable to excision Multiple involved lymph nodes Recurrence after simple excision Increase in cure rate vs. complications

Distal pancreatectomy ::!:: splenectomy

FIG 3

•

•

•

Loca l i zation a n d treatment of gastri n o m a .

than 2 e m in diameter is decreased, although lesions as small as 4 mm have been detected.8 EUS can detect smaller lesions (up to 2 to 3 mm, depending on operator experience) and also has the advantage of being able to obtain a cytologic specimen. Somatostatin receptor scintigraphy (SRS ) , also known as OctreoScan, takes advantage of the high level of somatosta­ tin receptor expression in gastrinomas by using radiolabeled 1 1 1 -indium pentetreotide to detect both primary tumors and hepatic metastases. Although the accuracy of other imaging modalities is improving, SRS continues to have a place in tumor localization and staging as it remains highly sensitive for detection of metastatic disease.9 Patients determined to have MEN- 1-related gastrinoma should be evaluated for hyperparathyroidism. If a primary hyperparathyroidism is present, it should be addressed prior to further surgical treatment as hypercalcemia may increase anesthetic risk and also elevates gastrin and acid production.

•

•

•

If the etiology is sporadic and no metastases are detected, then surgical exploration is indicated even if a tumor is not localized by preoperative imaging as these tumors can often be found with careful intraoperative exploration. The risk of liver metastases is increased when tumors are larger than 2 cm. 1 0 Patients who present with metastatic disease should undergo resection, if possible, as chemotherapy has limited efficacy in the treatment of gastrinomas. Other modalities, such as radio­ frequency ablation, hepatic artery embolization, liver trans­ plantation, and radiolabeled somatostatin therapy, may be considered when anatomic resection is not possible ( FIG 3} .

SURGICAL MANAGEMENT

Positioning •

Patients should be placed in the supine position for explor­ atory laparotomy to identify gastrinomas .

842

P a r t 3 OPERATIVE TECH NIQUES I N HEPATO-PANCREATO-B I LIARY SURGERY

Exploration and Kocher Maneuver

P LACEMENT OF INCISION E ither a b i l atera l su bcosta l i n c i s i o n or a n u p p e r m i d l i n e i ncision may be used to a p proach the d u o d e n u m a n d pancreas f o r exp loration (FIG 4) .

•

A

After incision and entry i nto the perito n e a l cavity a n d i n it i a l exp loration, the hepatic flexu re a n d asce n d i n g co l o n are m o b i l ized (FIG SA), the peritonea l reflection

•

B

FIG 4 • Potential i n cisions for explorat i o n . B i latera l su bcosta l i n cisions (A) o r u p p e r m i d l i n e i n cision (B) may be used .

Duodenum

•::=--..:....=:.::. . .::_ .. _

_ _ _ _

Su perior mesenteric artery

Manipu lated right colon

A

FIG 5 • Kocher maneuver. An extended Kocher m a neuver a l l ows l ifti n g of the pancreatic head out of the retroperitoneum for pal pation (C) after m o b i l ization of the right colon (A) a n d incision ofthe peritoneal reflection a l o n g the duodenum (B). Sep­ a ration from the tra nsverse mesoco lon a l l ows for com p l ete m o b i l ization of the pancreas a n d p a l pation of the pancreatic body a n d ta i l (D). (continued)

C h a p t e r 46 O P E RATIVE TREAT M E N T OF GASTR I N O M A

Gallbladder

Peritoneal reflect1on

Duodenum

B

�

.,.../ /

c

D

FIG 5

•

•

of the d uoden u m is i n c ised a l o n g the seco nd a n d t h i rd portion of the d u o d e n u m , a n d an extended Kocher ma­ neuver is pe rfo rmed i n order to expose a n d m o b i l ize the d u o d e n u m a n d head of the pancreas (FIG 58) . After exposure is o bta i n ed, the s u rgeon may p a l pate t h e d u o d e n u m a n d pa ncreatic h e a d . (FIG 5C) . I t is i m portant t o a lso p a l pate t h e pancreatic body a n d ta i l . To acco m p l ish this, t h e l esser sac is opened a n d t h e avascu­ lar i nferior pancreatic border i ncised; this can be a i ded by

•

(con tinued) .

mobi l iz i n g the s p l e n i c flexure if necessa ry. Once exposed, the pancreatic body and ta i l may be carefu l ly p a l pated to detect any additional tumors (FIG 50).

Intraoperative Ultrasound •

After m o b i l ization of the d u o d e n u m a n d pancreas a n d detection of v i s i b l e a n d p a l p a b l e t u m o rs, a n u ltraso u n d p r o b e is u s e d to v i s u a l i z e sma l l t u m o rs i n the d u o d e n u m

843

844

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

Fingerti p probe

•

•

Duodenum •

and pancreas. The relationsh i p of any t u m o r to the pan­ creatic d u ct s h o u l d be n oted if a n en ucleation will be pe rfo rmed (FIG 6) . The type of probe used s h o u l d be d i ctated by s u rgeon expe rience a n d p refere nce. We p refer a f i n ge rt i p tra ns­ d ucer in o u r i nstitut i o n . D u r i n g u ltraso u n d exa m i nation, the s u rgeon's l eft h a n d i s genera l ly p l aced posterior to the d u o d e n u m a n d p a n ­ creas, wh i l e the r i g h t h a n d h a n d les the probe. At this time, the l iver is a lso exa m i ned for any pos­ s i b l e m etastatic lesio ns, and suspicious lesions should be biopsied.

Intraoperative Endoscopy •

N ext, a gastroscope is used to perform i ntraoperative end osco py. The gastroscope is adva nced ora l ly i nto the stomach and then d u o d e n u m where tra nsi l l u m i n ation i s used to identify any rem a i n i n g gastr i n o m a s . These le­ s i o ns, l ocated i n the s u b m ucosa of the d uoden u m, w i l l a p p e a r as shadows u p o n tra nsi l l u m i n ation (FIG 7) .

Duodenotomy FIG 6

A

•

U ltraso u n d exa m i nation of the d u o d e n u m a n d pan creas.

•

A 2- to 3-cm l o n g i tu d i n a l d u odenotomy is created o n the a n t i m esente ric aspect of the seco nd porti on of the

FIG 7 • I ntrao perative endosco py. The endosco pe i s adva n ced i nto the d u o d e n u m (A) where s u b m ucosa l tumors may be visua l ized d i rectly (B) or through transi l l u m i n ation (C) . (continued)

C h a p t e r 46 O P E RATIVE TREAT M E N T OF GASTR I N O M A

FIG 7

•

•

d u oden u m . If duodenal lesions were identified d u ri n g exp loration prio r t o th is, then the d u odenotomy may b e rel ocated to e n a b l e excision o f the lesion. Once the d u odenotomy is made, the d u o d e n a l wa l l i s p a l pated ca refu l ly with the i ndex f i n g e r a n d t h u m b (FIG 8) . T h e t h i rd a n d fo u rth portions o f the d u o d e n u m may b e d iffi cult to exa m i ne, a n d so the m u cosa can be everted

•

845

(contin ued).

i nto the d u odenotomy usi ng the i ndex f i n g er. This e n a b l es d i rect visu a l i zation of all portions of the d u ode­ num (FIG 9) . A f u l l -th ickn ess excision is perfo rmed f o r a ny d u o d e n a l l e s i o n fo und, a n d a m a rg i n of at least 2 m m s h o u l d b e obta i ned. Lesions fo u n d o n the medial wa l l of the d u o d e n u m s h o u l d n o t be excised u n t i l the pan creatic d uct a n d

•

•

8

A

F I G 8 • T h e d u odenotomy i s made on the a n t i m esenteric aspect of the seco nd portion of the d u oden u m (A) . This e n a b l es pa l pation of the d uoden u m with the t h u m b a n d i n dex f i n g e r (B) so t h a t s m a l l t u m o rs may be detected.

846

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

a m p u l l a of Vater a re identified. This may be a i ded with use of a sma l l catheter passed t h ro u g h the a m p u l l a .

Excision o f Pancreatic Tumors •

•

Tu m o rs fo u n d in the pancreas a re m a naged based on size a n d locat i o n . Tu m o rs fo u n d in the head of the pa ncreas may be e n u c l eated if they are exo phytic, but if they a re i nvasive or n e a r the m a i n pan creatic d u ct, a pan creatico­ d uodenectomy may be req u i red. Tu m o rs fou n d in the d i sta l p a n creas req u i re d ista l pan­ createctomy. S p l e n ecto my i s not m a n d ated; need for s p l e n ectomy i s based on the t u m o r location a n d suspi­ cion of lym ph node m etastases. (See Part 3, Cha pters 3 3 to 4 1 for deta i l s of pan creaticod uodenectomy a n d Part 3, Cha pters 40 to 42 for deta i l s of d i stal pan createctomy.)

Periduodenal Lymph Node Dissection •

•

•

A lymph node d i ssection encompass i n g the peri d u o d e n a l a n d peri pancreatic n o d e s i s i m po rtant as t h e y may con­ ta i n m i crosco pic m etastases or actu a l ly represent p r i m a ry t u m o rs. Lym p hatic tissues are identified a n d excised from a ro u n d the pan creatic h e a d , ce l i ac axis, co m m o n hepatic a rte ry, superior m esenteric a rtery, common b i l e d u ct, a n d por­ tal ve i n . Lym p h a d e n ectomy s h o u l d beg i n in the he pato­ d u o d e n a l l i g a m e n t and p roceed from porta hepatis to ce l i ac axis, fo l l owed by excision of a l l lym p h nodes from the anterior and posterior aspects of the p a ncreatic head (FIG 1 0) . If a p r i m a ry t u m o r is identified, then that reg i o n s h o u l d be p a i d specific atte ntion as positive lym p h n o d e s a re most l i kely to be fo u n d close to the p r i m a ry t u m or. "

F I G 9 • Eversion o f t h e m u cosa o f the t h i rd a n d fo u rth portions of the d u oden u m i nto the d u odenotomy.

Celiac nodes

Pyloric nodes

Su perior pancreatic nodes

Ht--- Splenic nodes

Anterior pancreatico duodeal

A

Su perior mesenteric nodes

FIG 10 • Lym p hadenecto my for gastr i n o m a s h o u l d encom pass nodes i n the hepatod uodenal l i g a m e nt, ce l i a c axis a n d a nterior (A) as we l l as posterior (B) pa ncreatic head. (contin ued)

C h a p t e r 46 O P E RATIVE TREAT M E N T OF GASTR I N O M A

B

FIG 10

Closure of Duodenotomy •

•

•

After co m p l etion of exploration a n d excision of gastrinomas, the d u odenotomy is cl osed tra nsverse ly if poss i b l e i n order to p revent n a rrow i n g of the l u m e n . This is not a l ways poss i b l e when a l o n g d uodenotomy was req u i red. If this is the case, then a ca refu l l o n g i t u d i ­ n a l c l o s u r e may be u s e d (FIG 1 1 ) .

A

•

•

(con tinued)

The d u o d e n u m is cl osed in two l ayers. E ither i nterru pted o r a r u n n i n g closure may be performed based o n s u rgeon's prefe rence. We p l ace a J ackson-Pratt (J P) d ra i n adjacent to the c l osed d uodenotomy in order to m o n itor output i n the posto p­ erative sett i n g . If pan creatic t u m o rs have been e n ucle­ ated, then a n a d d i t i o n a l d ra i n may be p l aced overlyi n g the resected lesion.

B

Longitudinal closure

FIG 1 1 • A tra nsverse closure of the d u odenotomy (A) is preferable, but the i ncision l e n gth may m a ke a ca refu l l o n g i tu d i n a l closure (B) necessa ry.

847

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

PEARLS AND PITFALLS Operative i n d ications

• • • •

S u rg ical exploration

• • • •

B i och e m i c a l d ia g nosis of spora d i c gastri n o m a Gastri n o m a > 2 em i n M E N - 1 patie nts No evidence of u n resecta b l e o r extensive m etastatic d isease Reaso n a b l e surgical ca n d i d ate I ntraoperative u ltraso u n d a n d endoscopy with tra nsi l l u m i n ation g reatly aid detection of t u m o rs. D u odenotomy s h o u l d be perfo rmed i n a l l patients as d u o d e n a l t u m ors are the m ost freq u e ntly m issed. Tu m o rs req u i re f u l l -thickness excision with a 2-m m m a rg i n . Avo i d e n u c l eation o f pancreatic t u m o rs if i nvasive or n e a r m a i n d u ct; resection i s i n d icated.

Lym p hadenecto my

•

Explorati o n and excision of lym p h nodes is cruci a l .

Closure

•

Cl ose d uodenotomy tra nsversely, if poss i b l e .

POSTOPER ATIVE CAR E •

•

After exploration, the patient should be placed on a surgi­ cal floor and be kept NPO until return of bowel function. Drain output should be monitored closely for character and volume until PO intake is resumed. If there is clinical con­ cern of a leak, then a Gastrografin swallow study should be obtained for confirmation. We remove the JP drain when output is less than 50 mL per day and serosanguineous once patient is eating normally. Three and 6 months after discharge, patients should return to clinic for history and physical, CT or MRI, and serum fasting gastrin and secretin stimulation tests. Subsequent follow-up should occur every 6 months until 3 years postoperation and should include these same studies. OctreoScan is not recommended for routine surveillance by current National Comprehensive Cancer Network (NCCN) guidelines. 1 2

OUTCOMES •

•

•

Mortality from this disease is due to metastasis, and it is thought that at least 6 0 % of gastrinomas are malignant. Patients who present with liver metastases have a 1 0-year overall survival of 3 0 % , whereas patients without liver me­ tastases have a 1 5 -year overall survival of 8 3 % Y Sporadic disease i s potentially curable b y surgical explora­ tion. A large series comparing surgical versus medical treat­ ment demonstrated a 4 1 % cure rate at 12 years as well as significantly fewer liver metastases ( 5 % vs. 29 % ) . Disease­ related survival at 15 years was 9 8 % with surgical interven­ tion versus 74 % with medical treatment.14 Patients with MEN- 1 are not typically curable, as only 1 % to 6 % are disease-free at 5 yearsY Long-term survival is still possible despite the lack of biochemical cure, and 5-year survival rates of 9 8 % have been reported. 16

COMPLICATIONS • • • • • •

Recurrence Residual tumor left after exploration Duodenal leak Pancreatic leak Infection (intraabdominal abscess) Duodenal stricture

REFERENCES 1.

2. 3. 4.

5.

6.

7.

8.

9.

10.

11.

12. 13.

14. 15.

16.

Mozell E, Stenzel P, Woltering EA, et al. Functional endocrine tumors of the pancreas: clinical presentation, diagnosis, and treatment. Curr Prahl Surg. 1 9 90;27:301-3 8 6 . Roy PK, Venzon OJ, Shojamanesh H, e t a l . Zollinger-Ellison syndrome. Clinical presentation in 261 patients. Medicine. 2000;79 : 3 79-4 1 1 . Meko JB, Norton JA. Management o f patients with Zollinger-Ellison syndrome. Annu Rev Med. 1 9 95;46:395-4 1 1 . Guo SS, Sawicki MP. Molecular and genetic mechanisms o f tumori­ genesis in multiple endocrine neoplasia type- 1 . Mol Endocrinol. 200 1 ; 1 5 : 1 653-1664. Frucht H, Howard JM, Slaff JI, et al. Secretin and calcium provoca­ tive tests in the Zollinger-Ellison syndrome. A prospective study. Ann Intern Med. 1 9 8 9 ; 1 1 1 :71 3-22. Berna MJ, Hoffmann KM, Long SH, et al. Serum gastrin in Zollinger­ Ellison syndrome: II. Prospective study of gastrin provocative testing in 293 patients from the National Institutes of Health and comparison with 537 cases from the literature. Evaluation of diagnostic criteria, proposal of new criteria, and correlations with clinical and tumoral features. Medicine. 2006;85:33 1-364. Nobels FR, Kwekkeboom OJ, Coopmans W, et al. Chromogranin A as serum marker for neuroendocrine neoplasia: comparison with neuron-specific enolase and the alpha-subunit of glycoprotein hor­ mones. I Clin Endocrin Metabol. 1997;82:2622-2628. Khashab MA, Yong E, Lennon AM, et al. EUS is still superior to mul­ tidetector computerized tomography for detection of pancreatic neu­ roendocrine tumors. Gastrointest Endosc. 20 1 1 ;73 :69 1-696. Schirmer WJ, Melvin WS, Rush RM, et al. Indium- 1 1 1 -pentetreotide scanning versus conventional imaging techniques for the localization of gastrinoma. Surgery. 1 9 9 5; 1 1 8 : 1 1 05-1 1 1 3; discussion 1 3-14. Norton JA, Jensen RT. Resolved and unresolved controversies in the surgical management of patients with Zollinger-Ellison syndrome. Ann Surg. 2004;240: 757-773 . Zogakis TG, Gibril F, Libutti SK, et al. Management and outcome of patients with sporadic gastrinoma arising in the duodenum. Ann Surg. 2003;238 :42-4 8 . Kulke MH, Benson A B 3rd, Bergsland E, e t a l . Neuroendocrine tumors. I Nat/ Compr Cane Netw. 2 0 1 2 ; 1 0 : 724-764. Weber HC, Venzon OJ, Lin JT, et al. Determinants of metastatic rate and survival in patients with Zollinger-Ellison syndrome: a prospective long-term study. Gastroenterology. 1 9 9 5; 1 0 8 : 1 637-1 649. Norton JA, Fraker DL, Alexander HR, et al. Surgery increases survival in patients with gastrinoma. Ann Surg. 2006;244 : 4 1 0-4 1 9 . Wiedenmann B, Jensen RT, Mignon M, e t a l . Preoperative diagnosis and surgical management of neuroendocrine gastroenteropancreatic tumors: general recommendations by a consensus workshop. World I Surg. 1 9 98;22:309-3 1 8 . Thompson NW. Management o f pancreatic endocrine tumors i n pa­ tients with multiple endocrine neoplasia type 1. Surg Oneal Clin N Am. 1998;7: 8 8 1-89 1 .

I

-

C h apter

47

Lateral Pancreaticojej unostomy with (Frey) or without (Puestow) Resection of the Pancreatic Head

. --------------------------------------- ·----------------------------------------------------- ...

Ke vin E. Behrns

DEFINITION •

Chronic pancreatitis is an inflammatory disease that encom­ passes a spectrum of morphologic, histologic, and clinical features, which range from subclinical inflammatory changes evident only in histologic specimens to marked morpho­ logic gland destruction accompanied by acinar cell dropout, prominent deposition of fibrous extracellular matrix, and pancreatic duct strictures.

IMAGING AND OTHER DIAGNOSTIC STIJDIES •

•

DIFFERENTIAL DIAGNOSIS • • • •

Acute pancreatitis Autoimmune pancreatitis Pancreatic adenocarcinoma Intraductal papillary mucinous neoplasm (IPMN)

Jose G. Trevino

Computed tomography ( CT) is the imaging procedure of choice. Intravenous contrast-enhanced, multiplanar, thin­ slice CT provides excellent imaging of pancreatic paren­ chymal and ductal anatomy. 11 CT characteristics of chronic pancreatitis include an enlarged pancreatic head with multiple calcifications and a dilated pancreatic duct distally ( FIG 1 ) . Detection o f early-stage disease may b e enhanced b y magnetic resonance (MR) with cholangiopancreatography (MRCP) with or without secretin administration. Morphologic changes

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

•

•

•

•

Advanced stages of chronic pancreatitis manifest clinically by disabling pain and pancreatic exocrine and endocrine insufficiency. 1•2 The most prominent etiology of chronic pan­ creatitis is excess consumption of alcohol. Other forms of chronic pancreatitis including autoimmune pancreatitis, para duodenal pancreatitis, and familial pancre­ atitis are attributed to genetic mutations. z-s Differentiating alcoholic chronic pancreatitis from auto­ immune pancreatitis, especially focal autoimmune pancre­ atitis/ and adenocarcinoma of the pancreas may require extensive evaluation and prove challenging.7 Important risk factors that exacerbate the development of chronic pancreatitis include alcohol use and smoking cigarettes. 8•9 A detailed history of alcohol consumption should be obtained; heavy alcohol use ( > 5 drinks per day) is present in the maj ority of patients with chronic pancreatitis.8•9 The pain associated with chronic pancreatitis may be either episodic or persistent.2 Episodic abdominal pain has a duration of 1 to 2 weeks and is interrupted by pain-free periods of a few months. Persistent pain occurs daily but on occasion may spontaneously resolve for a period of a month or more. 10 The weight loss seen in chronic pancreatitis typically occurs over months to years, but it may be more rapid if morpho­ logic changes such as pseudocyst formation induce gastro­ duodenal obstruction. Other complications of chronic pancreatitis include j aun­ dice from biliary obstruction and upper gastrointestinal bleeding from gastric varices secondary to splenic vein obstruction.

A

B FIG 1 • A. CT of the a bd o m e n d e m onstrat i n g an e n l a rged head of the pan creas with m u lt i p l e calcifi cations i n d icative of a lco h o l i c c h r o n i c p a ncreatitis. A sma l l pseud ocyst is a l so noted i n t h e h e a d (arrow). B. T h e d ista l pan creas conta i n s ca lcifications a n d a d i l ated pancreatic d uct.

849

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

Table 1 : Preoperative Check l i st for Patients Undergoing a Frey Procedure

Parameter Alcohol abstinence Failed medical o r endoscopic m a n agement Laboratory eva l uation

Assessment of p a n creatic parenchyma for fl u i d collections or mass lesions Assessment of pan creatic d u ct Assessment of b i l i a ry obstruction

FIG 2 • E n dosco pic u ltraso u n d demo nstrating a d i l ated pancreatic d u ct (short arrow) with a ca l c u l u s (long arrow) in a patient with c h ro n i c pa ncreatitis.

•

•

in the pancreatic duct and hydrodynamic-significant strictures may be evident on these images.12 Endoscopic ultrasound (EUS) with or without functional testing by administration of secretin may aid in the diagno­ sis of early fibrosis in chronic pancreatitis ( FIG 2 ) . EUS has a sensitivity of 84% and a specificity of 1 0 0 % , correlating with histology for chronic pancreatitis.U Furthermore, EUS is advantageous when mass lesions are present in chronic pancreatitis because EUS-guided biopsy is the most reliable method of confirming malignancy. Imaging of the pancreatic duct prior to surgical intervention is essential because all strictures and intraductal calculi must be addressed by the operative approach. Ductal anatomy can be delineated by MRCP or endoscopic retrograde chol­ angiopancreatography ( ERCP ) . ERCP is often performed in the context of pancreatic duct stenting as endotherapy often precedes operative management.

SURGICAL MANAGEMENT •

Operative management of chronic pancreatitis by lateral pancreaticojej unostomy with or without pancreatic head resection is indicated in patients with disabling abdominal pain, weight loss, and evidence of pancreatic duct obstruc­ tion.14 Morphologic characteristics are associated with out­ comes. An excellent response to pancreatic head resection with pancreaticojejunostomy is most likely in the setting of an enlarged head of the pancreas and a distally dilated pan­ creatic ductY

E n ro l l m e n t i n s u bstance abuse program with aftercare Deta i l e d review of previous medical h i story Blood chemistries, hematologic assessment, l iver function tests including coagu lation profi le, pa ncreatic function test (fecal fat) CT or M R I

MRCP or ERCP Liver chemistries, c h o l a n g iogram

o; computed tomography; MRI, magnetic resonance imaging; MRCP, magnetic resonance with cholangiopancreatography; ERCP, endoscopic retrograde cholangiopancreatography.

Preoperative Planning •

•

•

•

These patients are often afflicted with a chronic disease and have lacked regular medical care, thus a thorough evalua­ tion of the patient prior to pancreatic head resection and duct drainage is essential. Patients should be alcohol-free for at least 6 months and enrolled in an alcohol cessation program with aftercare. Ideally, cigarette smoking would also be stopped prior to an operation, although this is difficult for most patients. Specific attention should be paid to the nutritional status of pa­ tients with chronic pancreatitis because they often meet criteria for severe protein and caloric malnutrition. Fat-soluble vitamin deficiency should also be considered. If malnutrition is evident, a nasojejunal feeding tube should be placed with the delivery of enteral feeds with pancreatic enzyme supplementation prior to operative intervention. Additional protein supplementation may also be necessary. Generally, 2 to 4 weeks of enteral nutrition prior to an operation will place the patient in an anabolic state. Table 1 highlights the preoperative checklist of patients who are candidates for a Frey procedure with longitudinal drain­ age of the pancreatic duct.

Positioning •

EXPOSURE OF T HE PANCREAS •

Assessment

A m i d l i n e ce l i otomy is created to a l low adequate exposure of the upper a b d o m e n . After a thorough exp l o ration of the a bdomen, the pa ncreas i s exposed by e l evat i n g the omentum off the tra nsverse co lon a n d p a ncreatic head back to the o ri g i n on the stomach. The hepatic fl exu re is m o b i l ized as necessa ry a n d the d u o d e n u m is widely Ko­ cherized. Frequently, the poste rior wa l l of the sto mach is a d herent to the pancreas a n d m u st be d i ssected free . At

The patient is placed on the operating room table in a supine position. Because the risk for blood loss is moderately high, at least two large-bore intravenous cannulas should be established or a central line should be placed. Arterial monitoring is recom­ mended for patients with comorbidities.

the i nferior border of the pancreatic neck, the r i g ht gas­ troe p i p l o i c ve i n i s ci rcumferent i a l l y d issected a n d d ivided at the i nsertion i nto the superior mesenteric ve i n (SMV). The d ista l stomach and proxi m a l d u o d e n u m a re m o b i ­ l i zed f r o m the head of the pancreas to a l l ow adequate exposure for resection of the pancreatic head. The SMV s h o u l d not be d issected free from the poste rior s u rface of the pancreas fo r fea r of ve nous i nj u ry. These m a n e uvers s h o u l d provi de wide exposure of the pancreas from the d u o d e n u m to the ta i l of the pancreas (FIG 3) .

C h a p t e r 47 LATERAL PANCREATI COJ E J U N OSTOMY WITH (FREY) OR W I T H O U T ( P U E STOW) RESECTION

851

H ead

Duodenum Pancreas

Su perior mesenteric vein

B FIG 3 • The p a ncreas is exposed from the head of the g l a n d to the ta i l . A . T h e omentum i s d i ssected off t h e tra nsverse colon a n d tra n sverse m esoco lon back to its orig i n on the sto m a c h . The poste rior gastric wa l l is freed from the anterior s u rface of the pan creas a n d the d u o d e n u m i s widely m o b i l ized. B. The duodenum a n d anterior su rfaces of the head, body, a n d ta i l o f the pancreas are we l l exposed . The genera l l ocation o f the S M V i nferiorly a n d porta l ve i n su periorly a re noted as a n ato m i c l a n d m a rks.

A

PANCREATIC HEAD RESECTION •

The gastrod uodena l a rtery is identified at the superior border of the pa ncreas a n d l i g ated with a f i g u re-of-e i g ht 4-0 Pro lene suture. The resection of the pan creatic head should be m a p ped with ca re to avoid i nj u ry to the SMV. The pan creatic head is generously resected, l eavi n g o n l y a t h i n r i m (3 to 5 m m ) of tissue a lo n g the d u o d e n a l wa l l a n d posteriorly (FIG 4) . U s u a l ly, t h e pa ncreatic d u ct i s evi dent with excavati o n o f t h e head, a n d t h e d uct may be fo l l owed d i stal ly. Resection of the pancreatic head

should not be deeper t h a n the posterior su rface of the pancreatic d u ct. If t h i s plane is not rea d i ly a p p a rent, the d u ct s h o u l d be identified in the body of the g l a n d (descri bed i n t h e fo l l owi n g text) a n d its cou rse fo l l owed p roxi m a l ly to the head of the g l a n d . B l e ed i n g d u r i n g the pa ncreatic h e a d resection may be b r i s k a n d req u i res meticu l o u s l igation with 5-0 Prolene sutures. The use of e l ectroca utery to control a rte r i a l b l eed i n g s h o u l d be avoided beca u se t h i s often leads to te m porary sea l i n g of the vesse l .

852

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

A B FIG 4 • The e n l a rged head of the p a ncreas is resected, taking ca re to ide ntify safety l a n d m a rks i n c l u d i n g the SMV, porta l ve i n , a n d the poste rior s u rface of the pancreatic d u ct. A. The head of the pan creas is resected by o ut l i n i n g the resection bed to the right of the SMV a n d porta l ve i n . The head is resected deeper i n i ncreme nts such that the pan creatic d u ct i s identified. The resection s h o u l d n o t go deeper than the poste rior s u rface of the pancreatic d uct. Bleed i n g s h o u l d be contro l l ed by suture l i g a t i o n . All sto ne materi a l s h o u l d be removed. The probe identifies the pancreatic d uct ente r i n g the duoden u m . B. T h e d rawing d e m o n strated excavati o n o f the h e a d o f t h e pa ncreas with i m po rtant l a n d m a rks.

LONGITUDINAL PANCREATIC DUCTOTOMY •

If the pancreatic d u ct is identified d u ri n g the pan creatic head resection, it can be fo l l owed d i sta l ly by i nsert i n g a probe i nto the d u ct a n d cutt i n g down on the probe with caute ry. H owever, extens ive f i b rosis with d ucta l stric­ tu res may p revent identification of the d u ct i n the head of the g l a n d or prec l u d e p roxi m a l tracing of the d uct.

If the d uct ca n n ot be identified or traced, it can often be accessed we l l to the l eft of the SMV. Care s h o u l d be taken n ot to identify the d uct over the SMV-s p l e n i c ve i n confl uence. Once t h e d uct is identified d ista l ly, i t s h o u l d be o p e n e d f r o m the ta i l of the pancreas to the j u ncti on of the pa ncreatic head a n d duodenum (FIG 5) . A l l pan­ creatic sto nes should be rem oved u n l ess extraction of the sto ne would cause su bsta ntia l pa renchym a l d a m a g e .

FIG 5 • The pancreatic d uct is opened from the head of the pan creas to the ta i l . A. O n ce the pancreatic head is resected, the pan creatic d u ct can be fo l l owed d i sta l ly and opened over a probe until the d u ct i s opened out to the ta i l of the g l a n d . B. lf the pancreatic d u ct ca n not be i d entified i n the head of the g l a nd, a d i l ated d u ct can be opened to the l eft of the SMV i n the ta i l of the gland and fo l l owed d i sta l ly to the pancreatic head resect i o n . (con tin ued)

C h a p t e r 47 LATERAL PANCREATI C OJ E J U N OSTOMY WITH (FREY) OR W I T H O U T ( P U E STOW) RESECTION

FIG 5 • (continued) C. The d rawing demonstrates the pancreatic d u ct opened from the d u o d e n u m to the head of the g l a n d .

INTRAPANCREATIC BILIARY SPHINCTEROP LASTY •

Patie nts with b i l i a ry strict u re are ca n d i d ates for an i ntra­ pancreatic b i l i a ry s p h i nctero p l a sty, which i s acco m p l ished by identify i n g the bile d u ct along the d u o d e n a l wa l l in the depths of the excavated pa ncreatic head . T h i s por­ tion of the proce d u re is m a rked ly a i ded by preoperative b i l i a ry ste nt p l acement. The i ntrapa ncreatic b i l e d u ct can

be p a l pated b y tra nsd u o d e n a l co m p ression on the b i l i a ry ste nt. The b i l e d u ct is opened over the stent with the l o n ­ g itud i n a l b i l e d u ctoto my exte n d i n g u p to the entra nce of the b i l e d u ct i nto the pa ncreas. The ste nt is rem oved and not replaced. Once opened, the b i l e d u ct s h o u l d accept at l east a 6- to 8-mm p r o b e . The b i l e d u ct is t h e n c i rcumferent i a l l y sewn w i t h i nterru pted 6 - 0 polyd i oxa­ none (PDS) sutu res to the surro u n d i n g pa ncreatic paren­ chyma such that the bile d u ct is widely opened (FIG 6) .

F I G 6 • An i ntrapa ncreatic b i l i a ry sphi ncteroplasty m a y b e performed i n patients with a b i l e duct stricture. A longitud i n a l b i l e ductotomy is performed. T h e b i l e duct s h o u l d be opened su periorly to its entrance i n the pancreas. The bile is secu red circu mferentia l ly to the pancreas with i nterrupted 6-0 PDS sutu res. The b i l e d uct should accept a probe of 6 to 8 mm i n d i a m eter.

853

854

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

ROUX-EN-Y PANCREATICOJEJ UNOSTOMY •

A

A Roux-en-Y l i m b of jej u n u m is prepared by d ivid ing the jej u n u m 1 5 to 30 em d ista l to the l i g a ment of Treitz. The mesentery is tra nsected back towa rd its origin by d ivid­ i n g bridg i n g vesse ls. The Roux-en-Y l i m b is del ivered to the pancreas in a retroco l i c position to the right of the m i d d l e col i c vascu lature. The d ivided end of the jej u n u m is

oriented to the ta i l of the pancreas, a n d a two-l ayer side­ to-side pancreaticojej u nosto my is created with r u n n i n g 4-0 Prolene sutu res (FIG 7) . T h e epith e l i u m o f the pancre­ atic d uct need not be i ncorporated with the i n n e r l ayer of sutu ri ng. The jej u n u m should be opened in i ncrements to avoid the creation of an overly long jej u notomy. A jej u no­ jej u nostomy is created 40 to 50 em dista l to the pa ncreati­ cojej u nostomy to reesta b l ish i ntest i n a l cont i n u ity.

B FIG 7 • A. A Ro ux-e n-Y l i m b is del ivered to the pancreas in retroco l i c fash i o n to the r i g ht of the m i d d l e co l i c ve i n . The l i m b i s sewn t o t h e p a ncreas i n two l ayers with r u n n i n g 4-0 Pro l e n e . B. T h e d rawing demonstrates t h e co m p l eted side-to-si d e pancreatoj ej u n osto my.

P LACEM ENT OF A FEEDING J EJ UNOSTOMY •

A feed i n g jej u nostomy is a p pro priate in m a l n o u r­ ished patie nts. A red rubber catheter or a lternative device is p l aced a p p roxi m ately 30 em d i sta l to the

jej u n ojej u n osto my. The t u be may be p l aced by i m b ri cat­ ing the tube to create a t u n n e l , and the tube s h o u l d be tacked to the a bdom i n a l wa l l i n fo u r-q u a d rant fas h i o n . Two cl osed suction d ra i ns a re p l aced at the s u p e r i o r a n d i nfe rior aspects o f the p a ncreaticoj ej u n osto my, a n d t h e abdomen is cl osed .

PEARLS AND PITFALLS Patient selection

• •

Pancreatic head resection

Alcohol a bsti n ence, chronic pain m a n ag e m e nt O pti m u m o utco m es a re observed in patients with an e n l a rged head of the pancreas a n d d i lated pancreatic d u ct.

•

Ligate the gastrod uoden a l a rtery fi rst. Pe rfo rm a generous resection leavi n g o n l y t h i n (3-5 m m ) r i m of pancreatic tissue. D i ssection of the superior m esenteric vei n should be avoided. Suture l i gation, not cauterization, of b l eed i n g vessels

Pancreatic d u ctoto my

•

D u ctoto my should extend from d u oden u m to the fa r ta i l of pancreas.

l ntra p a n creatic b i l i a ry s p h i nctero p l a sty

•

Assess b i l i a ry obstruction; p l ace a b i l i a ry ste nt preoperatively if i ntra pancreatic b i l i a ry s p h i n ctero p l a sty is antici pated .

Pancreaticoj ej u n osto my

•

Open the j ej u n u m i ncrementa l ly to avoid an ove rly l a rg e jej u n otomy.

• • •

C h a p t e r 47 LATERAL PANCREATI C OJ E J U N OSTOMY WITH (FREY) OR W I T H O U T ( P U E STOW) RESECTION

POSTOPER ATIVE CARE •

•

•

Because of the risk of postoperative bleeding, the patient should be admitted to a monitored setting. The initial 24 to 48 hours require close observation for hemorrhage. If hem­ orrhage occurs, a CT arteriogram should be obtained to look for blood in the gastrointestinal lumen versus intraab­ dominal hemorrhage. Bleeding into the gastrointestinal tract will require an operative approach, whereas intraabdominal bleeding may be treated by angioembolization. Oftentimes the exposure of the pancreas requires dissection of chronically inflamed adhesions and, therefore, the fluid requirements postoperatively may be high; close monitoring of the urine output is required. Early initiation of postoperative enteral nutrition is neces­ sary because most of these patients are malnourished with low protein stores.

OUTCOMES •

•

•

A randomized trial comparing endoscopic therapy with stents to surgical drainage confirmed superior results for surgical treatment. 1 6 Patients treated with pancreatic drain­ age procedures had better pain control, and 4 7% of patients initially managed by endoscopic therapy ultimately required surgery. Operative treatment of chronic pancreatitis may include resection with standard or pylorus-preserving pancreato­ duodenectomy or a drainage procedure such as the Frey procedure. The merits of each of these operations have been debated, but a randomized, prospective trial demonstrated that the Frey operation was associated with better short­ term outcomes, although the procedures were equivalent in terms of pain control and pancreatic function in long-term analysisP Table 2 summarizes the results of patients undergoing the Frey procedure.

COMPLICATIONS • • •

Postoperative hemorrhage Pancreatic fistula is distinctly uncommon. Delayed gastric emptying

Tab l e 2: Outcomes fol lowing Loca l

Pancreatic Head Resection with Longitud inal

Pancreaticojej unostomy

Parameter

Frequency (%)

Rei nterve ntion req u i red Exocri n e i n sufficiency E n d ocrine insufficiency Return to work Continued alcohol consu m ption

8 86 61 42 21

Adapted from Strate 7; Bachmann K, Busch P, e t at. Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial. G astroenterology.

2008; 134: 1406- 1 4 1 7 .

855

Table 3 : Com p l i cations fol lowing Loca l

Pancreatic Head Resection with Longitu d i n a l Pancreaticojej unostomya

Complication Major compl ications B i l i a ry stricture Pan creatic fist u l a

Frequency (%) 23 11 7

'Unpublished data from the authors' experience.

•

Table 3 includes the anticipated frequency of other compli­ cations, which may occur following pancreatic head resec­ tion and lateral pancreaticoj ejunostomy.

REFER ENCES 1. Warshaw AL, Banks PA, Fernandez-Dei Castillo C. AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology. 1 9 9 8 ; 1 1 5 : 765-776. 2 . Frulloni L, Falconi M, Gabbrielli A, et al. Italian consensus guidelines for chronic pancreatitis: Dig Liver Dis. 2010;42(suppl 6 ) : S 3 8 1-S406. 3 . Chari ST, Longnecker DS, Kloppel G. The diagnosis of autoimmune pancreatitis: a Western perspective. Pancreas. 2009; 3 8 : 846-848 . 4. Layer P, Yamamoto H, Kalthoff L, et a!. The different courses o f early­ and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroen­ terology. 1 994; 107 :14 8 1-1487. 5 . Whitcomb DC. Genetics of alcoholic and nonalcoholic pancreatitis. Curr Opin Gastroenteol. 2012;28:50 1-506. 6. Clark CJ, Morales-Oyarvide V, Zaydfudim V, et al. Short-term and long­ term outcomes for patients with autoimmune pancreatitis after pancreatec­ tomy: a multi-institntional study.] Gastrointest Surg. 2013;17(5):899-906. 7. Bauer AS, Keller A, Costello E, et al. Diagnosis of pancreatic ductal adenocarcinoma and chronic pancreatitis by measurement of micro­ RNA abundance in blood and tissue. PLoS One. 2 0 1 2;7:e34 1 5 1 . 8 . Yadav D, Whitcomb D C . The role o f alcohol and smoking i n pancre­ atitis. Nat Rev Gastroenterol Hepatol. 2 0 1 0;7: 1 3 1-145. 9 . Yadav D, Hawes RH, Brand RE, et al. Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch Intern Med. 2009; 1 6 9 : 1 035-1045. 1 0 . Ammann RW, Muelhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology. 19 9 9; 1 1 6 : 1 1 32-1 140. 1 1 . Siddiqi AJ, Miller F. Chronic pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultra­ sound CT MR. 207;28 :384-394. 1 2 . Matos C, Metens T, Deviere J, et al. Pancreatic duct: morphologic and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology. 1 9 9 7;203:435-44 1 . 1 3 . Albashir S, Bronner MP, Pari MA, e t al. Endoscopic ultrasound, secretin endoscopic pancreatic function test, and histology: correlation in chronic pancreatitis. Am ] Gastroenterol. 2 0 1 0 ; 1 05 :2498-2503. 14. Behrns KE. Local resection of the pancreatic head for pancreatic pseu­ docysts. ] Gastrointest Surg. 2008;12:2227-2230. 15. Amudhan A, Balachander TG, Kannan DG, et al. Factors affecting outcome after Frey procedure for chronic pancreatitis. HPB (Oxford). 2008; 10:477-482. 1 6 . Cahen DL, Gouma DJ, Laramee P, et al. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis. Gastroenterology. 2 0 1 1 ; 1 4 1 : 1 690-1 695. 17. Strate T, Bachmann K, Busch P, et al. Resection vs drainage in treat­ ment of chronic pancreatitis: long-term results of a randomized trial. Gastroenterology. 200 8 ; 1 3 4 : 1 406-1 4 1 1 .

-

I

Chapter

48

Enteric Drainage of Pancreatic Pseudocysts: Pancreatic Cyst Gastrostomy and Cyst Jej unostomy ·----------------------------------------------------- ....

t

Kenneth K. W Lee

DEFINITIONS •

Collections of fluid or solid material may arise from epi­ sodes of acute pancreatitis. Although frequently referred to collectively as pancreatic pseudocysts, the 2 0 1 2 revision of the Atlanta classification of acute pancreatitis distinguishes among several types of local collections that arise in acute pancreatitis based on their pathogenesis and imaging char­ acteristics. 1 An understanding of these different collections is important as their management differs. Acute peripancreatic fluid collections (APFCs) ( FIG 1 A, B) arise early in the course of interstitial edematous acute pancreatitis. APFCs lack a wall, are confined by fascial planes, and rarely require intervention as the risk of com­ plications such as infection is very low and they usually resolve spontaneously (FIG 2A,B ) .

APFCs that fail to resolve may become pancreatic pseu­ docysts with well-defined walls. Pancreatic pseudocysts (FIG 3A) are encapsulated, well-defined peripancreatic or intrapancreatic fluid collections that arise from focal dis­ ruption of the pancreatic ductal system in the setting of acute or chronic pancreatitis or trauma. In contrast to cystic neoplasms of the pancreas, pseudocysts lack true epithelial walls and instead have walls composed of fibrous tissue containing histiocytes, giant cells, granulation tissue, and rarely eosinophils. The fluid within a pseudocyst is charac­ teristically amylase rich as it arises from disruption of the pancreatic ductal system. The 2 0 1 2 revision of the Atlanta classification of acute pancreatitis also emphasizes that pseudocysts are not associated with detectable amounts of pancreatic or peripancreatic necrosis and do not contain a solid component. Magnetic resonance imaging ( FIG 38) or ultrasound may be useful for identification of solid mate­ rial not distinguishable on computed tomography.

'

, �

\)

t

' '

A

/

- ��... '• .

r

A

;-

\

l '

' B FIG 1 • Acute peri pancreatic f l u i d co l l ecti o n . A. The pancreas a p pears edematous with sm a l l a m o u nts of f l u i d surro u n d i n g it. B. Peripancreatic f l u i d tracks latera l l y a nterior to the k i d n ey but re m a i n s confi ned by fasc i a l p l a nes.

856

-�-

•

/

........

B

FIG 2 • A,B. Acute peri pancreatic f l u i d col lect i o n . The acute f l u i d co l l ections a re resolved 3 weeks later.

857

C h a p t e r 48 E N T E R I C D R A I N A G E OF PANC R EATI C P S E U D O CVSTS

FIG 3 • Pan creatic pseudocyst. A. A homo­ geneous f l u i d co l l ecti o n is su rrou nded by a d i screte wa l l that is a p pa rent desp ite the a bsence of i ntravenous contrast. B. M a g n etic reso na nce i m a g i n g confi rms the a bsence of so l i d m ateri a l (n ecrotic deb ris) with i n t h e pseud ocyst.

A

B

In contrast to APFCs and pancreatic pseudocysts, acute necrotizing pancreatitis is defined by the presence of pan­ creatic and/or peripancreatic tissue necrosis. In the early stages of acute necrotizing pancreatitis, the necrotic tissue is described as an acute necrotic collection (AN C ) (FIG 4} . Such collections may additionally contain fluid leaking from the pancreatic duct or resulting from liquefaction of necrotic tissue. The natural history of ANCs is variable. Such collections may persist or absorb, remain solid or liquefy, remain sterile or become infected. Fibrous walls form around necrotic collections that are not reabsorbed or do not require early surgical debridement. As with acute necrotic collections, areas of walled-off necrosis (WON) (FIG S} may contain fluid in addition to solid material. A

'

. •

0 '· FIG 4 • Acute necrotic co l l ecti o n . Areas of pancreatic a n d peripancreatic necrosis surro u n d portions of v i a b l e (e n h a n c i ng) pancreas.

...

B FIG 5

•

•.

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1...

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•

-

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A.B. Wa l l ed-off necrosis.

858

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

Although the pathogenesis and contents of WON differ from pancreatic pseudocysts, their management is simi­ lar to pseudocysts, particularly if communication with the pancreatic ductal system is suspected. DIFFERENTIAL DIAGNOSIS • • •

•

•

•

Pancreatic pseudocyst Walled-off necrosis Pancreatic cystic neoplasms possess a true epithelial lin­ ing and thereby differ from pseudocysts that are lined by fibrous tissue (see earlier discussion) . Cystic neoplasms pri­ marily fall into two categories. Microcystic cystadenomas contain serous fluid and carry minimal if any risk of malig­ nant transformation. Treatment by means of surgical resec­ tion is reserved for those that are symptomatic. Macrocystic cystadenomas contain mucinous material, are characterized by the presence of ovarian stroma, and have the potential for malignant transformation. Surgical resection is therefore usually recommended for such lesions. Neoplasms with cystic morphology. Adenocarcinomas of the pancreas may have cystic components. Areas of tumor necrosis, for example, may liquefy and appear cystic on im­ aging studies. Pancreatic ductal adenocarcinomas may also cause proximal ductal obstruction that may resemble cysts in the pancreas. Pancreatic endocrine tumors may also oc­ casionally be predominantly cystic. Intraductal papillary mucinous neoplasms may arise in the main pancreatic duct or in side branch ducts and on imaging appear as solitary or multiple pancreatic cysts. Other benign cystic abnormalities include lymphoepithelial cysts and inclusion cysts. If diagnosed, treatment is reserved for those that are symptomatic. Mucinous cysts that do not contain ovarian stroma and do not appear to have potential for malignant transformation may also occur in the pan­ creas. Differentiation of such benign mucinous cysts from mucinous cystadenomas may be difficult.

•

•

IMAGING AND OTIIER DIAGNOSTIC STUDIES •

•

•

EVALUATION

History and Physical Examination •

•

•

A thorough medical history must be taken to confirm a history of acute pancreatitis, or less commonly, pancreatic trauma. In the absence of such a history, the diagnosis of a pancreatic pseudocyst should be questioned, and the diagno­ sis of a neoplasm should be considered. As several weeks are required for a pseudocyst to form, the diagnosis of a pseudo­ cyst should also be questioned if the clinical history of acute pancreatitis or pancreatic trauma is very recent and a cystic abnormality with an already well-formed wall is seen. The history should also attempt to identify the etiology of the patient's pancreatitis, as treatment of the etiology (e.g., cho­ lecystectomy, lipid- and triglyceride-lowering medications, abstinence from alcohol consumption) should be considered. Symptoms potentially attributable to a pseudocyst should be elicited. Most frequently, these will include abdominal or back pain, abdominal pressure or fullness, early satiety, nausea, vomiting, or obstructive symptoms. If a complication of the pseudocyst such as infection, bleeding, or rupture has occurred, symptoms relating to the complication such as fever, light-head­ edness, or diffuse abdominal pain may also be present.

The general medical history and overall health of the pa­ tient are important in determining the manner of treatment appropriate for the patient. Past surgical history should be reviewed with particular emphasis on prior operations on the stomach or small intestine and incisions that may impact on laparoscopic or open access to the abdomen. An abdominal mass or fullness should be sought on physical exam, and if found, its location should be noted in planning subsequent surgical procedures. Abdominal surgical scars should also be noted.

•

•

The presence and location of cystic changes of the pancreas are best determined by means of contrast-enhanced com­ puter tomography (CT) or magnetic resonance imaging (MRI ) . The imaging characteristics on these studies may help to differentiate among the various types of cystic pan­ creatic abnormalities listed earlier. Cross-sectional imaging also demonstrates the relationship of the cyst to the stomach and other structures as well as the thickness of the cyst wall and thereby aids in treatment planning. Pancreatic ductal abnormalities that may influence treatment decisions can be identified by means of magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde pancreatography ( ERP) . MRCP is preferred as it is noninva­ sive, usually does not require patient sedation, and avoids the risks of procedure-induced pancreatitis or infection of fluid collections in communication with the pancreatic duct. If the clinical history and imaging findings are not sufficient to determine the specific type of cystic abnormality and in particular to exclude the diagnosis of a neoplastic cyst with potential for malignant transformation, further imaging by means of endoscopic ultrasound (EUS) can be performed. Under EUS guidance, fine needle aspiration of the cyst con­ tents and cyst wall can be performed to obtain samples for biochemical and pathologic analysis. EUS can also identify solid material within the cyst and assess the thickness of the cyst wall. ERP is not routinely performed for evaluation of pseudo­ cysts, but in selected cases may be performed to evaluate ductal anatomy when MRCP cannot be performed or is in­ conclusive. Because of the potential for introducing infection into a sterile pseudocyst, ERP should be limited to patients selected for treatment (see the following text) and should be performed shortly before treatment. Although the pathogenesis and pathology of pancreatic pseudocysts and WON differ, their management is simi­ lar and therefore differentiating between pseudocysts and WON is not always required. In the discussion that follows, the term pseudocyst is used to describe both pseudocysts and WON as defined in the 2 0 1 2 revision of the Atlanta classifi­ cation of acute pancreatitis.

SURGICAL MANAGEMENT

Indications for Treatment •

•

Treatment should be considered for symptomatic pseudo­ cysts or enlarging pseudocysts. Emergency treatment of complications such as infection, rupture, or bleeding into the pseudocyst may be required.

C h a p t e r 48 E N T E R I C D R A I N A G E OF PANC R EATI C P S E U D O CVSTS

•

•

Small, asymptomatic, nonenlarging pseudocysts do not require treatment as the risk of developing acute complications is low. However, as the risk of complications arising in large asymp­ tomatic, nonenlarging pseudocysts is uncertain and may be larger, treatment of such large pseudocysts can be considered. Treatment should be considered if the diagnosis of a neo­ plasm with malignant potential cannot be excluded.

Treatment Options • •

•

Surgical resection can be performed for removal of a pseudocyst. External drainage may be achieved by percutaneous or sur­ gical means. Internal drainage of a pseudocyst creates a communication between the pseudocyst and the gastrointestinal tract. Drainage into the stomach is achieved by creating a com­ munication between the posterior wall of the stomach and a pseudocyst known as a cyst gastrostomy. This may be achieved by endoscopic means, surgical means, or a hybrid combination of these methods. The anastomosis can be fashioned within the stomach via an anterior gas­ trotomy, outside the stomach via the lesser sac, or within the stomach via endolaparoscopic means. Drainage into the small intestine is achieved by surgical creation of an anastomosis between a defunctionalized segment of the small intestine (Roux limb) and a pseudo­ cyst known as a cyst j ejunostomy. Pseudocysts arising in the head of the pancreas are infre­ quently drained by creation of an anastomosis between the descending duodenum and the pseudocyst known as a cyst duodenostomy.

Choice of Procedure •

•

Surgical resection should be considered when the diagnosis of a cystic-appearing neoplasm such as a mucinous cystad­ enoma cannot be excluded or selectively by means of a distal (left) pancreatectomy for a pseudocyst or WON involving the tail of the pancreas. Distal ( left) pancreatectomy is dis­ cussed elsewhere in this text. Because of the greater morbid­ ity and mortality of a pancreaticoduodenectomy (Whipple procedure) , resection should not be considered for pseudo­ cysts in the head of the pancreas. As pseudocysts arise as a result of disruption of the pancre­ atic ductal system and WON is also commonly associated with pancreatic duct disruption, external (percutaneous) drainage of pseudocysts or WON may give rise to a pan­ creatic fistula. Therefore, when treatment is necessary, in­ ternal drainage into the gastrointestinal tract is preferred.

DESCRIPTION OF P ROCEDU RES •

G astric d r a i n a g e p roced u res Tra nsgastric cyst gastrosto my • Extra gastric cyst gastrosto my • l ntragastric cyst gastrosto my J ej u n a l d r a i n a g e proce d u re • Roux-en-Y cyst j ej u n ostomy •

•

•

•

•

859

However, external drainage may be preferred if treatment of the pseudocyst is required before a wall suitable for con­ struction of an anastomosis has formed. Temporary relief of symptoms may be achieved by large volume fine needle aspiration. Infection of an evolving pseudocyst is treated by placement of a drainage catheter. External drainage may also be considered if internal drainage does not appear safe for treatment of acute complications such as pseudocyst rupture or infection that arise in mature pseudocysts. Surgical drainage is most commonly performed into either the stomach or the small intestine. Cystojejunostomies have a lower incidence of pseudocyst recurrence and periopera­ tive bleeding compared to cystogastrostomies but require creation of a Roux limb and an intestinal anastomosis (see below ) . Additionally, pseudocyst recurrence after creation of a cyst gastrostomy may be amenable to endoscopic treat­ ment. Therefore, if the stomach suitably abuts the pseu­ docyst, a cyst gastrostomy is usually created. Otherwise, a Roux-en-Y cyst jejunostomy is created. Endoscopic cyst gastrostomy ( discussed in detail elsewhere in this text) is especially well suited for treatment of true pseudocysts containing only fluid and no necrotic tissue. Open and minimally invasive (laparoscopic or robot-assisted) techniques of creating cystogastrostomies and Roux-en-Y cystojejunostomies are fundamentally identical.

Preoperative Preparation •

•

•

• •

•

Patients should be prepared m routine fashion for major abdominal surgery. Comorbidities such as hypertension and cardiopulmonary disease should be optimized. Patients should be evaluated and treated for pancreatic endocrine and exocrine insufficiency. Coagulation disorders if present should be corrected. Routine antibiotic and thromboembolic prophylaxis should be administered. In malnourished patients, surgery should be delayed and preoperative nutritional support should be given when pos­ sible. Enteral nutrition is preferred but may not be possible due to the mass effects of the pseudocyst.

Positioning •

•

For either open or minimally invasive procedures, the patient is placed in a supine position. Arms may either be tucked or extended outward. Table-mounted retractors are used as needed for open procedures.

860

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

T RANSGAST RIC CYST GASTROSTOMY •

A m i d l i n e i ncision provides exce l l ent exposure for open Pal pation of the a bdom e n after i n d uction of a n esthesia a n d review of the patie nt's preoperative i m a g i n g stu d i es wi l l g u i d e p l ace­ ment of the i n c i s i o n . A wou nd p rotector is p l aced, thorough exp loration of the a b d o m e n is pe rfo rmed, a n d the fu l l ness posterior to the sto mach caused by the pse u d ocyst is p a l pated a n d l oca l ized . If n ecessa ry, the pseud ocyst can be further l o ­ cal ized u s i n g u ltraso u n d (FIG 6) . Port p l acement for minimally invasive transgastric cyst gastrostomy w i l l vary a ccord i n g to the size a n d position of the pseud ocyst. I n general, however, o n e m i da b d o m i n a l 5-mm port, two r i g ht u p p e r a b d o m i n a l 5-mm ports, a n d two l eft u p p e r ab d o m i n a l 5-mm ports w i l l suffice. These ports a re u psized as n ecessa ry for i nsertion of sta­ p l e rs and u ltraso u n d probes. Stay sutu res are p l aced over the epicenter of t h i s f u l l ­ n ess (FIG 7), a n d a l o n g itud i n a l anterior gastroto my i s m a d e u s i n g e l ectroca utery (FIG 8) . This i ncision s h o u l d be centered between the lesser a n d g reater cu rvatu res of the sto mach to fac i l itate su bseq uent closure of the a nterior gastroto my. The anterior gastric wa l l i s u s u a l l y m o b i l e and, conseq uently, the a nterior gastrotomy c a n

transgastric cyst gastrostomies.

•

•

•

•

•

usua l l y be made short. The l o n g i tu d i n a l orientation of the gastroto my a l l ows it to be l e n gthened p roxi m a l l y or d i sta l ly, if needed. Through the poste rior wa l l of the sto mach, the pseudo­ cyst is p a l pated. The location of the pseud ocyst ca n be confi rmed by means of i ntraoperative u ltraso u n d (FIG 9) or passa ge of a needle thro u g h the poste rior wa l l of the stomach i nto the pseud ocyst a n d a s p i ration of f l u i d f r o m the pseudocyst (FIG 1 0) . B o t h measu res a lso pro­ vide an est i m ate of the d i stance between the sto mach a n d the pse udocyst cavity. Fluid o bta ined by a s p i ration can be sent for biochemical, m i cro b i o l o g ic, cyto log ic, and path o l o g i c stu d ies as i n d icate d . The pseud ocyst is entered through the poste rior wa l l of the sto mach u s i n g e l ectroca ute ry at the site determ ined

FIG 6 • U ltraso u n d can be u s e d to loca l i ze the pse u d ocyst a n d assist i n posit i o n i n g of the a nterior gastrosto my (lapa rosco pic cyst gastrostomy).

FIG 8 • A l o n g i tu d i n a l a nterior gastrotomy is made. A. Open cyst gastrostomy. B. Laparosco pic cyst gastrosto my.

FIG 7 • Stay sutu res p l a ced i nto the anterior wa l l of the sto mach may fa c i l itate creation of the a nterior g astrosto my (open cyst gastrosto my).

FIG 9 • U ltraso u n d exa m i nation t h ro u g h the poste rior wa l l of the sto mach assists i n loca l i zation of pse u docyst a n d positi o n i n g of the cyst gastrosto my i ncision ( l a p a roscop i c cyst gastrosto my).

C h a p t e r 48 E N T E R I C D R A I N A G E OF PANC R EATI C P S E U D O CVSTS

FIG 10 • Tra nsgastric a s p i ration of the pseud ocyst confi rms the l ocation of the pseud ocyst and d ista nce from the gastric wa l l a n d assists i n posit i o n i n g of the cyst gastrosto my i n cision (open cyst gastrosto my).

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by u ltraso u n d o r a s p i ration and the conte nts of the pseu­ docyst a re evacu ated (FIG 1 1 ) . Any necrotic debris with i n the cavity is removed. A portion of the pse u docyst wa l l i s excised a n d s e n t for frozen section eva l u ation to confi rm the presence of a fibrous wa l l a n d to exc l u d e the p res­ ence of an epithe l i a l l i n i n g (FIG 1 2) . The o p e n i n g i nto the pseud ocyst is e n l a rged u s in g e l ectroca utery or a n other type of energ i zed device. A finger o r u ltraso u n d probe p l aced i nto the pse u d ocyst h el ps to defi ne the extent to which the poste rior wa l l of the stomach i s a d h e rent to the a nterior wa l l of the pse u­ d ocyst. A cyst gastrosto my of 5 em or more i s desi ra b l e when possi b l e . The pse u d ocyst cavity is exp l o red a n d any loculations with i n it are opened. Absorba b l e 2-0 sutu res a re p l a ced c i rcu mferentia l ly that a p p roxi m ate the poste rior gastric wa l l to the pse u d ocyst wa l l (FIG 1 3) . These sutu res re info rce the a d h e rence of

F I G 1 2 • A portion o f t h e cyst wa l l is exci sed a n d sent fo r frozen section exa m i nation to confi rm the presence of a f i b rous wa l l consistent with a pse u d ocyst a n d a bsence of a n epith e l i a l l i n i n g sugg estive o f a cystic neoplasm ( l a p a rosco p i c cyst gastrosto my).

•

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the pseud ocyst to the sto mach and promote h e mostasis along the cyst gastrosto my. After the i n it i a l entry i nto the pseud ocyst, the cyst gas­ trosto my can a lso be e n l a rged usi ng a l i n ear surgical sta­ p l e r. H owever, it re m a i n s m a n d atory to excise a portion of the pse u d ocyst wa l l for h i stologic eva l u a t i o n . After ensuring that hem ostasis is satisfacto ry, a nasogas­ tric tube is positi o n ed i n the sto mach and the anterior gastroto my i s c l osed usi ng sutu res or sta p l e rs. Depe n d i n g o n the length a n d position o f the gastrotomy a n d t h e s i z e o f the sto mach, the closure i s oriented l o n g i tu d i n a l ly or tra nsverse ly. A f i n a l exp loration of the a b d o m e n is perfo rmed, a n d the m i d l i n e i n cision i s closed . D ra i n s a re not rout i n e l y p l a ced .

A

A

B FIG 1 3 • A B. Sutu res are p l aced c i rcu mferent i a l ly a l o n g cyst gastrosto my to rei nforce the a d h erence of the sto mach to the pseudocyst wa l l a n d to e n s u re satisfactory hem ostasis along the cyst gastrosto my. A. Open cyst gastrosto my. B. Laparosco p i c cyst gastrosto my. ,

FIG 1 1 • The pseud ocyst is entered (A) a n d its conte nts i n c l u d i n g any necrotic m ateri a l a re rem oved (B) .

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EXT RAGASTRIC CYST GASTROSTOMY •

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Lesser sac pseudocysts i n p roxi m ity to the posterior wa l l of the sto mach can be a n a stom osed in sid e-to-si d e fash i o n to the stomach without ente r i n g the sto mach t h ro u g h a n anterior ga strostomy. The l esser sac is widely entered t h ro u g h the gastroco l i c omentu m . T h e poste rior wa l l o f t h e sto mach a n d t h e anterior wa l l o f t h e pse udocyst a r e identified where they l i e i n cl ose proxi m ity but are not a d h e rent to one a n other. S m a l l o p e n i n g s a re m a d e in the poste rior wa l l of the sto mach a n d the anterior wa l l of the pse u docyst where they l i e in cl ose proxi m ity to o n e a n other, a n d a l i ne a r sta p l e r i s i nserted i nto th ese o p e n i n g s a n d f i r e d . Ad d i ­ t i o n a l a p p l ications of the sta p l e r a re u s e d as necessa ry t o

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ENDOLAPAROSCOPIC INT RAGASTRIC CYST GAST ROSTOMY •

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La parosco p i c access i nto the perito n e a l cavity is a c h i eved in the u s u a l m a n n er. Th ree rig ht-sided 5-mm ports are i n itia l ly p l aced . The m o b i l ity of the anterior wa l l of the body of the sto mach i s assessed to determ i n e if it wi l l reach t o t h e ab d o m i n a l wa l l . To d o so, t h e p n e u m o peri­ to n e u m may need to be decreased. Once confi rmed, traction sutu res a re p l a ced i nto the sto mach at t h i s l oca­ tion, and passed out through the a b d o m i n a l wa l l at the previously dete r m i ned site. The j ej u n u m is fo l l owed from the d u odenojej u n a l j u nc­ tion to a site where the jej u n u m is m o b i l e . A noncrush i n g bowel c l a m p is a p p l ied across the j ej u n u m t o prevent d is-

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create an adequate a n astomosis. The common open i n g is then cl osed using sta p l e rs or sutures. Alternatively, para l l e l i ncisions are made in the poste rior wa l l of the sto mach a n d the a nterior wa l l of the pseudo­ cyst a n d a h a n d-sewn a nastomosis i s fash ioned. This tech n i q u e of a n asto m osis between the sto mach and pseud ocyst can be performed as either a n open o r m i n i­ m a l ly i nvasive proce d u re. With t h i s tech n i q ue, the a n astomosis between the sto m­ ach a n d the pse u docyst is not l i m ited by the extent of t h e i r a d h e rence to one a n other. Co m p l ications a r i s i n g f r o m the a nte rior gastroto my a re a lso e l i m i n ated . H owever, a l e a k at the cyst gastrosto my wi l l result i n extra l u m i n a l extravasation o f gastroi ntest i n a l conte nts and a gastric fistu l a . Placement of a d ra i n adjacent to the cyst gastrosto my s h o u l d be considered.

tention of the i ntest i n e during su bseq uent i nsuffl ation of the stomach. A 1 2- m m port i s i nserted at the p revi ously dete r m i n e d s i t e . A sma l l gastroto my is made at the center of the traction sutu res, a n d the 1 2- m m port i s adva n ced through t h i s open i n g i nto the stomach. The traction sutu res a re used to h o l d the sto mach u pward a g a i nst the a b d o m i n a l wa l l . T h i s i s fac i l itated b y a lso u s i n g a cuffed 1 2- m m port (FIG 1 4) . T h e stomach is i n suffl ated t h ro u g h the i ntragastric port, a n d l a p a rosco pic exa m i nation of the i n s i d e of the sto m­ ach is performed. The bulge i n the poste rior wa l l of the stomach caused by the retrogastric pseud ocyst is visi b l e (FIG 1 5) . An e n d oscope is the passed via the m o u t h i nto the sto m­ ach, provi d i n g i ntragastric visu a l ization a n d a l lowi n g for l a p a rosco p i c i n strum entation to be passed i nto the sto m ­ ach through the s i n g l e i ntragastric port (FIG 1 6) . After local ization o f the pseud ocyst b y m e a n s o f as­ p i rati o n o r u ltraso u n d eva l u ation, a n i ncision is m a d e through the poste rior wa l l of the stomach i nto the pse u­ docyst u s i n g e l ectroca ute ry or oth er types of energy de­ vices (FIG 1 7) . A s m a l l portion of the pseud ocyst wa l l is excised for froze n section eva l u ation, and the cyst gastrosto my i s

A

B FIG 14 • A.B. Ass isted by traction sutu res, a cuffed 1 2- m m port is i n serted i nto the sto mach (A), a n d the stomach is p u l led u pward a g a i n st the a b d o m i n a l wa l l .

FIG 15 • After passage of a l a p a rosco pe i nto the stomach through the i ntragastric port, a b u l g e i n the posterior wa l l of the sto mach caused by the retrogastric pse u d ocyst is vis i b l e .

C h a p t e r 48 E N T E R I C D R A I N A G E OF PANC R EATI C P S E U D O CVSTS

e n l a rged u s i n g either sta p l i n g or e n ergy devices. Particu l a r atte ntion i s g iven to e n s u r i n g satisfacto ry h e m ostasis. Thro u g h the cyst gastrosto my d r a i n a g e a n d d e b r i d e m e n t of the cyst cavity are co m p l eted (FIG 1 8) . S m a l l a m o u nts of res i d u a l debris w i l l s u b­ seq uently pass t h ro u g h the cyst g a strosto my. A nasogastric tube is positioned in the sto mach, the port is rem oved from the sto mach, a n d the gastrot­ omy is cl osed u s i n g either sutu res or sta p l e rs. The bowel clamp is rem oved from the i ntest i n e a n d the rem a i n i n g l a pa rosco p i c ports a re re m ove d . A d ra i n is not routi nely p l a ce d .

FIG 16 • An endoscope passed through the mouth i nto the sto mach p rovides i ntragastric visu a l ization and perm its passa ge of l a p a rosco pic i n stru ments through the s i n g l e i ntragastric port.

FIG 17 • Under endoscopic visu a l i zation a n d afte r loca l ization of the retrogastric pseud ocyst, a sma l l i ncision is made i n the posterior wa l l of the sto mach a n d the pseudocyst i s entered.

FIG 1 8 • The cyst gastrosto my is e n l a rged usi ng sta p l e rs or energy devices, a n d d r a i n a g e a n d debridement of the pseud ocyst a re co m p l eted.

ROUX-EN-Y CYST JEJUNOSTOMY

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A m i d l i n e i ncision provides exce l l ent exposu re for open Roux-en-Y cyst jejunostomies. Pal pation of the a bdomen after i n d uction of a n esthesia a n d review of the patie nt's preoperative i m a g i n g stu d i es w i l l g u i de p l acement of the i n c i s i o n . As the operation is perfo rmed pred o m i n a ntly below the tra nsverse mesoco l o n , the i ncision is usua l ly s l i g htly more i nferior t h a n the i n cision used fo r creation of a cyst gastrosto my. A wo u n d p rotecto r is p l aced a n d thorough exploration of the abdomen is performed. The pseud ocyst typ i ca l ly presents as fu l l ness b u l g i n g i nto the transverse meso­ colon, and the fu l l ness caused by the pseud ocyst is p a l ­ pated a n d loca l i zed . Port p l acement for minimally invasive Roux-en-Y cyst jejunostomy w i l l va ry accord i n g to the size a n d posi­ tion of the pseudocyst. In general, h owever, ports a re positioned lower in the a b d o m e n than for creation of a m i n i m a l ly i nvasive cyst gastrostomy. Port p l acement is selected not o n ly for creation of the cyst j ej u n ostomy but a lso fo r creation of the Roux l i m b a n d su bseq uent enteroenterosto my.

The tra nsverse colon is e l evated u pward, a l lowi ng visu­ a l ization of the tra nsverse m esoco l o n a n d the b u l g i n g resulting f r o m the pse udocyst. T h e l ocation of the pseu­ docyst can be confi rmed by a s p i rat i o n . If the l ocati o n of the pseud ocyst is not rea d i l y a p p a rent, i ntraoperative u ltraso u n d can be used with refe rence to the patient's preope rative i m a g i n g stu d ies (FIG 1 9) . U ltraso u n d eva l u­ ation may a l so assist in identify i n g m esenteric vessels overlying the pseud ocyst that should be avoided i n fash-

FIG 19 • I ntraoperative u ltraso u n d loca l i zation of pancreatic pse u d ocyst b u l g i n g through the tra nsverse mesentery.

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

FIG 20 • D i ssection a n d exposu re of pse u d ocyst b u l g i n g t h ro u g h the tra nsverse m esentery.

FIG 22

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FIG 21 • Creation of Roux l i m b u s i n g a l i ne a r sta p l e r to d ivide the j ej u n u m a n d its mesentery.

Creation of sid e-to-side enteroente rosto my usi ng a l i n ear sta p l e r.

i o n i n g the cyst j ej u n ostomy. Ad hesions overlyi n g the pseu d ocyst are then taken down using sharp a n d b l u nt d i ssection (FIG 20) . With the pseud ocyst i d entified a n d exposed, a defunc­ t i o n a l ized Roux l i m b is then prepared . The conseq uences of a l e a k su bseq uently occu r r in g at the cyst j ej u n ostomy are m iti gated by use of a Roux l i m b rath e r than a func­ t i o n a l loop of j ej u n u m . The j ej u n u m is fo l l owed from the d u odenojej u n a l j u nction to a site where the m o b i l ity of the jej u n u m a n d the confi g u ration of its vascu l a r a rcades a re s u ita b l e . As the cyst j ej u n ostomy is positioned below the m esoco lon, m o b i l ity of the Roux l i m b is rarely an issue. H owever, occasi o n a l ly, the j ej u n a l m esentery may be very foreshorte ned o r th ickened as a res u lt of the prior episode(s) of pancreatitis. The i ntesti ne i s d ivided us ing a l i n e a r sta p l e r, and the m esentery i s d ivided, tak­ i n g care to ensure that hemostasis is meticu l o u s a n d that the blood s u p p l y to both ends of the j ej u n u m is satisfac­ tory (FIG 2 1 ) . Gastro i ntest i n a l conti n u ity c a n be reesta b l ished before o r after creat i n g the cyst j ej u n osto my and can be per­ formed us ing sta p l e rs, sutu res, or a co m b i n ation of both (FIG 22) . The a n astomosis can be perfo rmed in either a side-to-s ide or end-to-si d e fash i o n . A Roux l i m b measur­ i n g 40 to 50 em s h o u l d be created . I n some i n stances, a l o n g e r Roux l i m b may be created if the patie nt's h is­ to ry or i m a g i n g resu lts suggest the poss i b l e need for an a d d i t i o n a l cyst jej u n ostomy or b i l i a ry reconstruc­ tion in the future. I n this case, the m a n ne r in which the

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enteroente rosto my is made a n d the posit i o n i n g of the Roux limb should be ca refu l ly considered. After co m p l et­ i n g the enteroente rostomy, the res u l t i n g m esenteric de­ fect is cl osed with sutu res to p revent hernias. The Roux l i m b i s positioned next to the pseud ocyst a n d a side-to-si d e a n astomosis measu r i n g 3 to 5 em i n length is then created between the pse u d ocyst a n d the Roux l i m b . As with the extra gastric cyst gastrosto my, this a n as­ tomosis can be pe rfo rmed u s i n g sta p l e rs (FIG 23) a n d/or sutu res (FIG 24) . Sta p l e r and suture choice i s dete r m i ned by the th ickness of the pseud ocyst wa l l . A d ra i n is p l a ced adjacent t o t h e a n asto m osis, a n d after confi r m i n g that h e m ostasis is satisfactory, the i ncision or ports are cl osed .

FIG 23 • Creation of sid e-to-si d e Ro ux-en-Y cyst jej u n osto my u s i n g a l i near sta p l e r. The jaws of the sta p l e r are positioned in the Roux l i m b (right) and pseud ocyst (left).

C h a p t e r 48 E N T E R I C D R A I N A G E OF PANC R EATI C P S E U D O CVSTS

865

FIG 24 • Creation of side-to-side Roux-e n-Y cyst jej u nostomy using sutu res. Suture has been passed through the Roux limb (top) a n d is now being passed through the pseudocyst (bottom).

PEARLS AND PITFALLS Differenti a l d i a g nosis

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Cystic neoplasm m ust a l ways be considered.

I m a g i n g a n d oth e r d i a g nostic stu dies

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M a nagement is d riven by h i g h -q u a l ity i m a g i n g . The a n ato m i c re lationsh i ps, presence of necrotic deb ris, and i nvolvement of p a ncreatic d uct m ust be we l l -dete r m i n e d to i m p l ement a p p ropri ate thera py. Be m i n dful of a potent i a l d isco n n ected pancreatic d u ct.

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Preoperative p l a n n i n g

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S u rg ical m a n a g ement

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Ti m i n g of i ntervention is key. The g o a l is to a l low the p rocess to a d e q u ately mature w h i l e m i n i m i z i n g the d u ration of d i sa b i l ity. Anato m i c relati onsh i ps d rive m a n a g e m ent. • Cyst gastrostomy is tec h n i ca l ly least d e m a n d i n g but associated with h ig h e r recurrence rates. • Approach the pseud ocyst from the tra nsverse m esoco l o n for cyst j ej u n osto my. • Consider l a p a rosco p i c a p p roach or endosco pic assista nce. Look for ve nous throm bosis and va rices. Debride a l l necrotic materi a l . Respect varices. Be l i bera l with l igati o n . R u n n i n g or l o c k i n g sutu res to fash i o n the a n astomosis are advised to m i n i m ize the risk of postope rative b l eed i n g .

POSTOPER ATIVE CARE •

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A nasogastric tube i s routinely placed i n patients who un­ dergo creation of a cyst gastrostomy and left in place until gastric emptying appears satisfactory. Drain output is evaluated for the presence of amylase and lipase. If present, the drain is left in place until output has ceased. Routine antibiotic and thromboembolic prophylaxis are ad­ ministered. Other aspects of routine postoperative care are followed. Patients are evaluated for resolution of symptoms previously attributed to the pseudocyst. If symptoms persist, follow­ up imaging ( CT or MRI) is performed. Otherwise, routine

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follow-up imaging is obtained after 3 months to confirm resolution of the pseudocyst. Thereafter, further evaluations are dictated by the development of new symptoms. If symptoms persist after a cyst gastrostomy and imaging confirms the presence of a residual pseudocyst, endoscopy should be performed to evaluate the patency of the cyst gas­ trostomy. If narrowed, the cyst gastrostomy can be endo­ scopically dilated. The residual pseudocyst can be accessed, debrided, and drained endoscopically. Additionally, a nasa­ cystic catheter can be placed for irrigation of the cavity. If symptoms persist after a Roux-en-Y cyst j ejunostomy and imaging confirms the presence of a residual pseudocyst, the cyst jej unostomy can occasionally be evaluated and if

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

necessary be dilated endoscopically. However, the Roux construction often prevents this from being accomplished. Although revision of the cyst jejunostomy may need to be considered, if imaging studies demonstrate evidence of patency of the cyst jej unostomy (e.g., air in the pseudocyst) , consideration should b e given t o allowing additional time for resolution of the pseudocyst before proceeding with sur­ gery. Additionally, careful evaluation of the patient's symp­ toms should be performed to ensure that they are caused by the residual pseudocyst before embarking on further surgery. COMPLICATIONS •

In addition to intraperitoneal bleeding, bleeding may occur from gastrotomies used to access the stomach and from any of the anastomotic sites. The cyst gastrostomy is particularly prone to bleeding because of the inherently rich blood sup­ ply of the stomach and the inflammation associated with the episode of pancreatitis and pseudocyst formation. Endos­ copy is useful for not only evaluating the cyst gastrostomy but also for evaluating for bleeding within the pseudocyst cavity. However, accumulation of blood, fluid, and debris within the cavity may hinder thorough evaluation and

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consideration should be given to early angiography. Angiog­ raphy should also be strongly considered for evaluation of bleeding from a Roux-en-Y cyst jejunostomy, as this anasto­ mosis cannot be readily evaluated endoscopically. Leakage can occur at anastomotic and gastric closure sites. Leakage from an anterior gastrotomy closure or entero­ enterostomy is managed as with any gastrointestinal leak. Leakage from a Roux-en-Y cyst jej unostomy can be man­ aged nonoperatively if controlled satisfactorily by the drains placed at the time of surgery. Additional drains can be in­ serted percutaneously if needed. As the Roux limb is defunc­ tionalized, surgical exploration is not required if adequate drainage is established. If leakage occurs from an extragas­ tric cyst gastrostomy, the patient should initially be made nil per os (NPO ) . With adequate drainage from the surgically placed drains, leaks from either type of anastomosis will usually heal spontaneously.

REFERENCE 1.

Banks PA, Bollen TL, Dervenis CL, et al. Acute Pancreatitis Work­ ing Group. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2 0 12;62: 1 02-1 1 1 .

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Chapter

49

Pancreatic Debridement 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ..

Nicho las J. Zyromski

DEFINITION •

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Two hundred and seventy thousand patients are admitted to U.S. hospitals yearly with the primary diagnosis of acute pancreatitis. Among these patients, 1 0 % to 1 5 % will de­ velop severe acute pancreatitis with variable necrosis of the peripancreatic soft tissue and pancreatic parenchyma. Necrotizing pancreatitis (NP) is a serious problem with at­ tendant mortality of approximately 2 0 % . Once pancreatic and peripancreatic necrosis have been es­ tablished, one of the three outcomes will present itself. FIG 1 illustrates these potential outcomes. A small percentage of patients will resolve their necrosis with no intervention. An­ other portion of patients will develop infection in the ne­ crosis; this typically demands treatment. A third group of patients will have persistent necrosis. If the necrosis causes no symptoms, no intervention is necessary. However, symp­ tomatic necrosis remains an indication for intervention. Symptoms may include fullness/early satiety, general mal­ aise, and back pain. These symptoms are related to mass effect of the necrosis as well as to the inflammatory response.

PATIENT HISTORY AND PHYSICAL FINDINGS •

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The etiology of pancreatitis should be investigated. Patients with biliary pancreatitis should be considered for chole­ cystectomy with cholangiography at the time of pancreatic debridement. A significant number of patients will have idiopathic cause; current data implicates microlithiasis and/ or sludge in many of these cases. Therefore, strong consider­ ation should be given to cholecystectomy if technically pos­ sible and safe at the time of debridement. NP patients have widely variable physiologic condition prior to necrosectomy. On two ends of the spectrum, a patient may be acutely ill with systemic sepsis and require debridement

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IMAGING AND OTHER DIAGNOSTIC STUDIES •

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4 weeks

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Intervention

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FIG 1

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Necrosis outco m es. Sx, sym ptoms.

urgently for infectious control. On the other hand, many pa­ tients may be "walking wounded"-that is to say, they are home from the hospital managing some oral alimentation and are in reasonable physical health; however, they remain moderately to profoundly symptomatic. All efforts should be made to optimize nutritional and physi­ cal condition prior to pancreatic debridement. The clinician should understand that obj ective nutritional values will never normalize with a volume of necrotic tissue in the retro­ peritoneum generating a persistent inflammatory response. Enteral alimentation is ideal; parenteral nutrition may be necessary to supplement caloric and protein intake. It must be emphasized that multiple approaches are avail­ able to treat NP patients. The disease is extremely hetero­ geneous and no one intervention fits all patients. Ideally, a multidisciplinary team consisting of surgeons, interventional endoscopists, and interventional radiologists are invested in evaluating these patients. One doctor must be responsible for the long-term care of these patients as the recuperation typically encompasses 6 to 12 months or longer.

A current cross-sectional image-that is, computed tomog­ raphy ( CT) or magnetic resonance imaging (MRI) scan-of the abdomen and pelvis is critically important to use as a road map guiding debridement. An important diagnostic consideration involves estimating the volume of solid material (as opposed to fluid) in the peripancreatic collection. MRI is more accurate than CT in making this estimation. Ultrasound may be most accurate; however, transabdominal ultrasound is plagued by artifact from hollow viscus. Endoscopic ultrasound (EUS) is an ex­ cellent modality; however, it requires sedation and is moder­ ately invasive. FIG 2 illustrates MRI and ultrasound images. Endoscopic retrograde pancreatography (ERP) is most accu­ rate in defining pancreatic ductal anatomy and, specifically, the presence of disrupted main pancreatic duct. If ERP is undertaken in the setting of NP, it should be done a short time before planned debridement, as ERP has a high chance of contaminating what otherwise may be sterile necrosis. Fine needle aspiration of the pancreatic and peripancreatic necrosis is relatively sensitive in diagnosing infection. This modality is not commonly necessary or used in contempo­ rary practice. Transabdominal ultrasound of the gallbladder should be performed to diagnose stones or sludge and inform the need for cholecystectomy. Broad-spectrum empiric antibiotic treatment is not recom­ mended currently. Antibiotic therapy should be reserved for documented infections with a discrete endpoint in treatment. NP patients have an extremely high ( 5 6 % ) incidence of ve­ nous thromboembolic events. Screening duplex ultrasonog­ raphy should be considered in all NP patients.

867

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P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

A B FIG 2 • A. M R I show i n g so l i d a n d f l u i d components (arro w) of peri pancreatic co l l ections. B. I O U S i m a g e of the same co l l ecti o n . S o l i d necrosis i s h i g h l i g hted w i t h arrow.

SURGICAL MANAGEMENT •

•

•

Perhaps the most important concept regarding NP is that this disease is extremely heterogeneous. The intervention/opera­ tive approach is dictated primarily by anatomic distribution of necrosis, involvement of the pancreatic parenchyma by necrosis, and specific individual clinical situation. Treatment approaches include percutaneous drainage, endo­ scopic drainage, a combination of percutaneous and endoscopic approaches, retroperitoneal debridement (videoscopic-assisted retroperitoneal debridement [VARD] or sinus tract necro­ sectomy), surgical transgastric approach, or traditional open operative debridement with external drainage.

FIG 3

•

•

FIG 3 illustrates typical patterns of necrosis. The image on the left with necrosis confined to the lesser sac may be ap­ proached through the posterior stomach either endoscopi­ cally or surgically. The middle image with necrosis extending down the left paracolic gutter may be best approached from the retroperitoneum (YARD ) . The image on the right with necrosis extending down both paracolic gutters and/or the small bowel mesentery root poses a challenging problem. This group also includes patients with pancreatic head in­ volvement. These patients may be best approached by open operative debridement. Definitive intervention should not be undertaken earlier than 4 weeks from the incident episode of pancreatitis.

N ecrosis patte rns.

C h a p t e r 49 PANCREAT I C D E B R I D E M E N T

G o a l s of p a ncreatic debridement a re shown in Ta b l e 1 . Tab l e 1 : Goa l s of Debridement

Debride as m u c h solid necrotic tissue as poss i b l e safely. Provide wide drainage of the pan creas (exter n a l l y or into the a l i me ntary tract if possible). Esta b l i s h enteral access. Perform chol ecystectomy and c h o l a n g i og raphy if i n d icated. Perfo rm all the a bove with as l ittle physiologic derangement as possible.

3 4 5

OP EN NECROSECTOMY

Debridement

Exposure

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•

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•

•

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The patient may be a p p roached t h ro u g h the m i d l i n e o r a l o w tra nsverse i ncision, which provides s u p e r b access t o the u p p e r a b d o m e n . I nt ra o perative u ltraso u n d ( I O U S) s h o u l d be perfo r m ed p r i o r to d i s r u pt i n g a n y of t h e co l l ect i o n s . I O U S pro­ v i d e s i m p o rt a n t i nfo r m a t i o n a bo u t vo l u m e of so l i d necrosis. The surgeon s h o u l d review recent cross-sect i o n a l i m a g e i m m ediately before operat i n g; this is a g o o d " road m a p " d i rect i n g debridement as we l l as to refresh m em o ry of d a n g e r spots. Specific attention s h o u l d be paid to the re l ationsh i p of necrosis to the superior m esenteric and porta l ve ins. A moderate a m o u nt of oozing from the d i ffuse i n f l a m ­ matory p rocess is co m m o n . l n fraco l i c adhesio ns, p a rticu­ l a rly to the u n d e rs u rface of the tra nsverse m esoco lon, are q u ite co m m o n; these s h o u l d be d ivided with ca refu l b l u nt d i ssection as we l l as sharp d i ssect i o n . The gastroco l i c l i g a ment s h o u l d be d ivided. The i n ­ f l a m m atory response co m m o n ly foreshortens the gas­ troco l i c l i g a ment and atte ntion s h o u l d be paid not to i nj u re either the gastroe p i p l o i c vessels o r the tra nsverse colon wa l l . Lesse r sac necrosis is a lways more cra n i a l than it may see m . If necrosis extends down the paraco l i c g utters, these pro­ vide a reaso n a b l e and safe point of entry i nto the retro­ perito n e u m . Debridement s h o u l d prog ress from l atera l to m e d i a l , paying speci a l care to the known position of the superior mesenteric ve i n a n d porta l ve i n a ro u n d the pancreatic head (FIG 4). Catastro p h i c h e m o rr h a g e m a y occ u r from i n a dvertent v i g o r o u s d e b r i d e m e n t in t h e a rea of the s u p e r i o r m es­ enteric vei n/p o rt a l ve i n (SMV/PV) . The wa l l of the ve i n i s weak from t h e i n fl a m m atory p rocess. Proxi m a l a n d d i sta l vascu l a r control i s c h a l l e n g i n g beca use o f t h e i n ­ fl a m m atory p rocess a n d i n a desperate c i rc u m st a n ce, a p p ly i n g a long stra i g ht vascu l a r c l a m p across t h e porta hepatis a n d root of the s m a l l bowe l mesentery may be a l ife-sa v i n g m a n e u ve r, a l l ow i n g time to l i gate t h e S M V/PV. It is i m po rtant to release the colic flexu res to provide fu l l exposure o f t h e upper retro perito n e u m . Samp les o f t h e peri pancreatic col lection a r e com m o n ly sent for Gram sta in, aerobic, anaerobic, and fu ngal cultu res.

•

•

The best tool for d e b ri d i n g pancreatic necrosis is the experie nced s u rgeon's "ed ucated fin g e r. " A r i n g forcep a lso is a n exce l l ent i nstrument. It is critica l to o n ly take the necrosis that is free ly m o b i l e . Vigorous debridement of i m mature necrosis, p a rticu l a rly a l o n g the a rea of major vei ns, i s fra ught with hazard. A reaso n a b l e a p p roach is to debride one fi eld at a time a n d to pack that a rea before m ovi n g onto the next a rea of debridem ent. For exa m p l e, debride the l eft paraco l i c g utte r, then p a c k t h i s a rea w i t h l a p a rotomy sponges, a n d t h e n m ove i nto the lesser s a c o r other a reas i n a stepwise fash i o n . Oozing from the retroperito n e u m i s very com­ m o n; h oweve r, the vast majo rity of t h i s b l eed i n g w i l l stop with a short period of tamponade.

__ _ ....: :... ::_ _..:

Transverse colon

FIG 4 • If necrosis extends down the right p a raco l i c g utter, (1) t h i s route provi des safe access to the retro perito n e u m . W h e n d i v i d i n g the gastroco l i c l i g a ment (2), atte ntion s h o u l d be focused t o preserv i n g the gastroe p i p l o i c vessels a n d avo i d i n g tra nsverse c o l o n i nj u ry. T h e asterisk h i g h l i g hts t h e d a n g e r z o n e with u n derlying SMV/PV.

869

870

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

FIG 6 • I ntraoperative p h otog ra p h showing densely i nflamed g a l l b l a d der/r i g ht u p p e r q u a d ra nt (arrows) i n the sett i n g of b i l i a ry acute N P. FIG 5 • I ntrao perative photog ra ph of right tra nsverse m esoco lon vesse ls skeleton ized by adjacent necrosis (arrow). The tra nsverse co lon is reflected cra n i a l ly i n the surgeon's h a n d .

Enteral Access •

•

•

Vigorous i rrigation of the retro perito n e u m h e l p s d is­ lodge sma l l vo l u m e necrosis. It is com mon to see skeleton ized vessels both in the m esoco l o n as we l l as the retro perito n e u m . These are q u ite f r i a b l e; it i s preferable to l i gate these vessels if any q u estion a bout t h e i r i ntegrity exists. M a n y of these are a l ready throm bosed (FIG 5) .

Cholecystectomy •

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•

•

C h o l ecystectomy may be perfo rmed at t h i s p o i nt in the proced u re if i n d icated a n d if the patient is p hysi o l o g i ca l ly sta b l e . Obviously, the decision to perfo rm cholecystec­ tomy is a j u d g ment ca l l . A patient who i s septic, req u i r i n g vaso pressor s u p p o rt d u ri n g debridement, is n o t the idea l ca n d i d ate for a chol ecystectomy, which is typ i ca l ly not a stra ig htfo rwa rd p roced ure a n d may i nvolve su bsta ntia l hemorrhage. C h o l ecystectomy is typ ica l ly perfo rmed in the retrograde fas h i o n . If the infl a m m ato ry process is too de nse, cho­ lecystectomy may be deferred, a lt h o u g h it s h o u l d not be a ba n d o ned and co m p l etely forg otten as a s i g n ificant n u m ber of patie nts (3 5 % ) w i l l have recurrent b i l i a ry sym ptoms (either chol ecystitis or pan creatitis) if chol ecys­ tectomy i s not performed with i n the n ext seve ra l m o nths. I n the sett i n g of a densely i nflamed r i g ht u p p e r q u a d ­ ra nt, su btota l chol ecystectomy (Th orek's procedu re) is a cce pta b l e (FIG 6) . C h o l a n g iography s h o u l d be perfo rmed for a l l patients with b i l i a ry pancreatitis. Co m m o n b i l e d u ct exp loration is potent i a l ly q u ite hazardous i n t h i s situation a n d expe­ rienced j u d g ment s h o u l d be sought before u n d e rta k i n g common d uct exploration i n the sett i n g o f N P. H owever, documenting the presence of c o m m o n b i l e d u ct sto nes i s i m porta nt to d i rect further m a n a g e m ent.

•

•

M a ny patie nts with retroperito n e a l necrosis have gastric i l eus a n d/o r sma l l bowe l i l e us. Our p refe rence i s to p l ace gastroj ej u n osto my feed i n g tu bes l i bera l ly (FIG 7) . This tube i s easy to p l ace and perm its deco m p ression of the stomach and feed i n g d i stal to the l i g a ment of Treitz to provide enteral n utrition in the i m m ediate postoperative period. The tube is then easily rem oved i n the office once the patient has recuperated co m p l etely. The gastrosto my tube is p l aced in the a nterior body i n t h e fash i o n o f Sta m m . The stomach s h o u l d be tacked securely to the a nte rior a bdom i n a l wa l l with h eavy suture to permit re p l acement of the gastrojej u n osto my tube should d i s l od g e m e nt occ u r.

FIG 7 • Gastrojej u n ostomy fee d i n g tube perm its feed i n g downstrea m o f l i g a m ent o f Tre itz w h i l e s i m u lta neously deco m p ress i n g the sto m a c h .

C h a p t e r 49 PANCREAT I C D E B R I D E M E N T

Drains • •

•

Debridement beds are d ra i ned wide ly. O u r p reference is to use cl osed sucti on l a rge-ca l i ber ( 1 9 mm) d r a i n s (FIG 8) . Th ree-way d r a i ns, although attractive i n theory, are extre mely c h a l l e n g i n g to m a n ­ age i n the i ntensive c a r e u n it a n d on the hosp ita l ward . If d isco n n ected pancreatic d u ct is suspected a n d extern a l d r a i n a g e e m p l oyed, it i s critica l to m a i nta i n t h i s d r a i n , which contro ls the fist u l a exte r n a l ly.

Abdominal Closure •

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•

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The fasci a is m ost often a b l e to be cl osed p r i m a ri ly, a l ­ t h o u g h the operator s h o u l d p a y cl ose atte ntion to t h e p e a k a i rway p ressu res a t the t i m e o f closure. The need for true rete ntion sutu res is u n u s u al; how­ ever, a co m b i nation of ru n n i n g a n d i nterru pted slowly reabsorba b l e m o n ofi l a m e n t sutu res seems prudent. The i ncidence of ventra l hernia after open pan creatic debridement i s su bsta ntia l (42% ) . T h e s k i n is typica l ly left open t o close b y secondary i ntention .

T RANSGASTRIC NECROSECTOMY •

Tra nsgastric necrosectomy may be a p p roached l a pa­ rosco p i ca l ly o r through a short upper m i d l i n e i n cision (FIG 9) . This tech n i q u e i s sel ectively a p p l i ed to patients with necrosis isol ated i n t h e lesser sac; it m a y be p a rticula r ly effective for patients w i t h a d isco n n ected pan creat ic ta i l . C l i n ic i a n s s h o u l d be aware that necrosis exte n d i n g d o w n the sma l l bowel mesenteric root or paraco l i c g utter may not be a p p ropriate for this tech n i q u e .

F I G 8 • Larg e-ca l i be r cl osed suction d r a i n s typica l ly p rovi de adequate drainage of necrosis bed if thorough debridement is ach i eved . D ra i n s are p l a ced a bove the tra nsverse colon; sto mach is retracted cra n i a l ly.

I O U S is a critica l adj u n ct, especia l ly if the majority of the necrosis is so l i d as o p posed to l i q u i d . U ltraso u n d s h o u l d be a p p l ied t h r o u g h the front wa l l of the sto mach a n d p a rticu la rly t h r o u g h the b a c k wa l l o f the sto mach to h e l p loca l i ze poste rior gastrotomy (FIG 1 0) . The s u rgeon s h o u l d be aware of the potent i a l for hem­ orrhage from va rices i n the gastric wa l l i n the sett i n g of l eft-sided (si n istra l) porta l hyperte n s i o n . Stay sutu res in the posterior gastric wa l l a re extremely h e l pf u l i n the l a p a rosco p i c a p proach, del ive r i n g t h i s

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A

B

FIG 9 • A. D i a g ra m show i n g port p l acement f o r l a p a rosco p i c tra nsgastric debridem ent. B. Posto perative photog ra p h : even with heavy body h a b itus, open transgastric debridement may be a c h i eved through a short (6 em) upper m i d l i n e i n c i s i o n .

871

872

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

A

FIG 1 0 • I O U S is critica l, p a rticu l ar l y in the l a p a rosco pic a p p roach.

•

open i n g i nto the ope rative f iel d (FIG 1 1 ) . Wide poste­ rior gastroto my is created either with ca utery or a l i n ear sta p l i ng device. The poste rior gastroto my is sutu red to the cyst with permanent suture. This a i d s i n hem ostasis as we l l as i n d u ra b l y m a i nta i n i n g t h i s osto my. G e ntle debridement a n d copious i rrigation are a p p l ied. The cond uct of debridement is s i m i l a r to that i n the open situation (FIG 1 2) . Anterior gastroto my is cl osed with suture or sta p l e r (FIG 1 3) . Ofte n, the sto mach i s thick a n d sutu r i n g pro­ vides a more secu re closure.

FIG 11 • I ntraoperative photog ra p h show i n g anterior gastroto my a n d l a rge posterior cystogastrosto my. N ote stay sutu res on poste rior gastric wa l l .

B FIG 1 2 • I ntrao perative photog ra phs of l a p a rosco p i c transgastric debridem ent. A. Camera i s i n necrosis cavity. B. After debridement. Long arrow shows d isco n n ected pancreatitis ta i l ; short arrows show s p l e n i c a rte ry.

FIG 1 3 • Anterior gastrotomy may be cl osed with suture o r sta p l e r (shown).

C h a p t e r 49 PANCREAT I C D E B R I D E M E N T

•

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If gastrosto my or g a strojej u n osto my feed i n g tube i s i n d i cated, p l a c i n g t h i s p r i o r to c l o s i n g the a nterior gastroto my affo rds visu a l ization of the tube pass i n g t h ro u g h the d u o d e n u m . Ca re s h o u l d be t a k e n to p l a ce the gastrostomy at a d ista nce away from the g a stroto my c l o s u re site. N o drains a re necessa ry with tra nsgastric necrosectomy. C h o l ecystectomy a n d c h o l a n g iography may be performed if i n d icated.

873

Distal Pancreatectomy + I - Splenectomy •

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I n the sett i n g of major body necrosis with a very sma l l a m o u nt o f v i a b l e pancreatic ta i l , t h e s u rgeon m a y con­ sider d i sta l pancreatectomy at the time of operative debridem ent. This s h o u l d be reserved for h i g h ly sel ect cases. It is a l most a lways n ecessa ry to perform splenec­ tomy in t h i s sett i n g d u e to the s i g n ificant i n fl a m m atory response a n d frequent i ncide nce of gastric varices. Preoperative e m b o l ization of the s p l e n i c a rtery s h o u l d be co nsidered i n t h i s c l i n ica l sce n a r i o .

PEARLS AND PITFALLS S u rg i c a l decision m a k i n g

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Operative tech n i q u e

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Posto perative care

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N P i s a n extre mely heterog eneous d isease. Appropriate treatment m ust be based o n the u nderlying necrosis a n atomy as we l l as the patie nt's genera l cond iti o n . I d e a l ly, treatment decisions a re made i n t h e context o f m u ltid isci p l i n a ry revi ew. Defi n itive i nte rve ntion s h o u l d not be a p p l i ed before 4 weeks' t i m e . S h o u l d i nfection occur before 4 weeks' time, percuta neous d ra i nage is t h e m ost appropriate i nterventio n . K e e p i n m i n d the potent i a l for colon isch e m i a at a ny p o i nt i n the cou rse of t h i s d i sease. If forced t o operate (to p rove o r exc l u d e c o l o n ische m ia) p r i o r to 4 weeks, wide d r a i n a g e o f i m m a t u re necrosis is p referred to attem pts at d e b ri d i n g i m mature necrosis. I n the sett i n g of d i sconn ected pa ncreatic ta i l , the tra nsgastric a p p roach may be most a p p ro p r i ate. Alternative ly, d i stal p a ncreatectomy plus s p l e n ecto my may be co nsidered i n h i g h ly sel ect patients. Be aware of the potent i a l fo r viscera l a rte r i a l pseudoa n e u rysm . When m a n u a l ly debrid i n g pancreatic necrosis, o n ly ta ke t h e necrosis that comes easi ly. In b i l i a ry p a ncreatitis, chol ecystectomy a n d c h o l a n g iography s h o u l d be pe rfo rmed if tech n ica l l y poss i b l e at t i m e o f debridem ent. C h o l ecystectomy may be hazardous a n d c l i n ical j u d g ment reg a rd i n g exte nt of operation is i m porta nt here. Do not be afra i d to reope rate if the patient is not fo l l owi ng the expected co u rse. It i s i m portant to reg a i n control of a poorly contro l l ed or u ncontro l led p a ncreatic fistu l a . It i s a lso i m po rtant to exc l u d e isch e m i c co l itis i n the early posto pe rative p e r i o d fo l l owi n g the fi rst debridem ent.

POSTOPER ATIVE CARE •

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Optimal nutrition support is critical for expedient recupera­ tion. Oftentimes, this requires some combination or paren­ teral and enteral nutrition. While recognizing the crucial importance of enteral alimentation, the surgeon should be cognizant of small bowel and gastric ileus that are very com­ mon in the setting of NP and postdebridement. Increasing tube feeding volume too rapidly may be detrimental. Aggressive physical rehabilitation is also critical. Early plan­ ning for discharge to an extended-care treatment facility is prudent; direct communication with health care providers at these facilities is important to maintain the continuity of care. Venous thromboembolism is common occurrence in the setting of NP. Patients should be observed carefully and pos­ sibly screened with ultrasound on a regular basis. Bright red blood in the surgical drain should be considered visceral arte­ rial pseudoaneurysm until proven otherwise. Often, a small amount of blood is from retroperitoneal venous hemorrhage; however, visceral arterial pseudoaneurysm is a potentially lethal problem that should not be missed. Cross-sectional

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imaging with computed tomography angiography ( CTA) is rapid and widely available; CTA is an excellent first-line test with which to diagnose or exclude pseudoaneurysm. Appropriate duration of antibiotic treatment after satisfac­ tory source control is important. However, no clear data exist to inform this treatment decision. Antibiotic treat­ ment of no shorter than 7 days should be employed. We have tried to cut down antibiotic treatment and had recur­ rent retroperitoneal infected collections. It is noteworthy that retroperitoneal collections infected with resistant bac­ teria and yeast are extremely hard to clear. Consideration should be given to extended-duration antibiotic treatment in these cases. The patient should be observed for the presence of external pancreatic fistula. Measurement of amylase and surgically placed drains will diagnose this condition. Enterocutaneous fistulas may occur. These should be managed in a similar fashion to enterocutaneous fistulas developing from other conditions. Duodenal fistula is extremely chal­ lenging. Percutaneous transhepatic drainage with diversion of the biliopancreatic secretion will occasionally allow these fistulas to close with nonoperative management.

874

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

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FIG 14 • M R I 2 years afte r transgastric debridement showing d i l ated main a n d side branch pancreatitis d ucts (short arro ws) in the d isco n n ected ta i l . The eti o l ogy of t h i s patie nt's pan creatitis was the side-branch I P M N (long arrow).

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Patients dismissed from the hospital with controlled external pancreatic fistula and/or supplemental enteral and parenteral nutrition should have early and frequent postoperative fol­ low-up. Patients who fail to progress as expected should have early cross-sectional imaging. Additional percutaneous drainage or reoperation may be necessary to regain control of an un­ controlled pancreatic fistula. Long-term follow-up is crucial for patients undergoing transgastric debridement, as long-term outcomes from this relatively new approach are unknown. A small number of patients will manifest recurrent pancreatitis ( FIG 1 4) or re­ current retroperitoneal fluid collections (pseudocyst) after transgastric debridement.

OUTCOMES •

Mortality after pancreatic debridement in contemporary se­ ries ranges from 5% to 1 0 % at specialized centers. Although this mortality is relatively high, this represents substantial improvement from historical mortality figures and is likely

•

most related to improved operative selection. Patients and family members should be educated from the start of this disease process that NP is a long-term problem and that even in the best of circumstances, patients should expect a recu­ peration period measured in months. In general, reports of long-term outcomes for patients with NP and operative debridement are scarce. Ideally, patients will have long-term follow-up with primary physician and/or gastroenterologist attentive to exocrine and endocrine functions as well as digestive function. A small number of patients with NP will have intraductal papillary mucinous neoplasm (IPMN) or pancreatic adeno­ carcinoma as the cause. Unfortunately, prognosis in this sub­ group of patients is uniformly poor. A small subgroup of patients with NP is too well to die but too sick to recuperate with reasonable quality of life. This is an extremely challenging group of patients to care for. How­ ever, in a highly select number of these patients, hospice care may be appropriate. These patients, for example, have pro­ tracted immobilization, protracted organ failure, and unre­ constructable enteric fistulas. A highly select number of patients may be candidates for intestinal or multi visceral transplant. Obviously, this is deci­ sion making that must be undertaken in conjunction with the organ transplant group.

COMPLICATIONS •

Complications after pancreatic necrosectomy may be related to disease progression or operation. Table 2 highlights these complications.

Table 2 : Compl i cations of Necrotizing Pancreatitis

Short-Term

Long-Term

Pancreatic fistu l a (particularly with disruption of the main pan creatitis d u ct) C o l o n i c isch e m i a

Recurrent retroperito neal coll ections/ i nfection

Ve n o u s thromboembolism E nteric fistu l a Viscera l arte r i a l pseud o a n e u rysm

B i l e d u ct or d u o d e n a l obstructi o n f r o m stricture Exocrine and endocrine i n suffi ciency C h ro n i c p a i n Recurrent a c u t e p a n creatitis prog ress i n g to chronic p a n creatitis i n the remnant pancreas Ventra l hernia

I

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Chapter

50

Laparoscopic Pancreatic Debridement 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ....

0. Joe Hines

DEFINITION •

•

•

Laparoscopic pancreatic debridement is a minimally inva­ sive technique for pancreatic resection and is indicated in the case of infected pancreatic necrosis as a result of acute pancreatitis. Additional options for pancreatic necrosec­ tomy include laparotomy as well as other minimally invasive methods such as percutaneous catheter drainage and endo­ scopic drainage. Methods of laparoscopic debridement will be the focus of this chapter.

Differential Diagnosis •

Ka thleen Hertzer

The differential diagnosis of acute pancreatitis includes bili­ ary colic, peptic ulcer disease, cholecystitis, acute mesenteric ischemia, small bowel obstruction, visceral perforation, vas­ cular catastrophes such as ruptured aortic aneurysm, as well as intraabdominal infection. In the setting of recent, severe acute pancreatitis, character­ istic CT findings and patient history and physical findings are strongly supportive of infected versus sterile pancreatic necrosis, pancreatic abscess, or pancreatic pseudocyst.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

•

•

Acute pancreatitis has a broad range of clinical symptoms. The maj ority of cases can be mild and self-limiting; however, about 2 0 % of these patients will develop severe acute pan­ creatitis and among these patients, approximately 3 0 % to 70% will develop infected necrosis.1 Severe acute pancreatitis is associated with high mortal­ ity and morbidity; these patients are at risk for infection, multisystem organ failure, and death. Secondary infection of pancreatic necrosis occurs by bacte­ rial or fungal translocation through the GI tract or by seed­ ing through transient bacteremia from invasive monitoring in the intensive care setting. Infection of pancreatic necrosis can occur as early as 10 days after the onset of acute pancreatitis. More typically, infec­ tion ensues 3 to 6 weeks after the initial onset of symptoms. Patient history and physical examination for pancreatitis and pancreatic necrosis include a recent history of acute pan­ creatitis and continued abdominal pain, chronic low-grade fever, nausea, lethargy, and inability to eat. Those patients with infected pancreatic necrosis will show signs of intraab­ dominal infection including tachycardia, hypotension, fever, and deteriorating organ function. Conservative management is recommended in the case of sterile necrosis. Surgical management can be considered in symptomatic sterile necrosis; not infrequently, occult infec­ tion proves to be present. In the setting of clearly infected pancreatic necrosis, debridement or drainage is the preferred method of treatment.

Methods for debridement include open necrosectomy and multiple minimally invasive modalities, including laparo­ scopic debridement. Minimally invasive necrosectomy is technically achievable and although there is evidence that a step up minimally invasive technique (percutaneous drain­ age with or without following retroperitoneal necrosectomy) may reduce morbidity and mortality amongst patients with infected necrotizing pancreatitis, it is unclear if minimally invasive techniques are cost effective. 2 •3

•

Plain radiographs are nonspecific. Ultrasound (US) may show a diffusely enlarged, hypoechoic pancreas and can be important in identification of the etiology of pancreatitis (e.g., gallstones ) . Appropriate imaging for acute pancreatitis includes contrast­ enhanced computed tomography ( CT) scan when complica­ tions are clinically suspected. Complications of pancreatitis evolve with time and impending necrosis may not be ap­ preciated on CT imaging obtained within the first 24 to 48 hours of symptoms. CT imaging in the case of mild acute pancreatitis will show pancreatic enlargement, edema, peri­ pancreatic fat stranding as well as effacement of the normal contours of the organ. In the setting of pancreatic necrosis, IV contrast can help delineate areas of poor perfusion as well as the extent of necrosis and can be used to predict the severity of disease. Visualization of air bubbles within necrotic tissue is diagnos­ tic of infection (FIG 1 ) .

F I G 1 • I n fected p a ncreatic necrosis. C T sca n show i n g a hypoe n h a n c i n g pan creas, i n d icat i n g necrosis, with gas b u b b les i n d icat i n g bacte r i a l i nfection of the necrotic m ateri a l . This is l i kely necrosis m ixed with peri pan creatic p h l e g m o n .

875

876

P a r t 3 OPERATIVE TECH NIQUES IN HEPATO-PANCREATO-B I LIARY SURGERY

Table 1 : Computed Tomography Grading System

•

of Acute Pancreatitis

Findings

Grade A 8

Score

Normal pan creas Foca l o r d iffuse e n l a rgement of the p a ncreas, i rreg u l a r organ conto u r Peri pan creatic infl a m m ation w i t h intrinsic pancreatic a b n o r m a l ities Fluid coll ections either i ntra p a ncreatic o r extra pancreatic Two or more large co l l ections of gas i n the pa ncreas o r retroperito n e u m

c

D

0 1

4

Commonly, the Atlanta classification is used to divide acute pancreatitis into mild and severe categories. The criteria for severe acute pancreatitis include the following: a Ranson's score of 3 or greater, an APACHE II score of 8 or greater within the first 48 hours, organ failure, or local complications (necrosis, abscess, or pseudocyst involving the pancreas) . Other predictors o f disease severity within the first 2 4 hours of hospitalization include a C-reactive protein of greater than 120 mgldL, procalcitonin greater than 1 . 8 ng/mL, and a he­ matocrit greater than 44.5

SURGICAL MANAGEMENT

Preoperative Planning • •

•

•

The grading of severity of pancreatitis can be classified into five categories (Table 1 ) and a CT severity index can be cal­ culated based on the grading of unenhanced CT findings and the percentage of necrosis demonstrated on contrast­ enhanced CT (Table 2 ) . The CT severity index is the sum of the unenhanced CT score and the necrosis score where the maximum is 10 and greater than or equal to 6 indicates severe disease.4 If infected pancreatic necrosis is suspected, the diagnosis is confirmed with culture results from CT-guided fine nee­ dle aspiration (FNA) or from specimens collected during necrosectomy. FNA and culture should be obtained in patients who show clinical features of sepsis or those with a deteriorating clini­ cal course 1 to 2 weeks after the onset of disease.

•

•

•

Table 2 : Necrosis Score

% Necrosis

Score

0 50% s u rface a rea or expa n d i n g ; ruptu red subcapsu l a r or pa renchym a l hematoma; i ntra p a renchym a l hematoma > 5 em or expa n d i n g > 3 em parenchym a l d e p t h o r i nvolvi n g trabecu l a r vessels Laceration i nvolving seg mental o r h i l a r vesse l s prod ucing major devasc u l a rization ( > 2 5 % of spleen) C o m p l etely sh attered spleen H i l a r i n j u ry with devascu l a rized spleen

Laceration

Ill

H e m atoma

Laceration IV

Laceration

v

Laceration Vasc u l a r

Adapted from Moore EE, Cogbill TH, Jurkovich GJ, et a/. Organ injury scaling: spleen and fiver (1 994 revision). J Tra u m a . 1 995;38(3)323-324

900

•

•

Sa leem Islam

all current medications and allergies. Particular attention should be directed to eliciting any symptoms of liver disease, clotting or bleeding disorders, and a blood product transfu­ sion history. Patients presenting with splenic trauma require rapid assess­ ment making use of the principles outlined in the American College of Surgeons Advanced Trauma Life Support (ATLS®) protocol. Hemodynamic instability is a general contrain­ dication to splenorrhaphy. A thorough history should be obtained as outlined earlier. Particular attention must be paid to associated injuries as these will influence decisions regarding nonoperative management (NOM) , splenorrha­ phy, or splenectomy ( FIG 1 ) . In pediatric patients, NOM is the preferred treatment choice and early consultation with a pediatric surgeon is highly recommended. Adult trauma pa­ tients with low-grade splenic injuries may be managed with NOM (Table 2 ) . Patients presenting with hemoglobinopathies have abnor­ mal laboratory profiles and often present with abdominal pain/discomfort, a history of jaundice, or splenomegaly. Rarely, patients will be completely asymptomatic. Patients with HS often present with sequestration of abnormal red blood cells (RBCs) and may have splenomegaly.2•3 Histori­ cally, these patients benefited from splenectomy. Recently, clinical evidence demonstrates that patients with HS are amenable to partial splenectomy (PS), eliminating the need for repeat transfusions and significantly reducing the risk of overwhelming postsplenectomy infection ( OPSI ) . Addition­ ally, patients with sickle cell anemia have shown improve­ ment following PS.2-4 A complete and thorough physical examination should be performed on all patients. The presence or absence of sple­ nomegaly should be noted. All signs of portal hypertension or liver failure should be elicited. Presence or location of surgical scars must be considered prior to determining op­ erative approach. Splenorrhaphy is best performed via an open technique, which allows full visualization of the injury. An open ap­ proach allows easy conversion to a splenectomy should the clinical situation warrant this. Elective PS may be performed via an open or laparoscopic technique. Laparoscopic PS re­ quires substantial experience in minimally invasive surgery and therefore, we prefer an open or a laparoscopic-assisted technique.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

All patients with a suspected or known hemoglobinopathy require input from a hematologist. Patients should have a blood smear and/or bone marrow analysis, a complete blood count (CBC), and specialized blood studies as indicated by the disease process. Computed tomography ( CT) scanning should be performed for all hemodynamically stable patients with suspected splenic trauma. CT is an excellent modality for preoperative

C h a p t e r 5 3 S P L E N O RRHAPHY

• •

• •

•

• • •

•

•

Nonoperative management (NOM) (see Table 2) Capsule sutures Omental patch Electrocautery/argon beam coagulator Tapical hemostatic agents o Absorbable gelatin sponge o Fibrin sealants Embolization with interventional radiology (IR)

901

Concurrent abdominal injury Significant neurologic/orthopedic or life­ threatening injuries Hemodynamic instability AAST grade V

Consider partial splenectomy (PS)

Failure to control bleeding

FIG 1 • Treatment a l gorithm fo r s p l e n i c i nj u ry o ut l i n i n g various opti ons based on g rade of i nj u ry. AAST, American Association for the S u rg e ry of Tra u m a .

•

planning t o evaluate injury extent and t o delineate vascular anatomy. CT is recommended for elective PS to determine the relationship of the spleen to adj acent organs, splenic size, and potential locations of accessory spleens ( FIG 2 ) . Ultrasound (US) i s a noninvasive imaging modality t o as­ sess for splenomegaly, presence of splenic cysts/masses, and determination of portal hypertension in selected patients. US

Tab l e 2: Criteria and Contra indications to

•

Nonoperative Management for Splenic I nj u ry

Criteria for Nonoperative management (NOM) o o

o o o o

Hemodynamic sta b i l ity No additional comorbid i n j u ries (e. g . , head i n j u ry, s i g n ificant orthopedic tra u m a ) L i m itation of s p l e n i c-related b l o o d transfusion (52 u n its) CT scan documenti n g s p l e n i c i n j u ry and g rade Absence of active i ntrasp l e n i c bleed i n g o n CT Absence of other i ntra a bd o m i n a l inju ries o n CT req u i r i n g operative inte rvention

SURGICAL MANAGEMENT

Preoperative Planning •

Contra indications for NOM o

o o o o o o

H e m odyn a m i c insta b i l ity :±: perito nitis Associated intra a b d o m i n a l/retroperitoneal organ i n j u ry I n a b i l ity to perform re l i a b l e serial abdo m i n a l exa ms N eed for a nticoag ulation I n a b i l ity to correct coa g u l o pathy O n g o i n g blood transfusion req u i rement AAST grade V s p l e n i c i n j u ry •

o; computed tomography; AAST, American Association for the Surgery of Trauma.

is particularly useful in assessing the spleen in children with the added advantage of minimizing ionizing radiation expo­ sure. In the evaluation of trauma patients, focused abdomi­ nal sonography for trauma (FAST) is an accepted screening tool to diagnose intraperitoneal fluid or blood. Preoperative US should be performed for all patients with symptomatic biliary colic and patients with hemoglobinopathies to evalu­ ate for cholelithiasis. Patients with cholelithiasis should be considered for concurrent cholecystectomy. Magnetic resonance imaging (MRI) is a recognized method for evaluating splenic lesions without the use of ionizing radia­ tion. MRI is not recommended in the setting of splenic injury.

Patients undergoing PS for elective indications should receive vaccinations for encapsulated organisms (Haemophilus in­ fluenzae B, Streptococcus pneumoniae, and Neisseria men­ ingitidis) 2 to 4 weeks prior to surgery. Although PS should theoretically eliminate the risk of 0 PSI, vaccinations should be administered in the event that a total splenectomy is performed. Patients undergoing PS in the setting of splenic injury should receive vaccinations 2 to 4 weeks postopera­ tively. Current guidelines for OPSI prevention are outlined in Part 3, Chapter 52, Table 2 . Blood products should be ordered a n d available intraopera­ tively including packed red blood cells (PRBCs) , platelets, and fresh frozen plasma (FFP ) .

902

P a r t 3 OPERATIVE TECHNIQUES I N HEPATO-PANCREATO-BILIARY SURGERY

A

B

c

D

FIG 2 • CT sca n of s p l e n i c laceration (A,B) a n d s p l e n i c cyst (C,D) . A. CT demo nstrati n g isol ated i n j u ry to the spleen (white arro w) from b l u nt abdom i n a l tra u m a with hem o perito n e u m . N ote the proxim ity to the s p l e n i c a rtery (SA) . B. CT from same patient demo nstrati n g extent o f s p l e n i c i n j u ry (white arro w) exten d i n g t o i nfe rior p o l e . N ote the p roxi m ity o f the s p l e e n to the ta i l o f the p a ncreas (P). C. CT demo nstrati n g a l a rge s p l e n i c cyst (SC) co m p ress i n g n o r m a l s p l e n i c p a renchyma (white arrow). The cyst is compress i n g the sto mach (St) . D. CT i m a g e from same patient d e m o nstrati n g the re l ationsh i p of the SC to the SA. This patient u n d e rwent successf u l l a p a rosco pic PS with preservati o n of n o r m a l s p l e n i c parenchyma. Large white arrow, s p l e n i c laceration; narrow white arrow, n o r m a l spleen.

•

•

•

•

•

•

All patients should receive prophylactic antibiotics to cover skin flora within 60 minutes prior to the skin incision. Appropriate antithrombotic precautions should be insti­ tuted, including sequential compression devices (SCDs) for all patients age 12 years and older. Appropriate anticoag­ ulation medications (e.g., low-molecular-weight heparin) should be administered preoperatively per hospital protocol. A nasogastric tube (NGT) should be inserted following in­ duction of anesthesia to decompress the stomach and aid in visualization. Consideration should be given to leaving the NGT in situ for 24 to 48 hours postoperatively to prevent gastric distension. An open approach is recommended for patients undergo­ ing splenorrhaphy for splenic inj ury. The human hand as a retractor to provide compressive hemostasis is invaluable in the successful performance of PS. This approach also pro­ vides good exposure and allows for possible splenectomy should attempts at splenorrhaphy prove unsuccessful. PS may be performed by a laparoscopic approach in the elec­ tive setting. Laparoscopic PS requires advanced laparoscopic skills and should only be undertaken by a surgeon familiar with the procedure. In adult splenic trauma patients, consideration should be given to preoperative splenic artery embolization ( SAE) by interventional radiology. SAE has been demonstrated

to improve the use of NOM, with improvement in splenic salvage, length of hospital stay, and mortality.5 Pediatric patients with splenic trauma rarely require embolization and consultation with a pediatric surgeon is highly recom­ mended before treatment with SAE is commenced.6

Positioning •

•

For open splenorrhaphy, patients are placed in a supine po­ sition with both arms extended. For patients with isolated splenic trauma, an upper midline incision from the xiphoid process to the umbilicus allows adequate exposure. This in­ cision can be extended inferiorly if additional exposure is required or other intraabdominal injuries are identified. For pediatric patients, a left subcostal incision or a transverse in­ cision starting at the left 1 2th rib tip can be used (see Part 3 , Chapter 5 2 , FIG 5 ) . Patients undergoing laparoscopic PS can b e positioned supine with both arms tucked at the side. A beanbag or kidney rest is placed under the left flank to increase exposure between the 1 2th rib and iliac crest. The table may be rotated to allow near-supine positioning for port placement and then rotated during the operation to achieve a right lateral decubitus po­ sition. As with all operations, all pressure points should be appropriately padded (see Part 3, Chapter 52, FIG 4 ) .

C h a p t e r 53 S P L E N O RRHAPHY

SPLENORRHAP HY Incision •

A va riety of i ncisions can be used to perfo rm s p l e n o rrha­ phy depend i n g on the c l i n ical situat i o n . • Tra u m a p a t i e nts. A m i d l i n e i n c i s i o n exte n d i n g from t h e x i p h o i d p rocess to t h e p u b i s i s used t o enter t h e perito n e a l cavity. T h i s i n c i s i o n a l l ows m a x i m a l expos u re . A q u i c k t h o r o u g h i n spect i o n of each q u a d ra nt a n d t h e p e l v i s s h o u l d b e p e r­ fo r m e d . Act ive b l e ed i n g s h o u l d be i m m e d iately a d d resse d . Retract o rs s h o u l d b e p l aced to maxi­ m i ze visu a l i z a t i o n and dete r m i n e i f a d d i t i o n a l so u rces of b l e ed i n g are present. A l l fl u i d a n d p a rt i c u l ate m atte r s h o u l d be q u i c k l y eva l u ate d . A d d i t i o n a l a b d o m i n a l/retro p er ito n e a l l n J u nes d i scovered at t h e time of l a pa rotomy should be p r i o ritized and dealt with a s o u t l i n e d i n corre­ s p o n d i n g c h a pters. • Isolated s p l e n i c i n j u ry. A m i d l i n e i ncision exte n d i n g f r o m the x i p h o i d p rocess to the level o f the u m b i ­ l icus can be used . S h o u l d a d d i t i o n a l exposu re b e req u i red, the i n cision can be extended i nferio rly. Retractors are p l aced to a l low maxi m a l exposu re of the l eft u p p e r q u a d ra nt. If a s p l e n i c i nj u ry occurs w h i l e perfo r m i n g an upper ab d o m i n a l l a p a rosco pic p roced u re, consideration s h o u l d be made to con­ vert to a n open proced u re depe n d i n g o n the exte nt of the i n j u ry. For h i g h e r g rade i n j u ries (Am erican Association for the S u rg e ry of Tra u m a [AAST] g rades I l l a n d IV), a l eft su bcosta l i n cision can be made a p­ p roxi mately 3 em i nfe rior to the costal m a rg i n (see Part 3, C h a pter 52, F I G 5). • Ped iatric patients. A m i d l i ne i ncision ca n be used s i m i l a r to a d u lt patie nts i n the sett i n g of tra u m a . F o r isol ated s p l e n i c i n j u r i es, either a l eft su bcosta l i ncision or a tra nsverse i ncision can be used. For a transverse i ncision, the t i p of the 1 2th r i b is identi­ fied a n d the i n cision is exte nded m ed i a l ly to a l low for exposure of the s p l e e n .

Mobilization •

•

Anato m ical ly, the spleen resides su periorly a n d poste­ riorly in the l eft u p p e r a b d o m e n . For adequate assess­ ment of a s p l e n i c i nj u ry and successf u l splenorrhaphy, the spleen m ust be co m p l etely m o b i l ized by removi ng all perito n e a l a n d viscera l attac h m ents. This i n c l udes the s p l e n o p h re n i c attachm ents to the d i a p h ra g m , the sple­ noco l i c l i g a ment to the splenic fl exu re of the colon, the s p l e n o rena l l i g a m e nts, a n d the gastrosp l e n i c l i g a ment (see Part 3, C h a pter 52, F I G 6). The s p l e n o p h re n i c and s p l e n o rena l l i g a m ents a re avascu l a r a n d can be d ivided sharp ly. Conversely, the gastros p l e n i c l i g a ment (conta i n ­ i n g short gastric vesse ls) a n d the splenoco l i c l i g a ment req u i re caref u l attention to ensure exce l l ent h e m ostasis. Vessels i n these l i g a me nts should be l i g ated with ties o r a n energy-based sea l a nt device. D ivision of the l i g a m ents beg i n s fi rst with the s p l e n o­ co l i c l i g a m e nt, a l lowi ng the s p l e n i c fl exu re of the colon

•

•

•

•

to be m o b i l ized away from the spleen. Splenic m o b i l iza­ tion is further achieved by the operat i n g s u rgeon p l a c i n g t h e i r l eft h a n d poste riorly o n the spleen ( a l a pa roto my pad may i m p rove the g ri p) and rotati n g it a ntero m e d i ­ a l ly. This m a n e uver w i l l bette r expose the s p l e n o p h re n i c a n d s p l e n o rena l l i g a m e nts. O n ce the s p l e e n i s free o f these atta chme nts, it ca n be ca refu l l y m o b i l ized i nto the wo u n d . The gastros p l e n i c l i g a ment is then ca refu l ly di­ vided. Lapa roto my pads can be ca refu l l y p l aced poste ri­ orly to further a i d i n m o b i l izat i o n . D ivision of the l i g a m e nts s h o u l d be made 2 to 3 em from the spleen to avo i d i nj u ry to both the spleen and adja­ cent organs (i.e., pan creas). The ta i l of the p a n c reas extends to the s p l e n i c h i l u m i n m ost patients. Ca re m u st b e taken d u ri n g m o b i l i za ti on of t h e s p l e e n to avo i d iatrog e n i c i n j u ry. The ta i l of t h e p a n creas s h o u l d be f u l l y v i s u a l i zed, p a rti c u l a rl y as t h e s p l e e n i s rotated i nto t h e o p e rative fi e l d . The s p l e n i c a rtery a n d ve i n a re l ocated o n t h e s u p e r i o r b o r d e r o f t h e p a n creas a n d m u st be ca refu l ly i s o l ated to avo i d i n j u ry. Once the spleen is m o b i l ized from the retroperito n e a l atta chme nts, control of the h i l a r vesse ls can be q u ickly ach i eved if necessa ry to control b l eed i n g . Active b l eed­ i n g can be contro l led by d i rect com p ression of the h i l a r vessels between t h e s u rgeon's t h u m b a n d forefi nger. This m a n euver a l l ows for thoro u g h assessment of the extent of s p l e n i c i nj u ry. Note: F u l l s p l e n i c m o b i l ization may be u n n ecessa ry for sma l l isol ated i n j u ries (e. g . , capsu l a r tear) that occ u r i n ­ traoperatively a n d can be com p l etely visu a l ized. I n a l l oth e r situations, co m p l ete s p l e n i c m o b i l ization s h o u l d be performed.

Repair of Low-Grade Splenic Injuries (AAST Grades I and II) •

•

•

After m o b i l i z i n g the spleen, a thorough i nspection can occur to a l l ow co m p l ete assessment of the i nj u ry (see Ta b l e 1 and FIG 1 ) . If necessa ry, vascu l a r control ca n be o bta ined by compression of the h i l a r vessels as d i scussed e a r l i e r. G rades I a n d I I inju ries can genera l ly be contro l led by s i m p l e tech n i q ues i n c l u d i n g the fo l l ow i n g : • D i rect compression (fo r m i n o r capsu l a r tears < 1 em) • A p p l i cation of to pi ca l hem ostatic ag ents Absorba b l e gelatin sponge Absorba b l e oxi d i zed reg enerated ce l l u l ose F i b r i n sea l a nts • E l ectroca utery or argon beam coa g u l ator (ABC) (FIGS 3 and 7) • Absorb a b l e sutu res p l a ced in the capsu l e (i nter­ ru pted o r r u n n i n g) (FIGS 3 and 8) . For most l ow­ g rade i n j u ries, suture p l edgets a re not req u i re d . F o l l ow i n g repa i r, the i nj u ry s h o u l d be o bserved for 5 t o 1 0 m i n utes to ensure that b l eed i n g i s contro l led. Ongo­ i n g b l eed i n g may req u i re a co m b i nation of tech n i q ues l i sted e a r l i e r to repa i r the i nj u ry. O n ce the i nj u ry is con­ tro l led, the spleen is ca refu l ly retu rned to the l eft u p p e r abdomen.

903

904

P a r t 3 OPERATIVE TECHNIQUES I N HEPATO-PANCREATO-BILIARY SURGERY

Diaphragm Splenic vein Splenic artery

Splenophrenic ligament

�---::--- Capsular tear with sutures

1""1--t-:---� Sutures holding omentum in place

Omentum swung up from transverse colon

Splenic flexure

Omentum

FIG 3 • S p l e n orrhaphy tech n i q u e demo nstrating ( 1 ) use of i nterrupted sutu res for l i near capsu l a r tea r a n d (2) patch with omentu m m o b i l ized and rotated u pward. Sutu res a re p l aced i nto s p l e n i c caps u l e and around omentum to b uttress i nj u ry.

Repair of Moderate to High-Grade Splenic Injuries (AAST Grades ill and IV ) •

•

After complete mobil ization of the spleen, a thorough in­ spection is performed. The vascu lar supply of the spleen is ca refu l ly i nspected and if a n i nj u ry is present, PS may be pos­ sible if 20% or more of the spleen can be sa lvaged (FIG 1 ). If sign ificant injury to the splenic artery or vei n is present, then consideration for a splenectomy should be strongly consid­ ered (see Part 3, Chapter 52). Vascu lar control is achieved by com pression of h i l a r vessels as discussed earl ier. Devita l i zed tissue s h o u l d be debrided either sharply o r w i t h e l ectroca utery to hea lthy s p l e n i c tissue (FIG 4) . • Penetrat i n g vesse ls to a devita l i zed seg ment s h o u l d be l igated. If a l i ne of d e m a rcati o n is p resent, t h e s p l e n i c capsu l e can be i ncised w i t h e l ectroca utery. A l i near sta p l i n g device ca n be used to tra nsect a devita l i zed pole. • C l i ps can be a p p l ied to trabec u l a r vesse ls. Gentle compression of the cut of the edge of the spleen wi l l help control bleed i n g . • An ABC c a n be used t o a c h i eve hem ostasis. Alterna­ tively, m attress sutu res can be p l aced a l o n g the cut edge. Pledgets are reco m mended to p revent further capsu l a r d a m a g e (see FIGS 7 a n d 8) . • To p ica l h e m ostatic ag ents ca n be a p p l i ed a n d p res­ s u re h e l d with a l a p a rotomy pad for 1 0 m i n utes. Cont i n ued b l eed i n g wi l l req u i re a d d i t i o n a l hemo­ static agent a n d compress i o n .

Alternatively, omentum from the tra nsverse co lon can be swu n g u p a n d placed i n the s p l e n i c l aceration. M attress sutu res ca n then be p l a ced to co m p ress the edges a n d secure the omentum i n p l ace (FIG 3). He­ m ostatic mesh can be used i n p l ace of o m entu m . PS can be considered fo r seg m enta l i nj u ry a n d w i l l be d i scussed i n the fo l l owing text.

•

•

AAST Grade V Splenic Injuries •

S p l e norrhaphy is not i n d icated for AAST g rade V i n j u ries. Patie nts with these i n j u ries req u i re exped itious sple nec­ tomy (see Part 3, C h a pter 52).

Closure •

•

•

Once s p l e n orrhaphy has been successful, the spleen i s ca refu l ly i n spected to e n s u re hem ostasis. The spleen i s then ca refu l ly returned to the u p p e r l eft a b d o m e n . Ca ref u l i nspection of the a b d o m e n s h o u l d be u n d e rtaken by the s u rgeon a n d assistant s u rgeon i n depend ently to ensure a l l l a p a rotomy pads have been removed. A pre­ l i m i n a ry count should be s i m u lta neously performed. The a b d o m e n is then i rrigated to rem ove all b l ood clots. The a bdomen is then c l osed in the u s u a l fash i o n . D r a i n s i n the l eft u p p e r a bd o m e n a re u n n ecessa ry u n l ess there i s a suspected o r kn own i nj u ry to the ta i l of the pa ncreas. I n the sett i n g of a bdom i n a l tra u m a, a decision may be made to leave the a bd o m e n open, a l lowi ng for a " sec­ ond look" operation in 24 to 48 h o u rs.

C h a p t e r 5 3 S P L E N O RRHAPHY

Splenophrenic l igament

Diaphragm

Spleen Splenic vein Splenic artery

Fracture of spleen Ties on branches of splenic artery and splenic vein

FIG 4 • Division of spleen u s i n g electroca ute ry. A s p l e n i c fract u re of the lower pole i s present. B ra nches of t h e s p l e n i c a rte ry a n d ve i n h a v e b e e n l i g ated a n d d ivided with su bseq uent d e m a rcati o n of the avascu l a r lower pole. The splenic caps u l e is now d ivided a lo n g the line of d e m a rcat i o n . The s p l e n i c a rtery a n d ve i n can be co m p ressed between the t h u m b and f i n g e r of the operative s u rgeon to control b l ood loss w h i l e the parenchyma is d ivided.

Splenocolic ligament Splenic flexure

PARTIAL SP LENECTOMY Incision •

•

For open PS, the i ncision w i l l be dependent on the age of the patient a n d i n d ications for s u rgery. • Ad u lt patie nts. An u p p e r m i d l i n e i ncision exte n d i n g f r o m the x i p h o i d process to the u m b i l i cus s h o u l d a l low adequate expos u re. This i ncision can be ex­ tended i nfe riorly s h o u l d a d d i t i o n a l exposure be req u i red. Alternatively, a l eft su bcosta l i n c i s i o n can be used for isol ated s p l e n i c lesions. Caution s h o u l d be exercised i n u s i n g t h i s i ncision if s p l e n o m e g a l y is present. • Ped iatric patients. A l eft u p p e r ab d o m i n a l tra ns­ verse i n cision can safe ly be used, sta rt i n g from the 1 2th r i b t i p a n d exte n d i n g m ed i a l ly. Alternatively, a l eft su bcosta l i ncision can be used. For l a p a rosco pic-assisted PS, ports are p l aced in a s i m i l a r fash i o n t o a l a p a rosco pic s p l e nectomy (see Part 3, C h a p­ ter 52). After m o b i l izati o n of the spleen, a l eft tra nsverse or l eft su bcosta l i ncision can be used to perform the PS.

•

Division of Spleen •

•

Mobilization •

The spleen s h o u l d be com p l etely m o b i l ized by d iv i d i n g the s p l e n o p h ren ic, splenorenal, spl enocol ic, a n d gastro­ s p l e n i c l i g a m e nts (see e a r l i e r d iscussion). • For open PS, m o b i l ization beg i n s in a s i m i l a r fash i o n to open sple nectomy (see Part 3, C h a pter 5 2 ) a n d

as d i scussed u n d e r the " S p l e n orrhaphy" sect i o n . The spleen needs to be co m p l etely m o b i l ized. For l a p a rosco p i c-assisted PS, m o b i l ization beg i n s i n a s i m i l a r fas h i o n as d i scu ssed i n p reced i n g c h a pters (see Part 3, C h a pter 52). O n ce the spleen is com­ p l etely m o b i l ized l a p a rosco p i ca l ly, a n open i ncision ca n be m a d e as described i n the p reced i n g sect i o n . The s p l e e n n e e d s to be m o b i l i zed to a l l ow it to b e brought co m p l etely i nto the i n c i s i o n .

•

Once the spleen is co m p l etely m o b i l ized i nto the i ncision, the splenic vessels can be identified. Depend i n g on the location of the lesion, branches of the splenic a rtery and splenic ve i n ca n be l i g ated (FIG 3) . The main splenic a r­ tery a n d ve i n branches at the h i l u m s h o u l d be p reserved . Once the penetrat i n g vessels a re l i g ated, the spleen w i l l d e m a rcate (FIGS 3-5) . F o r P S t o be effective, a p proximately 1 0 % t o 20% o f the spleen should rem a i n vascu l a rized after l i gation of pen­ etrating vesse ls to preserve physiologic function of the splenic rem n a nt.• Ca re m u st be taken to ensure that the rem a i n i n g b lood supply is from a splenic a rtery bra nch. Re­ lyi ng solely on short gastric a rteries will not be adeq u ate to m a i nta i n adequate b l ood flow to the splenic re m n a nt. Once the spleen dema rcates, the s p l e n i c capsu l e can be i ncised usi ng e lectroca utery (FIG 4) . Pote nti a l b l ood loss ca n occu r; a n esthesia tea m should be notified a n d blood

905

906

P a r t 3 OPERATIVE TECHNIQUES I N HEPATO-PANCREATO-BILIARY SURGERY

Splenophrenic ligament •

Splenic vein Splenic artery •

•

splenic vein and artery •

Splenocolic ligament

Splenic flexure

FIG S • D ivision of the spleen with a l i n ear sta p l i n g device. F o l l ow i n g l i gation and d ivision of branches of the s p l e n i c a rtery a n d ve i n to the lower p o l e , the dema rcated s p l e e n i s then d ivided u s i n g m u lt i p l e fi res of a l i n ea r sta p l i n g device. Sta p l e size is d i ctated by the size of the spleen. Vasc u l a r control can be ach i eved by c o m p ression o f the m a i n b r a n c h of the s p l e n i c a rtery a n d ve i n between the s u rgeon's th u m b a n d i ndex f i n g e r u n t i l the s p l e e n is d ivided. s h o u l d be ava i l a b l e i n the operat i n g r o o m (OR) p reoperative ly. Vasc u l a r control can be ach ieved by compression of the main s p l e n i c a rtery a n d ve i n (between the t h u m b a n d forefi nger as d i scussed e a r l i er). The s p l e n i c parenchyma can be d ivided u s i n g e l ectroca u­ tery or a l i near sta p l i n g device (FIGS 4 a n d 5) . Gentle

•

•

co m p ression can be a p p l i ed to vascu l a rized s p l e n i c edge to assist i n contro l l i n g bleed i n g . Once the splenic parenchyma is com p l etely d ivided a n d the specimen passed off the table, a n ABC is used to control bleed i n g from the cut edge. The ABC is used until bleed­ ing is m i n i m ized and the cut edge is thoro u g h ly cauterized (FIG 7). N ote that the source of a rgon gas is not pressure reg u lated . During lapa roscopy, i ntraabdo m i n a l pressure m ust be closely mon itored and the abdomen vented as in­ d i cated to prevent i ntraabdo m i n a l hypertension. An a bsorba b l e top ica l hem ostatic agent is then a p p l ied to the cut edge a n d pressure i s h e l d with a l a pa roto my pad (FIG 6) . Press u re is held for 5 m i n utes and the l a p ­ a rotomy pad is then ca refu l ly rem oved a n d o n g o i n g b l eed i n g is assesse d . Add iti o n a l u s e of ABC may be nec­ essa ry to contro l poi nts of bleed i n g . B l e ed i n g from the cut edge of the spleen can be further contro l l ed by p l acement of a bsorba b l e m attress sutu res as d i scussed in the " S p l e norrhaphy" section (FIG 8) . O nce hem ostasis is meticu l o usly a c h i eved, t h e re m a i n ­ d e r o f the s p l e e n is o bserved f o r a d e q u ate b l ood fl ow. Ag a i n , 1 0 % to 20% of the tota l s p l e n i c tissue s h o u l d rem a i n v i a b l e to preserve s p l e n i c phys i o l o g i c funct i o n . The s p l e n i c re m n a nt i s then ca refu l l y returned to the l eft upper abdomen. • To prevent torsion of the splenic rem n a nt, consider­ ation can be g iven to performing spleno pexy. Sutures a re ca refu l ly placed in the splenic capsu le and then attached to the lateral abdom i n a l wa l l or retroperi­ to neum for fixation. At least two poi nts of fixation should be used. Once p l aced, these sutu res should have m i n i m a l tension to avoid tea ring the capsu le. • Depe n d i n g on the site of PS, omentum can be p l aced a g a i nst the cut su rfa ce of the spleen. Sutures can be p l a ced to h o l d the omentu m i n p l a ce as d i scussed in the p reced i n g sect i o n . In the case of PS for hemog l o b i nopathies (e .g., H S), a thorough sea rch for accessory s p l e n i c tissue s h o u l d be performed. The i n c i d ence of accessory spleens is 1 0 % to 3 0 % . The m ost c o m m o n l ocati o n for a n accessory spleen i s at the s p l e n i c h i l u m (a pproximately 7 5 %), fo l l owed by the ta i l of the pa ncreas (a p p roxi mately 2 0 % ) . The

B

A

FIG 6 • A. Large epidermoid cyst (SC) ofthe l ower pole of the spleen. B. Following d ivision of the s p l e n i c p a renchyma, the superior pole (SP) re m a i n s perfused. Absorba b l e hem ostatic agent is a p p l ied to the cut edge fo l l owi n g coag u l ation with an ABC (arrows) . SC, s p l e n i c cyst; SP, superior pole of spleen; a rrows, a bsorba b l e hem ostatic agent.

C h a p t e r 53 S P L E N O RRHAPHY

Spleen Spl e nic

I

Splenophreni c ligament

1

o; , ph mg m

Argon beam spray Coag u l ated s u rface Cut edge

of spleen

Divided s p l e n i c vein Splenocolic l igament Splenic flexure

/

FIG 7 • Use of ABC to coag u l ate cut surface of spleen. B ra n ches of the s p l e n i c a rtery a n d ve i n t o the l ower pole have b e e n l igated . The s p l e n oco l i c l i g a m ent has been d ivided for s p l e n i c m o b i l izat i o n .

Diaphragm Splenophren i c ligament

Div id e d s p l e ni c S p leen

artery and vein

Tied suture

Splenic

with pledget

Pledget with suture

Cut edge

of spleen

Divided splenocolic l igament

_.,..___-.:-;=---'--

Splen ic flexure

FIG 8 • Use of i nterru pted horizontal m attress sutu res with pledgets for hem ostasis fo l l owi n g PS. The s p l e n i c a rte ry a n d ve i n branches h a v e b e e n d ivided to the l ower pole and the lower pole removed. Sutures a re p l aced i n close p roxi m ity t o rea p p roxi m ate t h e capsu l e . T h e u s e of pledgets is reco m m ended to p revent sutu res from tea r i n g the s p l e n i c capsu le.

907

908

P a r t 3 OPERATIVE TECHNIQUES IN HEPATO-PANCREATO-BILIARY SURGERY

•

re m a i n d e r is l ocated a l o n g the s p l e n i c a rte ry, in the mesentery, o r i n the omentum.7 If accessory splenic tissue i s l ocated, it should be co m p l etely rem oved with ca refu l atte ntion to hem ostasis. Consideration s h o u l d be g iven to a concu rrent chol ecys­ tectomy for patients with sympto m atic b i l i a ry co l i c o r preoperative U S evi de nce of cholel ithiasis.

Closure •

After retu r n i n g the spleen to the l eft u pper a bdomen, a thoro u g h i n spection of the perito n eal cavity is perfo rmed

•

•

to ensure there are no reta i ned l a p a roto my pads. A p re­ l i m i n a ry count s h o u l d be perfo rmed prior to clos i n g . The a bdomen is thoro u g h ly i rrigated w i t h warmed n o r­ m a l sa l i n e. A l l b l ood s h o u l d be rem oved from the a bdo­ men. The spleen s h o u l d be i n s pected to ensure exq u isite hemostasis. T h e a bd o m i n a l i n c i s i o n i s then c l osed in t h e sta n d a rd fash i o n . D r a i n s a r e n ot n e cessa ry. If t h e p roced u re was p e rfo r m e d w i t h l a p a rosco p i c a s s i sta n ce, p o rts a re rem oved a n d p o rt sites are c l osed in the sta n d a rd fash i o n .

PEARLS AND PITFALLS I n d ications

• • •

I m a g i n g a n d other d i a g nostics

• • • •

Preoperative p l a n n i n g

• • • • •

Tec h n i q u e-sp lenorrhaphy

• • • • • • •

Tech n i q ue-PS

• • • • • • • • •

Tec h n i q u e-c losure

•

S p l e norrhaphy is used to repa i r an i n j u red spleen (AAST g rades I-IV) . S p l e norrhaphy is contraindicated i n AAST g rade V i n j u ries. PS can be used as a splenorrhaphy tech n i q u e or to treat va rious h e m o g l o b i nopath i es (e .g., H S), s p l e n i c cysts, or splenomega ly. CT sca n n i n g is reco m mended for h e m odyn a m ica l ly sta b l e patie nts with suspected i ntraabd o m i n a l tra u m a . Patie nts with h e m o g l o b i nopathies s h o u l d have preoperative i m a g i n g t o p l a n ope rative a p p roach (i .e., vessel l ocation, s p l e n i c size) Patie nts u n derg o i n g PS for h e m o g l o b i nopathies a re reco m m e nded to have preoperative US eva l u ­ ati n g f o r c h o l e l it h i asis. I nvolvement of a hemato l o g i st is essent i a l for patients with h e m o g l o b i nopath i es for proper d i a g ­ n o s i s a n d preo perative medical m a n a g e m ent. Vacc i n ations need to be a d m i n istered 2 weeks prior to e l ective PS. C rossm atched b l ood and b lood prod ucts s h o u l d be rea d i ly ava i l a b l e i ntraoperative ly. Consideration of stress-dose ste ro ids for patients with h e m o g l o b i n o path i es (review past med ication h i sto ry) CT i m a g i n g (see e a r l i e r d i scussion) ava i l a b l e in the OR for i ntraoperative g u i d a nce Placement of a n NGT for gastric deco m p ression H e modyn a m ica l ly unstable patie nts are not ca n d i d ates for splenorrhaphy. Co m p l ete m o b i l ization of the spleen is key to assess i n g i n j u ry a n d perfo r m i n g splenorrhaphy. Work l atera l to m e d i a l for m o b i l izat i o n . Leave a 1 - to 2 - c m cuff of perito n e u m to p revent d a m a g e to surro u n d i n g organs. Lower g rade i n j u ries can often be repa i red with sutu res. M oderate to h i g h-grade i n j u ries may req u i re a co m b i n ation of tech n i q ues i n c l u d i n g PS. Be prepa red to p roceed to tota l sple nectomy s h o u l d s p l e n o rrha phy tech n i q ues fa i l . M a y be performed v i a open o r l a p a rosco p i c a p p roach Laparosco pic PS req u i res adva n ced m i n i m a l ly i nvasive ski l l s a n d a n e l ective sett i n g . I d e ntify the s p l e n i c a rtery a n d ve i n . A v i a b l e s p l e n i c r e m n a n t req u i res b l ood s u p p l y f r o m t h e a rte ry. Do not rely on short gastric b l ood s u p p l y fo r rem n a nt. After d ivision of b l ood s u p p ly, a l l ow spleen to d e m a rcate prior to d i v i d i n g spleen. Approxi m ately 3 0 % of the spleen s h o u l d rem a i n v i a b l e for s p l e n i c functi o n postope rative ly. A thorough sea rch for accessory spleens s h o u l d be u n d e rtaken (and rem oved if fou n d ) . Consider perfo r m i n g s p l e n o pexy to p reve nt torsion of rem n a nt. Consideration for concu rrent chol ecystectomy for patie nts with sym ptomatic b i l i a ry co l i c o r preop­ erative U S evidence of c h o l e l it h i asis. D r a i n s should not be used u n l ess there i s a kn own o r suspected pan creatic i nj u ry.

C h a p t e r 5 3 S P L E N O RRHAPHY

POSTOPER ATIVE CARE •

•

•

•

Patients undergoing splenorrhaphy will require ongoing hemodynamic monitoring in the immediate postoperative period. Hemodynamic instability should prompt further in­ vestigation for bleeding from the splenic repair. The NGT can be removed when evidence of bowel func­ tion is present. A diet can be initiated and advanced as tolerated. Careful attention to pulmonary toilet should be made, in­ cluding the use of incentive spirometer, early mobilization, and pain control. Most patients undergoing splenorrhaphy will have concur­ rent injuries that will require continued attention.

COMPLICATIONS

Splenorrhaphy Bleeding (most common) Pancreatic injury/fistula • Atelectasis/pneumonia/left pleural effusion • Intraabdominal abscess ( 3 % to 1 3 % ; higher rates with use of drains ) • Wound complications (higher rates with open procedures) Seroma Infection Wound dehiscence Note: Complication rates will be higher in multisystem trauma patients. • •

OUTCOMES

Partial Splenectomy

Splenorrhaphy

•

•

•

•

•

NOM should be considered the standard of care for low­ to moderate-grade splenic injuries. NOM has demonstrated splenic preservation rates ranging from 8 1 % to 9 1 % for AAST grades I to III injuries. 8 Splenectomy has been demonstrated to be an independent risk factor for infectious complication following blunt splenic trauma. The authors recommend broader consid­ eration for the use of splenic-preserving techniques.9 Splenorrhaphy has been shown to be successful in 8 6 % of patients with intraoperative splenic inj ury. 1 0 However, some caution is warranted in interpreting these findings as most reports of this nature are based on small sample SIZeS. The use of ABC dramatically improved rates of successful splenorrhaphy. ABC can be used for many splenic injury types/grades. The ABC can also be used successful with lapa­ roscopic procedures.

Partial Splenectomy •

•

•

PS for HS leads to clinically significant improvements in hematologic profiles and symptoms in the pediatric popu­ lation. Hemoglobin levels significantly increased, whereas reticulocyte count and bilirubin levels decreased. 2 PS for other congenital hemolytic anemias (i.e., sickle cell disease) has been demonstrated to control symptoms of hy­ persplenism and splenic sequestration. Splenic immune func­ tion also appears to be preserved in patients following PS who were followed for 4 years from surgery.3•4 PS can be safely performed with few conversions to total splenectomy. Consideration should be given at the time of operation for cholecystectomy for children with symptoms of biliary colic and/or preoperative US demonstrating chole­ lithiasis.

909

• •

• • • •

Bleeding Splenic regrowth Disease recurrence (may occur when too large of a splenic remnant remains) Need for total splenectomy Splenic remnant torsion Pancreatic injury/fistula Wound complications (higher rates with open procedures)

R EFER ENCES 1. 2.

3.

4.

5.

6.

7.

8. 9.

10.

Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling: spleen and liver ( 1 994 revision). 1 Trauma. 1995;3 8 ( 3 ) : 323-324. Buesing KL, Tracy ET, Kiernan C, et al. Partial splenectomy for heredi­ tary spherocytosis: a multi-institutional review. 1 Pediatr Surg. 20 1 1 ; 46( 1 ) : 1 78-1 8 3 . Vick L R , Gosche J R , Islam S. Partial splenectomy prevents splenic se­ questration crises in sickle cell disease. 1 Pediatr Surg. 2009;44 ( 1 1 ) : 208 8-209 1 . Rice HE, Oldham KT, Hillery CA, e t al. Clinical and hematologic benefits of partial splenectomy for congenital hemolytic anemias in children. Ann Surg. 2003;237(2 ) : 2 8 1 -2 8 8 . S ab e AA, Claridge JA, Rosenblum DI, e t a l . The effects o f splenic artery embolization on nonoperative management of blunt splenic injury: a 1 6-year experience. 1 Trauma. 2009;67(3 ) : 565-572; discussion 71-72. Zamora l, Tepas JJ III, Kerwin AJ, et al. They are not j ust little adults: angioembolization improves salvage of high grade IV-V blunt splenic injuries in adults but not in pediatric patients. Am Surg. 2012;78 ( 8 ) : 904-906. Impellizzeri P, Montalto AS, Borruto FA, et al. Accessory spleen tor­ sion: rare cause of acute abdomen in children and review of literature. 1 Pediatr Surg. 2009;44 ( 9 ) :e 1 5-e 1 8 . Renzulli P, Gross T, Schnuriger B, e t a l . Management o f blunt injuries to the spleen. Br 1 Surg. 2 0 1 0;97( 1 1 ) : 1 696- 1 70 3 . Demetriades D, Scalea T M , Degiannis E, et a l . Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study. 1 Trauma Acute Care Surg. 2012;72 ( 1 ) :229-234. Chung Bl, Desai MM, Gill IS. Management of intraoperative splenic injury during laparoscopic urological surgery. B1U Int. 2 0 1 1 ; 1 0 8 ( 4 ) : 572-576.

Th i s page i nte nti o n a l ly l eft b l a n k .

4

Operative Techniques in Colon and Rectal Surgery

Laparoscopic Small Bowel Resection 977 Oliver Varban

Strictureplasty and Small Bowel Bypass in Inflammatory Bowel Disease 925 Douglas W. Jones and Kelly A. Garrett

Surgical Management of Enterocutaneous Fistula 934 William Sanchez

End and Diverting Loop Ileostomies: Creation and Reversal 943 Kathrin Mayer Troppmann

Jejunostomy Tube 957 Rebecca L. Wiatrek and Lillian 5. Kao

Appendectomy: Open Technique 963 James Suliburk and David Berger

Appendectomy: Laparoscopic Technique 970 Roosevelt Fajardo

Appendectomy: Single-Incision Laparoscopic Surgery Technique 976 Reshma Brahmbhatt and Mike K. Liang

Right Hemicolectomy: Open Technique 984 Soma/a Mohammed, Kathleen R. Liscum, and Eric J. Silberfein

Laparoscopic Right Hemicolectomy 993 Craig A. Messick, Joshua S. Hill, and George J. Chang

Right Hemicolectomy: Hand-Assisted Laparoscopic Surgery Technique 1001 Matthew A lbert and Harsha Polavarapu

Right Hemicolectomy: Single-Incision Laparoscopic Technique 1009 Theodoros Voloyiannis

Transverse Colectomy: Open Technique 1011 Y. Nancy You

Laparoscopic Transverse Colectomy 1025 Govind Nandakumar and Sang W. Lee

Transverse Colectomy: Hand-Assisted Laparoscopic Surgery Technique 1033 Daniel A lbo

Left Colectomy for Colon Cancer 1041 Saul J. Ruge/es and Luis Jorge Lombana

Left Hemicolectomy: Laparoscopic Technique 1049 Erik A skenasy

Left Hemicolectomy: Hand-Assisted Laparoscopic Technique 1057 Steven A. Lee-Kong and Daniel L. Feingold

Sigmoid Colectomy: Open-Technique 1064 Wayne A . /. Frederick, Tofu/ope Oyetunji, and Shiva Seetahal

Sigmoid Colectomy: Laparoscopic Technique 1012 Arden M. Morris

Hand-Assisted Laparoscopic Sigmoidectomy 1081 Daniel A. A naya and Daniel A lbo

Sigmoid Colectomy: Single-Incision Laparoscopic Surgery Technique 1089 Rodrigo Pedraza and Eric M. Haas

Surgical Management of Complicated Diverticulitis: Perforation and Colovesical Fistula 10 99 Scott E. Regenbogen

Total Abdominal Colectomy: Open Technique 1108 Tarik Sammour and A ndrew G. Hill

Total Abdominal Colectomy: Laparoscopic Technique 1115 Matthew G. Mutch

Total Abdominal Colectomy: Hand-Assisted Technique 1121 Daniel A lbo

Low Anterior Resection and Total Mesorectal Excision/Coloanal Anastomosis: Open Technique 1139 Konstantinos I. Votanopou/os and Jaime L. Boh/

Low Anterior Rectal Resection: Laparoscopic Technique 1148 Joel Leroy, Didier Mutter, and Jacques Marescaux

Low Anterior Resection: Hand-Assisted Laparoscopic Surgery Technique 1158 Matthew G. Mutch

Low Anterior Rectal Resection: Robotic-Assisted Laparoscopic Technique 1168 Mehraneh D. Jafari and Alessio Pigazzi

Total Mesorectal Excision with Coloanal Anastomosis: Laparoscopic Technique 1177 John H Marks and Elsa B. Valsdottir

Abdominoperineal Resection: Open Technique 1190 Curtis J. Wray and Stefanos G. Mil/as

Abdominoperineal Resection: Laparoscopic Technique 1198 Joel Leroy, Didier Mutter, and Jacques Marescaux

Hand-Assisted Laparoscopic Abdominoperineal Resection 1208 Daniel A lbo

Abdominoperineal Resection: Robotic-Assisted Laparoscopic Surgery Technique 1211 Rodrigo Pedraza and Eric M. Haas

Restorative Proctocolectomy: Open Technique (Ileal Pouch-Anal Anastomosis) 1228 Hasan T. Kirat and Feza H. Remzi

Restorative Proctocolectomy: Single-Incision Laparoscopic Technique (Including Pouch lleoanal Anastomosis) 1239 Theodoros Voloyiannis

Restorative Proctocolectomy: Hand-Assisted Laparoscopic Surgery Ileal Pouch-Anal Anastomosis 1251 Robert R. Cima

Pelvic Exenteration 1261 Cherry E. Koh and Michael J. Solomon

Transanal Excision of Rectal Tumors 1275 Ryan M. Thomas and Barry Feig

Transanal Endoscopic Microsurgery 1282 Margaret V. Shields and John H Marks

Transanal Single Port Excision of Rectal Lesions 1293 Avo A rtinyan and Daniel A lba

Laparoscopic Diverting Colostomies: Formation and Reversal 1302 David Taylor and A ndrew Stevenson

Surgical Management of Hemorrhoids 1314 Bidhan Das

Surgical Management of Anal Fissures 1325 Daniel A lba

Operative Treatment of Rectal Prolapse: Perineal Approach (Aitemeier and Modified Delorme Procedures) 1332 Valerie Bauer

Operative Treatment of Rectal Prolapse: Transabdominal Approach 1339 Karin M. Hardiman

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Dissemination of Colorectal Cancer 1349 Reese W. Randle, Konstantinos I. Votanopoulos, Edward A. Levine, Perry Shen, and John H. Stewart, IV

I

Chapter

1

Laparoscopic Small Bowel Resection

---------------------------------------- · -----------------------------------------------------

�

Oliver Varban

DEFINITION •

Laparoscopic small bowel resection involves laparoscopic segmental resection of a portion of the duodenum, j ej unum, or ileum as well as its associated mesentery. A small bowel resection may be performed in the setting of obstruction, bleeding, or malignancy.

•

•

DIFFERENTIAL DIAGNOSIS •

The following conditions represent pathology that may require a small bowel resection: Inflammatory bowel disease ( Crohn's disease) Polyp Tumor. Tumors of the small intestine are rare and rep­ resent only 1 % to 3% of all gastrointestinal neoplasms. (Table 1 ) Ulcer Diverticula Stricture Intussusception

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

Obstruction results in nausea, vomiting, obstipation, ab­ dominal pain, and distension with absent bowel sounds. Peritoneal signs and fever may indicate ischemia, necrosis, or perforation. Bleeding may result in hematemesis, hematochezia, or heme­ positive stools. Additionally, a brisk bleed may result in he­ modynamic instability with hypotension and tachycardia. Abdominal pain is typically absent, unless bleeding is associ­ ated with ulcer disease or obstruction.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

Computed tomography ( CT ) with oral and intravenous ( IV) contrast can assist with the location and etiology of

•

•

•

•

•

SURGICAL MANAGEMENT Preoperative Planning •

•

•

•

Table 1: Tumors of the Small Bowel

M a l ig n a n t

GIST ( b e n i g n o r l e i omyoma) Adenoma Lipoma Hemangioma Aden ocarci n o m a C a rc i n o i d Lym p h o m a GIST ( m a l i g n a nt)

•

•

GIST, gastrointestinal stromal tumo'

The patient requires adequate IV access for resuscitation and, if necessary, blood transfusion if bleeding. A nasogastric tube assists in gastric and proximal small bowel decompression. This decreases the risk of aspiration during intubation as well as inj ury to the stomach or small bowel during port placement. A Foley catheter is placed for accurate intraoperative assess­ ment of urine output and also to decompress the bladder for safe port placement. Preoperative antibiotics should cover enteric organisms in the event of spillage.

Positioning •

Ben i g n

obstruction. A transition point is noted when the proxi­ mal small bowel is dilated and the distal small bowel is decompressed. Magnetic resonance imaging (MRI) and magnetic resonance enteroclysis (MRE) along with CT may assist with the diag­ nosis of small bowel tumors. 1 Tagged red blood cell (RBC) scan and CT angiogram may localize intraluminal bleeding in cases where bleeding rates are at least 0 . 1 to 1 . 0 mL per minute. A technetium-99m pertechnetate, or Meckel scan, can detect gastric mucosa associated with a Meckel's diverticulum. Small bowel enteroscopy and capsule endoscopy may also be used to identify the location of a tumor or site of bleeding in a stable patient. If small bowel enteroscopy is performed, the location of the tumor can be tattooed for easy intraop­ erative identification. Diagnostic laparoscopy can assist with localization of dis­ ease and can help avoid unnecessary laparotomy. An elevated white blood cell (WBC) count and lactate level is concerning for ongoing ischemia or necrosis. A decrease in hemoglobin or hematocrit is indicative of bleeding.

The patient is placed in the supine position. Arms may be out at 90 degrees or tucked at the side of the patient. Tuck­ ing the arms may assist with the ergonomics of the operation as both surgeon and assistant may stand on the side of the patient comfortably. For operations that take place on the proximal small bowel, it is optimal for the surgeon to stand on the patient's right ( FIG 1 ) . Meanwhile, for operations that take place in the distal small bowel, it is optimal for the surgeon to stand on the patient's left. Operations that take place solely on the duodenum may be performed in split-leg position.

917

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

Video monitor

Video monitor

Assistant

Surgeon

N u rse

Sterile table

FIG 1

•

Room set u p for l a p a rosco p i c s m a l l bowe l resect i o n .

ACCESS TO THE ABDOMI NAL CAVITY •

•

Accessi n g the a b d o m i n a l cavity can be performed in a va riety of ways based on s u rgeon's comfort ( i . e . , open cut-down tech n i q u e vs. Veress n eed l e i n suffl ation). An open cut-down tech n i q u e may be advantageous in the sett i n g of obstruction because the c h a n ce of b l i n d ly in­ j u r i n g d i l ated bowel is l ower. Typ i c a l i n s uffl ation sett i n g s for l a p a roscopy i n c l u d e a n i ntraabdom i n a l pressure o f 1 5 m m H g a n d a f l o w o f 20 L per m i n ute. • Veress need l e entry With a n asogastric tube in p l a ce a n d the sto m ­ ach deco m p ressed, a sta b i n c i s i o n w i t h a n o . 1 1 b l a d e i s made t h r o u g h the d e r m i s i n t h e l eft u p p e r q u a d ra n t of the a bd o m e n , below the costa l m a rg i n i n t h e m i d c l avicu l a r line (FIG 2) . A Ve ress need le is p laced t h r o u g h t h i s i n cision a n d adva nced until two d i st i n ct c l i cks a re heard, s i g n a l i n g that the b l u nt-tip portion of the Veress need le has sprung forwa rd . The second click is heard as the need le e nters the peritoneal cavity. A " d ro p test" can be performed by p l a c­ i n g 1 0 ml of sa l i n e t h r o u g h the need l e u s i n g

FIG 2

•

Veress n eed l e entry i n the l eft u p p e r q u a d ra nt.

C h a pter 1

LAPAROSCOPIC SMALL BOWEL RESECTION

FIG 4 • Veress need l e co n n ected to insufflator t u b i n g for creation of p n e u moperito n e u m . FIG 3 • Drop test performed w i t h sa l i n e u s i n g a syri n g e w i t h o u t a p l u n g e r. S a l i n e is expected to e n t e r the a b d o m i n a l cavity freely b y g ravity a l o n e .

•

a syri n g e w i t h o u t a p l u ng e r (FIG 3) . If the sa l i n e d rops i nto the a b d o m i n a l cavity with g ravity a l one, then the need l e may be con­ nected to the i n suffl ator (FIG 4) . Once the a b d o m e n is fu l ly i n sufflated to a n i n ­ traa bdom i n a l pressu re o f 1 5 m m Hg, the Ve ress need l e is removed and a 5-mm port is p l aced t h r o u g h the same i n c i s i o n . The port is t h e n c o n n ected to the insufflator. Open cut-down tech n i q u e A2 -cm c u rvi l i n e a r i n c i s i o n is m a d e w i t h a n o . 1 1 b l a d e j ust below the u m b i l icus a n d tissue i s d is­ sected d own to the l evel of the fasc i a .

5 -s h a ped o r L-sha ped retractors a re p l aced to assist with expos u re . The u m b i l ical sta l k i s then g rasped w i t h a Kocher a n d e l evated, t h u s p u l l i n g the fascia away from the u n d e r l y i n g bowe l . A 2 -cm l o n g itu d i n a l i n c i s i o n is m a d e i n t h e fascia with a n o . 1 5 b l ade, a n d the edges a re g rasped a n d retracted u s i n g Kocher c l a m ps . The perito n e u m is i d e ntified bel ow, g rasped with D e B a key forceps i n two sepa rate l oca­ tions, and then i ncised u n d e r d i rect v i s i o n . A H a sson port is p l aced i nto the a bd o m i n a l cavity a n d t h e n co n n ected t o t h e i n sufflator.

PORT PLACEM E N T •

•

•

•

•

•

•

After t h e fi rst p o rt is p l aced, a l a p a roscope is i ntro­ d u ced i nto t h e a b d o m i n a l cavity. A 5-mm o r 1 0-m m , 30-deg ree a n g l ed l a p a rosco pe i s used to p e rform t h e operat i o n . After p l a cement of the fi rst po rt, the l a p a roscope is used to exa m i n e the bowe l and organs j ust below the site of port entry to e n s u re n o i n a dvertent i n j u ry occu rred d u r­ i n g i n s uffl ation/e ntry of the a b d o m i n a l cavity. The re m a i n i n g po rts a re p l a ced u n d e r l a p a rosco p i c visu a l ­ ization, w h i c h assists i n avo i d i n g i n j u ry to i ntraa bdom i n a l organs a n d the i nferior e p i g astric vesse ls. The 5-mm po rts acco m m odate most l a p a roscopic g rasp­ ing and d i ssect i n g i n st r u m e nts (FIG S). The 12 - m m po rts acco m m odate l a p a rosco p i c sta p l i n g devices a n d a utosutu r i n g devices. Port p l acement for opti m a l exposure a n d m a n i p u lation of the proxi m a l small bowe l is d e m o n strated i n FIG 6. Port p l acement for opti m a l exposure a n d m a n i p u lation of the d ista l small bowe l is d e m o n strated i n FIG 7.

FIG 5 • Lapa rosco p i c atra u matic g raspers a n d d i ssectors that can be used through a 5-mm port.

91 9

920

P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

5 mm 5 mm 0 1 2 mm

5 mm 0

...

5 mm •.....

...

5 mm

1 2 mm

()

5 mm

•....•

FIG 6 • O pti m a l port p l acement for exposu re of the p roxi m a l sma l l bowe l .

FIG 7 • O pti m a l port p l acement for exposure of the d ista l sma l l bowe l .

I D E NTIFICATION OF D I S EASE •

•

The sma l l bowe l is r u n from the l i g a ment of Tre itz to the term i n a l ileum u s i n g atra u m atic n o n locking g raspers . To i d e n t ify t h e l i g a m e nt of Tre itz, t h e a s s i sta nt g ra s p s t h e e p i p l o i c a e of t h e tra n sverse c o l o n a n d retracts it ce p h a l a d , g a i n i n g exposu re to t h e base of t h e c o l o n mesentery. T h e s u rg e o n t h e n g ra s p s t h e s m a l l bowel and fo l l ows it b a c k h a n d over h a n d towa rd t h e base of t h e m esentery until t h ey fee l resist a n ce and see the p rox i m a l j ej u n u m e m a n ate from t h e retro p e r i to n e u m

(FIG 8) . •

With the proxi m a l sma l l bowe l i d e ntified, the s m a l l bowel can be r u n , h a n d over h a n d t o the term i n a l i l e u m u n t i l the d i seased port i o n ca n be i d e ntified.

• I d entification o f t h e l i g a ment o f Tre itz req u i res e l evat i o n of the transverse colon and exposure of the transverse mesoco l o n . The sma l l bowel i s g rasped and fo l l owed hand over hand proxi m a l ly u n t i l it can be seen emanating from the retro perito n e u m .

FIG 8

SMALL BOWEL RES ECTI ON •

•

The s u rgeon g rasps the p roxi m a l s m a l l bowe l, a n d the assista nt g rasps the d i sta l s m a l l bowe l . Creation of a mesente ric w i n dow is performed u s i n g a M a ry l a n d d issector (FIG 9) at a l ocation both p roxi m a l a n d d ista l t o the d iseased port i o n o f s m a l l bowe l .

•

A l a p a roscop i c d iv i d i n g sta p l e r (gastro i ntest i n a l a n a sto· mosis [G IA] type) is t h e n p l aced t h r o u g h t h i s w i n dow a n d the bowe l i s d ivided at p roxi m a l a n d d ista l poi nts o f re­ sect i o n . A sta p l e r loaded with 2 . 5-mm sta ples is typ i ca l ly used (FIG 1 0) .

C h a pter 1

9 • Creat i o n of mesente ric w i n d ow, a l l ow i n g for p l acement of the l a p a rosco p i c d i v i d i n g sta p l e r. FIG

LAPAROSCOPIC SMALL BOWEL RESECTION

• M esenteric d ivision u s i n g a n e n e rgy device ( i . e . , u ltraso n i c sca l p e l ) .

FIG 11

A FIG 1 0 • Placement of the lapa roscopic divi d i n g sta pler through the mesenteric window. Arrow represents: Lapa roscopic sta pler.

•

The m esentery is d ivided u s i n g an e n e rgy device, such as a n u ltraso n i c sca l p e l o r l a p a rosco p i c bipolar device

•

T h e seg ment o f resected bowel is t h e n p l aced i nto a l a pa­ rosco pic speci m e n retri eva l bag (FIG 12A ) a n d rem oved t h r o u g h the 12 - m m port site (FIG 1 2 B) . T h i s can be per­ formed either before or after the a nasto mosis.

(FIG 1 1 ) .

SMALL BOWEL ANASTOMOSIS •

•

•

The two d ivided ends of small bowel a re placed side-to-side and a seromuscular traction sutu re is placed using2 -0 a bsorb­ able sutu re, approximately 8 to 10 em from the ends along the a nti mesenteric surface of the bowel . A freehand suture may be performed or may be placed using an a utosuture device. The tails of the sutu re a re cut approximately 5 em long so that they may be g rasped and used for retraction. With the assista nt holding the traction sutu re, the surgeon creates a n enterotomy i n each seg ment of bowel, approxi­ mately 1 em from the sta pled ends. E nterotomies may be cre­ ated with an L-hook cautery or with an u ltrasonic sca lpel. The enteric contents a re suctioned in order to conta i n spil lage. Each l i m b of a l a p a rosco p i c l i n e a r sta p l e r (2 . 5 - m m sta­ p l es, 60 mm in l e n gth) is p l aced sepa rate ly i nto each enterotomy and a l i g n e d along the a n t i m esenteric bor­ d e r (FIG 1 3). The sta p l e r is c l osed a n d fi red to create the a n asto mosis. Once the sta p l e r is removed, the i n s i d e of the sta p l e line is exa m i ned for h e m ostasis.

B FIG 1 2 • Placement of spec i m e n i n a l a p a rosco p i c retrieva l bag (A) a n d remova l from 12 - m m port site (B) .

•

•

•

•

The c o m m o n enteroto my can be cl osed u s i n g a r u n n i n g sutu re o r i n a sta p l e d fash i o n . W h e n c l o s i n g the c o m m o n ente roto my w i t h a sta p l e r, t h ree tract i o n sutu res a re p l aced (one at each e n d a n d o n e i n the m i d d le) t o a p p roxi m ate the ente roto my a n d e l evate the edges. T h e ta i l s o f e a c h suture a re l eft l o n g (a p p roxi m ately 5 e m ) t o a l low f o r easy m a n i p u lati o n . A l a p a rosco p i c sta p l e r (2 . 5 - m m sta p l es, 6 0 m m i n l e n gth) is positioned beneath the cut edges a n d fi red . Ca re i s u s e d to a v o i d i n c l u d i n g excessive a m o u nt of t i s s u e i n the sta p l e r a s it can n a rrow the a n a stomosis (FIG 1 4A). When closing the common enterotomy with sutu re, a run­ ning 2 -0 a bsorba ble suture may be p laced for the i n n e r layer and i nterru pted2 -0 permanent sutu res may be placed i n the serom uscu lar l ayer for the outer layer. Sutu res may be p laced freehand or with a n a utosutu re device (FIG 1 4B). The mesenteric defect (FIG 1 5A) is c losed w i t h e i t h e r a r u n n i n g or an i nterru pted series of2 -0 permanent sutu res to p revent an i ntern a l hernia. Sutu res a re p laced superfi­ ci a l ly i n order to avoid i nj u ri n g the b l ood supply (FIG 1 5B).

92 1

922

P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

Laparoscopic stapler

FIG 1 3 • P l acement of a l a p a rosco pic l i n e a r sta p l e r i n sepa rate ente roto m i es m a d e o n each l i m b o f bowel for creati o n of a n astomosis. A tract i o n suture p l a ced 8 to 10 em from the ends is h e l d by the assista nt.

Traction sutures

A

Stapler placed for closure of common enterotomy

Anastomosis

Anastomosis Proximal bowel

• A. Sta pled closu re of the com m o n enteroto my is performed by placing traction sutu res at either end of the enterotomy and one i n the m i d d l e . The ta i l s of the sutu res a re left long so they may be g rasped a n d assist with p lacement of the sta pler. The enterotomy is closed tra nsversely so as to avoid na rrowing the a n astomosis. B. Sutu re closure of the co m m o n enterotomy is performed using a n a utosutu re device. It may be performed with free h a n d sutu r i n g as wel l . T h e fi rst row is perfo rmed with a 2 -0 a bsorba ble suture in a r u n n i n g fash ion, closing the enterotomy tra n sverse ly. The secon d layer consists of i nterru pted serom uscu l a r i m bricati n g sutu res u s i n g a 2 -0 nonabsorba ble suture.

FIG 1 4

B

Autosuture device

2-0 absorbable suture

C h a pter 1

A

REMOVAL OF SPEC I M E N

of the port sites. Alternatively, the speci m e n may be re­ m oved from a sepa rate i n c i s i o n a n d with the use of a wo u n d p rotect i o n device.

O n ce the speci m e n is p l aced i n a l a p a rosco p i c retrieva l bag, it may be rem oved by expa n d i n g the size of o n e

CLOSURE •

•

A

923

FIG 1 5 • The mesenteric defect (A) is approximated with a ru n n i ng permanent suture (B).

B

•

LAPAROSCOPIC SMALL BOWEL RESECTION

It is reco m m e n d e d to close the fascia fo r a l l port s ites g reater t h a n 10 m m . This may be performed u s i n g a s i n g l e a bsorba b l e or permanent 0-sutu re a n d a CarterThomason sutu re-passer device (FIG 1 6A-C) . The site of spec i m e n extract i o n may be cl osed in a s i m i l a r fas h i o n ; h oweve r, l a rg e r d efects d o n o t m a i nta i n

•

•

p n e u m o perito n e u m and a re m o re d iffi c u l t to close l a pa­ rosco pical ly. As such, these may be cl osed by p l a c i n g in­ terru pted sutu res i n a n open fash i o n using a suture o n a U R-6 need l e . The s k i n is cl osed w i t h i nterru pted a bsorba b l e su bcuticu­ lar sutu res. D r a i n s a re not req u i re d .

B c A. A Ca rter-Thomason sutu re-passer device is used to pass a free suture t h r o u g h the port site defect u s i n g a cone to d i rect the passage of the suture t h r o u g h one s i d e of fasc i a l d efect. B. The Ca rter-Thomason is then passed without the suture o n the opposite s i t e o f the d efect i n order to g rasp the s u t u r e . C. The end o f the suture is then p u l led u p t h r o u g h the fascia a n d tied. FIG 1 6

•

PEARLS AND PITFALLS Port p l acement

• • •

I d e ntification o f d i sease

• •

O pti m a l port p l acement e n h a nces operative exposu re and use of l a p a roscopic i n strum ents i n a n ergonomic fas h i o n . Po rts s h o u l d be p l a ced at least 10 em a p a rt and a l low fo r tria n g u l ation of camera a n d i n st r u m e nts. An open cut-down tech n i q u e may reduce the risk of i n a dvertent i n j u ry in the case of o bstructive d isease and d i lated bowe l . Loca l izati o n o f i ntra l u m i n a l t u m o rs ca n be fac i l itated w i t h M R E o r p reope rative d o u ble-ba l l oon e nteroscopy a n d tatto o i n g . If u n s u re, a reas o f suspected d isease can be m a rked w i t h a sutu re l a p a rosco p i ca l ly a n d t h e n a h a n d-port or m i n i l a pa rotomy i n c i s i o n can be used for a tact i l e eva l uati o n .

924

P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

S m a l l bowe l resect i o n

•

Small bowe l a n asto mosis

•

•

•

Creation of a m esenteric w i n d ow a l l ows for easy p l acement of a l a p a rosco p i c G IA sta p l e r. E d e m atous or t h i cker bowel may req u i re 3 . 5- m m sta p l e r cartridge. Tract i o n sutu res p l aced along the com m o n enterotomy assist i n accu rate p l acement of a l a p a rosco pic G I A sta p l e r d u ri n g closure of the c o m m o n enterotomy. If the a n asto mosis a p pe a rs n a rrowed w i t h p l acement of the sta p l e r, a sutu red closu re is p refe rred . E ns u re that the bowe l u n d e rg o i n g a n a sto mosis is we l l vasc u l a rized a n d n o t u n d e r tensi o n . E d e m atous bowel is best a p p roximated b y a h a n d -sewn a n asto mosis. T h i s may a l so be performed a s an extracorpore a l a n asto mosis through a sma l l i n c i s i o n .

Rem ova l of speci m e n

•

Use of a l a p a rosco p i c catch bag o r wo u n d p rotector can r e d u c e the risk o f wo u n d i nfect i o n .

C l o s u re

•

Remove po rts u n d e r l a p a rosco p i c visu a l i zation a n d i n spect for b l eed i n g p r i o r to c l o s u re .

procedure, the patient's overall health, and the length of bowel removed.

POSTOPERATIVE CARE •

•

•

•

After a laparoscopic small bowel resection, patients are ad­ mitted to the hospital for observation. If an extensive adhe­ siolysis is performed, a nasogastric tube may be placed at the end of the operation. Return of bowel function is signaled by production of flatus or formed bowel movements. A clear liquid diet may be started on postoperative day 1 after an uncomplicated laparoscopic small bowel resection. A solid diet may be started after return of bowel function. The patient may ambulate immediately after laparoscopic sur­ gery and does not require prolonged bladder catheterization. Patients are usually seen in follow-up within 2 weeks of surgery.

OUTCOMES •

•

•

•

Laparoscopic small bowel resection is safe and effective re­ sulting in lower lengths of hospital stay, less wound com­ plications, and better cosmesis when compared to an open approach. 2 •3 Laparoscopy also minimizes pain and severity of ileus as well as adhesive disease.4 Small bowel obstruction makes laparoscopic surgery chal­ lenging and increases the likelihood for conversion to an open procedure.5•6 Surgeons must acquire suturing skills to assure safe perfor­ mance of advanced laparoscopic surgery? Complete recovery is expected after small bowel resec­ tion. However, results depend on the condition prior to the

COMPLICATIONS Postoperative ileus Wound infection Anastomotic leak Anastomotic stricture Small bowel obstruction Port site incisional hernia

• • • • • •

REFERENCES 1.

2. 3. 4.

5.

6.

7.

Miao F, Wang ML, Tang YH. New progress in CT and MRI examina­ tion and diagnosis of small intestinal tumors. World J Gastrointest Oneal. 2010;2:222-228. Duh QY. Laparoscopic procedures for small bowel disease. Baillieres Clin Gastroenterol. 1993;7:833-850. Rosenthal RJ, Bashankaev B, Wexner SD. Laparoscopic management of inflammatory bowel disease. Dig Dis. 2009;27:560-564. Angenete E, Jacobsson A, Gellerstedt M, et al. Effect of laparoscopy on the risk of small-bowel obstruction: a population-based register study. Arch Surg. 2012;147:359-365. Kirshtein B, Roy-Shapira A, Lantsberg L, et al. Laparoscopic man­ agement of acute small bowel obstruction. Surg Endosc. 2005;19: 464-467. O'Connor DB, Winter DC. The role of laparoscopy in the manage­ ment of acute small-bowel obstruction: a review of over 2,000 cases. Surg Endosc. 2012;26:12-17. Soper NJ, Brunt LM, Fleshman JJ, et al. Laparoscopic small bowel resection and anastomosis. Surg Laparosc Endosc. 1993;3:6-12.

I

Chapter

2

Strictureplasty and Small Bowel Bypass in Inflammatory Bowel Disease

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

,_ ----------------------------------------------------

Douglas W Jones

DEFINITION •

•

•

Strictureplasty and small bowel bypass are methods used to avoid bowel resection in patients with Crohn's disease. The technique of strictureplasty was initially described in the treatment of tuberculous strictures as an alternative to resec­ tion. This procedure is mainly used in patients with j ejunoileal Crohn's disease but may also be used in select patients with du­ odenal disease. There are different techniques, but all involve division of the strictured area either transversely or longitudi­ nally with a distinctive closure that serves to widen the lumen. Small bowel bypass involves bypass of an affected segment of small intestine that is deemed unsuitable for resection or strictureplasty. Resection of the diseased segment is usually preferred. Bypass may be used in gastroduodenal Crohn's disease, complex small bowel disease, or ileocolic disease when a patient's comorbidities preclude resection.

•

•

•

•

•

A thorough history and physical examination should be per­ formed. History should include duration and distribution of disease as well as current or prior medical therapy. Crohn's disease may manifest in one of three disease patterns: fibrostenotic, inflammatory, or perforating. Fibrostenosing disease is the most common and typically presents with a progressive course in which stricturing of the small bowel leads to obstructive symptoms. 1 Pattern of disease distribution should be determined prior to operative intervention. Anatomic location of disease can be classified as terminal ileal, colonic, ileocolonic, and upper gastrointestinal ( GI ) . Over time, 1 5 % of patients experience a change in anatomic location and 4 6 % of patients demon­ strate an alteration in disease behavior.2 Past surgical history is of particular importance because many Crohn's disease patients have had prior abdominal surgery and this may affect operative planning. A detailed surgical history also allows for an estimation of the length of remaining small boweL A detailed description of the patient's medical manage­ ment should be obtained. The disease can be managed with antiinflammatory medications such as derivatives of 5 -aminosalicylic acid; with immunosuppressors such as cor­ ticosteroids, azathioprine, 6-mercaptopurine, and metho­ trexate; and/or with immunomodulators such as antibodies targeting tumor necrosis factor-a. These medications can influence perioperative morbidity. A detailed history should also be obtained in order to dis­ tinguish Crohn's disease from ulcerative colitis. The two inflammatory bowel diseases can have similar patterns of pre­ sentation, although they have different principles of surgical management.

Kelly A Garrett

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

�

•

•

•

The distribution of active disease needs to be mapped out pre­ operatively. Thought should be given to the risk of exposure to ionizing radiation as many patients with Crohn's disease can have flares over the course of many decades and hence require repeat imaging studies. Conventional radiologic techniques for imaging the small bowel include small bowel enteroclysis ( SBE) and small bowel follow-through (SBFT ) . Strictures may appear as narrowed areas with delayed passage of contrast. Dynamic images may reveal impaired peristalsis in strictured areas. Computed tomography ( CT) and magnetic resonance (MR) enterography have almost completely replaced the use of these studies at most academic centers. CT performed with intravenous and oral contrast is helpful in identifying abscesses and other inflammatory processes outside the bowel lumen. Recent developments have also improved the ability of CT to identify strictures, fistulas, and areas of active inflammation. CT enterography uses low­ density oral contrast in place of barium or iodine-based oral contrast used in standard scans. This in combination with intravenous iodinated contrast allows for better definition of the mucosa and thickness of the bowel walL MR enterography is being increasingly used to evaluate extent of active disease.3 MR enterography can also be performed using low-density oral contrast and offers the additional benefit of sparing patients' exposure to radiation. Ultrasound, although not as widely used, may be able to iden­ tify areas of bowel wall thickening, strictures, and decreased peristalsis. It is also useful for identifying abscesses and fis­ tulas. Although ultrasound spares patients' exposure to ion­ izing radiation, it is operator dependent and may not be able to distinguish inflammatory versus fibrotic strictures. All of the previously described imaging studies may help de­ termine whether an area of stricture has an active inflamma­ tory component that may respond to medical therapy, aid in determining the extent of disease prior to surgery, and facili­ tate operative planning.

SURGICAL MANAGEMENT Preoperative Planning •

•

Indications for surgery in patients with Crohn's disease include the following: failure of medical therapy, perforation, obstruction, worsening inflammation, hemorrhage, neoplasia, growth retardation, and/or extraintestinal manifestations. 3 When preoperative imaging reveals stricturing small bowel disease with minimal area of inflammation in patients with obstructive symptoms, additional medical therapy is unlikely to resolve the symptoms and the patient should be considered for surgery. Patients with suspected active inflammation who have failed medical therapy should also be considered for surgery.

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

Strictureplasty should not be performed in every patient with stricturing Crohn's disease. In most patients, simple resection and reanastomosis is sufficient. Indications for strictureplasty are the following:4 Diffuse j ej unoileitis causing obstructive symptoms unre­ sponsive to medical therapy Recurrent stricturing disease in patients with multiple prior intestinal resections (high risk for short bowel syndrome) Recurrence of strictures within 12 months of prior resection Isolated ileocolonic anastomotic strictures Selected duodenal strictures such as proximal lesions near the pylorus5 Contraindications to strictureplasty are the following:4 Diffuse peritonitis Free intraabdominal perforation of the affected bowel segment Phlegmon or abscess of affected bowel segment Fistulous disease with significant inflammation of affected bowel segment Multiple areas of stricture, within a short distance of each other, more amenable to single resection Suspicion for neoplasia Hypoalbuminemia In some cases, bypass of affected segments of the GI tract are indicated. These include the following: Gastroduodenal Crohn's disease-The duodenum is in­ volved in 0 . 5 % to 4% of patients with Crohn's disease and can cause obstruction or hemorrhage.6 In this scenario, resection is excessively morbid, so strictureplasty and by­ pass play a larger role. With obstruction of the first or second portions of the duodenum, a gastrojejunostomy should be performed. Although traditionally performed to prevent marginal ulceration, current use of effective acid-suppressing medi­ cations have rendered vagotomy unnecessary.6•7 Further­ more, vagotomy may increase morbidity in patients already predisposed to diarrhea from extensive or poorly controlled Crohn's disease or short-gut syndrome. In patients with obstruction of the third or fourth por­ tions of the duodenum, a duodenojej unal bypass should be performed.

•

Active inflammation of the duodenum and small bowel can lead to duodenoenteric fistula formation, commonly involving recurrence at a previous ileoco­ lic anastomosis. Resection of diseased areas may re­ quire partial resection of involved duodenum as well. In these cases, bypass with a gastrojej unostomy may be required. In complex small bowel or ileocolonic Crohn's disease. 8 Bypass should be considered when resection would be un­ safe as in the presence of an ileocecal phlegmon that is adherent to the retroperitoneum or iliac vessels. Bypass of small bowel disease should be avoided if resec­ tion is possible. An excluded segment should eventually be resected in order to avoid development of perforation, recur­ rent disease, carcinoma, or blind loop syndrome. 8

Preparation •

•

•

A mechanical bowel preparation is not necessary for patients who are undergoing small bowel or ileocolic resection and should be avoided in patients with stricturing disease. If there is a chance that a stoma will be created, the patient should be evaluated by an enterostomal nurse to help avoid the development of pouching problems postoperatively. Appropriate antibiotic and venous thromboembolism pro­ phylaxis are administered prior to incision.

Positioning •

•

Supine position is useful for patients who have uncompli­ cated ileocolic disease or gastroduodenal disease. Modified lithotomy position is preferred if patients have distal disease that may require intervention. This allows for intraoperative colonoscopy to be performed for diagnos­ tic purposes or to interrogate an anastomosis or repair if necessary. This position is also advantageous if the proce­ dure will be done laparoscopically as it allows the surgeon to stand between the patient's legs, which can assist with running the small bowel or with mobilization of the flexures if needed.

APPROACH

Evaluation of the Bowel

Placement of Incision

•

•

•

•

•

The proced u re can be performed via a l a p a roscop i c o r open a p proa c h . Lapa roscopy for i l eoco l i c Croh n 's d isease has been shown to result i n e a r l i e r return of bowel function, shorter length of stay, and d ecreased postope rative p a i n .9 This a p p roach may n ot be fea s i b l e for all patients, h owever, as m a n y will have h a d exte nsive p revi ous abdom i n a l s u rg e ry. For open s u rg e ry, a sta n d a rd m i d l i n e l a p a rotomy i n c i s i o n is u s u a l l y perfo r m e d . This can be l i m ited to the u p per m i d l i n e if m i n i m a l ly active d i sease i s suspecte d . In patients with m u ltiple abdom i n a l o pe rations, enter­ i n g the abdomen in an a rea that has n ot previously been opened is recommended to avoid inadvertent bowel i n j u ry.

•

•

Adhesio lysis may be necess a ry to a l low f o r com p l ete eva l u a t i o n of the sma l l bowe l . Strictu red a reas a re often i d e ntified by f i b rotic, n a rrowed bowe l with proxi m a l d i lati o n . Other exte r n a l i n d icat i o n s o f strictu re a re fat wra p p i ng, th ickened mese ntery a n d serosa l corkscrew vesse ls. • Areas of suspected strict u re a re m a rked with a stitch on the anti mesenteric bowe l s u rface. In patie nts with m u lt i p l e p revi o u s a b d o m i n a l operat i o n s a n d o b l iterative sca r t i s s u e , the use of i njecta b l e sa l i n e c a n be usefu l to h e l p d e l i n eate bowel loops. After the m ost obvious a rea of strictu re is i d e ntified, the lumen i s opened l o n g it u d i n a l ly along the a nti m esenteric border i n preparation for strict u re p l a sty o r resect i o n . A F o l ey catheter is p l aced i nto the bowel l u m e n a n d

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STRI CTU R E P LASTY A N D SMALL BOWEL BYPASS I N I N FLAM MATORY BOWEL D I SEASE

f i l led with va ry i n g a m o u nts of water. The catheter i s t h e n adva nced or withdrawn t h r o u g h bowel in both d i rect i o n s to identify a rea of strictu re that may not be exte r n a l l y evident. Patie nts may have m u lt i p l e a reas of d isease that req u i re a co m b i nation of resect i o n a n d strict u r e p l a sty. Resections should be performed fi rst.

H E I N EKE-M IKU LICZ STRI CTU REPLASTY •

The strict u re is isolated p roxi m a l l y a n d d ista l ly u s i n g u m b i l ical tape o r bowe l c l a m ps. The strictu re is opened l o n g it u d i n a l ly o n the a n t i m esenteric border, beg i n n i n g i n n o r m a l bowel a p p roxi m ately 2 to 3 em f r o m the strict u re . A c l a m p is p l aced i nto the bowe l l u m e n a n d the incision is carried across the stricture u s i n g e l ectroca utery a n d e n d i n g 2 to 3 em i nto n o r m a l bowe l .

•

O n c e the d e c i s i o n is m a d e to p e rform a strict u re p l a sty, t h e l e n gt h of affected s m a l l bowel m u st be d ete r m i n e d a s t h i s d i ctates t h e t y p e of st r i ct u re p l a sty p e rfo r m e d . • Less than 8 to 1 0 em: Hei neke- M i k u l icz strictureplasty • 1 0 to 2 5 e m : F i n ney strict u r e p l a sty • Exte n sive, l o n g-seg ment d i sease: s i d e-to-si d e isope­ rista ltic strictureplasty

•

Two 3-0 polyg l a ct i n sutu res a re p l aced on o pposite s i d es of the i n c i s i o n i n the center of the stricture. These a re used to create tension perpe n d i c u l a r to the i ncision, thereby open i n g t h e i ncised a rea of bowe l a n d a l l ow i n g the bowe l to be cl osed tra n sve rse ly. I nterru pted sero m uscu l a r 3-0 polyg l a ct i n sutu res a re t h e n p l aced to c l ose the i n c i s i o n transverse ly. 10 (FIG 1 )

•

A

B

c

FIG 1 • H e i neke-M i k u l icz strict u re p l a sty. The bowel is opened l o n g itud i n a l ly across the stricture (A) a n d then cl osed transverse ly (B) to i ncrease the bowel lumen (C).

F I N N EY STRICTU REPLASTY •

•

•

For strictures 1 0 to2 5 em in length, a Hei neke-M i k u l icz stric­ tureplasty creates excessive tension, so the F i n ney strictu re­ plasty is preferred. A Fin ney strictu replasty should not be performed in a strictu red seg ment that is longer than2 5 em, however, because this may risk a b l i n d loop synd rome. The strictu red a rea of bowe l is isol ated as p reviously de­ scribed and the bowel is p l a ced i n a U shape with the m i d po i nt of the strictu re a s the a pex i n order to s i m u late the f i n ished strictureplasty and g u i d e the bowel i n c i s i o n . The bowel is i ncised on the a n t i m esenteric border beg i n n i n g i n normal bowe l 2 to 3 em from the strict u re . This i n c i s i o n is then c a r r i e d t h r o u g h the strictu re u s i n g

•

e l ectroca utery. As the i n c i s i o n reaches the a pex o f the U sha pe, it s h o u l d take a g rad u a l cou rse towa rd the m es­ enteric border a s t h i s a l l ows for bette r tissue a p positi o n . T h e i n c i s i o n f i n ishes i n 2 t o 3 em o f n o r m a l bowel after h a v i n g been brought back to the a nti mesenteric border. I nterru pted, ful l-thickness 3-0 polyg l act i n sutu res a re used as m a r k i n g sutu res to a p p roximate n o r m a l bowel edges at the base of the stricturepl asty and a re a lso used to fix the d i seased bowel at the a pex. Cont i n uous 3-0 po lyg lacti n suture is then used to close the posterior wa l l fo l l owed by the a nterior wa l l of the strictureplasty. I nterru pted sutu res may a lso be used to rei nforce the cont i n u o u s suture at va rious poi nts and m a i ntain tissue a p position • (FIG 2).

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• F i n ney strictureplasty. The bowel open i n g is m a d e l o n g itu d i n a l ly across the strictu re a l o n g " a n omega l o o p " a n d is then closed si de-to-side (poste rior a n d a n t e r i o r rows) .

FIG 2

S I D E-TO-S I D E ISOPERI STALTIC STRICTU REPLASTY •

•

For extensive strict u r i n g Cro h n 's d isease not a m e n a b l e to strict u re p l a sty of isol ated seg m e nts, the s i d e-to-s ide isoperista ltic strictureplasty can be perfo r m e d . The affected bowel is fi rst transected at the m i d po i nt. The p roxi m a l bowel is then brought to ove r l i e the d i stal seg­ ment i n a n isoperista ltic fash i o n (FIG 3) . An e nterotomy

•

•

is performed on the a nti mesenteric border a n d extended 2 to 3 em i nto n o r m a l m ucosa (FIG 4). The transected e n d s of bowel a re spatu l ated i n order t o avo i d creati o n of b l i n d stu m ps . S i m i l a r to the F i n ney strict u re p l a sty, t i s s u e s a re b r o u g h t toget h e r at b o t h e n d s of the treated seg ment with i nterru pted 3-0 polyglactin sutu res. The poste r i o r l ayer is closed with a ru n n i n g 3-0 polyglactin suture fo l l owed by closu re of t h e anterior layer (FIG S).

• S i d e-to-si d e isoperista ltic strictureplasty. The affected bowel is fi rst tra n sected at the m i d po i nt . The p roxi m a l bowe l is t h e n brought to ove r l i e the d i stal seg ment in an isoperistaltic fash i o n .

FIG 3

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STRI CTU R E P LASTY A N D SMALL BOWEL BYPASS I N I N FLAM MATORY BOWEL D I SEASE

• Side-to-side isoperista ltic strict u replasty. An enterotomy is performed on the a nti mesenteric border and extended 2 to 3 em i nto normal m ucosa .

FIG 4

FIG S

• S i d e-to-side isoperista ltic strictureplasty. S i m i l a r to the F i n ney strict u re p l a sty, tissues a re brought toget h e r at both e n d s of the treated seg ment with 3-0 polyglactin sutu res.

SMALL BOWEL BYPASS

colon mese ntery a n d a l so keeps the a n a stomosis away from the retro pe rito n e u m .

Gastrojejunal Bypass •

G a st rojej u n osto my is performed by b ri n g i n g the m ost prox i m a l loop of j ej u n u m that easily reaches the g reater c u rvatu re of the sto m a c h . The a n a stomosis can be d o n e u s i n g e i t h e r a h a n d -sewn (FIG 6) o r sta pled tech n i q u e (FIG 7) . It can a l so b e d o n e a nteco l i c o r retroco l i c. T h e a n ­ teco l i c a p proach avo i d s d i ssect i o n t h r o u g h the transverse

Duodenojejunal Bypass •

A l o n g itud i n a l enterotomy i n the proxi m a l jej u n u m i s m a d e i n a n a rea t h a t is free of d isease. A F o l ey catheter is i nserted and passed proxi m a l ly t h r o u g h the d u od e n a l sweep a n d f i l led w i t h va ryi n g a m o u nts o f water to assess for d u o d e n a l stricture. If t h e re is a strictu re isol ated to

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

FIG 6

•

G a strojej u n a l bypass: h a n d-sewn tec h n i q u e .

the t h i rd a n d fou rth portions o f the d u o d e n u m a n d it is determ i n e d that t h e re is healthy, patent bowe l in the fi rst a n d seco n d portion, then a bypass may be performed. A l o n g itud i n a l d u o d e n otomy is performed i n the healthy portion of the d u o d e n u m . 3-0 polyglactin sutures a re p l aced to a p p roxi m ate the j ej u n a l ente rotomy to the d u o d e n otomy.

•

8 • D u o d e n oj ej u n a l bypass: A poste r i o r l a y e r of i nterru pted 3-0 s i l k sutu res is p l a ced to a p p roxi m ate the duodenal a n d jej u n a l seg m e nts.

FIG FIG 7

•

Gastrojej u n a l bypass: sta pled tech n i q u e .

A poster i o r l ayer of i nterru pted 3-0 s i l k sutu res is p l aced to a p p roxi m ate the d u o d e n a l and j ej u n a l seg m e nts (FIG 8) . T h i s is fo l l owed by a conti n u o u s i n ne r suture l ayer of 3-0 polyg l a ct i n sutu re. A layer of i nterru pted 3-0 s i l k is then p l a ced o n the a nterior s u rface to com­ p l ete the a n a stomosis (FIG 9). The use of a sta p l e r i s not reco m m e n d e d ."

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STRI CTU R E P LASTY A N D SMALL BOWEL BYPASS I N I N FLAM MATORY BOWEL D I SEASE

• D u od e n oj ej u n a l bypass: A cont i n u o u s i n n e r sutu re layer of 3-0 polyg lact i n suture a n d a layer of i nterru pted 3-0 s i l k a re then p l aced on the a nterior s u rface to co m p l ete the a n asto mosis.

FIG 9

I LEOTRAN SVERSE BYPASS •

•

•

When i l eoco l i c d i sease is severe a n d resect i o n is deemed u n safe, a n i l eotransverse bypass may be perfo r m e d . The s m a l l bowe l is transected p rox i m a l to the i nvolved ileum. A h a n d-sewn a n astomosis is performed i n an e n d ­ to-s i d e fash i o n with the e n d of t h e t ra n sected i l e u m

FIG 1 0

•

l l eotra n sverse bypass: h a n d-sewn tech n i q u e .

a n a stom osed to t h e s i d e of a seg ment of transverse co l o n (FIG 1 0) . This i s d o n e in a s i m i l a r fa s h i o n as described for t h e d u o d e n oj ej u n a l bypass. Alternatively, t h e a n astomosis c a n be perfo rmed i n a s i d e-to-s i d e fas h ­ i o n u s i n g a g astroi ntest i n a l a n a stomosis (G IA) sta p l e r8

(FIG 1 1 ) .

FIG 1 1

•

l l eotra n sverse bypass: sta pled tech n i q u e .

93 1

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

OTH E R CO N S I D E RATI O N S •

D u o d e n a l strictu res Patients with non perforated, n o n p h legmonous stric­ tu res of the d u o d e n u m can u n dergo H e i n e ke-M i k u l icz strictureplasty. • Patie nts with refractory obstruction, p a i n , or exten­ sive d u o d e n a l strict u r i n g may req u i re bypass with g a strojej u n osto my o r d u od e n ojej u n osto my. The role of vagotomy in this sett i n g h a s been d e bated; •

•

h owever, as stated p revi ously can m ost often be o m itte d . • D u o d e n a l resection is n ot i n d i cated f o r C ro h n 's d i sease d u e to its excess ive m o r b i d ity. C o l o n i c strictu res that ca n n ot be eva l u ated by colonos­ copy b i o psy o r cyto logy s h o u l d be resected as a p p roxi­ m ately 7% of these may conta i n occ u l t m a l i g n a n cy." B i o psy of the strictu red bowe l wa l l s h o u l d be considered to eva l u ate fo r poss i b l e occ u l t m a l i g n a ncy.' 2

PEARLS AND PITFALLS Imaging

• •

Choice of procedure

• • • • • •

Preoperative i m a g i n g stu d i e s s h o u l d be used to determ i n e the exte nt of d isease a n d to fac i l itate s u r g i c a l planning. Exte nt o f active i n f l a m mation s h o u l d be est i m ated p reoperatively as t h i s is potenti a l ly respo nsive to m e d i c a l thera py. Resect i o n with s i m p l e rean asto mosis s h o u l d be performed for m ost patie nts with s m a l l bowe l a n d i l eoco l i c d i sease. Strictureplasty s h o u l d be performed i n patie nts with p revi o u s resect i o n s who a re at risk for s h o rt bowe l syn d ro m e or patie nts with d i ffuse or recu rrent strictu r i n g d i sease. Bypass of affected seg m ents is m ost u sefu l for gastrod u o d e n a l Cro h n 's d i sease and s h o u l d o n ly be e m p l oyed i n s m a l l bowel o r i l eoco l o n i c Cro h n 's d isease if resect i o n is deemed too u nsafe. When a strictu red a rea is i d e ntified, a l o n g it u d i n a l i n c i s i o n is made and the prox i m a l and d i stal bowe l is eva l u ated with a F o l ey catheter to determ i n e extent of d i sease. M eta l l i c c l i ps s h o u l d be p l aced o n the mesentery at the strict u re p l a sty sites for future i d e ntificat i o n d u r i n g i m a g i n g o r s u rg e ry. The l e ngth of re m a i n i n g s m a l l bowe l s h o u l d be measu red a n d reco rded, especi a l ly i n patients who a re havi n g reoperations. This wi l l h e l p in p l a n n i n g d u ri n g possi b l e future operations.

been performed with good results. Major morbidity of these procedures may be as high as 2 7 % . It is thought that use of laparoscopy to perform gastrojejunostomy may decrease com­ plication rates. 6 Recurrence and reoperation rates are variable.

POSTOPERATIVE CARE •

Patients undergoing resection, strictureplasty, or bypass for Crohn's disease often have proximally dilated small bowel. Chronically dilated intestine should be expected to have dysfunctional peristalsis, and as such, recovery of full bowel function may take up to 1 week or more. For severe obstruction, nasogastric tube decompression may be indi­ cated. Total parenteral nutrition may also be useful in the postoperative period to allow adequate healing at anasto­ mosis or strictureplasty sites.

OUTCOMES •

•

•

Resection: Recurrence of stricturing disease requiring sur­ gery occurs in 2 5 % and 5 0 % of patients at 5 and 10 years, respectively. 1 Recurrence is unaffected by the presence of active microscopic inflammation at the resection margin and as such, only macroscopically involved segments of bowel should be resected. 10 Strictureplasty: Recurrence following strictureplasty occurs in 2 8 % and 3 4 % of patients at 3 . 5 and 7.5 years, respec­ tively. Younger patients are at higher risk for recurrence following stricturoplasty. 1 Overall recurrence rates are com­ parable to those following resection. Duodenal Crohn's disease: Bypass or strictureplasty of the duodenum are relatively uncommon procedures but have

COMPLICATIONS • • • • • • •

Surgical site infection lntraabdominal infection Anastomotic leak Anastomotic hemorrhage Ileus Small bowel obstruction Short bowel syndrome

REFERENCES 1. Dietz OW, Laureti S, Strong SA, et a!. Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease. JAm Call Surg. 2001;192(3):330-337; discussion 337-338. 2. Louis E, Collard A, Oger AF, et a!. Behaviour of Crohn's disease according to the Vienna classification: changing pattern over the course of the disease. Gut. 2001;49(6):777-782. 3. Saibeni S, Rondonotti E, Iozzelli A, et a!. Imaging of the small bowel in Crohn's disease: a review of old and new techniques. World ] Gastroenterol. 2007;13(24):3279-3287. 4. Milsom JW. Strictureplasty and mechanical dilation in strictured Crohn's disease. In: Michelassi F, Milsom JW, eds. Operative Strategies in Inflammatory Bowel Disease. New York, NY: Springer; 1999:259-267.

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5 . Lu K C , Hunt S R . Surgical management of Crohn's disease. Surg Clin North Am. 201 3 ;93(1):167-185. 6. Shapiro M, Greenstein AJ, Byrn J, et al. Surgical management and outcomes of patients with duodenal Crohn's disease. JAm Coli Surg. 2008;207(1):36--42. 7. Worsey MJ, Hull T, Ryland L, et a!. Strictureplasty is an effective option in the operative management of duodenal Crohn's disease. Dis Colon Rectum. 1 999;42(5):596-600. 8. Wolff BG, Nyam D. Bypass procedures. In: Michelassi F, Milsom JW, eds. Operative Strategies in Inflammatory Bowel Disease. New York, NY: Springer; 1 999:268-278.

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9. Tan JJ, Tjandra JJ. Laparoscopic surgery for Crohn's disease: a meta­ analysis. Dis Colon Rectum. 2007;50(5):576-585. 10. Fazio VW, Marchetti F, Church M, et al. Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A random­ ized controlled trial. Ann Surg. 1 996;224(4):563-571; discussion 571-573. 1 1 . Strong SA, Koltun WA, Hyman NH, et a!. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum. 2007;50(1 1 ):1 735-1 746. 12. Strong SA. Surgical treatment of inflammatory bowel disease. Curr Opin Gastroenterol. 2002;18(4):441--446.

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Chapter

3

Surgical Management of Enterocutaneous Fistula 1

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William Sanchez

Intermediate output: 200 to 500 mL per day Low output: less than 200 mL per day

DEFINITION •

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A fistula is an abnormal communication between two epi­ thelialized surfaces. An enterocutaneous fistula (ECF) is an abnormal communication between the bowel lumen and the skin. An enteroatmospheric fistula (EAF) is the communica­ tion between the bowel and the environment, with absence of skin continuity ( open abdomen fistula). Anastomotic leaks occurring during the first postoperative week are considered anastomotic line failures and not fistulas (no epithelialized tract has formed during that short period of time) . They are usually detected because of drainage of intestinal material in the peritoneal cavity leading to the for­ mation of an abscess or diffuse peritonitis. These patients are taken to surgery urgently either to repair the leak or to per­ form proximal diversion ostomies to ensure patient recovery.

Prognostic Factors •

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CLASSIFICATION AND PROGNOSTIC FACTORS Classification •

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Anatomic: on the basis of the affected segment Gastrocutaneous, duodenocutaneous, enterocutaneous, and colocutaneous Etiology: Multiple causes are described, including the following1• 2 : Infectious and inflammatory ( Crohn's disease, ulcerative colitis, tuberculosis, mycosis, diverticulitis, salmonellosis, amoebic abscess) Iatrogenic (postoperative, open abdomen, postradiation) Traumatic Cancer Foreign bodies Fistula output: High output: more than 500 mL per day. These fistulas are associated with a severe electrolyte and nutritional abnormalities.

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Deep EAFs drain the intestinal content into the abdominal cavity, giving rise to peritonitis. Mortality associated with this condition is higher than that of the superficial fistula that drains its content to the outside, creating an abdominal granulation wound with no diffuse contamination of the abdominal cavity.3 In surgical patients with secondary fistula, we characterize the most important adverse prognostic factors associated with the course of treatment, which are analyzed follow­ ing the initial resuscitation and stabilization stage (48 to 72 hours) . These factors include the following: Open abdomen Diameter larger than 5 mm; output greater than 500 mL per day Presence of abscess and/or diffuse peritonitis, generalized sepsis Need for mechanical ventilation Inability to provide enteral feeding Presence of multiple fistulas (FIG 1 ) Severe comorbidities (cancer, immunosuppression, radia­ tion therapy, etc . ) The probability o f a spontaneous fistula closure i s related to different factors summarized in Table 1 . Three risk groups are then established in order to arrive at an objective deter­ mination of the degree of complexity of the fistula, the goals of the proposed treatment, and the predicted clinical course (Table 2 ) . Risk group I: good prognosis. This group includes patients with no debilitating disease who are in good general con­ dition and no systemic inflammatory response syndrome ( SIRS ) , with fistulas that have a good probability of clos­ ing spontaneously (diameter < 5 mm, output 2 e m N o a b d o m i n a l wa l l d efect A l b u m i n level > 25 gil N o FRIE N D factors' Output 1 e m F i s t u l a tracts < 2 e m Open abdomen Albumin level 500 m lid Surgical treatment

'Nonhealing ECFs are associated with FRIEND factors: Foreign body, Radiation,

FIG 1

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Patient with open a b d o m e n and m u lt i p l e EAFs.

Inflammation, Infection, Inflammatory bowel disease, Epithelization of the fistula tract, Neoplasms, and Distal obstructions.

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Table 2: Fi stula Treatment Outcomes, Prognostic Risk Groups

Prognostic Group Degree of complexity of the fistula Goals of the proposed treatment Predicted clinical course (mortal ity)

Ill

II Low

I ntermed iate

High

Sponta neous closure

Ea rly s u rgical closure

Late s u rg i c a l closure

Excepti o n a l m o rtal ity

M o rtal ity

M o rtal ity

1 0 %-2 5%

>25%

Risk group II: intermediate prognosis. This group includes patients in acceptable general condition with no SIRS but with fistulas that have small probability of closing spon­ taneously ( diameter >5 mm, output > 5 0 0 mL per day, multiple fistulas ) . The treatment strategy is to initially sta­ bilize the patient and subsequently perform early surgical closure. Risk group III: poor prognosis. This group includes pa­ tients in poor condition who are malnourished, with debilitating diseases, who exhibit SIRS, and who have fistulas with small probability of closing spontaneously. The initial goal of treatment is to reduce fistula output, to achieve granulation and ostomization of the fistula, as well as to care for the open abdomen. The surgical closure is performed at a later stage (6 to 12 months ) , once the patient has recovered and both objective and subjective signs of recovery are satisfactory.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

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The role of imaging is to define the anatomy, evaluate as­ sociated processes, and provide therapeutic alternatives for treatment. Fistulograms are the most direct method of linking a cuta­ neous opening with the gastrointestinal ( GI ) tract. In the absence of sepsis, fistulograms may be the only imaging study needed. Two classes of contrast media are commonly used to evaluate the fistula tract, each with particular risks and benefits . Barium is a non-water-soluble media with high radiographic density, isotonic osmolarity, and an inert nature. Barium provides high-quality mucosal im­ ages, demonstrating areas of inflammation and the pres­ ence of fistula tracts with good accuracy. Unfortunately, if extravasated, barium causes significant peritoneal inflam­ mation, including foreign body granulomas and peritoneal adhesions. Aqueous contrast agents, such as Gastrogra­ fin, are hyperosmolar and water-soluble. Water-soluble agents provide less mucosal detail; areas of inflammation, mucosal proj ections, and fistula tracts themselves may be missed. Gastrografin is rapidly absorbed within the perito­ neal cavity if extravasated with minimal inflammation. To minimize risk and maximize benefits, water-soluble con­ trast material is often inj ected initially, followed by barium

FIG 2 • CT scan s h owi n g a o rtoenteric fist u l a with gas a r o u n d the a o rta.

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if no extravasation is seen and additional information is required. 1•3•4 Small bowel follow-through ( SBFT) studies provide a more global view of the intestinal tract. Multiple views are typi­ cally taken to optimize visualization. Ideally, barium is used for contrast as Gastrografin can be diluted as it moves dis­ tally through the GI tract. Fistulas with narrow lumen and distal fistulas may not be detected in SBFT studies. Previ­ ously opacified loops of bowel may complicate visualization of the fistula. Ultrasound. Limitations of ultrasound include operator de­ pendency, obesity, and difficulty of evaluating certain portions of the small bowel including duodenum and jejunum. Injec­ tion of hydrogen peroxide through the fistula orifice has been reported to increase the diagnostic accuracy of ultrasound from 2 9 % to 8 8 % in ECF complicating Crohn's disease.5 Computed tomography ( CT) allows for the identification of extraluminal pathology, downstream disease, and inflamma­ tion ( FIG 2) . Computed tomography enterography ( CTE) uses " negative " contrast, which appears dark, allowing for distention of the bowel. With the concomitant administration of intravenous (IV) contrast that will delineate mucosa, negative contrast provides additional information concerning the mucosa sur­ rounding a fistula tract. 4 Magnetic resonance imaging (MRI) is a promising adjunct to primary imaging modalities. Its use in ECF evaluation is beginning to be understood.

SURGICAL MANAGEMENT Preoperative Planning •

The fundamental pillars for fistula management, initially described by Chapman, 6 can be summarized by the SOWATS acronym: management of the Septic condition, Optimiza­ tion of the nutritional status, surgical Wound care, fistula Anatomy, right Timing for surgery, and Surgical strategy. 1 By adopting this strategy, they reduced ECF mortality from 4 0 % down to 1 5 % . Sepsis: Associated infection i s the primary cause of death in fistula patients. The initial management of a patient with an ECF, with or without associated infection, is fluid resuscitation to address dehydration and prevent renal

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failure. Blood transfusion has to be considered if required. There are two stages associated with the management of infection: Early stage. When a fistula is suspected or diagnosed, the goal is to prevent or control generalized contamination of the abdominal cavity and subsequent peritonitis. Treatment at this stage is surgical or percutaneous inva­ sive therapy together with the use of antibiotics. Late stage. After the fistula tract has been established, the goal is to prevent or treat any secondary focus of infection, usually nosocomial (catheter-related sepsis, pneumonia, residual abscesses, etc . ) . Treatment at this stage is systemic or preventive. Optimization of the nutritional status: Effective nutri­ tional support is a priority. Although parenteral nutrition may be needed in some cases, recent publications favor enteral nutrition as a protective factor against associated infections. The enteral route must be considered when it is suspected that the fistula will not close spontaneously, when it is a low-output fistula, or when it is localized in the terminal ileum or the colon. The use of somatostatin and octreotide, which lower endocrine and exocrine se­ cretion, reduces fistula output. The use of antiperistaltic agents such as loperamide and codeine is also helpful. The basic nutritional requirements consist of carbohydrates and fats 20 kcaVkg/day and proteins 0 . 8 g/kg/day. Caloric and protein requirements may increase to 30 kcal/kg/day and 1 . 5 to 2 . 5 g/kg/day, respectively, in patients with high­ output fistulas. 1•3 Surgical wound care: The goal of treatment is to avoid maceration and excoriation of the skin surrounding the ECF, one of the main causes of chronic pain in these pa­ tients. Multidisciplinary treatment is recommended pref­ erably in a specialized wound clinic. Fistula anatomy: It is crucial to identify the origin and tract of the fistula in order to plan treatment. Diagnos­ tic imaging studies with water-soluble contrast through the fistula tract or through the GI route provide accurate information about the problem. CT scans are useful to assess the entire abdominal cavity and to identify other associated problems requiring treatment ( abscesses, free fluid collections, obstructions, etc . ) . In some cases, endo­ scopic evaluation is useful, given the possibility of per­ forming therapeutic maneuvers to obliterate the fistulous tract (stent, clips, glue sealant).7 Right timing for surgery: The decision on the right tim­ ing for the surgical closure of an ECF must be made after analyzing all prognostic variables for each individual pa­ tient. A period of 6 weeks is considered the minimum time between the development of the fistula and the surgical repair procedure because it is the time required for the patient to recover from the inflammatory response and to achieve a good nutritional status that will help avoid a new, possibly fatal, complication. Preoperative albumin level of less than 2.5 giL is a strong adverse prognostic factor associated with mortality (p < . 0 0 1 ) ; this result has been replicated in other series. 2 In open abdomens, the time required for regression of the inflammatory state, the nutritional recovery, and the best course of potential ab­ dominal adhesions is between 6 and 1 2 months. Patients are eligible for surgery when septic foci have been treated

adequately and the subjective criteria for a good clinical and nutritional condition are satisfactory. These criteria include a patient who can walk, feels well, interacts ac­ tively, and is impatiently waiting for the restorative sur­ gery. The absence of signs of sepsis is determined by the increase in albumin and hemoglobin levels, together with lower leukocyte, reactive protein C, and thrombocytosis values. 1•3 Surgical strategy: There are multiple surgical techniques and strategies for the treatment of ECFs. There is no single tech­ nique, and the combination of several different strategies is usually required. Generally, the surgical goals include the following: Fistula resection Restore continuity of bowel transit. Address the factors that promote fistula formation ( obstruction, foreign body, tumors, diverticular disease, inflammations ) . Abdominal wall closure Perform as few anastomoses as possible, all of which need to be covered by healthy tissue and separated from other anastomosis lines. Avoid the use of nonabsorbable mesh for closure of the abdominal wall. Avoid leaving skin defects that might promote the for­ mation of a new fistula. Ensure adequate nutrition. Surgical Tips •

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In established fistulas with a defect larger than 5 mm in di­ ameter and an output greater than 500 mL per day, attempt­ ing a primary closure with sutures is often ineffective and may increase the size of the damage to the intestinal wall. In order to attempt the primary closure of the fistula, all granu­ lation tissue at the edges must be removed, the closure must be done under no tension, and the defect must be covered. No balloon catheters (Foley) must be introduced or inflated inside the fistula tract or the gut lumen because this will in­ crease the size of the fistula. When the fistula is close to the ligament of Treitz, a feeding tube may be introduced distally for enteral nutrition. In fistulas with an open abdomen, the use of the Bogota bag is not very effective because it does not allow for control of ongoing contamination of the abdominal cavity and there is persistence of skin erosion. These problems are solved with the use of the wound vacuum-assisted closure (VAC®) system (the right foam must be selected in accordance with the clinical situation) . In some cases, VAC® therapy together with other strategies results in primary closure of the fistula. If primary closure is not achieved, VAC® therapy promotes granulation and wound healing, maturation of the fistula into a controlled stoma, and patient recovery so that surgi­ cal closure and abdominal wall reconstruction may follow ( FIGS 3-S) . 8•9 Patients with ECF difficult to reach and/or control (i.e., ECF in frozen open abdomen, duodenal fistulas, aortoenteric fistula, etc . ) can develop ongoing peritonitis leading to persistent sepsis. Attempting extensive surgery (pancreato­ duodenectomy, diverticulization, etc . ) or multiple diver­ sions in this setting usually results in a poor outcome and

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extremely high mortality rates. I n these critical situations, we pass a self-expandable coated stent or an impermeable corrugated prosthetic tube through the fistula defect and into the intestinal lumen in an attempt to seal off the fistula, to restore intestinal transit, and to prevent ongoing soilage of the peritoneal cavity. The use of the wound VAC® therapy in this setting collects any spillage of bowel fluid leaks that may occur and promotes granulation and healing of the ab­ dominal cavity. Surgery must be performed at an early stage, before the patient goes into multiple organ failure and is be­ yond rescue. After the patient recovers (weeks or months later) , and if the fistula has closed, an attempt is made to recover the prosthesis through enteroscopy or surgery. If the fistula has not closed, the relevant repair surgery is planned. The introduction of this concept is controversial, but its use may be acceptable in extreme situations, based on the wide clinical experience with the use of stents or shunts in other GI, vascular, and colonic diseases (FIG 6 ) . 10

FIG 3

• S o l d i e r wo u n ded i n combat with m u lt i p l e i ntraabdom i n a l i n j u ries a n d com p l ex E C F.

FIG 4 • Wo u n d VAC® thera py is very effective to a l low control of fist u l a f l u i d s or of conta m i n at i o n of the a b d o m i n a l cavity.

• Wo u n d VAC® therapy promotes g r a n u lation, wound h e a l i ng, a n d control of the fistu l a . T h i s a l l ows the patient to recover i n preparation for s u rg i c a l closure a n d abdom i n a l wa l l reco nstruct i o n .

FIG 5

FIG 6

• Use of a ste nt o r corrugated prosthetic tube with i ntest i n a l bypass i n a patient with a co m p l ex fist u l a i n the fo u rth port i o n of d u o d e n u m .

SURG I CAL CLOSURE OF COM PLEX ENTE ROATMOSPHERIC FISTULA Step 1 . Peritoneal Contamination Control •

Remove the Bogota bag (FIG 7), wash a n d c l e a n the a b ­ d o m i n a l cavity, a n d then place a tube for entera l feed­ ing, cove r i n g the open a b d o m e n p a rti a l ly with a wo u n d VAC® system (FIG 8) .

FIG 7

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Te m p o ra ry a b d o m i n a l closure with a Bogota b a g .

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

Step 2. Granulation of the Abdominal Wound and Conversion of the Fistula into a Stoma •

Conti n u e with wo u n d VAC® therapy u nti l the perito n e a l conta m i nation is u n d e r control, p ro m oti n g g ra n u l at i o n of the a b d o m i n a l wo u n d (FIG 9) . The e n d point of t h i s step is to ach ieve convers i o n of the fist u l a i nto a f u n c­ t i o n a l stom a (FIG 1 0) .

Step 3 . E n Bloc Resection o f the Fistula and Abdominal Wound •

E n b l o c d i ssection is performed of the e n t i re a b d o m i n a l sca r co m ponent a n d the fist u l a , wo r k i n g i nwa rd from the s u rface (FIG 1 1 A,B) .

FIG 8

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A

Placement o f feed i n g t u b e a n d a wo u n d VAC® system .

B FIG 1 1

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A,B. En bloc d i ssect i o n of E C F a n d g r a n u lation

tissue bed.

F I G 9 • T h i s strategy a l l owed f o r exce l l ent g ra n u l at i o n tissue to form around the E C F i n t h e open a b d o m i n a l wo u n d .

FIG 1 2

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Resect i o n of the ECF.

Step 4. Reconstruction of the Intestinal Transit and the Abdominal Wall •

• T h e e n d p o i nt o f thera py p r i o r t o s u rg i c a l excision of the E C F is when the fist u l a h a s been tra n sformed i nto a sta b l e sto m a .

FIG 1 0

The E C F is then resected (FIG 1 2), a n d the i ntest i n a l t ract is reco nstructed with a h a n d-sewn (FIG 1 3) o r sta p l e d tech n i q u e (FIG 1 4) . The a b d o m i n a l wa l l is reconstructed u s i n g p a rti a l ly a bsorba b l e mesh with carboxymethyl cel l u lose coat i n g or, p refe rab ly, with a b i o l o g i c coat i n g

(FIG 1 5) .

C h a p t e r 3 S U RG I CAL MANAG E M E N T OF ENTEROCUTA N E O U S F I ST U LA

1 3 • Reesta b l i s h m e n t of i ntest i n a l conti n u ity. E n d -to-e n d h a n d-sewn a n asto mosis tech n i q u e .

FIG

FIG 1 4 • Reesta b l ishment o f i ntest i n a l cont i n u ity. S i d e-to-si d e sta p l e d a n asto mosis tech n i q u e .

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

FIG 1 S • The a b d o m i n a l wa l l is reco nstructed u s i n g pa rti a l ly a bsorba b l e mesh with ca rboxymethyl ce l l u l ose coat i n g .

NONSURG I CAL CLOSURE OF A COMPLEX ENTE ROATMOSPH E R I C FI STULA •

A n ewborn, 3 1 weeks of gestati o n with n ecrot i z i n g enteroco l itis, d evelops EAF after right h e m i c o l ectomy (FIG 1 6) . I n patie nts such as this o n e, with oth e rwise n o s i g n ificant comorbid iti es, a n o n s u rg i c a l a p p roach to E C F closu re may be atte m pted .

Step 1 : Peritoneal Contamination Control •

• A wo u n d VA� has been p l aced t o control t h e fistu la, p rotect the skin, a n d promote g ra n u lation tissue formation.

FIG 1 7

Sta rt with g e n e r a l resuscitati o n measu res a n d use of the SOWATS p rotoco l . Control conta m i n at i o n a n d i ntest i n a l fl u i d l e a ks u s i n g w o u n d VAC® therapy (FIG 1 7) .

Step 2 : Granulation o f the Abdominal Wound and Fistula Control •

Cont i n u e the wound VAC® thera py u n t i l the perito n e a l conta m i nation is u n d e r control, p ro m oti n g g ra n u l ation of the a b d o m i n a l wound, a n d channel the fistu l a to reduce output gradually (FIG 1 8) .

FIG 18

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Exce l lent g r a n u lation tissue h a s been a c h i eved .

Step 3 . Closure o f the Fistulous Tract Using Fibrin Glue •

O n ce the fist u l a output is down to a m i n i m u m , f i b r i n g l u e is a p p l ied t h r o u g h the fist u l a tract (FIG 1 9) . C o n ­ t i n u e w i t h g e n e ra l m e a s u res a n d wound VAC® thera py u n t i l h ea l i n g of the fist u l a a n d closu re of the a b d o m i n a l wa l l a re a c h i eved (FIG 20) .

FIG 1 9 • F i b r i n g l u e a p p l icati o n i nto the fist u l a tract to acce l e rate ECF closure.

FIG 1 6 • Newborn with enteroco l itis.

E C F seco n d a ry to n ecrot i z i n g

FIG 20 • F u l l h ea l i n g of ECF after n o n o p e rative m a n agement of ECF fistu l a .

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PEARLS AND PITFALLS Burn injury

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An E C F may occ u r from a bowel lesion created i n a dve rte ntly by d i ath e r m i a d u r i n g open or l a p a rosco p i c s u rg e ry (FIG 2 1 ) .

Suture line protection

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An asto motic l i nes s h o u l d n o t be i n contact w i t h other suture l i nes o r p rostheses. An omental ped icle f l a p is a g o o d option to p rotect t h e a n asto mosis. Alth o u g h the u s e o f f i b r i n g l u e sea l a nts has a lso been a dvocated for this p u rpose, there is n o concl u s ive evi d e n ce i n the l iterature a bout t h e i r benefit.

Use of n o n a bsorba b l e mesh in d i rect contact with the bowe l s should be avo i d e d .

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A good option i s to use b i o l o g i c mesh o r synthetic mesh coated with ca rboxymethyl cel l u l ose ( n o n a d h e rent).

Fistulas secondary to adhesions

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The prophylact i c use of a n t i a d h esive su bsta n ces, such as carboxymethyl cel l u lose and hya l u ro n i c acid, h a s been shown to red uce the presence and d e g ree of co m p l exity of t h e a d hesions and, conseq u e ntly, l ower the poss i b i l ity of fist u l a fo rmation seco n d a ry to s u rg i c a l i n j u ries."

Open abdomen-related fistulas (2 5 % incidence)

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The fistu l a forms as a res u l t of d i rect i n j u ry, desiccat ion, o r eros i o n d u e t o fore i g n bod i es t h a t become i n corporated i nto the g u t wa l l (Pa c k i n g , Witt m a n n Patch). Part i a l cove rage of the a b d o m i n a l cavity u s i n g the VAC® system is a good option for lowe r i n g the proba b i l ity of fistu l a fo rmation 8•9

• A fistu l a may o r i g i nate from a bowe l lesion created i n adverte ntly by d i atherm i a .

FIG 21

COMPLICATIONS •

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Local: abscess, diffuse peritomns, other fistulas, bleeding

from erosion of adj acent structures, skin damage Systemic: fluid and electrolyte imbalances, malnutrition, abscess of distant solid viscera (liver, lung, brain), sepsis, SIRS

CONCLUSION •

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Currently, the main causes of ECFs are those associated to the complications of surgery. Review and practice of pro­ phylactic surgical tips can reduce its incidence. The treatment of fistulas must be multidisciplinary. Ad­ herence to a driving guide, such as SOWATS, allows for

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a sequential a n d ordered therapeutic strategy with an increased chance of better clinical outcomes. Patients with intestinal fistulas should be categorized into risk groups in order to predict its prognosis and to define the management strategy necessary. There is no one single stan­ dard treatment; the selection of the treatment depends on the individual condition of each patient and the characteristics of the fistula itself.

REFERENCES 1 . Schecter WP, Hirsberg A, Chang DS, et al. Enteric fistulas: principles of management. JAM Coil Surg. 2009;209(4) :484-4 9 1 . 2. Berry SM, Fischer J E . Classification and pathophysiology of enterocu­ taneous fistulas. Surg Clin North Am. 1 996;76 : 1 009- 1 0 1 8 .

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3. 4. 5.

6. 7.

P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

Lee SH. Surgical management of enterocutaneous fistula. Korean 1 Radio/. 2 0 1 2 ; 1 3 (suppl 1 ) : S 1 7-S20 . Lee JK, Stein S L . Radiographic and endoscopic diagnosis and treatment of enterocutaneous fistulas. Clin Colon Rectal Surg. 201 0;23 ( 3 ) : 149-160. Maconi G, Parente F, Porro G. Hydrogen peroxide enhanced ultra­ sound-fistulography in the assessment of enterocutaneous fistulas complicating Crohn's disease. Gut. 1 999;45 ( 6 ) : 8 74-8 7 8 . Chapman R, Foran R, Dunphy J E . Management of intestinal fistulas. Am 1 Surg. 1 964; 1 0 8 : 1 5 7-164. Avalos-Gonzales J, Portilla-deBuen E, Leal-Cortes C. Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin seal­ ant. World 1 Gastroenterol. 2 0 1 0 ; 1 6 (22) :2793-2800.

8 . Sanchez MW. VAC® Una Opci6n Terapeutica Para el Abdomen Abierto. Investigaciones Medicas. 2005;24 ( 1 3 1 ) : 6-8 . 9. D'Hondt M, Devriendt D, Van Rooy F. Treatment of small-bowel fis­ tulae in the open abdomen with topical negative-pressure therapy. Am J Surg. 2 0 1 1 ;202(2) :20-24. 1 0 . Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta­ analysis. Gastrointest Endosc. 2 0 1 2;75 ( 2 ) : 2 8 7-29 3 . 1 1 . Kumar S, Wong PF, Leaper D J . Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstructions after non-gynaecological abdominal surgery. Cochrane Database Syst Rev. 2009; ( 1 } : CD005080.

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Chapter

4

End and Diverting Loop Ileostomies: Creation and Reversal

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Kathrin Mayer Troppmann

END AND DIVERTING LOOP ILEOSTOMIES: CREATION DEFINITION •

An ileostomy is an artificially created opening of the distal ileum that is externalized on the abdominal walL It can be temporary or permanent.

PATIENT lllSTORY AND PHYSICAL FINDINGS •

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A thorough review of the patient's history and a physical ex­ amination, including a review of all past operative notes and diagnostic studies, are necessary to carefully select patients who are appropriate candidates for an ileostomy and to de­ termine the most appropriate type of ileostomy to be created. The history and the physical examination should be ob­ tained with the functional and anatomic implications, treat­ ment plan, and prognosis of the underlying disease in mind. Additionally, the patient's comorbidities, ability to perform activities of daily living and self-care, mobility limitations, and body contour must be thoroughly assessed.

PREOPERATIVE IMAGING AND OTHER DIAGNOSTIC STUDIES •

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Appropriate imaging studies must be obtained according to the patient's underlying disease and diagnosis. Any abnor­ mal findings should be thoroughly worked up to ensure that the correct operation and diversion techniques are chosen. These tests may include the following: Colonoscopy with biopsy if malignancy or inflammatory bowel disease is suspected Computed tomography ( CT) scan, upper gastrointestinal contrast study, and fistulogram to rule out intestinal ob­ struction or leak and to assess underlying disease severity Anal manometry and endorectal ultrasound to evaluate the anal sphincter Colonic motility study (e.g., SITZMARKS® test) to iden­ tify the region of intestinal dysmotility and to tailor the procedure and type of stoma to the patient's needs Prior to ileostomy formation, the nutritional status must be assessed (including albumin and prealbumin levels) and the patient's comorbidities must be addressed (e.g., coro­ nary artery disease, diabetes [HbA c) ) in order to minimize 1 perioperative risk.

SURGICAL MANAGEMENT General Considerations •

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�

If possible, a stoma should be avoided, as the morbidity of creation and reversal can be significant. An ileostomy can be constructed as an end ileostomy (Brooke ileostomy) or as a diverting loop ileostomy. Alternatives to

the more commonly used end and loop ileostomy techniques include the divided (or separated) loop ileostomy for maxi­ mizing fecal diversion and the end-loop (or loop-end) ileos­ tomy for patients with a short, contracted mesentery and vascular pedicle. An end ileostomy is the preferred configuration for a perma­ nent ileostomy because it allows for a symmetric and pro­ truding spout that is more easily constructed and managed. Permanent end ileostomies are usually created when the dis­ tal intestine is not suitable for restoration of intestinal con­ tinuity due to underlying disease or poor intestinal function. Typical scenarios include: Following total proctocolectomy for inflammatory bowel disease or familial adenomatous polyposis Following subtotal colectomy for slow-transit constipation with concomitant severe pelvic floor dyssynergia Fecal incontinence Congenital anomalies Temporary end ileostomies are typically created under the following circumstances: Following subtotal colectomy for acute diverticular bleed­ ing or ulcerative colitis-related toxic megacolon Temporary or permanent diverting loop ileostomies are cre­ ated when diversion of the fecal stream and decompression of the distal bowel are necessary: Following distal ileal or colonic anastomoses at high risk for disruption due to: Malnutrition or immunocompromised status Anastomotic location within an irradiated, inflamed, or contaminated field Low pelvic anastomotic location following sphincter­ preserving procedures (e.g., ileal pouch-anal anastomo­ ses, coloanal or low colorectal anastomoses) Disruption of a previously created distal anastomosis Distal bowel perforation Pelvic sepsis Rectal trauma Complicated diverticulitis Following anal sphincter reconstruction Following rectovaginal fistula repair Fecal incontinence Severe radiation proctitis Obstructing or nearly obstructing colorectal cancer, carci­ nomatosis, and Crohn's disease Sacral decubitus ulcer Necrotizing perineal and gluteal soft tissue infections.

Preoperative Planning •

The ideal stoma has no necrosis, prolapse, or retraction. Daily output ranges from 500 to 1000 mL, the appliance does not leak, and the skin is healthy. The importance of ap­ propriate planning to ensure an optimal ileostomy location

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

and to maximize the opportunity for creation of a viable, tension-free, and well-functioning ileostomy cannot be over­ emphasized. Attention to these principles will decrease the time required for stoma management and minimize patient frustration. A comprehensive discussion with the patient about the pro­ posed ileostomy procedure, alternatives, and postoperative lifestyle is imperative. Most stoma patients are elderly and many have their stoma care performed by a spouse, offspring, or caretaker; it is thus critical to involve these providers in the stoma education process. Ideally, patients must be mentally and physically ready for a stoma and must therefore be informed as early as possible in their course of the disease regarding the potential need for a stoma. For many patients, though, an ileostomy is cre­ ated in an acute setting at the end of a long, often life-saving procedure.

should occur pre- and postoperatively (particularly dur­ ing the first 3 to 6 months) . Stoma preparedness literature The American College of Surgeons has created a com­ prehensive stoma preparedness kit including an edu­ cational DVD and manual, a stoma model, and stoma appliance samples. Stoma Site Marking •

•

Stoma Education •

A comprehensive perioperative educational program de­ creases readmissions and complications related to dehydra­ tion and appliance problems and optimizes postoperative patient satisfaction and participation in activities of daily life. Wound ostomy continence nurse (WOCN) or enterosto­ mal therapy (ET) nurse Optimal stoma management begins with preoperative patient education in regard to diet, activities, clothing, and sexuality. The nurse can provide emotional and physical support. The patient must be informed that self-care may be awkward initially but that it can be learned and mastered. Patient support groups, United Ostomy Association visitor Patients should be introduced to other individuals with ileostomies who have similar socioeconomic and disease backgrounds. These encounters and relationships can help to improve morale and can reassure patients that they can have a satisfactory quality of life. Meetings

•

The stoma location must be carefully planned to minimize complications and to prevent leakage. The patient may wear the stoma appliance faceplate prior to the operation. The optimal location of the stoma should be assessed with the patient standing, sitting, and bending. Where does the patient wear the waist of the pants ? Range of motion and physical limitations must be evaluated to de­ termine if the patient can visualize the stoma and can ma­ nipulate the appliance (e.g., the site may be placed higher on the abdomen for a wheelchair-bound patient ) . Care must be taken to avoid stoma placement beneath an abdominal pannus to ensure that the stoma remains visible and easy to access for the patient or caretaker. In general, the ileostomy should be placed through the rectus muscle (to minimize parasternal herniation) , at the summit of the right paramedian infraumbilical fat pad. The umbili­ cus, bone, scars, skin folds, and abdominal panni should be avoided ( FIG 1 ) . The skin site can be identified with a perma­ nent marker and a scratch can be made with a small needle.

Intraoperative Positioning •

Supine or lithotomy position may be used based on the need for an adjunctive procedure for assessment of the colon, rectum, or perineum prior to ileostomy creation (e.g., colonoscopy) .

Antibiotic Prophylaxis •

Intravenous antibiotics must be given prior to the incision.

• Preope rative m a r k i n g of the i l eostomy site. The i l eosto my is p l aced in the r i g h t lower q u a d ra nt of the a b d o m e n in a right p a ra m e d i a n , i nfra u m b i l ical posit i o n .

FIG 1

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

•

CREATION OF AN END I LEOSTOMY •

M eti c u l o u s construct i o n of an e n d i l eostomy is para m o u nt because the i l eal contents are l i q u id, b i l ious, a n d vo l u m i­ nous. An everted, spout-sha ped e n d i l eostomy (B rooke i l eostomy) is best su ited to add ress these cha l l e nges.

•

Abdominal Wall Skin Incision for Exploratory Laparotomy and/or Bowel Resection •

•

•

If an a bdom i n a l i ncision for bowel resection is n ecessa ry, a l eft para m e d i a n skin incision ca n be made a n d a n g led towa rd the m i d l i n e. The a bdomen can then be e ntered t h rou g h the l i nea a l ba . This a p p roach maxi m i zes the d is­ tance a n d a mo u nt of skin between the i leosto my a n d the s k i n incision.

Ileal Limb Preparation and Placement

Ileal Mobilization •

The i l e u m is prepared by re leasi n g the l atera l attach­ m ents a l o n g the pelvic brim and by fu l ly m o b i l i z i n g the e m b ryo n i c root of the term i n a l ileal m esentery to the l evel of the d u o d e n u m .

•

Stoma Site Skin Incision •

Fol lowi n g the i ntest i n a l resection, the s k i n o pe n i n g i s created i n the r i g ht lower q u a d ra n t at the prema rked site. The skin is g rasped with a Koch e r c l a m p and a c i rcu­ lar s k i n incision of 2 em i n d i a meter (FIG 2A) is m a d e tan­ genti a l ly beneath the Kocher clamp with a n o . 1 0 blade. The excised s k i n d isc is remove d .

Abdominal Wall Aperture Creation for the Stoma •

Stoma placed through the center of the rectus muscle belly

•

•

Bovie e l ectrocautery is used to perpe n d i c u l a rly d ivide the su bcuta neous fat i n the right paramed i a n plane at the il­ eostomy site. H a n d h e l d retractors can be g e ntly used. The su bcuta neous fat s h o u l d be p reserved as m uch as poss i b l e . The a nterior rectus sheath is i d e ntified a n d i n cised i n a cruci ate fas h i o n for a p p roxi m ately 1 em in both d i rections. (The horizontal l i m b s h o u l d n ot be p l a ced too c l ose to the m i d l i ne.)

•

M ayo c l a m ps are used to s p l i t the rectus m u scle b l u ntly i n order to expose the poste r i o r rectus sheath a n d perito­ n e u m . The rectus m u scle fibers a re not d ivided (FIG 28). The s u rgeon p l aces one h a n d i nto the a b d o m i n a l cavity b e h i n d the m a rked sto m a site to p rotect the a bd o m i n a l contents. The a bdom i n a l cavity is entered through the sto m a i nci­ sion with a t h i n-point c l a m p (e .g., Sch n i dt o r tonsil c l a m p) . T h e d efect i n the poste r i o r rectus sheath a n d perito n e u m is w i d e n e d to a l l ow f o r passa g e of the i l e u m without c o m p ro m i s i n g its mese nte ric b l ood s u p p ly. The a p p ropri­ ate d efect size i s o bta i n e d by d i g ita l l y d i lati n g the sto m a s i t e w i t h the tips of t w o d i g its to create a n a p p roximately 2-cm a pertu re (FIG 2C) .

•

At least 6 em of viable d ista l or term i n a l i l e u m with the adjacent m a rg i n a l a rtery s h o u l d be p reserved to m a i nta i n a n opti m a l blood s u p p ly. The mesentery s h o u l d n ot be stri pped (FIG 2D ) . The i l e a l l i m b preparation s h o u l d be perfo rmed as early as possi ble d u ri n g the cou rse of the op­ eration to a l l ow for sufficient time to observe a n d assess the i l e u m 's vasc u l a rity. The mesentery m ust be h a n d led gently to avoid hematomas a n d mesenteric vasc u l a r i n j u ry. The i l e u m is gently adva nced (pushed rather t h a n p u l led) t h ro u g h the split m uscle a n d the a b d o m i n a l wa l l to a bout 4 em beyo n d the s k i n level (usi n g a B a bcock c l a m p to g rasp the i l e u m o n ly if n ecessa ry) . If the i l e u m a n d adjacent tissues a re t o o b u l ky t o pass easily t h r o u g h the a p e rtu re, the e p i p l oic fat can be excised . To faci l itate a futu re i l eostomy reversa l procedu re, an ad­ hesion barrier (e.g., Seprafi l m®) can be used at the time of i l eostomy creation. The adhesion barrier is wrapped around the ileal limb used for the i leostomy, extending along the i ntraabd o m i n a l i leal seg ment for approxi m ately 5 em. The i l e a l mesentery may be secured to the perito n e u m over a l e n g t h of 3 to 4 em if a p e r m a n e n t sto m a i s p l a n n e d . (Th is s t e p may p reve nt t o r s i o n , retraction, a n d prola pse of the i l e u m .)

Anterior rectus sheath Rectus abdominis muscle

A

R

L

FIG 2 • Creation of an end i leostomy. A. A ci rcu lar skin incision for the ileostomy is made over the center of the rectus m uscle belly and carried through the su bcuta neous fat. B. A cruciate incision is made i n the a nterior rectus sheath to expose the u nderlyi ng rectus m uscle. The rectus m uscle is split b l u ntly along the d i rection of its fi bers to expose the posterior sheath and peritoneum. (continued)

Peritoneum

B

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

Middle colic artery

Su perior mesenteric artery

c

4 cm

F

E

(contin ued) C. The perito n e u m is i n cised l o n g it u d i n a l ly a n d the i n c i s i o n is widened by stretc h i n g it with two d i g its to o bta i n the desired a perture. D. The vasc u l a r end a rcade and the mesentery a re p reserved o n the i l e a l segment that is to be used for the end i l eosto my (dotted arrow). E. The i l e u m i s advanced t h r o u g h the a b d o m i n a l wa l l sto m a a pertu re so that it protrudes for a bout 4 em beyo n d the skin l eve l . Fol lowi n g rem ova l of the sta p l e l i ne, t h ree-po i n t sutu res a re p l a ced t h r o u g h the end of the i l e u m (fu l l t h ickn ess), the sero m uscu l a r l ayer at the base of the sto m a 4 em from the end of the i l e u m , and the derm is, respectively. N o e p i d e r m i s s h o u l d be i n c l uded in stitc h . F. The sutu res a re p l aced ci rcumferential ly. They are o n ly tied after a l l of them have been p l aced, evert i n g the i l e u m to create a 2-cm-h i g h i l eosto my.

FIG 2

•

•

•

Both edges of the recta l stu m p (or other potent i a l ly re m a i n i n g d i stal bowel seg m e nt) a re tagged with polypropylene suture to fa c i l itate i d e ntification of the d i stal i ntest i n a l seg m e nt for potenti a l i l eosto my reversa l . To p reve nt wound conta m i nation, the s u rg i ca l a b d o m i n a l i n c i s i o n is cl osed n ext a n d t h e n covered with a p rotective wound d ress i n g p r i o r to matu r i n g the sto m a .

Stoma Maturation • •

The sta p l e l i n e is removed from the i l e u m . 3-0 a bsorba b l e (e . g . , Vicryl®) i nterru pted stitches a re p l aced (but n ot i m m e d i ately tied), with the stitches r u n ­ n i n g t h r o u g h t h e fo l l ow i n g t h ree poi nts (FIG 2E ) : • e n d of the i l e u m (fu l l -th i ckness) • s k i n - l evel base of the sto m a (4 em from the e n d of the i l e u m) (sero m uscu l a r l ayer)

•

•

•

•

Dermis ( l a rg e bites of the s u bcuticu l a r layer s h o u l d be avoided to p reve nt " b utto n h o l i n g " a n d m u cos a l i s l a n ds). O n e stitch is p l aced in each q u a d rant fo l l owed by o n e stitch betwee n e a c h q u a d ra n t stitch for a tota l of seve n to e i g ht stitches. E n s u re that one stitch is o n each s i d e of, a n d adjacent t o , the mesentery ( b u t n o t t h r o u g h t h e mese ntery) . To a l l ow for m o re p recise placement, each stitch s h o u l d be i n d iv i d u a l l y t a g g e d a n d t i e d o n ly when a l l stitches have been p l aced . The su bcuta neous and mesenteric fat can be tucked in a s each sutu re is tied. The goal is to create a sto m a with a spout that p rotrudes a bout 2 em beyo n d the s k i n l evel when co m p l eted (FIG 2F ) . The i l eostomy a p p l i a nce is p l aced o v e r the sto m a . Water­ proof, n o n a l l e r g e n i c tape ca n be used to f u rther secu re the edge of the a p p l i a nce to the sk i n .

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

•

CREATION OF A LOOP I LEOSTOMY Stoma Site Skin Incision and Abdominal Wall Aperture Creation •

The s k i n i n c i s i o n for a loop i l e osto my is s i m i l a r to the i n ­ c i s i o n f o r a n e n d i l eostomy, except t h a t it can be m a d e s l i g htly l o n g e r a n d s l i g htly o b l o n g . I n o bese patie nts, some of the s u bcuta neous tissues may have to be excised down to the fascia i n the shape of a co n e (a pex at s k i n l evel) so a s to n o t constrict the affe rent a n d effe rent l i m bs of the loop i l eosto my.

•

•

Ileal Limb Preparation and Placement •

•

An i l e a l seg ment 20 to 30 em p roxi m a l to the i l eoceca l va lve is identified. The seg ment is sel ected so as to maxi­ m ize m esenteric ped i c l e l e n gt h a n d to avoid comprom is­ ing the i l eocecal valve. The seg m e nt's mesentery a n d vasc u l at u re a re preserved (FIG 3A) . Two d ifferent orienti n g sutu res a re p l aced on the a nti­ mesenteric s i d e of the ileum to m a r k the affe rent a n d effe rent s i d e of t h e i l e a l seg ment (e . g . , by u s i n g sutures of d ifferent colo rs, or sutures with o n e knot for the affe rent seg ment a n d two knots for the effe rent seg m e nt)

(FIG 38) . •

An u m b i l i ca l tape is passed beh i n d the i l e u m at the i l e a l ­ mesenter i c i nterface. The i l e a l loop is advanced t h r o u g h the a b d o m i n a l wa l l u s i n g the u m b i l i ca l tape a s a g u i de, ta k i n g ca re to m a i nta i n proper orientation and to avo i d tors i o n .

A

•

The affe rent (prod uctive) l i m b of the loop i l eostomy is p l aced i nfe riorly so that its spout will be located o n the ca u d a l aspect of the sto m a . T h i s req u i res a p a rt i a l (about 90 deg rees) twist for correct ori entat i o n . Altern ative ly, the afferent l i m b can be p l aced on the m e d i a l or superior s i d e of the sto m a site, depe n d i n g o n s u rgeon p refe rence and a m o u nt of tension o n the i l eostomy. O pti o n a l ly, sutu res may be p l a ced between the i l e a l mese ntery a n d perito n e u m to m a i nta i n the a p p ro p riate rotation speci a l ly i n obese patie nts. The u m b i l ical tape i s rem oved and may opti o n a l ly be re p l a ced with a s u p po rt i n g rod o r a 6-cm seg ment of red r u b b e r catheter (wh i c h may be looped and sutu red to itse lf a bove the loop i l eosto my o r secured to the s k i n ) . To p revent conta m i n at i o n of the l a p a rotomy i ncision, the s u rg i c a l a b d o m i n a l i n c i s i o n (m i d l i n e o r l eft parame­ d i a n) is cl osed n ext a n d a p rotective wound d ress i n g is p l aced prior to sto m a maturat i o n .

Stoma Maturation •

•

It is i m portant to create an adeq u ate spout on the affer­ ent bowe l l i m b . F i rst, t h e efferent (d i sta l) l i m b o f t h e i l e u m is transversely i n cised 1 em a bove the skin s u rface for a p p roximately 75 % of the ci rcu mference of the i l e u m to a l low for ap­ propriate sto m a evers i o n (FIG 3C) . This a l l ows for a l a rg e " h ood " a n d for the os o n the affe rent p rod u ctive l i m b t o be l a rg e r (enco m pass i n g 80% to 90% of the i l e ostomy) t h a n the os of the effe rent l i m b .

B •

Creati o n o f a l o o p i l eosto my. A . An i l e a l seg ment t h a t is 20 t o 30 em p roxi m a l t o t h e i l eoceca l j u nct i o n (arro w) i s i d e ntified. T h e seg m e nt's mesentery a n d vasc u l at u re a re p reserve d . B. M a r k i n g sutu res (e . g . , sutu res o f d iffe rent c o l o rs o r with d iffe r i n g n u m bers of knots) a re p l aced o n the afferent and effe rent l i m bs . The i l e u m i s adva nced through the a b d o m i n a l wa l l sto m a a pertu re s o that i t p rotrudes for a bout 3 t o 4 e m beyo n d t h e s k i n leve l . (con tinued)

FIG 3

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2-point sutures Afferent l i m b

Lumen of afferent limb

Long "hood " to form proximal (productive) spout

c

Efferent limb

3-point sutures

D

FIG 3 • (con tinued) C. The i l e u m is i n cised 1 em a bove the s k i n level on the effe rent l i m b s i d e for 75 % of t h e c i rcu mference to create a l a rg e affe rent spout. D. The loop i l eostomy is matu red by p l a c i n g two-point sutu res (fu l l t h i c k n ess t h r o u g h the end of the i l e u m a n d the derm is) o n the effe rent l i m b a n d t h ree- p o i n t sutu res (fu l l t h i c k n ess t h r o u g h the end of i l e u m , the seromuscu l a r layer at t h e base o f sto ma, a n d the d e r m i s) o n the affe rent l i m b t o evert the i l e u m .

•

The sto m a is created a n d m a t u red w i t h 3-0 a bsorb­ able s u t u re (e . g ., V i c ry l ®) . F i rst, t h e effe rent sto m a i s s e w n f l u s h with t h e d e r m i s by u s i n g a two- p o i n t s u t u r­ i n g tech n i q u e , w i t h e a c h stitch ta k i n g a f u l l -t h i c k n ess b ite t h r o u g h the cut edge of i l e u m and t h e n t h r o u g h t h e d e r m i s . N ext, t h e afferent sto m a i s m a t u red w i t h a t h ree- p o i n t s u t u r i n g tech n i q u e as a l re a d y d e s c r i b e d i n p r i n c i p l e for t h e e n d i l eosto m y (F I G 3D ) . T h e m a i n d i fference w i t h a n e n d i l eostomy i s t h a t f o r a l o o p i l eosto m y, t h e s e ro m u sc u l a r st itches at t h e base of t h e

CREATION OF A D I V I D E D LOOP

•

•

•

I LEOSTOMY •

A d ivided (or sepa rated) loop i l eostomy is a n a ltern ative tech n i q u e for creat i n g a p rotect i n g loop i l eostomy; it may res u l t i n a m o re co m p l ete feca l d ivers i o n .

Stoma Site Skin Incision and Abdominal Wall Aperture Creation •

The s k i n i n cision a n d a b d o m i n a l wa l l a pertu re a re cre­ ated as for a loop i l eostomy.

Ileal Limb Preparation and Placement •

The i l e u m is d ivided with a l i ne a r cutt i n g sta p l e r 20 to 30 em p roxi m a l to the i l eoceca l valve. The mese ntery and vasc u l at u re a re o n l y m i n i m a l ly d ivided (FIG 4A) .

affe rent sto m a a re c l o s e r to t h e sto m a 's os (a b o u t 3 to 4 em) a n d t h e sto m a s p o u t m a y t h u s n ot p ro t r u d e q u ite a s m u c h a s w i t h a n e n d i l eostomy. Also, s u t u res ca n n ot be p l aced o n the poste r i o r b r i d g e of i l e u m t h a t j o i n s t h e affe rent a n d effe rent l i m bs . O pti o n a l ly, as the sutu res a re tied, the spout ca n be formed over a s u p po rt i n g rod (or catheter), which is l eft in p l ace for 3 to 5 d ays posto pe rative ly. The edge of the a pe rtu re in the i l eostomy face p l ate is p l aced beneath the rod o r catheter.

The sta pled afferent l i m b is advanced through the ab­ d o m i n a l wa l l apert u re so that it p rotrudes 4 em beyond the skin a n d the sta ple l i ne is removed. Only the an­ timesenteric corner of the efferent l i m b is external ized, thus m i n i m i z i n g the need for d ivision of the mesentery

(FIG 4B). Stoma Maturation •

•

Afferent l i m b-Th e sto m a is constructed in the same m a n n e r as described for a n e n d i l eostomy, u s i n g a th ree­ stitch tech n i q u e (FIG 4C). Effe rent l i m b-The a nti mese nte ric corner is excised to deco m p ress the d ista l bowe l if desired. A two-stitch tech­ n i q u e is then used, p l a c i n g sutu res that encom pass the fu l l -t h i c k n ess edge of the i l e u m and the d e r m i s . Alter­ native ly, the effe rent l i m b can re m a i n sta p l e d cl osed if co m p l ete feca l d ivers i o n is desired.

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

Afferent l i m b

A

Efferent limb

B

2-point sutu res

Efferent limb • Creati o n of a d ivided loop i l eosto my. A. The i l e u m is d ivided using a l i n e a r cutt i n g sta p l e r, 20 to 30 em proxi m a l to the i l eoceca l valve (solid arrow). The mesentery a n d vasc u l at u re a re o n l y m i n i m a l ly d ivided (dotted arrow). B. The sta p l e d affe rent l i m b is adva nced t h r o u g h the a b d o m i n a l wa l l a pe rtu re so that it p rotrudes for a bout 4 em beyo n d the s k i n l evel, a n d t h e enti re sta p l e l i n e is then cut off. Opti o n a l ly, if d i sta l deco m p ression i s desi red for the effe rent l i m b, o n l y the a n t i m esenteric corner is exte r n a l ized, excised, and matured. The sta p l e l i n e may a l so be l eft i ntact on the efferent l i m b for tota l d ivers i o n . C. The affe rent l i m b o f t h e i l eosto my is matu red with th ree-point sutu res. The effe rent l i m b can be matured with two-p o i n t sutu res.

FIG 4

Afferent limb

3-point sutures c

CREATION OF AN E N D-LOOP I LEOSTOMY •

An e n d - l o o p (or l o o p - e n d ) i l e osto my is f u n ct i o n a l l y n ot d i fferent from a n e n d i l eostomy, b u t t h e sto m a m a t u ­ rat i o n i s a k i n to t h e tec h n i q u e for a l o o p i l eostomy. A n e n d - l o o p i l eostomy a l l ows for p reservat i o n of a n a d ­ e q u ate mesente r i c b l o o d s u p p ly w h e n t h e mesentery wo u l d oth e rwise be too s h o rt fo r a d e q u ate adva n ce­ ment t h r o u g h the a b d o m i n a l wa l l (e . g . , in case of a s h o rtened mese ntery or a t h i c k e n e d a b d o m i n a l wa l l ) . T h i s tech n i q u e i s often used i n o bese p a t i e nts a n d those with prior o p e rat i o n s .

Stoma Site Skin Incision and Abdominal Wall Aperture Creation •

The s k i n a n d sto m a site a re prepared as described for a loop i l eosto my.

Ileal Limb Preparation and Placement •

•

The mesentery a n d vascu latu re a re d ivided to o bta i n as m u c h l e n gt h as possi b l e (FIG SA) . Fol lowi n g the d ista l i ntest i n a l resect i o n or d ivision, the sta p l e l i n e at the e n d o f the i l e u m is oversew n .

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•

The seg ment of i l e u m to be used for the stoma creation is typica l l y located about 10 em p roxi m a l to the oversewn i l e a l sta ple l i ne. The segment m ust h ave adequate mo­ b i l ity to reach the p roposed stom a site without tensi o n . With i n the abdom i n a l cavity, the afferent l i m b is oriented i nferiorly and the effe rent l i m b superio rly. The seg ment of i l e u m to be used for the stom a is then advanced through the abdo m i n a l wa l l as for a loop i l eostomy (FIG SB).

•

•

O pt i o n a l ly, a s u pport i n g rod or catheter can be passed beh i n d t h e i l e u m at the i l e a l - m esenteric i nterface. O pt i o n a l ly, the i ntra a bd o m i n a l i l e a l mese ntery may be sutu red to the perito n e u m .

Stoma Maturation •

The end-loop i l eostomy is matu red as described for a loop i l eostomy (FIG 3C, D) .

Afferent l i m b mesentery i s sutured to peritoneal lining

.... ..._

� Efferent l i m b staple l i n e is oversewn

A •

B

Creat i o n of an e n d - l o o p i l eosto my. A. The mesentery a n d vasc u l at u re a re d ivided p roxi m a l ly to o bta i n as m u c h l e n g t h a s poss i b l e . B. M a rk i n g sutu res a re p l a ced o n t h e affe rent a n d effe rent l i m bs . The sta p l e l i n e c l o s i n g off t h e i l e u m is oversewn with Lembert sutu res a n d re m a i n s i n t h e a b d o m e n . A m o re prox i m a l seg m e n t of i l e u m to be used for t h e i l eosto my, a p p roximately 1 0 em p roxi m a l to t h e oversewn i l e a l sta p l e l i ne, is exte r n a l ized so that t h e affe rent l i m b is i n t h e i nfe r i o r posit i o n o n t h e a b d o m i n a l wa l l . The m ese ntery may be affixed to t h e a b d o m i n a l wa l l to p reve nt sto m a p r o l a pse, tors i o n , o r a n i ntern a l h e r n i a .

FIG 5

LAPAROSCOPIC CREATION OF A N

p a i n , fewe r wound com p l i cations, more ra p i d ret u r n of bowel function, and s h o rter h osp ita l stay.

I LEOSTOMY •

•

•

•

The l a p a rosco p i c a p p roach can be used for tempora ry a n d permanent e n d i l eosto m i es, loop i l eosto m i es, d i ­ vided l o o p i l eosto m i es, a n d end-loop i l eostom ies. The entire a b d o m i n a l cavity ca n be v i s u a l ized and in­ spected, which can be benefi c i a l as it a l l ows for as­ sessment of the u n derlyi n g d i sease and the extent of a d hesions. Additi o n a l ly, l a p a roscopy a l l ows for precise i d e ntificat i o n of the i l e a l seg ment to be used for the sto m a a n d can help to e n s u re its proper ori entat i o n . The laparoscopic approach may not be feasible if the patient has extensive ad hesions from prior operations or a n insufficient i ntraa bdom i n a l doma i n due to i ntestinal d i l atation. Lapa rosco p i c i l eostomy creati o n may res u l t i n s h o rter tota l i n c i s i o n l e n gth, s h o rter operative t i m e, decreased

Stoma Site Skin Incision and Port Placement •

•

•

•

•

The 2-cm s k i n i n c i s i o n fo r the sto m a site can be m a d e prior to i nsufflation at the t i m e of port s i t e creat i o n o r after d i a g n osti c l a p a roscopy a n d select i o n of the i l e a l seg ment to be exte r n a l ized (see "Abd o m i n a l Wa l l Aper­ t u re Creati o n for the Sto m a " ) . A 5-mm or 1 0- m m port is p l aced t h r o u g h the u p per m i d l i n e f o r the camera. A 1 0- m m port is p l aced t h r o u g h the i ntended i l eostomy site. A 5-mm port i s p l aced in the l eft l ower q u a d ra n t for bowel m a n i p u lation and a d h e s i o lysis as n ecessa ry. An a d d i t i o n a l 5-mm port may be p l aced in the l eft s u p ra­ pubic reg i o n if needed.

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

Ileal Limb Preparation and Placement •

•

•

• •

The m ost d i st a l seg m e nt of i l e u m that can reach the i ntended sto m a site without tension i s i d e ntified l a p a rosco p i c a l ly. For loop i l eosto m i es, sutu res or c l i ps a re p l aced to m a r k the affe rent a n d effe rent i l e u m p r i o r to extern a l izat i o n . A l a p a rosco p i c bowe l c l a m p is p l aced t h r o u g h the 1 0- m m port at the sto m a s i t e to g rasp the i l e u m . The p n e u moperito n e u m is released . To fa c i l itate the passa g e of the loop of i l e u m , the a nte­ rior rectus sheath can be f u rt h e r stretched o r i n cised with a cruciate i n c i s i o n .

•

951

The i l e u m , bowe l c l a m p, a n d 1 0- m m port a re p u l led out of the a b d o m e n .

Laparoscopic Confirmation of Proper Stoma Orientation •

•

Adeq u ate sto m a loop orientat i o n a n d h e m ostasis a re confirmed after reesta b l i s h i n g p n e u m o perito n e u m . A l l po rts a re rem oved a n d the s k i n i n c i s i o n s a re c l osed with rea bsorba b l e sutu re.

Stoma Maturation •

The sto m a is matu red as described for the open tech n i q u e .

PLACEMENT OF THE I LEOSTOMY APPLIANCE •

Most appliances are disposable and available as one-piece or two-piece products. A basic appliance consists of an adhesive faceplate with a central opening and a collection bag. When cutting out the definitive stoma aperture in the appliance faceplate, the stoma aperture is cut offset (i.e., medially in relation to the precut stoma aperture) so as to shift the entire appliance laterally on the patient. As a result, the portion of the appliance directly over any mid­ line incision can be minimized. The edges of the cut-out area of the appliance should be 1 to 2 mm away from the edges of the ileostomy to avoid appliance trauma to, and leakage from, the ileostomy ( FIG 6) .

• I l eostomy a p p l i a n ce. T h e face p l ate sto m a a perture is cut off-center i n a medial d i rect i o n to m i n i m i ze t h e port i o n of the face p l ate that lays d i rect ly over a m i d l i n e incision (a l l ows for a sh ift latera l l y off of the m i d l i n e if an i n c i s i o n if p resent).

FIG 6

END AND DIVERTING LOOP ILEOSTOMIES: REVERSAL

•

•

DEFINITION •

Ileostomy reversal ( synonyms: ileostomy takedown or clo­ sure) is a procedure that reestablishes intestinal continuity in a patient with an ileostomy.

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

Reversal of a temporary ileostomy is usually performed at the earliest 2 to 3 months after ileostomy creation in order to allow for optimal healing of the area from which the enteric contents were diverted (e.g., distal anastomosis, bowel repair) or to allow for the distal inflammation to subside. An end ileostomy following subtotal colectomy may be reversed if the rectal and anal complex are healthy and without disease or malfunction. Modifiable risk factors (e.g., malnutrition) must be optimized and any chemotherapy and radiation should be completed. Reversal may be necessary at an earlier date for selected pa­ tients in the presence of an ileostomy complication such as pro­ lapse or recurrent serious fluid and electrolyte abnormalities.

Ileostomy reversal can be associated with considerable mor­ bidity. Up to 3 0 % of patients with potentially reversible ileosto­ mies never have their ileostomies reversed due to underly­ ing health issues, underlying disease prognosis, or patient preference.

PREOPERATIVE IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

The indications for preoperative imaging and diagnostic (e.g., functional) studies must be individualized for each patient. The routine use of contrast studies prior to ileostomy takedown to assess the distal bowel or anastomosis for stricture, obstruc­ tion, leak, recurrence of disease, or to assess pouch anatomy is controversial. If a study is performed, the contrast can be instilled through the efferent limb of a loop ileostomy or per anum, depending on the location of the area to be studied. An examination under anesthesia and an endoscopic assess­ ment may be performed to ascertain that a J-pouch is intact, to ensure that a distal anastomosis or repair has healed, and to ensure that a malignancy has not recurred.

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

If the anal sphincter was involved in the disease or repair, an anal manometry or endoscopic ultrasonography may be helpful to evaluate the sphincter.

emergency operation) . Bowel preparation can be achieved under those circumstances as follows: Patients with an end ileostomy and a rectal stump: trans­ anal enema Patients with a loop ileostomy: irrigation through the ef­ ferent limb or transanal retrograde enema, depending on the location of disease, repair, or anastomosis. The radiologist can be asked to irrigate the diverted seg­ ment (efferent limb or colon) with saline solution at the completion of a contrast study. Ureteral stents should be strongly considered if the patient has had significant pelvic inflammation.

SURGICAL MANAGEMENT Preoperative Planning •

•

•

•

•

Ileostomy reversal is not a minor operation and sometimes requires a full laparotomy. A loop ileostomy often facilitates subsequent ileostomy re­ versal by potentially obviating the need for a full laparotomy. The groundwork for successful ileostomy reversal is laid at the time of the construction of the ileostomy. To facilitate the ileostomy takedown procedure, an adhesion barrier should be placed at the time of ileostomy creation. Bowel preparation for the proximal intestine consists of 24 hours of clear liquids. Bowel preparation distal to the ileostomy is optional but is strongly recommended if no formal bowel preparation was performed prior to creation of ileostomy (e.g., in case of an

Positioning •

•

The patient is placed in lithotomy position if an endoscopic as­ sessment or exam under anesthesia is required, if the rectal vault requires irrigation and evacuation of inspissated mucus secre­ tions, or if an ileorectal or ileoanal anastomosis is to be created. Supine position is adequate if no access to the anus or rectum is required.

END I LEOSTOMY REVE RSAL Stoma Closure •

•

The sto m a is c l osed with a r u n n i n g 0-s i l k suture .

Mobilization and Resection o f Ileostomy •

•

A ci rcumferenti a l s k i n i n c i s i o n is m a d e s h a rply a r o u n d the cl osed i l eosto my j u st peri p h e ra l to the m ucocuta neous j u n ct i o n . S h a r p d i ssect i o n is used n ext to the bowe l wa l l , with j u ­ d i c i o u s u s e o f e l ectroca utery, to release the sto m a from the s u bcuta neous fat, rectus m u scle, and rectus s h eath (FIG 7) . Caution is used to avo i d an i n j u ry to the bowel

•

wa l l o r mesentery. East m a n o r Army-Navy retractors can fa c i l itate exposure a n d visua l i zati o n . Any a d hesions to the a b d o m i n a l wa l l adjacent to the i n ­ t e r n a l aspect o f the i l eostomy site a re lysed c i rcu mfere n ­ t i a l l y to c l e a r the perito n e a l s u rface for safe s u bseq uent rea pproximation and closure of the a b d o m i n a l wa l l de­ fect. A wound p rotector is p l aced to m i n i m ize wound conta m i n a t i o n . The i l eosto my is excised with its f i b rofatty tissue a n d a v i a b l e seg ment of i l e u m with i ntact serosa a n d a d e q u ate b l ood s u p p l y is p re p a red for the a na sto mosis. If a sta p l e d a na stomosis is p l a n ned, the a n v i l f r o m the c i rcu l a r sta p l e r is p l aced a n d secured i n the i l e u m .

Preparation o f the Distal Bowel Segment •

Typ ica l ly t h r o u g h a l a pa rotomy, the d i sta l bowe l seg­ ment to which the i l e u m is to be a n a stomosed (usu a l ly the rect u m ) is ca refu l ly m o b i l ized a n d prepared for a n asto mosis. The i ntest i n a l segment m u st be v i a b l e a n d o f a d e q u ate l e n g t h .

Anastomosis after Takedown of the End Ileostomy •

•

• S k i n i n c i s i o n and sto m a m o b i l ization for reversa l of an end o r loop i l eosto my. A ci rcumferenti a l s k i n i n c i s i o n is m a d e d i rect ly adjacent to the closed i l eosto my. The i n c i s i o n is d e e p e n e d across a l l a b d o m i n a l wa l l l ayers d o w n to the l evel of the a b d o m i n a l cavity. The i l eostomy a n d a d h erent fib rofatty tissues a re resected .

FIG 7

A sta n d a rd i l eorecta l (or i l eoa n a l or i l eoco l i c) a n asto mo­ sis can be created with a sta p l e r (e . g . , by using a c i rcu l a r e nd -to-end a n asto mosis [E EA] sta p l e r) o r a h a n d-sewn tech n i q u e (FIG 8) . A l e a k test is perfo rmed . Water is pou red i nto the pelvis until the a n asto mosis is s u b m e rg e d . The bowel is oc­ cluded proxi m a l to the a n asto mosis. A i r is i n sufflated per a n u m with a p roctoscope. • S m a l l l e a ks can be oversewn a n d the l e a k test is repeate d . If the l e a k test rem a i n s positive, t h e a n as­ tomosis can be red o n e with a low t h res h o l d for the p l acement of a p roxi m a l d ivert i n g loop i l eosto my and a pelvic d ra i n . • S m a l l l e a ks low i n the pelvis or l a rg e l e a ks s h o u l d be re p a i red o r the a n a stomosis s h o u l d be red o n e .

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

Fascial Closure •

•

The a b d o m i n a l wa l l sto m a d efect is cl osed without tension i n two layers with ru n n i n g o r i nterru pted 1 -polyd i oxa­ none (PDS) sutu re. O m e n t u m is p l a ced betwee n the a n asto mosis and the fasc i a l closu re, if ava i l a b l e . If the fascia is of poor q u a l ity, a b i o l o g i c mesh can be used for rei nfo rce ment.

Stoma Site Skin Closure •

• Reversa l of a n e n d i l eostomy. I ntesti n a l cont i n u ity is resto red with a c i rcu l a r cutt i n g sta p l e r (e. g ., by creat i n g a n i l eo recta l a n asto mosis).

FIG 8

•

Creati o n of a p roxi m a l d ivert i n g loop i l eostomy a n d i nserti o n o f a pelvic d r a i n s h o u l d be stro n g l y con­ s i d e red under those circumstances. The o m e ntu m s h o u l d be wrapped a r o u n d the a n a stomosis. Alternatively, the a n a stomosis can be visu a l i zed endosco p i ca l ly (with o r without i nject i o n of i ntrave n o u s fluoresc e i n to assess the i ntest i n a l b l ood s u p p ly) .

•

•

REVERSAL LOOP I LEOSTOMY •

•

•

The i l eosto my c l o s u re can usua l ly be performed t h r o u g h the i l eostomy site, w i t h o u t req u i ri n g a co m p l ete l a p a ­ rotomy. T h e steps l e a d i n g u p to t h e a n a st o m o s i s a re t h e sa m e a s for t h e reve rsa l of t h e e n d i l eostomy d i scussed e a r l i e r. A wound p rotector is p l aced to m i n i m ize wound conta m ination.

Anastomosis after Takedown o f Loop Ileostomy •

•

The a n asto m osis betwee n the p roxi m a l (affe rent) a n d d ista l (effe rent) i l e a l l i m bs c a n be either h a n d-sewn o r sta p l e d . The sto m a a n d f i b rofatty tissues a re resected with a l i n e a r cutt i n g sta p l e r to a level where there a re two d isti nct i l e a l l i m bs (FIG 9A) . • F o r a sta p l e d s i d e-to-s i d e a n asto m os i s, t h e a n ­ t i m es e n t e r i c co r n e r o f e a c h i l e a l e n d i s c u t a n d rem oved .

The skin can be cl osed with n u merous d ifferent tec h n i q ues, but in p r i n c i p l e, the closure s h o u l d n ot be watertig ht. Options i n c l u d e the fo l l owi n g : • P r i m a ry s k i n closure Loose skin closure with i nterru pted 2-0 nylon su­ tu res o r sta ples. Wou n d fluid d ra i nage s h o u l d be fac i l itated, for i n sta nce, by a p p l ication of wicks made of Kenda l l Te lfa® d ressi n g pads (the wicks s h o u l d be removed o n postoperative day 2 o r 3). D e l ayed p r i m a ry closure (performed o n post­ operative day 2 o r 3). Pu rse-string closu re. Loose ci rcu l a r (pu rse-string) skin closure with 2-0 r u n n i ng, su bcuticu l a r po ly­ propylene. The a p p roximately 1 to 1 . 5 em re­ m a i n i n g centra l opening is packed with moist g a u ze that is fi rst rem oved on postoperative day 2 a n d then exchanged d a i ly. The suture is re­ m oved on posto perative day 2 1 . The pu rse-string closure may be associated with a l ower surgical site i nfection rate than a primary closu re. Wo u n d h ea l i n g by seco n d a ry i ntenti o n . The wo u n d is l eft open a n d wet-to-d ry d ress i n g c h a n ges a re i n iti ated .

•

A s i d e-to-si d e, funct i o n a l e n d -to-e n d a n asto mosis is created with a l i n e a r cutt i n g sta p l e r (FIG 98) . The enteric d efect i s cl osed with a l i n e a r sta p l e r o r a h a n d-sewn tec h n i q u e . • The a n asto mosis can a l so be constructed with a c i rc u l a r sta p l e r or h a n d -sew n . Alternatively, a d i rect t ra n sverse closu re of the enteric d efect at the sto m a site can be performed . With this tec h n i q ue, t h e stom a a n d f i b rofatty tissues a re resected spari n g ly so that the c o n n ecti n g b r i d g e of i ntesti n a l wa l l o n t h e poste r i o r (mesente ric) aspect o f t h e loop sto m a re m a i n s i ntact (FIG 1 0A) . • The a nti mesente ric d efect ca n then be c l osed either by a h a n d -sewn tec h n i q u e (d o u b l e layer tech ­ n i q u e consist i n g o f 3 - 0 a bsorba b l e fu l l -t h i c k n ess sutu res [e.g., Vicryl®]. fo l l owed by 3-0 n o n a bsorb­ able Le m b e rt seromuscu l a r sutu res [e.g., s i l k]) (FIG 1 08) o r sta pled tech n i q u e (with a l i n e a r sta p l e r) w i t h opti o n a l oversew i n g of the sta p l e l i n e

(FIG 1 0C) .

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A

B •

Reve rsa l of a loop i l eosto my: option 1 (resu lts in l a rger a nasto motic cross section). A. The i l e u m is m o b i l ized from the a bdom i n a l wa l l . The stom a itself (incl u d i n g the sta p l es i n case of a d ivided loop i l eostomy) and adjacent fib rofatty tissues are resected with a l i near cutt i n g sta p l e r to a level where both l i m bs a re com p l etely sepa rated . B. A side-to-side (fu n ct i o n a l end-to-end) sta pled a n a stomosis is created w i t h a l i n ear cutt i n g sta p l e r inserted i nto the a n t i m esenteric aspect o f e a c h i l e a l l i m b . The re m a i n i n g i l e a l open i n g is cl osed off w i t h a l i near sta pler a p p l icati o n or b y u s i n g a h a n d -sewn tech n i q u e .

FIG 9

B

A FIG 1 0 • Reversa l of a loop i l eostomy: option 2 . A . T h e i l e u m is m o b i l ized from the a b d o m i n a l wa l l . T h e sto m a itse l f a n d adjacent f i b rofatty tissues a re resected spa r i n g l y so that the c o n n ecti n g b r i d g e of i l e u m on the poste r i o r/mese nte ric aspect of the loop i l eosto my is l eft i ntact. B. The ileal d efect is closed with a transverse two- layer h a n d -sewn tech n i q u e o r (C) with a l i n ear sta p l e r.

C

C h a p t e r 4 E N D A N D D I V E RT I N G LOOP I LEOSTO M I E S : Creation and Reversal

955

PEARLS AND PITFALLS Ileostomy Creation I n d icat i o n s

•

A d ivert i n g i l eosto my may p reve nt m o r b i d ity by p reve nting a d ista l a n astomotic d i s r u pt i o n i n h i g h-risk patients.

Preoperative ed ucation

•

Sto m a ed ucat i o n is crucia l to fa m i l i a rize the patient with the i m pe n d i n g sto m a and to m i n i m ize pote n t i a l com p l ications.

Sto m a p l acement

•

Preope rative i l eosto my site d eterm i n at i o n a n d m a r k i n g is critica l . The sto m a m ust be p l aced away from bony p ro m i n e nces, p a n n i , and scars to create a v i a b le, tension-free i l eosto my with a re l i a b l e a p p l i a nce sea l .

O r i e ntat i o n o f loop i l eostomy

•

Use m a r k i n g sutu res o n afferent and effe rent l i m bs . Avo i d tors i o n and mesente ric vascu l a r co m p ro m ise d u ri n g sto m a creat i o n .

Sto m a matu rat i o n

•

Creati o n of a 2 - c m B rooke i l eostomy (end o r d ivert i n g l o o p ) m i n i m izes the m o r b i d ity that ste m s from the i l eostomy eff l u ent.

Fol low- u p

•

Close fo l l ow- u p a n d the u s e o f i l eostomy ca re pathways a re critica l to recog n i ze a n d a d d ress sto ma­ site problems a n d to m i n i m ize rea d m issions for dehydration a n d e l ectro lyte a b n o rm a l ities.

H i story a n d physica l

•

I l eostomy reve rsa l is usua l ly an e l ective proced u re . Al low t h e patient to atta i n an opti m a l hea lth status before u n d e rta k i n g reversa l .

D i a g n ostic tests

•

Consider d i a g n ostic stu d i es to assess the d ista l bowe l or a n asto mosis p r i o r to c l o s u re . Th ese stu d ies may p reve nt m o r b i d ity and i m p rove outco m e .

Preparat i o n of the ileum for ta kedown

•

D i ssect the i l e u m to v i a b le, hea lthy i l e u m with adeq u ate b l ood s u p p ly. Avo i d tension o n the a n astomosis.

S k i n c l o s u re

•

H ea l i n g by seco n d a ry i ntention pred icta b l y p revents wo u n d i nfect i o n s a n d typica l ly h a s s i m i l a r cosmetic outcomes c o m p a red t o p r i m a ry closure. " P u rse stri n g " c l o s u re is a n i ncrea s i n g l y used a s s k i n closure optio n .

F o l l ow-u p

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Patie nts u n d e rg o i n g i l eosto my reversa l a re at r i s k f o r major m o r b i d ity a n d m o rtal ity a n d m u st b e fo l l owed c l osely posto perative ly.

Ileostomy Reversal

POSTOPERATIVE CARE

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For Ileostomy Creation Patients •

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Creation of an ileostomy results in the loss of the ileoce­ cal valve and of the colonic water reabsorption, leading to dehydration and electrolyte abnormalities. Postop­ eratively, the newly created ileostomy begins to function within 72 hours, often with high output (> 1 L) per day. Within weeks, the proximal small bowel adapts at least partially as water absorption increases and the effluent thickens . Ideal daily effluent volume after adaptation is 500 to 1 000 mL. Appropriate hydration and electrolyte levels ( sodium, potas­ sium, magnesium, and calcium) must be maintained, using electrolyte solutions (e.g., Pedialyte® ) and oral or intrave­ nous sodium chloride. After discharge, the patient must con­ tact his or her medical provider if the ileostomy output is greater than 1 L per day for 2 consecutive days. Psyllium (e.g., Metamucil®) can be used to thicken the enteric contents. Anticholinergic agents, opioid receptor agonists (e.g., lop­ eramide) , bile acid binders (e.g., cholestyramine ) , and nar­ cotic agents (e.g., tincture of opium, codeine) can be used to decrease ileostomy output. Vitamin B 2 is administered subcutaneously as needed. 1 Support belts may be helpful for securing poorly fitting appliances, especially in obese patients.

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Maintaining a healthy skin around the stoma is paramount. Allergic reactions to the appliance can occur and may be managed by changing appliance type or manufacturer. Pooling of ileal effluent must be avoided by frequent ap­ pliance changes or bag emptying. The appliance should be changed immediately postoperatively if the patient experi­ ences leakage or peristomal skin problems.

For Ileostomy Reversal Patients •

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The patients must be followed closely postoperatively to identify problems and complications after ileostomy take­ down. This is especially important in high-risk patients. Dehydration and electrolyte abnormalities may persist after ileostomy takedown.

OUTCOMES •

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Dietary indiscretion (e.g., high glucose, high fat) and al­ coholic beverages may result in diarrhea and dehydration. Dehydration contributes to readmission rates that can be as high as 2 0 % . A n " ileostomy care pathway, " including a standardized set of perioperative patient education tools, direct patient en­ gagement with stoma care, strict monitoring of stoma output postdischarge, and visiting nurse involvement, may all posi­ tively impact overall readmission rates (e.g., 3 5 % prepath­ way implementation vs. 2 1 % postpathway implementation)

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

and may decrease or even eliminate readmissions for dehy­ dration (e.g., 1 5 . 5 % prepathway implementation vs. 0 % postpathway implementation) . 1 The use of a sodium hyaluronate and carboxymethylcellulose­ based bioabsorbable membrane can significantly decrease ad­ hesion formation around a loop ileostomy as identified at the time of ileostomy reversal (e.g., no Seprafilm® vs. Seprafilm® around stoma, 3 0 . 6 % vs. 1 4 . 1 % ) . 2 In patients requiring a diverting loop ileostomy, a bridge (rod) does not significantly impact retraction or leakage s . 3 Laparoscopic creation of an ileostomy is safe a n d effective and should be considered for patients.4 Over 1 0 % of patients require ileostomy-related reoperations. Obesity is an independent risk factor for ileostomy complica­ tions and, along with smoking history, is associated with a lower likelihood of subsequent ileostomy reversal.5 Handsewn vs. stapled ileo-ileostomy anastomoses for il­ eostomy closure have similar major complications such as bowel obstruction (in about 1 5 % of cases) and anastomotic leak (in about 2% of cases) , with stapled anastomoses re­ sulting in shorter operation times.6

COMPLICATIONS Ileostomy Creation Patients •

• • •

Over 8 0 % of patients experience one or more stoma-related complications. Common problems include skin irritation (in up to 6 0 % ) , fixation problems (in up to 5 0 % ) , and peris­ tomal leakage (in up to 40% ) . Superficial necrosis, bleeding, and retraction can occur in up to 2 0 % , 1 5 % , and 1 0 % of patients, respectively. Stoma-related complications are even more common for stomas in suboptimal locations. Parastomal hernia Parastomal fistula High-output ileostomies may result in dehydration, elec­ trolyte abnormalities, and fat/fat-soluble vitamin mal­ absorption.

Ileostomy Reversal Patients •

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An analysis of the National Surgical Quality Improvement Program (NSQIP) demonstrated that following elective il­ eostomy closure, 9 . 3 % of patients had major complications (e.g., mortality, sepsis, return to the operating room, renal failure, major cardiac, neurologic, or respiratory episode) and 8 . 4 % had minor complications (e.g., wound infection or urinary tract infection within 30 days) . Mortality was 0 . 6 % . Independent predictors of major complications were American Society of Anesthesiologists (ASA) physical sta­ tus classification system score, functional status, history of chronic obstructive pulmonary disease ( COPD ) , dialysis, disseminated cancer, and prolonged operative time. Hand-sewn ileo-ileostomy and stapled ileo-ileostomy anas­ tomoses for ileostomy closure have similar major complica­ tion rates e.g., bowel obstruction in about 1 5 % of cases and anastomotic leak in about 2% of cases. Wound infections following ileostomy reversal are signifi­ cantly lower in patients undergoing delayed versus primary closure ( 0 % vs. 24 % ) with similar cosmetic outcomes.

REFERENCES 1 . Nagle D, Pare T, Keenan E, et a!. Ileostomy pathway virtually elimi­ nates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55 ( 12 ) : 1266-1272. 2. Salum M, Wexner SD, Nogueras JJ, et a!. Does sodium hyaluronate­ and carboxy cellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproct. 2006; 1 0 ( 3 ) : 1 8 7-190. 3 . Speirs M, Leung E, Hughes D, et a!. Ileostomy rod-is it a bridge too far? Colorectal Dis. 2006; 8 ( 6 ) :484-4 8 7. 4. Oliveira L, Reissman P, Nogueras J, et a!. Laparoscopic creation of stomas. Surg Endosc. 1 9 9 7; 1 1 ( 1 ) : 1 9-23 . 5 . Chun LJ, Haigh PI, Tam MS, et a!. Defunctioning loop ileostomy for pelvic anastomoses: predictor of morbidity and nonclosure. Dis Colon Rectum. 2012;55(2 ) : 1 6 7- 1 74. 6 . Leffler T, Rossion I, Bruckner T, et a!. Hand suture versus stapling for closure of loop ileostomy (HASTA trial) : results of a multicenter randomized trial. Ann Surg. 2 0 1 2;25 6 ( 5 ) : 828-8 3 5 .

I

Chapter

5

Jejunostomy Tube I

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Rebecca L. Wiatrek

DEFINITION •

A j ej unostomy feeding tube is a tube placed into the proxi­ mal j ej unum and brought out through the skin to allow for feeding distal to the stomach. Jej unostomy tubes are indi­ cated in patients who are unable to maintain adequate nutri­ tion orally and who are unable to be fed via the stomach. Examples of conditions that may require a j ej unostomy tube include, but are not limited to, gastric outlet obstruction, esophageal perforation, gastroparesis, or recurrent aspira­ tion. Jejunostomy tubes may be placed via a nasojejunal or percutaneous route; the latter can be approached via inter­ ventional radiology, via laparoscopic or open surgery, or via endoscopy, as an extension through a percutaneous gastros­ tomy tube.

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PATIENT HISTORY AND PHYSICAL FINDINGS •

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A complete surgical history should be elicited, focusing on prior abdominal operations. A complete abdominal examination should be performed, noting prior incisions and hernias. Because malnutrition may be an indication for placement of a j ej unostomy tube, a complete nutritional history should be obtained including recent weight loss. Physical examination should be focused on signs of severe malnutrition such as loss of subcutaneous fat, muscle wast­ ing, and/or presence of edema and ascites. The Subj ective Global Assessment Score combines the his­ tory and physical examination to provide a rating from A (well nourished) to C (severely malnourished) .

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IMAGING AND OTHER DIAGNOSTIC STUDIES •

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A nutritional assessment should be performed. Severe mal­ nutrition may be a reason for placement of a j ej unostomy tube, such as prior to major elective surgery. Indicators of preoperative malnutrition include weight loss greater than 1 0 % to 1 5 % over the previous 6 months, body mass index less than 1 8 . 5 kg/m2, Subjective Global Assessment Grade C, and/or serum albumin less than 3 g/dL.1 Electrolytes should be checked and replaced prior to sur­ gery. An electrocardiogram should also be checked in order to rule out cardiac abnormalities and arrhythmias. Additional studies and radiologic imaging should be based on the primary diagnosis. In patients with underlying malig­ nancy, staging studies should be recent enough to ensure that there are no changes in the cancer status that may affect the operative plan.

SURGICAL MANAGEMENT Preoperative Planning •

Although enteral feeding is preferred to the parenteral route, the surgeon should ensure that there are no contraindications

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Lillian S. Kao

to enteral nutrition such as distal obstruction, ileus, high­ output enterocutaneous fistula, or shock. Alternatives to j ej unostomy tubes include temporary nasally inserted feeding tubes and gastrostomy tubes. Temporary feeding access can be achieved using a nasogastric or a nasa­ j ej unal feeding tube; the latter can be placed with the assis­ tance of fluoroscopy or endoscopy. Smaller diameter feeding tubes may be more comfortable for the patient but also may be more prone to clogging. Gastrostomy tubes for longer term feeding access can be placed endoscopically, radiologi­ cally, or surgically. If enteral access is not the primary indication for surgery, then the complete operative plan should be considered. The anticipated duration of inability to take in oral nutrition or of inadequate nutrition ( < 6 0 % of caloric requirement) should be taken in consideration when deciding whether or not to place a feeding jejunostomy tube as well as in deciding the route of placement (nasojej unal vs. surgical). 1 In cancer patients, whether the goal of surgery is curative or pallia­ tive should be considered. A temporary feeding jejunostomy tube may be indicated after resection of cancer of the esoph­ agus, stomach, or pancreas to allow continued distal enteral nutrition in the event of an anastomotic leak. Palliative care may include placement of a surgical jeju­ nostomy tube. Cancer patients who are not candidates for curative treatment should be assessed for their preferences, quality of life, and resources. The risks of surgical inter­ vention should be weighed against the potential benefits of enteral nutrition. A candid discussion should be held with the patient regarding advanced directives and end-of-life care. When enteral access is the primary indication for surgery, the surgeon should discuss the planned operative approach with the patient. When a laparoscopic jejunostomy tube is planned, the surgeon should discuss the possibility of conver­ sion to open. If the j ej unostomy tube is palliative, the surgeon should discuss the possibility of aborting the procedure when the risks outweigh the benefits (i.e., in the setting of carcino­ matosis and inability to safely dissect the proximal jejunum ) . Although no randomized trials exist regarding antibiotic prophylaxis prior to j ej unostomy tube placement, there is high-quality evidence that antibiotic prophylaxis reduces surgical site infections across procedures and baseline risks. 2 In addition, a meta-analysis of randomized controlled tri­ als of antibiotic prophylaxis to prevent peristomal infection after percutaneous endoscopic gastrostomy demonstrated a significant risk reduction with cephalosporin and penicillin­ based prophylaxis.3

Positioning •

The patient should be positioned in the supine position. This is required for both laparoscopic and open techniques. For the laparoscopic approach, it is important to secure the patient to the bed with straps or tapes to allow for safe manipulation of the operating table.

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OPEN J EJ U NOSTOMY F E E D I N G TUBE PLACEMENT First Step-Placement o f Skin Incision •

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A l i m ited m i d l i n e i n cision, a p p roximately 5 em i n l e ngth, is m a d e a bove the u m b i l icus. T h i s a l l ows for i d e ntifica­ tion of the l i g a m e n t of Treitz. A l a rg e r i n c i s i o n may be needed if t h e patient has h a d m u lt i p l e p r i o r operations req u i ri n g a d h e s i o lysis. Once the a bdomen is entered, the omentum can be fo l l owed to the tra nsverse co lon, which is retracted ceph­ a l a d . The l ig a ment of Tre itz is l ocated at the base of the tra n sverse m esoco l o n to the l eft of the fo u rth port i o n of the d u oden u m (FIG 1 ) a n d is i d e ntified by visual ization a n d p a l patio n . A seg ment of j ej u n u m d i stal to the l i g a ­ ment o f Treitz is identified. A d ista nce o f 1 5 t o 20 em from the l i g a ment of Treitz w i l l a l l ow the jej u n u m to reach the abdom i n a l wa l l without tension, w h i l e a lso p rovi d i n g fo r e n o u g h l e n gth for a p roxi m a l revis i o n of the jej u n a l seg­ me nt, s h o u l d o n e be n ecessa ry i n the future. An exit site is id entified i n the skin of the l eft upper q u a d ­ ra nt, seve ra l ce nti m eters latera l f r o m the m i d l i n e . A sta b i n cision is made at t h i s level, a n d tonsil c l a m ps a re used to d e l iver the jej u n ostomy tube i nto the abdom i n a l cavity.

Second Step-Choice of Tubes •

The type of jej u n osto my tube used can be as s i m p l e as a 1 0or 1 2-French red rubber catheter or a s i l icone jej u n osto my tube s i m i l a r to those used i n l a p a rosco pic cases. S i l icone tu bes may have m o re longevity. • Avoid using b a l l oon­ t i p ped catheters (i.e., Foley catheters) o r, a ltern ative ly, Transverse colon

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ensure that the a b i l ity to i nfl ate the bal loon has been d is­ a b led to p reve nt future attem pts at i n suffl ati n g the bal­ loon that co u l d lead to s u bseq uent bowel o bstruct i o n . If u s i n g a r e d r u b b e r catheter, the t i p may be cut off, which a l l ows for exc h a n g e ove r a wi re s h o u l d the tube beco m e clogged . Additi o n a l s i d e holes may a lso be cut at the d ista l e n d of the tube i n order to i m p rove flow t h r o u g h the catheter.

Third Step-Suturing Tube into the Bowel •

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The p reviously chosen site of p rox i m a l jej u n u m is d e l iv­ ered i nto the wo u n d . The site of entry of the t u b e s h o u l d be o n the a n t i m esenteric s i d e of the jej u n u m . O n ce t h i s is i d e ntified, a 3 - 0 s i l k is u s e d to create a d i a m o n d -s h a ped p u rse-st r i n g suture. A sma l l o pe n i n g is made i n s i d e the p u rse-st r i n g suture with ca ute ry, o n ly l a rg e e n o u g h to a l low for the t u be to be i nserted i nto the bowe l . T h e t u b e is p l a ced i nto t h e bowel a n d adva nced i nto the d i stal portion of t h e j ej u n u m . The length of adva nce­ ment i nto the j ej u n u m s h o u l d be long e n o u g h to p revent backflow of feeds i nto the proxi m a l s m a l l i ntest i n e . The p u rse-string suture is secu red, a n d the t u be is p l a ced a lo n g the p roxi m a l bowel wa l l . The Witzel tech n i q u e is then used to p revent extravasatio n s of enteric feeds at the jej u n osto my tube entrance site. I n t h i s tech n i q ue, 3-0 s i l k serom uscu l a r sutu res a r e p l aced perpe n d i c u l a rly o n t h e a n t i mesenteric border o f the bowel o n both sides o f t h e feed i n g t u be (Le m be rt sutu res) i n o r d e r to i m bricate t h e bowel wa l l over the feed i n g tu be, creati n g a serosa l t u n ­ n e l (FIG 2) . T h i s s h o u l d be a p p roxi m ately 2 t o 3 em i n length a n d care s h o u l d be taken to n o t n a rrow the l u m en

Ligament of Treitz

Distal jejunum Duodenum

FIG 1 • Identification of the l igament of Treitz. With the tra n sverse colon retracted s u perio rly, the l i g a ment of Tre itz can be easily identified at the base of the transverse mesocolon a n d to the left of the fou rth portion of the d uoden u m .

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The open Witzel tech n i q u e . 3-0 silk sero m u sc u l a r sutu res a re p l a ced perpe n d i c u l a rly o n the a nti mesente ric border of the bowe l o n both sides of the feed i n g t u b e (Le m b e rt sutu res) i n order to i m b ricate t h e bowe l wa l l over the feed i n g t u be, creat i n g a seros a l t u n n e l .

FIG 2

C h a p t e r 5 J E J U N OSTOMY T U B E

i n fo u r q u a d ra nts a r o u n d the exit p o i n t o f the t u b e j ust proxi m a l to the l a st Witzel s u t u r e . Ca re s h o u l d be taken to avo i d perforat i n g the feed i n g t u be d u r i n g the p l acement of these sutu res, as this co u l d lead to extrav­ asation of the enteric feeds i nto the a b d o m i n a l cavity. O n e a d d i t i o n a l suture can be used to tack the jej u n u m t o t h e a b d o m i n a l wa l l d ista l t o t h e t u b e entrance site to p reve nt k i n k i n g or volvu l u s of the jej u n u m a r o u n d t h e tube site.

of the bowel or tube with these sutu res. Care s h o u l d a l so be taken to avoid perforati n g the feed i n g tube d u ri n g t h e placement o f these sutu res, as t h i s co u l d l e a d t o ex­ travasation of the enteric feed s i nto the a bdom i n a l cavity.

Fourth Step-Suturing the Tube to the Abdominal Wall •

The tube s h o u l d then be secured with 3-0 s i l k sero m us­ c u l a r sutu res to the a b d o m i n a l wa l l parietal perito n e u m

LAPAROSCOPIC JEJUNOSTOMY FEE D I N G TUBE PLACEMENT First Step-Laparoscopic Port Placement •

The a b d o m e n may be entered either by a cut-down tech ­ n i q ue, by u s e o f a n i nsufflation need l e fo l l owed b y entry with an optica l access trocar, or with an o ptica l access troca r a l o n e . One 5-mm port s h o u l d be p l a ced peri u m ­ b i l ica l ly a n d two a d d itional 5-m m ports s h o u l d be p l aced in a tri a n g u l ated fash i o n to a l l ow for m a n i p u lation of the j ej u n u m ; th ese s h o u l d be p l a ced u n d e r d i rect visu a l ­ ization to prevent bowe l i n j u ry. Th ese a re tra d it io n a l ly p l aced i n the right u p per a n d l eft lower q u a d ra nts.

Second Step-Identification of the Ligament of Treitz •

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The patient is p l aced in a Tre n d e l e n b u rg position a n d is rotated to the right s i d e i n order to faci l itate i d e ntifica­ t i o n of the l i g a m e n t of Treitz. The transverse colon is e l evated with an atra u m atic g rasper to ide ntify the l i g a ment of Tre itz, located at the base of the tra n sverse mesoco l o n a n d to the left of the fo u rth port i o n of the duodenum (FIG 1 ). A seg ment of j ej u n u m a p p roximately 15 to 20 em d i stal from the l i g a ­ ment t h a t w i l l e a s i l y a l low the jej u n u m to reach the a b ­ d o m i n a l wa l l without t e n s i o n is i d e ntified.

FIG 3 • A p u rse-string suture of 3-0 silk i s p l aced with an e n d osco p i c sewi n g device i n a c i rcu l a r manner at the site where the feed i n g t u b e will be i nserte d .

Third Step-Placing the Tube i n the Jejunum •

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A p u rse-st r i n g suture of 3-0 s i l k ca n be p l aced with a l a p a rosco p i c need l e d river or with an e n d osco p i c sew i n g device i n a c i rcu l a r m a n n e r, i n the same fas h i o n as per­ formed in open cases (FIG 3). U s i n g e l ectroca utery, m a k e a n open i n g i n t h e s m a l l bowel a n d d e l iver the feed i n g t u b e t h r o u g h the o pe n i n g a n d i nto t h e d i sta l jej u n u m . T h e p u rse-st r i n g suture i s tied i ntracorporeal ly. Le m b e rt sutu res are p l aced to create a Witzel serosa l t u n n e l a r o u n d the feed i n g tube. The j ej u n osto my t u b e i s t h e n tacked to the a nterior a b d o m i n a l wa l l w i t h a fo u r­ q u a d ra n t suture p l a ced i ntracorporea l l y prox i m a l ly to the Witzel t u n n e l . If u s i n g a laparosco pic jej u n osto my t u b e k i t that pro­ vides T-faste ners, the jej u n u m is g rasped with two atra u ­ m a t i c g raspers a n d the percuta neous T-fastener is p l aced through the skin and i nto the bowel j ust proxi m a l to where the tube wi l l enter the j ej u n u m . Care s h o u l d be taken n ot to p l ace the need le through a n d thro u g h the bowel (back-wa l l perforation) that wou l d lead to leakage

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of tube feeds a n d enteric contents i nto the abdom i n a l cav­ ity postoperative ly. O nce the needle is i nside the bowe l, the T-fastener is released by p u s h i n g i n the styl et (FIG 4} . T h e needle is t h e n removed, a n d a hemostat is used to p u l l u p o n t h e suture i n order t o p u l l t h e jej u n u m u p flushed to the abdom i n a l wa l l . Ad d it i o n a l T-fasteners a re p l aced in a d i a m o n d s h a pe around the p l a n ned i n sertion site. The jej u n u m is then accessed with a n eed l e, and a g u ide­ w i re is th readed i nto the bowel (FIG 5) . The w i re is fo l ­ l owed l a p a roscopica l l y to e n s u re it is g o i n g d o w n the d ista l jej u n a l l i m b . A s k i n i n c i s i o n is m a d e at the g u ide­ w i re exit site a n d the d i lator is p l aced over the w i re and i nto the jej u n u m . The d i lator i s exc h a n g e d for the peel­ away sheath . The w i re is rem oved a n d the t u b e is p l aced t h ro u g h the pee l-away sheat h . The sheath is then peeled away from t h e catheter (FIG 6) . Confirmation t h a t the tube is i n the bowel l u m e n can b e a c h i eved b y i nject i n g a i r i nto the tube a n d observi n g t h e bowel d i ste n d .

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• Lapa rosco p i c jej u n osto my k i t tech n i q u e . O n c e the n eed l e i s i n se rted i n s i d e the bowe l, pushing i n the stylet d e p l oys the T-fasten e r.

FIG 4

Fourth Step-Securing the Jejunum to the Abdominal Wall •

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The bowel can be faste ned to the a b d o m i n a l wa l l i n fo u r corners with 3-0 s i l ks u s i n g l a p a rosco pic n eed l e d rivers (FIG 3) . An a ltern ative method i s to p l a ce sutu res o n a l l fo u r q u a d ra nts a ro u n d t h e p u rse-st r i n g site a n d d e l iver them t h r o u g h the a b d o m i n a l wa l l with a suture passer. If T-faste n e rs a re used, they a re t h e n secured by cri m p i n g the m eta l faste n e rs a bove the b o l sters w i t h a stra i g h t

FIG S • Lapa rosco p i c jej u n ostomy kit tech n i q u e . T h e j ej u n u m is then accessed w i t h a n eed l e a n d a g u idew i re i s t h readed i nto the bowe l .

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h e m ostat, t h u s a p p roxi mati n g the jej u n u m to the a b ­ d o m i n a l wa l l . An a d d i t i o n a l T-faste n e r can be u s e d t o t a c k the j ej u n u m to the a b d o m i n a l wa l l d i stal to the tube i nsert i o n site to p reve nt volvu l u s (FIG 7) . I nject a sma l l a m o u nt o f sa l i n e o r a i r i nto the tube after i t has b e e n secu red to the a b d o m i n a l wa l l to e n s u re there is n o leak and that the tube i s patent.

FIG 6 • Lapa rosco p i c jej u n osto my kit tech n i q u e . The j ej u n osto my tube is p l aced through the peel-away sheath and i nto the d i sta l j ej u n a l l i m b .

C h a p t e r 5 J E J U N OSTOMY T U B E

96 1

FIG 7 • Lapa rosco p i c j ej u nostomy kit tec h n i q u e . A. The T-faste n e rs h ave been secured by c r i m p i n g the meta l fasten e rs a bove the bolsters, t h u s a p p roximating the jej u n u m to the a bd o m i n a l wa l l at the jej u n ostomy site. B. An additional T-faste n e r was p laced to tack the j ej u n u m to the a bd o m i n a l wa l l d ista l t o the tube i nsertion site t o p revent volvu l u s .

PEARLS AND PITFALLS Tec h n i q u e Open jej u n osto my tube p l acement Creati n g t h e serosa l t u n n e l

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When creat i n g the Witzel t u n n e l , it i s possi b l e to cause n a rrowi n g of the proxi m a l bowe l . The sutu res should be ca refu l ly p l a ced c l ose to the feed i n g tube to avoid t h i s p ro b l e m .

Lapa rosco p i c jej u n ostomy tube p l acement Using T-faste n e rs

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Wi re p l acement

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Confi rmation of tube p l acement

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Care should be taken n ot to p l a ce the n eed l e through a n d t h ro u g h t h e bowe l (avo i d back-wa l l pe rfo rat i o n o f t h e bowe l). When cri m p i n g the T-faste n e rs, e n s u re that the jej u n u m is f l u s h to the a b d o m i n a l wa l l . H owever, do n ot i n dent the s k i n s i g n ificant ly, w h i c h can cause n ecrosis of the s k i n a n d cause the patient s i g n ificant pa i n . Faste n e rs s h o u l d b e ca refu l l y p l a n ned as kits o n ly carry five fasten e rs a n d once t h r o u g h t h e s k i n a n d fascia, the faste n e r is n o t reusa b l e . E n s u re that the w i re is trave l i n g d i sta l ly when placed. E n s u re that the w i re i s freely mobile i n the bowel a n d h a s not d i ssected i nto the layers of the i ntesti n a l wa l l . E n s u re that t h e d i lator a n d tube a re v i s u a l ized l a p a rosco p i ca l ly wh i l e ente r i n g i nto t h e d ista l a spect of the j ej u n u m . I nject a sma l l a m o u nt o f s a l i n e o r a i r i nto t h e t u b e after it h a s been secured to t h e a b d o m i n a l wa l l t o e n s u re there is n o l e a k a n d that t h e t u be is patent.

POSTOPERATIVE CARE •

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•

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Postoperatively, the patient's j ej unostomy tube can be used immediately. The j ej unostomy tube should be flushed daily, before and after administration of medications, and after stopping tube feeds to prevent clogging and to ensure patency. If a laparoscopic j ej unostomy kit was used, the T-fasteners can be cut at the skin level 2 weeks after tube placement. Nutritional consultation should be considered in order to determine the patient's caloric needs. Nutritionists may also assist in the choice of enteral formula. There is data from meta-analyses of randomized trials suggesting a benefit to

•

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using immunonutrition in perioperative head/neck and gas­ trointestinal cancer patients. 5•6 In malnourished patients who are at high risk for refeeding syndrome, nutritional support should be started slowly.7 Fluid and electrolyte imbalances should be corrected. In addi­ tion, high-risk patients should be monitored closely in terms of their vital signs, electrolytes, weight, and neurologic signs and symptoms. Patients should be monitored for hypophos­ phatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hyponatremia upon initiation of feeds. Because of the risk of arrhythmias, telemetry may be indicated in severe cases. Diarrhea is a common side effect of enteral nutrition. High-quality data on preventive interventions are lacking. 8

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Persistent diarrhea ( > 72 hours) should trigger evaluation for Clostridium difficile infection, rectal examination to rule out fecal impaction, cessation of laxatives, and restoration of fluid and electrolyte balance. Addition of soluble fiber or modification of the composition of the enteral formula may reduce diarrhea. 8 Nonocclusive bowel necrosis is a rare but devastating com­ plication of enteral feeding. Tube feed tolerance should be monitored closely, particularly among patients with preex­ isting impaired gastrointestinal function. Signs of intoler­ ance may be nonspecific such as nausea, diarrhea, bloating, and abdominal pain. Mechanisms that may contribute to nonocclusive bowel necrosis include mesenteric hypoperfu­ sion, bacterial contamination, and hyperosmolarity of the tube feeds. Unfortunately, due to the rarity of nonocclusive bowel necrosis, specific risk factors cannot be identified.9 Therefore, a low threshold for diagnosis should be main­ tained and early reexploration performed when suspected.

OUTCOMES •

•

Outcomes after j ej unostomy tube placement are dependent on the primary diagnosis. In cancer patients undergoing curative treatment, enteral nu­ trition improves the tolerance and response to therapy. 10•1 1 I n cancer patients undergoing palliative treatment, enteral nutrition may improve symptoms and quality of life while reducing loss of autonomy. 10

COMPLICATIONS • • • • • •

Diarrhea Dermatitis Infection Tube leakage (peristomal or intraperitoneal) Small bowel perforation Displacement of the j ej unostomy tube

• • •

• •

Enterocutaneous fistula Refeeding syndrome Mechanical small bowel obstruction at the j ej unostomy tube site Volvulus around the jejunostomy tube site Nonocclusive bowel necrosis

REFERENCES 1 . Weimann A, Braga M, Harsanyi L, et a!. ESPEN guidelines on en­ teral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25 :224-244. 2 . Bowater RJ, Stirling SA, Lilford RJ. Is antibiotic prophylaxis in sur­ gery a generally effective intervention? Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009;249:55 1-5 5 6 . 3 . Jafri N S , Mahid S S , Minor KS, et a!. Meta-analysis: antibiotic pro­ phylaxis to prevent peristomal infection following percutaneous endo­ scopic gastrostomy. Aliment Pharmacal Ther. 2007;25:647-656. 4. Boullata JI, Nieman Carney L, Guenter P, et a!. A.S.P.E.N. Enteral Nutrition Handbook. Silver Spring, MD: American Society for Paren­ teral and Enteral Nutrition; 2 0 1 0 . 5 . Zhang Y, Gu Y, G u o T, et al Perioperative immunonutrition for gastro­ intestinal cancer: a systematic review of randomized controlled trials. Surg Oncol. 2012;2 1 : e8 7-e9 5 . 6. Osland E, Hossain M B , Khan S, et a!. Effect of timing of pharmaco­ nutrition (immunonutrition) administration on outcomes of elective surgery for gastrointestinal malignancies: a systematic review and meta-analysis. J Parenter Enteral Nutr. 2014;3 8 ( 1 ) :53-69. 7. Khan LU, Ahmed J, Khan S, et a!. Refeeding syndrome: a literature review. Gastroenterol Res Pract. 2 0 1 1 ;20 1 1 . 8 . Whelan K , Schneider SM. Mechanisms, prevention, and manage­ ment of diarrhea in enteral nutrition. Curr Opin Gastroenterol. 2 0 1 1 ;27: 1 52-1 5 9 . 9 . Melis M, Fichera A, Ferguson M K . Bowel necrosis associated with early jej unal tube feeding: a complication of postoperative enteral nutrition. Arch Surg. 2006; 1 4 1 : 701-704. 10. Marin Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007;26:289-3 0 1 . 1 1 . Paccagnella A , Morassutti I, Rosti G. Nutritional intervention for improving treatment tolerance in cancer patients. Curr Opin Oncol. 2 0 1 1 ;2 3 :322-3 3 0 .

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Chapter

6

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Appendectomy: Open Technique 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ..

t

James Suliburk

DEFINITION •

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Open appendectomy is defined as removal of the appendix via an incision in the abdominal wall without use of a camera. Prior to laparoscopy, it was the most commonly performed emergency general surgery operation in the United States. Open appendectomy has been replaced in frequency by laparoscopic appendectomy as the most common emergency general surgery operation performed. Laparoscopic appendectomy is not always possible, and an open approach may be preferred in patients who have had extensive abdominal or pelvic surgery. Additionally, it may be necessary to convert to an open technique from an initial laparoscopic approach due to technical or anatomic reasons. Open appendectomy can also be the preferred approach in patients who are pregnant in which the gravid uterus pre­ cludes laparoscopy.

DIFFERENTIAL DIAGNOSIS •

Patients presenting with appendicitis may have any number of conditions mimicking the classic right lower quadrant (RLQ) pain of appendicitis. Conditions that have to be con­ sidered in the differential diagnosis of acute appendicitis can be broken down in categories, including the following: Gastrointestinal: gastroenteritis, mesenteric lymphadeni­ tis, Meckel's diverticulum, intussusception, cholecystitis, inflammatory bowel disease, diverticulitis, perforated can­ cers, and perforated peptic ulcers Gynecologic: ectopic pregnancy, salpingitis, endometriosis, ovarian torsion, tuboovarian abscess Urologic: urinary tract infection, nephrolithiasis

PATIENT IDSTORY AND PHYSICAL FINDINGS •

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Patients most commonly present with appendicitis between the ages of 10 and 40 years. Approximately 75 % of patients will present with pain of less than 24 hours duration. Clas­ sically, the pain is described as starting at the umbilicus and then migrating over several hours' time to the RLQ as the stimulus changes from the visceral to somatic nerves. How­ ever, this classic migration is not always present, and nearly 40% of patients will have atypical pain, with only vague abdominal pain or even flank pain. Atypical pain can frequently be caused by subtle variation in the appendix location with right upper quadrant pain being caused by an anteriorly located appendix on a high-riding cecum, tenesmus triggered by an inflamed appendix tip in the pelvis, and flank pain triggered by a retrocecal appendix. Nausea, vomiting, and anorexia are classically associated with appendicitis but are variably present. Of these, the sequence of having anorexia and/or abdominal pain pre­ ceding vomiting is more consistent with appendicitis. When vomiting is the first symptom elicited, the diagnosis of appendicitis is questionable. Diarrhea is fairly nonspecific.

David Berger

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Physical exam findings consistent with appendicitis are dependent on the location of the appendix. Because the appendix may be located anywhere on the cecum, signs are extremely variable. Classic RLQ point tenderness at McBurney point is present in the normal anterior location of the appendix. Rovsing's sign (RLQ pain when left lower quadrant is pressed) may also be present. When the appendix is located in a retrocecal position, a pos­ itive psoas sign (pain with extension of the right thigh with the patient lying on the left side) can be elicited. When the inflamed appendix is in the pelvis, the classic obturator sign (pain with internal rotation of the flexed thigh in the supine position) may be positive. Additional tests for subtle peritoneal irritation, including gently shaking the hospital stretcher or having the patient walk, cough, or j ump to determine if this exacerbates pain, are nonspecific for appendicitis and simply indicate perito­ neal irritation. Diffuse peritonitis is consistent with ruptured appendicitis and intraabdominal sepsis. These patients usually present with temperature greater than 3 9° C and tachycardia.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

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Laboratory studies and radiologic studies can be complemen­ tary to history and physical exam in establishing the diagnosis. A mild leukocytosis is generally present. Occasionally, a " left shift" with normal leukocyte count is seen. Fewer than 5 % of patients presenting with acute appendicitis will have both a normal white blood cell (WBC) count and no shift. Urinary analysis may show a few white or red cells but should not reflect bacteriuria. Serum chemistry testing for amylase and lipase and liver function tests are useful in cases where the history of presen­ tation and physical exam findings are not classic and there is an atypical presentation. Imaging studies have come to the forefront of appendicitis diagnosis in recent years. Computed tomography ( CT) enhanced with intravenous (IV) and enteral contrast is the gold standard for evaluation of appendicitis. Case series dif­ fer slightly in their reports, but a reasonable estimation is that CT is 9 0 % sensitive and 9 5 % specific for detection of appendicitis. Widespread use of CT has been shown to reduce the inci­ dence of negative appendectomy. 1 Furthermore, findings of phlegmon or abscess on CT may prompt the surgeon to undertake an alternate approach in treating complex cases of appendicitis with percutaneous drainage and IV antibiotic therapy as the first step of therapy in order to minimize morbidity to the patient. Ultrasound remains an imaging modality that is operator dependent. In skilled centers, it can be especially helpful in pediatric patients and in early pregnancy.

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Plain abdominal radiographs should not be considered rou­ tine or mandatory in the specific evaluation of appendicitis but can be used as an initial test in patients presenting with diffuse peritonitis and signs of intraabdominal sepsis.

•

SURGICAL MANAGEMENT •

The bulk of surgical treatment should be discussed in the "Techniques" section. Here, consider indications and other more general concerns, such as discussed in the following sections.

Positioning

Preoperative Planning •

inflammation (systemic inflammatory response syndrome [SIRS] : fever, tachycardia, increased respiratory rate, WBC count � 12,000/mm3 or :s4,000/mm3, or > 1 0 % bands) . Evidence-based studies clearly indicate that as soon as the decision to operate on the patient is made, IV antibiotics cov­ ering facultative, gram-negative, and anaerobic flora should be promptly administered in an effort to reduce surgical site infection (SSI). 2 If simple (nonruptured) appendicitis is encountered at operation, there is no benefit in administra­ tion of postoperative antibiotics.

Patients should receive adequate preoperative fluid resuscita­ tion prior to operation in order to restore urine output. This is especially important for patients who show systemic signs of

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OPEN APPE N DECTOMY FOR PRI MARY

The patient is positioned on a supine position with the arms extended or tucked depending on surgeon preference. A Foley catheter can be inserted at the surgeon's discretion.

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TREATMENT OF APPE N D ICITIS First Step-Skin Incision •

A M c B u rney (o b l i q ue) or Rocky Davis (transverse) I n C I ­ s i o n i s m a d e i n the R L Q , s l i g htly s u pe r i o r to the p o i nt of maxi m a l tenderness fo u n d d u ri n g preoperative exa m, a n d centered o n the m i d c l avicu l a r line (FIG 1 ).

Second Step-Abdominal Wall •

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There a re th ree m uscle l ayers i n the latera l a b d o m i n a l wa l l . A s t h ese a re encou ntered w h e n ente r i n g the a bdo­ men, t h ese a re the exte r n a l o b l i q ue, the i ntern a l o b l i q ue, and the transversus a b d o m i n is m uscles. Each m uscle a p o n e u rosis is cut in t h e d i rection of t h e m uscle fi bers.

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A m u scle-s p l itt i n g tec h n i q u e is used to spread a p a rt each m uscle l ayer along the orientation of the m uscle fibers (FIG 2) u nt i l the perito n e u m is reached. The perito n e u m is then g rasped with forceps in order to ass u re no bowel is a d h erent a n d is i n cised with scissors to enter the a b d o m i n a l cavity (FIG 3) . An a p p ro p r i ate retractor is p l aced to e n h a nce operative expos u re. This can be either a B a l fo u r o r a Bookwalter retractor.

Third Step-Exposure of the Appendix •

After the perito n e u m is entered, the cec u m is identified . Sponge sticks can be h e l pf u l to sweep the s m a l l bowel in a latera l to m ed i a l d i rect i o n i n order to expose t h e cecu m .

Internal oblique

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· · ·\- - '·

External oblique Transverse abdominis muscle

• I ncision p l acement. A Rocky Davis (tra n sverse) o r M c B u rney (o b l i q ue) incision is used . The m i d po i nt of the i ncision should be centered over the maxi m a l point of tenderness.

FIG 1

FIG 2 • Abd o m i n a l wa l l open i n g . A m u scle-s p l itt i n g tech n i q u e is u s e d to s p read a p a rt e a c h m uscle l a y e r a l o n g the o r i e ntation of the m uscle fi bers.

C h a p t e r 6 APPE N D E CTOMY: Open Tech n i q u e

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Fai l u re to remove the base of the appendix may cause a closed loop obstruction between a persistent feca l ith at the base of the appendix a n d the stu m p sta ple l i ne. This may lead to a n a ppendiceal stu m p blowout postoperatively. I n cases of retroceca l a p p e n d icitis, t h e cec u m w i l l n eed to be fu l ly m o b i l ized i n a latera l to m e d i a l fas h i o n so that it i s co m p l etely refl ected from the retroperiton e u m in order to f i n d the a p p e n d ix.

Fourth Step-Ligation and Resection •

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FIG 3 • Abdom i n a l wa l l open i n g . The perito n e u m i s t h e n g rasped with forceps i n order to assu re n o bowel i s a d h e rent a n d is i n cised with scissors to enter the a b d o m i n a l cavity. •

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Once the cecu m is identified, the a nterior taenia is identi­ fied. The cecum is then m o b i l ized, fo l l owi n g the a nterior tae n i a to its confl u ence with the a p p e n d i ceal base (FIG 4) . The convergence of a l l th ree teniae co l i a l l ows for the correct i d e ntificat i o n of the base of t h e a p p e n d i x . T h i s i s critical to e n s u re t h a t the entire a p p e n d i x is remove d .

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The a p p e n d i x a n d cecu m a re gently p u l led i nto the wo u n d . The meso a p p e n d i x is transected a n d l i gated betwee n c l a m ps (FIG 5) . Abso rba b l e sutu re ties a re p l aced at the a p pendiceal base, a n d the a p p e n d ix is then tra n sected (FIG 6) . There is no s u p po rti n g data for e l ectroca utery a b l at i o n of the a p pendiceal m ucosa at the l i g ated stu m p, a n d t h i s com­ m o n practice clearly puts at risk the sec u rity of the sutu re used to l i gate the a ppend iceal stu m p . I nvers i o n of the a p pe n d iceal stu m p may be performed if t h e s u rgeon desi res. C o m m o n ly, a " Z-stitch " is used for this p u rpose (FIG 7) . In the Z-stitch, the u pper bite is p laced as a Lembert sutu re and then brought below the base of the appendiceal stu m p and a second serom uscu l a r stitch is placed. T h e base o f the appendix is then i nverted using forceps a n d the ends of the suture tied down over the i nverted stu m p (FIG 7). • I n cases of severe a pp e n d i ce a l stu m p edema a n d i nf l a m mation, a g a stroi ntest i n a l sta p l e r m a y b e used t o transect the base o f the a p p e n d ix, even i n c l u d i n g a segment of hea lthy ceca l base i n the resection; be ca refu l to avo i d i m p i ngement of the i l eoceca l va lve when f i r i n g the sta p l e r (FIG 8) .

Cecum

Ileum

M esoappendix

FIG 4 • Del ivery of the a p p e n d i x i nto the wo u n d . Once the cecu m is i d e ntified, the a nterior t e n i a e co l i i s identified. The cec u m is then m o b i l ized fo l l ow i n g the a nterior taenia to its confl u e n ce with the a p pendiceal base.

FIG 5 • C l a m p i n g a n d l i gation o f the mesoa ppend ix. T h e a p p e n d ix a n d cec u m a re gently p u l led i nto t h e wo u n d . T h e mesoa p p e n d i x i s transected a n d l i g ated between c l a m ps.

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

FIG 6 • Ligation of the a p p e n d icea l base. Absorba b l e suture ties a re p l a ced at t h e a p p e n d icea l base, a n d the a p p e n d i x is t h e n transecte d .

FIG 8 • Use o f g a stroi ntest i n a l sta p l e r to transect the a p p e n d icea l base.

•

I rrigation of the s u rg ica l field is of u nclear benefit. There a re l i m ited d ata i n a d u lts. A ra ndom ized p rospective study i n c h i l d ren fa i led to show any change i n i ntraabdom i n a l a bscess whether irrigation w a s used o r n ot used 3

Fifth Step-Closure • •

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FIG 7 • I nvers i o n of the a pp e n d i ce a l stu m p . The a p p e n d icea l stu m p is i nverted i nto the cecu m with the p l acement of a Z-stitch .

A l l th ree m u scle l ayers a re c l osed sepa rate ly with r u n ­ n i n g a bsorba b l e sutu re. The skin ca n be c l osed, left open, o r l oosely a p p roxi­ m ated, d e pe n d i n g o n the seve rity of conta m i nation encou ntered d u ri n g t h e case. For g a n g re n o u s o r perforated a p p e n d i citis, considered d e l ayed p r i m a ry c l o s u re o r p l a cement of a n egat ive p ress u re wo u n d t h e r a py device to m i n i m ize s u p e rfi c i a l s u r g i c a l s i t e i nfect i o n . N o d ra i n is i n d i cated i n s i m p l e a p p e n d icitis. D ra i n p l ace­ ment in cases of co m p l icated a p p e n d icitis i s a l so n ot s u p ­ ported by c l i n i ca l t r i a l s .

OPEN APPE N DECTOMY FOR APPE N D I CEAL N EOPLASMS •

Occa s i o n a l ly, the s u rgeon may encou nter an a p pendiceal neoplasm a s the cause of the suspected a p p e n d icitis. Overa l l , t h i s happens i n a p p roxi m ately 1 % of cases of suspected a p pe n d icitis. • A p p e n d i cea l t u m ors encou ntered may i n c l u d e car­ c i n o i d t u m o r, m uc i n o u s neoplasm, o r a p p e n d i ceal/ ceca l a d e n ocarci n o m a . I n th ese cases, it is esse n t i a l

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to u n d e rsta n d what operati o n n e e d s to be d o n e f o r the patient. FIG 9 is s h own as a q u ick refe rence g u ide. For carci n o i d t u m ors l ess t h a n 1 em i n si ze, a s i m p l e a p p e n d ecto my is sufficient. For carci n o i d t u m o rs between 1 a n d 2 em i n size, s u rg i c a l treatment w i l l depend o n the t u m o r loca­ tion. If the carci n o i d tumor is at the base of the a p p e n d ix o r if t h e t u m o r i nvades the mesoa ppend ix, then a r i g ht h e m i c o l ectomy is i n d i cated to o bta i n a n

C h a p t e r 6 APPE N D E CTOMY: Open Tech n i q u e

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Location at tip, or mid-appendix

Location at base: mesoappendiceal invasion; metastases •

FIG 9

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M a n a gement of a p pe n d icea l carci n o i d . •

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adeq u ate l y m p h a d e n ectomy. Otherwise, a s i m p l e a p p e n d ectomy i s suffi cient. For carci n o i d t u m o rs g reater t h a n 2 em i n s ize, a right hem icolecto my with a h i g h i l eoco l i c lympho­ vasc u l a r ped icle tra nsect i o n is i n d icated d u e to the higher i n c i d e nce of m etastati c d isease observed in the n o d a l bas i n i n these patients. •

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CONVERS I O N TO OPEN APPE N D ECTOMY AFTER FAILED ATTE M PT AT

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LAPAROSCOPIC APPE N DECTOMY First Step-Skin Incision •

When convert i n g to an open p roced u re from l a p a ros­ co py, a l ower m i d l i n e l a p a rotomy i n c i s i o n is p referred. The incision may be exte nded a bove the u m b i l i cus if a d d i t i o n a l exposu re is req u i re d .

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Second Step-Abdominal Wall •

It is esse n t i a l to stay i n the m i d l i n e, a l o n g the l i n ea a l ba, d u r i n g t h e fasc i a l incision i n order to fac i l itate opti m a l c l osu re a n d to p reve nt ventra l i n c i s i o n a l h e r n i a fo rma­ t i o n . Ca re should be taken not to extend the i n c i s i o n too fa r i nfe riorly a s the b l a d d e r is at risk of i n j u ry (especi a l ly i n cases where no Foley cath ete r is p resent).

Third Step-Appendiceal Resection •

O n ce the perito n e u m is entered, a n y a d hesions a re lysed s h a r p l y a n d an a p p ro p r i ate retractor is p l aced to

•

I n cases where r i g h t h e m icolecto my is i n d i cated, it is p r u d e nt to cl ose the RLQ incision a n d convert to a m i d l i n e l a p a rotomy. For m u c i n o u s a p p e n d icea l n e o p l asms, the extent of resect i o n w i l l be d i ctated by the deg ree of i nvas i o n . I ntraope rative ly, speci a l atte ntion s h o u l d be g iven to not r u ptu r i n g a n i ntact m u c i n o u s neoplasm . If r u pt u re of a m u c i n o u s neoplasm has occu rred, then the s u rgeon s h o u l d exa m i n e if m u c i n coats perito n e a l su rfaces. If m u c i n i s d iffusely coati n g the a bd o m e n , then right h e m i c o l ectomy is i n d icate d . If there is n o m u c i n conta m i n ation, a p p e n d ecto my with clea r m a r g i n s w i l l suffice. Pat h o l ogy m u st t h e n be fo l l owed u p to dete r m i n e if the lesion w a s m a l i g ­ n a n t o r not. If m a l i g n a ncy is i d e ntified, refer to a specia lty cen­ ter for consideration of right h e m i c o l ecto my (if n ot o ri g i n a l ly performed). D e b u l k i n g a n d i ntrape rito­ neal chemotherapy is a l so i n d i cated in cases of d if­ fuse m u c i n coat i n g of the a b d o m i n a l s u rfaces. 5 N o n m u c i n o u s a p pendiceal a d e n ocarci n o m a wa r­ rants a right h e m i c o l ecto my with a h i g h i l eoco l i c l y m p h ovasc u l a r tra nsect i o n i n o r d e r t o pe rfo rm a n adeq u ate l y m p h a d e n ecto my. For the tec h n i c a l description on how to perform a n open right h e m i c o l ectomy, p l ease refer to the desc r i pt i o n of this tech n i q u e e l sewhere in t h i s textbook.

e n h a nce operative expos u re . T h i s can be either a B a lfo u r o r a Bookwalter retractor. At t h i s poi nt, the cec u m is m o b i l ized a n d the a p p e n d i x is expose d . The mesoa p p e n d i x is t h e n d ivided a n d t i e d betwee n c l a m ps . The b a s e of the a p p e n d ix, i d e ntified by the convergence of the teniae co l i at the base of t h e cecu m, is l i gated with seq u e n t i a l a bsorba b l e sutu re ties as descri bed. lf the base is easily i d e ntified at the beg i n n i n g of the case, it may be h e l pf u l to pe rfo rm a " retrog rade" d i ssection of the a p p e n d i x . In t h i s tec h n i q ue, the a p pendiceal base is transected fi rst. The mesoa p p e n d i x is then seq u entia l ly transected from the a p p e n d icea l base to its t i p (FIG 1 0) . This tec h n i q u e ca n be usef u l when t h e mesoa p p e n d i x is seve rely a d h ered to the cec u m . If inflam mation is severe, a n i leocecectomy m a y be re­ q u i red or even partia l col ectomy. If inflam mation is so severe as to preclude m o b i l ization of the cecu m and term i­ n a l lieum, a cecostomy maybe created. Pl ease refer to the description of t h i s tech n i q u e d escribed elsewhere i n this textbook.

967

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P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

FIG 1 0 • " Retrog rade d issection " of the a ppendix. I n this tec h n i q ue, the a p pend i cea l base is transected fi rst. The mesoa ppendix is then seq uentia l ly tra nsected from the a ppendicea l base to its t i p . This tech n i q u e can be usefu l w h e n the m esoa ppendix is severely adhered to the cecu m .

PEARLS AND PITFALLS I n d i cations

•

B ewa re of atypical pathology i n the atypica l patient c l i n ical p resentati o n .

P l acement o f i n c i s i o n

•

M i d l i n e i n cision is p referred when convert i n g f r o m l a p a rosco p i c to open s u rg e ry. For p r i m a ry open RLQ i n c i s i o n a p p roach, p l a ce the i n ci s i o n s l i g htly h i g h e r t h a n the maxi m a l p o i nt of tenderness.

•

Exposu re

• •

Resect i o n

• •

•

C l o s u re

•

Use sponge sticks to sweep the bowe l out of the way a n d to expose the cec u m . Gen tly u s e B a bcocks t o p u l l the cecu m a n d a p p e n d ix i nto the wo u n d . Proper identification of the append icea l base by the convergence of the teniae co l i at the base of the cec u m is critica l to p revent i n com p l ete resection a n d poss i b l e a p p e n d icea l stu m p b l owout postoperatively. If the base of the a p p e n d i x is seve rely i nf l a m ed, use a gastroi ntest i n a l a n astomosis (G IA) sta p l e r to tra n sect, i n c l u d i n g a seg ment of hea lthy ceca l base in the resection (be ca refu l to avo i d i m p i n g e m e nt of the i l eoceca l va lve) . Consider perfo r m i n g a retro g ra d e a p p e n d ecto my in cases where the a p p e n d ix is densely a d h e red to the cecu m . For g a n g re n o u s or perforated a p p e n d icitis, considered d e l ayed p r i m a ry closure or p l acement of a negative pressu re wound therapy device to m i n i m ize s u perfi c i a l s u rg i c a l site i nfect i o n .

return of bowel function, and temperature lower than 3 8 °C. If these criteria are not reached by postoperative day 6, then a CT scan of the abdomen and pelvis with contrast is ob­ tained to evaluate for potential intraabdominal and/or pelvic abscess.

POSTOPERATIVE CARE •

•

For cases of simple appendicitis, antibiotics should be stopped within 24 hours of surgery. There is no evidence supporting improved outcomes with additional antibiotics beyond 24 hours of surgery end time. In cases of gangrenous or perforated appendicitis, empiric antibiotic therapy should be continued with coverage for facultative, gram-negative, and anaerobic bacteria. Endpoints of duration of IV antibiotic coverage include WBC count less than 12,000/mm\ less than 1 0 % bands,

COMPLICATIONS •

Appendectomy for simple appendicitis is performed with very low complication rate. Patients may be discharged home within 24 to 48 hours with no additional antibiotics needed.

C h a p t e r 6 APPE N D E CTOMY: Open Tech n i q u e

•

•

•

Appendectomy for complicated appendicitis carries signifi­ cantly increased morbidity and mortality rates as compared to simple appendectomy. Postoperative ileus is common, and diet should be initiated when clinical signs of return of bowel function exist. SSI is also a common complication. SSI is lower in children than adults, and as such, primary closure after perforated open appendectomy is indicated in this setting. Primary wound closure in adults should be done with caution as wound infection rates can approach 3 0 % .6 Intraabdominal abscess is treated with image-guided drain­ age and culture and IV antibiotic therapy tailored toward microbiology of the abscess. If the abscess is not accessible via percutaneous approach, a surgical drainage of significant collections via a laparoscopic or open approach is indicated. Append the seal stop blowout: Oftentimes, this is associated with incomplete resection of the appendix and may lead to severe peritonitis, necessitating repeat exploratory laparot­ omy. In these cases, an ileocecectomy and a possible perfor­ mance of a temporary ileostomy should be considered. If inflammation is so severe as to preclude mobilization of the cecum and terminal lieum, a cecostomy tube maybe placed through the hole where the base of the appendix connected to the cecum in order to created a controlled fistula that may be treated at a later date.

• •

969

Incisional hernia : Incidence is higher with midline incisions. Postoperative small bowel obstruction

REFERENCES 1 . Drake Ff, Florence MG, Johnson MG, et al. Progress in the diag­ nosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program. Ann Surg. 2 0 1 2;256(4): 5 8 6-594. 2. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and manage­ ment of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt). 2 0 1 0; 1 1 ( 1 ) :79-109. 3 . St Peter SO, Adibe 00, Iqbal CW, et al. Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a pro­ spective randomized trial. Ann Surg. 2 0 1 2;256(4) : 5 8 1-5 8 5 . 4. Kulke MH, Mayer RJ. Carcinoid tumors. N Eng/ ] Med. 1999; 340( 1 1 ) : 8 5 8- 8 6 8 . 5 . Chua T C , Moran BJ, Sugarbaker P H , et a l . Early- a n d long-term out­ come data of patients with pseudomyxoma peritonei from appendiceal origin treated by a strategy of cytoreductive surgery and hyper­ thermic intraperitoneal chemotherapy. J Clin Oneal. 2 0 1 2 ; 3 0 ( 2 0 ) : 2449-245 6 . 6. Mangram AJ, Horan T C , Pearson M L , et a l . Guideline for preven­ tion of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am ] Infect Control. 1 999;27(2):97-132; quiz 1 3 3-134; discussion 96.

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Chapter

7

Appendectomy: Laparoscopic Technique

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Roosevelt Fajardo

DEFINITION •

Acute appendicitis is the most frequent cause of acute surgi­ cal abdominal pain seen in the emergency services around the world. Close to 7% of the total world population will suffer from appendicitis at some point in their lives. Although it may occur at any age, its incidence is higher in childhood, with a peak incidence between 10 and 30 years of age. It is more frequent in men, with a male-to-female ratio of 1 .4 : 1 . Ad­ vances in laparoscopic surgery around the world have made laparoscopic appendectomy a safe and simple procedure.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

DIFFERENTIAL DIAGNOSIS • • • • • • • • • • • •

Urinary tract infection Intestinal obstruction Acute cholecystitis Mesenteric adenitis Meckel's diverticulitis Colonic diverticulitis Right ureteric colic Ectopic pregnancy Salpingitis, pelvic inflammatory disease Ruptured ovarian follicle Gastroenteritis Terminal ileitis

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

Despite advances in diagnostic imaging, diagnosis of acute appendicitis continues to be predominantly clinical. A good clinical history and a thorough physical examination should provide the surgeon with a high degree of suspicion. The characteristic clinical picture is one of abdominal pain that exacerbates with movement, starting in the periumbilical re­ gion and then migrating to the right lower quadrant. Fever, anorexia, nausea, and vomiting are frequent. The Alvarado score, a clinical scoring system used in the diagnosis of appendicitis, assigns points to six clinical items and two laboratory measurements with a maximum possible total of 10 points. With scores greater than 5, the probability of acute appendicitis increases. A popular mnemonic used to remember the Alvarado score factors is MANTRELS: Migration to the right iliac fossa, Anorexia, NauseaNomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever) , Leuko­ cytosis, and Shift of leukocytes to the left. Due to the popu­ larity of this mnemonic, the Alvarado score is sometimes referred to as the MANTRELS score. The location of the appendix may change the clinical presen­ tation. With the appendix in a retrocecal location, patients may present with right flank pain. With an appendix in a pelvic location, patients typically present with urinary symptoms and diarrhea .

970

•

The hemogram typically shows a leukocytosis, with a left­ sided shift. Female patients in fertile age should have a preg­ nancy test prior to surgery. Ultrasound ( FIG 1 ) has shown to have 8 6 % sensitivity and 8 1 % specificity for the diagnosis of acute appendicitis and has the benefit of not being invasive, but it is operator dependent. Computerized axial tomography (CAT; FIG 2) scan, with a 94% sensitivity and a 9 5 % specificity, has been shown to be the most accurate imaging study for the diagnosis of acute ap­ pendicitis but is expensive and may delay surgical intervention. Magnetic resonance imaging (MRI) is reserved for patients who cannot be exposed to radiation, such as pregnant women suspected of having appendicitis.

SURGICAL MANAGEMENT Indications • •

Same indications than for open appendectomy Any patient with diagnosis of appendicitis who can tolerate pneumoperitoneum and general anesthesia, provided that trained staff and the necessary equipment for a safe procedure are available

Preoperative Planning •

•

Appropriate prophylactic antibiotic should be administered 3 0 minutes before surgery. Decompression of the bladder by voiding before surgery or by using a Foley catheter may avoid injury of the bladder during trocar placement.

Patient and Team Positioning •

•

•

The patient is secured to the table with the arms padded and tucked to the side. The surgeon and the camera operator stand on the patient's left side ( FIG 3 ) . The monitor i s placed i n front o f the surgeon (at eye level) on the patient's right side.

• U ltraso u n d i m a g i n g i n a p p e n d icitis. Arrows s h ow a d iste nded a p p e n d i x with a t h ickened wa l l . A a n d B s h ow transverse vi ews of the a p p e n d ix. C s h ows a l o n g it u d i n a l view of the a p p e n d i x .

FIG 1

C h a p t e r 7 APPE N D E CTOMY: LAPAROSCO P I C TECH N I Q U E

A

97 1

B •

CAT scan i m a g i n g i n a p p e n d icitis. A: Axi a l vi ew. B: Coro n a l vi ew. Red c i rcles show acute a p pe n d icitis with periappend iceal i n f l a m m at i o n .

FIG 2

Port Placement Monitor Advanced device

•

I ntestinal Anesthesiolog ist

•

•

•

Surgeon

Scru b nurse

FIG 3

•

•

Camera operator

Patie nt, port, team, a n d operati n g room set u p .

Caudad

A FIG 4

•

A traditional laparoscopic appendectomy is performed using a three-port system ( FIGS 3 and 4) . The surgeon should be able to work two-handed. The ports are triangulated to enhance maneuverability and exposure. A 1 0-mm Hasson trocar is inserted in the umbilicus. This tro­ car will be used for C0 2 insufflation and also as a camera port. A 1 2-mm trocar is inserted in the left lower quadrant. In addition to being the main dissection port, this port will be used for the stapler and also as an extraction site. If a good quality 5-mm camera is available, then a 5-mm port can be inserted in this location; in this alternative setup, the speci­ men would be retrieved through the umbilical port site. A 5-mm trocar i s inserted i n the right lower quadrant. This trocar will be used to help retract and expose. Placement of a urinary catheter may be required before introducing the lower abdominal trocars in order to reduce the risk of blad­ der perforation during this step of the procedure.

Cephalad

B A.B. Port p l acement. The t h ree ports are tri a n g u l ated to e n h a nce m a n euvera b i l ity a n d v i s u a l izat i o n .

972

P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

STEP 1 . EXPOSURE OF THE APPE N D I X AND I D ENTI F I CATI O N OF T H E

Append iceal base

APPE N D ICEAL BAS E •

•

•

•

The patient is p l aced in a Tre n d e l e n b u rg positi o n a n d rotated with the r i g h t s i d e u p t o h e l p m o b i l ize the s m a l l bowe l o u t o f the f i e l d o f view a n d t o e n h a nce ope rative exposu re . The fo l d of Treves (a n a nti m esenteric fat fo l d a l so known as the sa i l sign) a l l ows fo r i d e ntificat i o n of the term i n a l i l e u m (FIG S). Fol lowi n g the term i n a l i l e u m d ista l l y to the i l eoceca l j u n ction fac i l itates identificati o n of the cecu m . The a p p e n d ix can usua l ly be seen at the base of the cec u m . I n retroceca l a p p e n d icitis ca ses, the cec u m may have to be m o b i l ized m ed i a l ly by transect i n g its l atera l perito­ n e a l atta c h m e nts in order to expose the a p pendix. The base of the i nf l a m e d a p p e n d ix is local ized by identi­ fyi n g the convergence of the th ree t e n i a e co l i at the base of the cecum (FIG 5) .

Treves

Teniae coli

/_ � Terminal ileum

FIG 5 • The append icea l base can be identified by the convergence of the ten iae col i at the base of the cecu m . Identifying the ileoceca l j u nction, with the fold of Treves i n the a nti mesenteric aspect of the term i n a l ileum, facil itates identification of the cecum and the appendix i n patients with severe inflam mation.

STEP 2. D I V I S I O N OF THE MESOAPP E N D I X •

•

O n ce i d e ntified, the t i p of the a p p e n d i x is p u l led up with a g rasper i ntrod uced t h r o u g h the right l ower q u a d ra n t port s i t e . T h i s a l l ows for the expos u re of the tria n g u l a r­ s h a ped space betwee n the a p p e n d ix, the cecu m , a n d term i n a l i l e u m , where the mesoa ppendix can be rea d i ly identified (FIG 6) . T h e mesoa p p e n d i x c a n t h e n be seq u e n t i a l ly tra n ­ sected w i t h a n a d v a n c e e n e rgy device ( L i g a S u re o r a

FIG 7 Appendix

• Exposure of the mesoa ppend ix. P u l l i n g up o n the tip of the a p p e n d i x exposes the tri a n g u l a r space between the a p p e n d ix, the cecu m, and term i n a l i l e u m , where the mesoa p p e n d i x can be rea d i l y i d e ntified.

•

Tra nsection of the mesoa ppendix with a n energy device.

H a rm o n ic) (FIG 7) very c l ose to the a p p e n d ix. Tra n sec­ tion of the m esoa p p e n d i x i s c a r r i e d down to the base of the a p p e n d ix (F I G 8) . Altern ative ly, the m e s o a p ­ p e n d i x m a y be tra n sected with a l i n e a r vascu l a r l o a d sta p l e r.

FIG 6

• The a p p e n d i x h a s been co m p l etely skeletonized by tra nsect i n g the mesoa p p e n d i x down to the l evel of the a p pendiceal base. The a p p e n d ix is now ready for transect i o n .

FIG 8

C h a p t e r 7 APPE N D E CTOMY: LAPAROSCO P I C TECH N I Q U E

STEP 3 . TRANSECTION O F T H E APPE N D I X •

The a p p e n d ix is tra nsected at its base, f l u s h to the ceca l wa l l .

•

This is critica l to avoid, potentia l ly leavi n g a feca l ith i m ­ pacted i n a reta i ned, long append iceal stu m p . I n t h i s situation, a d e a d space w i l l be left between the sta pled transected end of the appendix a n d the persistent l u m i ­ n a l obstruction produced b y t h e feca l ith at t h e base o f the

•

append ix. Prog ressive f l u i d a n d gas accu m u l ation in this dead space cou l d lead to a " b lown " append iceal stu m p a n d t h e development o f severe periton itis postoperatively. If the base of the a p pendix is sufficiently narrow, it may be l i g ated with 8- to 1 0-m m Hem-o-Lok c l i ps (FIG 9) or with a pretied Roeder's endoloop. In cases where the a p pendix is th icker a n d inflamed, a l i near 30- or 45-m m sta p l i n g device (i ntroduced through the right lower q u a d rant port site) may be used to tra nsect the appendix at its base (FIG 1 0).

A

B •

A,B. Ligation of the a p pendiceal base with H e m-0Lock c l i ps. T h i s is o n ly possi b l e when the a p p e n d i cea l base is suffi ciently n a r row.

FIG 9

• I n cases w i t h a t h i c k a p p e n d ix w i t h severe i n f l a m m ation, the a p p e n d i x i s transected at its base with a l i n e a r sta p l e r device.

FIG 1 0

STEP 4. RETR I EVAL OF THE SPEC I M E N •

With the a p p e n d ix transected, the a p pe n d iceal stu m p sta p l e l i n e is ch ecked f o r i nteg rity a n d h e m ostasis

•

The a p p e n d ix may be then retrieved t h r o u g h the 1 2- m m troca r s i t e u s i n g a n e n d o retrieva l bag (FIG 1 2) .

(FIG 1 1 ) .

FIG 11 • With the a p p e n d i x tra n sected, the a p p e n d icea l stu m p sta p l e l i n e is checked for i nteg rity a n d h e m ostasis.

973

974

P a r t 4 OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

FIG 1 2 • The a pp e n d i x may be then retri eved t h ro u g h the 1 2- m m trocar site u s i n g a n e n d o retri eva l b a g .

STEP 5. CLOSURE

•

•

•

•

•

The operative site is i rrigated with ste r i l e n o r m a l s a l i n e so l ut i o n . A d r a i n is p l a ced by the a p p e n d iceal stu m p o n ly in cases of perforated a p p e n d icitis.

The p n e u m operito n e u m is evacu ated . A l l po rts a re removed . The s k i n i ncisions a re c l osed with reabsorba b l e su bcuticu­ l a r sutu res.

PEARLS AND PITFALLS Loca l i zation o n the a p p e n d ix

•

By i d e ntify i n g the cec u m a n d fo l l owi n g the teniae co l i d i sta l l y or u s i n g t h e term i n a l i l e u m as a guide to reach t h e i l eoceca l va lve

Tra nsect i o n of the m esoa p p e n d i x

•

Stay c l o s e to the a p p e n d ix; t h i s wi l l m i n i m i ze c u m berso me b l eed i n g a n d w i l l fac i l itate the extraction of the spec i m e n from the a b d o m i n a l cavity.

Tra nsect i o n of the base of the a p p e n d ix

•

It is i m pe rative to tra nsect the base of the a p p e n d ix to p revent a potent i a l b l own a p p e n d icea l stu m p syn drome. If the base of the a p p e n d i x is too t h i ck, use a l i n ear sta p l i n g device.

•

Extraction from the a b d o m i n a l cavity

•

Use an e n d o retri eva l bag to protect the wo u n d . You may need to exp a n d the 1 2- m m troca r site if the a p p e n d ix is b u l ky.

Use of d r a i n a g e

•

O n l y leave a closed d r a i n a g e i n cases of perfo ration of the a p pe n d ix.

Image-guided percutaneous drainage may be needed for resolution.

POSTOPERATIVE CARE •

This procedure, done through laparoscopy, is less painful, and it may be done as an outpatient procedure in most cases of uncomplicated appendicitis. The patient can re­ sume oral feeding within a few hours of the surgery and go back to routine activities sooner than with traditional open surgery. Patients with perforated or complicated appendicitis are generally admitted for intravenous (IV) antibiotics until they are afebrile with a normal white blood cell count. Antibiotics are usually targeted toward gram-negative and anaerobic organisms. As with patients with simple appendicitis, discharge criteria include ability to toler­ ate oral intake and appropriate pain control . If patients continue to have abdominal pain, develop leukocy­ tosis, or become febrile after undergoing appendec­ tomy for perforated or complicated appendicitis, their symptoms may be signs of an intraabdominal abscess.

OUTCOMES •

Laparoscopic appendectomy has been shown to have mul­ tiple advantages over the open procedure, including a lower rate of wound site infection, although there are reports in the literature of an increased rate of residual abscesses when compared with open appendectomy.

COMPLICATIONS •

•

•

Complications of acute appendectomy are relatively rare, and they are more frequently associated with the disease sta­ tus or the presence of perforation. In nonperforated appendicitis, reported mortality is 0.8 per 1 ,000, and it increases to 5 . 1 per 1 ,000 in cases of perforation. Wound infection may vary from 5% to 50% in cases of per­ forated appendicitis.

C h a p t e r 7 APPE N D E CTOMY: LAPAROSCO P I C TECH N I Q U E

•

• • •

Surgical site infection is directly related to the status of the disease, and it increases by up to 2 0 % in cases of perforated appendicitis. With the advent of laparoscopic appendec­ tomy, this rate of infection has dropped dramatically. Hematoma Appendiceal stump leak/blowout Port site hernia

SUGGESTED READINGS Addiss D, Shaffer N, Fowler B, et al. The epidemiology of appendi­ citis and appendectomy in the United States. Am J Epidemiol. 1 990; 1 3 2 ( 5 ) : 9 1 0-925. 2. Humes DJ, Simpson J. Acute appendicitis. BMJ. 2006;3 3 3 : 530-534. 3 . Fajardo, R. Guia para el manejo de apendicitis aguda en adultos. Colombia: Ministerio de Ia Proteccion Social; 2005.

4.

5. 6. 7.

8.

1.

9.

97 5

Grunewald B, Keating J . Should the 'normal' appendix be removed at operation for appendiciti s ? J R Coli Surg Edinb. 1 99 3 ; 3 8 : 1 5 8- 1 6 0 . Patino JF. Apendicitis aguda. E n : Patino JF, e d . Lecciones d e Cirugia. Bogota, Buenos Aires: Editorial Medica Paname-ricana; 200 1 . Temple CL, Huchcroft SA. The natural history o f appendicitis in adults: a prospective study. Ann Surg. 1 995;22 1 :278-2 8 1 . Vargas Dominguez A , Ortega Leon LH, Miranda Fraga P. Sensibilidad, especificidad y valores predictivos de Ia cuenta leucocitaria en apendi­ citis. Ciruj General (Mexico). 1 994; 1 6 : 1-7. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005;242:439-449 . SAGES guidelines for laparoscopic appendectomy 2009. SAGES Society of American Gastrointestinal and Endoscopic Surgeons Web site. http:// www. sages. org/publications/guidelines/guidelines-for-laparoscopic­ appendecromy/. Accessed January 2012.

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Chapter

8

Appendectomy: Single- Incision Laparoscopic Surgery Technique �

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Reshma Brahmbhatt

DEFINITION •

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Single-incision laparoscopic surgery (SILS ) appendectomy is defined as laparoscopic removal of the appendix using a single skin incision. The entire procedure, including an intracorpo­ real appendectomy, is performed laparoscopically. This is in contrast to other methods of single-incision appendectomy, which use a single port/incision for dissection but then pro­ ceed to pull the appendix out of the incision and essentially perform an open appendectomy. The addition of an additional port distant from the single incision (usually the suprapubic region) is called a SILS plus one (SILS + 1 ) appendectomy.

DIFFERENTIAL DIAGNOSIS •

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The differential diagnosis for acute appendicitis in the healthy adult patient includes gastroenteritis, colitis, cystitis/ pyelonephritis, inflammatory bowel disease, and diverticulitis. Female patients have an expanded differential diagnosis, which can include pelvic inflammatory disease, ovarian pathology, ectopic pregnancy, endometriosis, and mittelschmerz. Pediatric patients can have acute mesenteric adenitis, espe­ cially following an upper respiratory tract illness, that can mimic acute appendicitis. Immunosuppressed patients may have opportunistic infec­ tions that present in a similar fashion to acute appendicitis, and consideration should be given to a full infectious workup.

PATIENT HISTORY AND PHYSICAL FINDINGS •

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For patients to undergo SILS appendectomy, they must be candi­ dates for traditional laparoscopic appendectomy. Patients with previous midline abdominal surgery or large ventral hernias may present a relative contraindication to SILS appendectomy due to adhesions and potential difficulty with abdominal entry. A thorough history and physical examination is necessary to carefully select patients for SILS appendectomy. Pediat­ ric, elderly, and pregnant patients are appropriate for SILS appendectomy. 1 Absolute and relative contraindications to SILS appendectomy are listed in Table 1 .

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to Single- I n c i s i on Laparoscopi c Surgery

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Appendectomy Absol ute contra i n d ications

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Re lative contra i n d ications

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H e m odyn a m i c i n stabil ity I n a b i l ity to u n d ergo gen eral a n esthesia I n a b i l ity to to l e rate a b d o m i n a l i n suffl ation Genera lized peritonitis H i story of m i d l i n e l a p a rotomy or u m b i l ical hernia rep a i r with prosthetic material Large m i d l i n e ventral hernia Surgeon i nexperienced with s i n g le-incision l a p a roscopic proced ures

Mike K. Liang

A thorough history should be performed, including location and duration of symptoms, previous history of similar epi­ sodes, and detailed past medical and surgical history. A short (1 to 2 days) history of nausea/vomiting, anorexia, fevers, and periumbilical or right lower quadrant pain in a previ­ ously healthy patient is suspicious for acute appendicitis. A longer ( 5 to 7 days ) history of nausea/vomiting, malaise, fevers, and right lower quadrant pain may be consistent with perforated appendicitis and abscess formation. A complete physical examination should be performed. Par­ ticular attention should be paid to the patient's vital signs and abdominal examination. The patient will often be ill ap­ pearing and prefer to lie stilL Classic abdominal findings of appendicitis include tenderness in the right lower quadrant with localized guarding and rebound. The abdomen is often soft with minimal to no distention. Female patients of childbearing age should undergo a bi­ manual vaginal examination to evaluate for gynecologic conditions, such as pelvic inflammatory disease or adnexal abnormalities, which may mimic appendicitis. Atypical presentations of acute appendicitis can include su­ prapubic pain, right flank pain, and right upper quadrant pain, depending on where the appendix may be located. Anatomic variations may cause pain in the right flank (retrocecal appendix) or even the absence of abdominal pain (pelvic-lying appendix ) . Right-sided pain on rectal examina­ tion may point toward an appendix hanging in the pelvis. It is also important to note that with very early appendicitis, the patient will often have mild (or even absent) signs and symptoms. These clinical variations should be kept in mind while evaluating the patient for acute appendicitis.

IMAGING AND OTHER DIAGNOSTIC STUDIES

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Table 1: Absolute and Relative Contra i n d i cati ons

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Standard laboratory studies ordered in the evaluation of acute appendicitis include a complete blood count, basic metabolic panel or electrolytes, and urinalysis and urine pregnancy test. An elevated white blood cell count suggests an inflammatory response such as appendicitis. Electrolyte derangements due to dehydration or vomiting should be corrected prior to surgical management. A urinalysis may show a urinary tract infection or cystitis to be the source of the patient's symptoms rather than ap­ pendicitis; however, identifying leukocytes in the urine is not uncommon with acute appendicitis. A positive urine pregnancy test should prompt further evaluation of another diagnosis ( such as ruptured ectopic pregnancy) and will affect the medications and anesthesia used during the procedure. Clinical scoring systems, such as the Alvarado score or the appendicitis inflammatory response score use various labo­ ratory and clinical findings to assess a patient's likelihood of having acute appendicitis. 2-3

C h a p t e r 8 APPE N D ECTO MY: Sing le-Incision Laparoscopic Surgery Technique

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Computed tomography ( CT) is the most ordered radio­ logic study in the evaluation of acute appendicitis. The scan should be ordered as a CT abdomen/pelvis with intravenous (IV) and oral or rectal contrast. CT findings consistent with appendicitis include appen­ diceal dilation, failure of appendiceal opacification with oral or rectal contrast, presence of a fecalith, periappen­ diceal fat stranding and enhancement, and pelvic free fluid. CT is excellent in visualizing perforated appen­ dicitis with an abscess and should be considered in any patient where the diagnosis of complicated appendicitis is entertaine d . Additionally, CT can provide information on other intraabdominal and pelvic structures/pathology ( FIG 1 ) . Transabdominal ultrasonography can b e used to evaluate for appendicitis as a nonradiating alternative to CT scans. Findings consistent with appendicitis include a thickened appendiceal wall, appendiceal dilation, identification of a

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97 7

fecalith, periappendiceal fluid, and a " target sign . " Limita­ tions to ultrasonography include operator dependence and difficulty in appendiceal visualization in patients with higher body mass index (BMI) ( FIG 2 ) . Ultrasonography is most often used in children and pregnant patients. Focused magnetic resonance imaging (MRI) has been used in specific cases as an alternative to CT scan and ultrasound. Pregnant women and children may benefit from this nonradiating imaging modality, but MRI may not be as readily available as ultrasound and CT scan in all centers. The need for MRI should be evaluated on a case­ by-case basis. Women of childbearing age may require evaluation of their ad­ nexal structures via CT scan or transvaginaVtransabdominal ultrasonography to rule out differential diagnoses. In adult male patients with a classic presentation of appendi­ citis, radiologic studies are not necessarily indicated and are used only at the discretion of the surgeon.

FIG 1 • CT sca n d e m on strat i n g acute a p p e n d i citis. The a p p e n d ix is d i lated, t h i c k-wa l l ed, a n d e n h a nces with IV contra st (arrow), suggesti n g i n f l a m m a t i o n . There is a lso stra n d i ng/th icke n i n g a r o u n d the adjacent ceca l wa l l .

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Anesthesiolog ist

Assistant

FIG 2 • U ltraso u n d exa m i n ation d e m o nstrating acute a p p e n d i citis. The a p p e n d i x is noncom press i b l e and conta i n s a visi b l e feca l ith (arrow).

Monitor Surgeon

SURGICAL MANAGEMENT Preoperative Planning •

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Preoperative antibiotics, with gram-negative and anaerobic coverage, should be administered before the incision is made. A Foley catheter should be placed to ensure bladder decompression. Patients with large midline laparotomy scars or periumbilical hernia repairs may have significant adhesions or prosthetic material at the level of the umbilicus, making safe abdominal entry potentially difficult. The surgeon should use his or her discretion at proceeding with a SILS appendectomy in these particular patients and should have a low threshold for add­ ing additional ports ( SILS + 1 appendectomy) for improved exposure and visualization.

N u rse

FIG 3 • Patient, tea m, a n d operat i n g room set u p . The surgical tea m sta n d s at the patie nt's l eft side. The patient i s positioned in a supine position, with the l eft arm tucked to provide a d e q u ate space for the s u rgeon a n d assista nt. The l a p a rosco p i c m o n itor s h o u l d be positioned at the right side of the patient.

Positioning •

SILS appendectomy is performed from the left side of the patient, similar to traditional laparoscopic appendectomy. The patient should be positioned in a supine position, with the left arm tucked to provide adequate space for the sur­ geon and the assistant ( FIG 3 ) .

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The patient's abdomen should b e prepped and draped from the xiphoid to the pubis, allowing for possible conversion to a traditional laparoscopic or open appendectomy if indicated. The laparoscopic monitors should be positioned at the right side of the patient or at foot of the operating table ( FIG 3 ) .

SKI N I N C I S I O N AND PORT PLACEMENT •

A 1 2- to 20-m m incision s h o u l d be made adjacent to or through the u m b i l icus, with consideration for the poten­ tial need to exten d the incision if conversion to a n open a p pendectomy is needed (FIG 4). I n patients with previ­ ous peri u m b i l ica l or m i d l i n e l a pa rotomy sca rs, the surgeon should consider a lternative methods of abdom i n a l entry

• P l acement of the i n c i s i o n . A 1 2- to 20-mm i ncision should be m a d e adjacent to o r t h r o u g h the u m b i l icus, with consideration fo r the potential need to extend the i n cision if conversion to a n open a p p e n d ecto my is needed.

FIG 4

C h a p t e r 8 APPE N D ECTO MY: Sing le-Incision Laparoscopic Surgery Technique

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(Veress need le i nsufflation through the left u pper quad­ ra nt, trocar i n sertion i n left upper q u a d ra nt, etc.) o r a lter­ nate p l acement of the S I LS port (su p ra u m b i l ical, left latera l abdomen). Alth o u g h these methods may res u lt in a S I LS + 1 appendectomy or in a more cha l l e n g i n g closure of the i n cision, they may a l l ow safer entry i nto the peritoneal cavity. The u m b i l i ca l s k i n i n c i s i o n s h o u l d be taken down t h r o u g h the su bcuta neous tissues. The m i d l i n e fascia c l ose to the u m b i l i cus ( u m b i l ical sta l k) should be i n cised i n a l o n g itu­ d i n a l m a n n e r. O n ce safe access i nto the perito n e a l cavity is confirmed, the port s h o u l d be p l aced through the i n cision fo l l ow i n g the port m a n ufactu re r's i n struct i o n s . There a re m a n y types of S I LS ports cu rrently ava i l a b l e; t h e type of S I LS port used is l eft to the d i scret i o n of the s u rgeon (FIG S). An a ltern ative to the p l acement of a S I LS port is to i nsert m u lt i p l e sta n d a rd po rts t h ro u g h a single skin incision. Prior to port p l acement, a s u r g i c a l sponge may be i ntro­ d u ced i nto the a b d o m i n a l cavity to fac i l itate retract i o n l ater i n the proced u re . Port p l acement v a r i e s d e pe n d i n g o n the s i n g le-port de­ vice used . O n ce the port is p l aced, p n e u mope rito n e u m is created a n d the l a p a rosco pic c a m e ra a n d i n st r u m e nts a re i ntroduced. It is advisa b l e to tria n g u late the ports to m i n i m ize i nstr u m e n t confl i ct.

FIG 5 •

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S I LS port p l a ced via u m b i l ica l incision.

A 30-deg ree c a m e ra a n d t ra d i t i o n a l stra i g h t l a p a roscop i c i nstr u m e nts a re u s e d . Alternative ly, a rti c u l ated i nstru­ me nts may be e m p l oyed. In order to affo rd maxi m a l operative reach and to avo i d i ntern a l a n d exter n a l i n strument confl i ct, bariatric a n d sta n d a rd l e n gt h i n stru m e nts may be used s i m u lta­ neously. M o reover, a rig ht-a n g l e l i g ht cord a d a ptor may be used to f u rther decrease confl ict. The patient i s p l a ced in a Tre n d e l e n b u rg position with the l eft s i d e down to h e l p m ove the sma l l bowe l i nto the l eft u p p e r q u a d ra nt, e n h a n c i n g exposure of the cecu m a n d the a p p e n d ix.

APPE N D I CEAL I D E NTIFICATI O N •

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The r i g h t l ower q u a d ra n t s h o u l d be exa m i ned c l osely (FIG 6) . S i g n ificant f l u i d o r a bscess co l l ecti o n s s h o u l d be ca refu l l y a s p i rated to a l l ow for visu a l ization of t h e right l ower q u a d ra nt . The p resence of s i g n ificant a d hesions may req u i re a d d i ­ t i o n a l port p l acement o r convers i o n to tra d i t i o n a l l a p a ­ rosco p i c a p p e n d ectomy (or open p roced u re) to a l low for a p p ro p r i ate visua l i zation a n d/o r a d h e s i o lysis. The a p pe n d icea l base s h o u l d be i d e ntified u s i n g the con­ vergence of the teniae co l i at the base of the cec u m as a l a n d m a rk. The s u rgeo n 's r i g h t- h a n d i n strument s h o u l d g rasp a n d e l evate the a p p e n d ix. The l eft- h a n d i n strument s h o u l d b l u ntly d i ssect a n y a d hesions, a l l ow i n g f o r fu l l visua l i za­ t i o n of the a p p e n d ix, from t i p to base. If the a p p e n d ix a p pe a rs to be co m p l etely n o r m a l , the right lower q u a d ra n t should be closely i nvest i g ated for other potential sou rces of the patie nt's sym ptoms. Any d i a g nosis other than a p p e n d icitis s h o u l d p r o m pt a p p rop r i ate m a nagement b y the s u rgeon a n d may req u i re convers i o n to a tra d i t i o n a l l a p a rosco pic o r open p roced u re . Appendectomy may be performed at the s a m e t i m e, a s per the s u rgeon's d iscret i o n .

• Exa m i n ation of right lower q u a d ra n t showi n g i nflamed a p p e n d ix.

FIG 6

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APPE N D I CEAL CRITICAL VI EW4 •

The appendix should be retracted to the 1 0 o'clock posi­ tion, the term i n a l i l e u m should be placed i n the 6 o'clock position, and the taen i a I i bera (anterior band of the ten iae co li) should be positioned i n the 3 o'clock position (FIG 7). This a l l ows for clear identification of the append icea l base and associated a n atomy prior to append icea l tra nsection.

•

If the critica l view ca n n ot be o bta i ned, or the a p p e n d i ­ cea l b a s e is n ot easily i d e ntified, a s u p r a p u b i c port can be p l aced to a l low for f u rther d i ssectio n/retraction (SILS + 1 a p p e n d ecto my) . If the a n atomy sti l l rem a i n s u nc l e a r, the proced u re ca n be converted to a traditi o n a l l a p a rosco p i c a p p e n d ecto my o r to a n open a p p e n d ectomy, a s per the su rgeon's d i screti o n .

Appendix

A FIG 7

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Taenia Ii bera

B A. The a p pend icea l critica l view. The a p p e n d ix is retracted to the 1 0 o'clock position, the term i n a l i l e u m is p l aced

i n the 6 o'clock position, and the t a e n i a I i bera (anterior band of the teniae coli) i s positioned i n the 3 o'clock posit i o n . The term i n a l i l e u m can be i d e ntified by the fo l d of Treves (fatty fo l d i n the a nti mesente ric border of the term i n a l i l e u m), a l so known as the " sa i l sig n . " B. I l l ustrat ion of t h i s ste p .

APPE N D I CEAL TRAN SECTI ON •

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Once the a p pendiceal base is i d e ntified, the s u rgeon's l eft- h a n d i nstr u m e n t m a kes a w i n d ow betwee n the a p p e n d icea l base a n d the cecu m . The append icea l base is then tra nsected using a linear vascu­ lar load endoscopic sta pler i n the surgeon's left hand (FIG 8).

A FIG 8

•

B A. Appendiceal base transect i o n by an e n d oscopic sta p l e r. B. I l l u stration of t h i s ste p .

C h a p t e r 8 APPE N D ECTO MY: Sing le-Incision Laparoscopic Surgery Technique

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The a p pendiceal m esentery is s i m i l a rly transected u s i n g a l i ne a r vasc u l a r load e n d osco pic sta p l e r. Altern ative ly, s i m i l a r to traditi o n a l l a p a rosco p i c a p p e n ­ d ectomy, e n e rgy devices a n d e n d o l oops may be u s e d as per the su rgeon's d i screti o n .

•

The a p p e n d i x is then p l aced in a retrieva l bag, if desi red, and rem oved via the port site. The spec i m e n s h o u l d be sent for path o l o g i c eva l u ation and assessment. A p ro­ portion of a p p e n d ecto m i es (up to 1 % ) h ave associated t u m o rs o r m a l i g n a ncies.

PORT S ITE CLOSURE •

Once the a p p e n d ix h a s been removed from the a b d o m i ­ n a l cavity, operative field i s exa m i n ed for h e m ostasis. M i n o r b l eed i n g from the mesenteric sta p l e line can be contro l led with e l ectroca utery. The a p p e n d iceal stu m p s h o u l d be exa m i ned t o e n s u re a co m p l ete sta p l e l i ne (FIG 9) . Any b l ood or p u r u l e nt mate r i a l s h o u l d be aspi­ rated out of t h e a b d o m i n a l cavity. D r a i n s should not be p l aced u n d e r rout i n e circumst a n ces.

• The fasc i a l d efect is cl osed with i nterru pted a bsorba b l e f i g u re-of-e i g h t sutu res.

FIG 10

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A •

A n y a d d i t i o n a l p o rts a re rem oved u n d e r d i rect v i s u ­ a l i z a t i o n a n d t h e a b d o m e n i s d e s u fflated . T h e S I LS p o rt is rem oved accord i n g to t h e p o rt m a n ufact u r e r's i n st r u ct i o n s . The fasc i a l defect is cl osed with i nterrupted a bsorba b l e figu re-of-eight sutu res (FIG 1 0). The s u bcuta neous tissues a re i rrigated and the skin is closed with a su bcuticu l a r stitch (FIG 1 1 ) . If the i n cision was m a d e t h r o u g h the u m b i l icus, ca re s h o u l d be taken to sew the u m b i l i cus d own to the fascia and to rea p p roxi m ate the u m b i l ical skin we l l to a l low for an aesthetica l ly p l e a s i n g c l o s u re and to p revent seroma formati o n .

B FIG 9 • A. After tra nsection, the operative field is i n spected to e n s u re a d e q u ate h e m ostasis and an i ntact a p p e n d icea l stu m p sta p l e l i n e . B. I l l ustration of t h i s ste p .

• T h e s u bcuta neous tissues a re i rrigated a n d the s k i n is cl osed with a su bcuticu l a r stitch .

FIG 11

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

PEARLS AND PITFALLS I n d i cations

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A co m p l ete h i story a n d phys i ca l exa m i nation a n d review of ava i l a b l e i m a g i n g s h o u l d t a k e p l a ce to confi rm the d i a g nosis o f a p p e n d icitis a n d to assure the patient is a su ita b l e c a n d id ate for S I LS a p p e n d ectomy.

Abdom i n a l e ntry

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If a safe peri u m b i l ica l entry is q u esti o n a b le, a ltern ate port site p l acement, or additional ports, may be p l a ced to assist i n S I LS port p l acement.

Critica l view

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The a p p e n d i x s h o u l d be retracted to the 1 0 o'clock position, the term i n a l i l e u m s h o u l d be p l a ced i n the 6 o'clock position, a n d the ta e n i a I i bera (anterior b a n d of t h e teniae c o l i ) s h o u l d be positioned i n the 3 o'clock posi t i o n . Co m p l ete visu a l i zation of the a p p e n d i ce a l b a s e is m a n d atory prior to transect i o n . If t h i s i s n ot poss i b le, convers i o n to a S I LS + 1 or to a tra d i t i o n a l l a p a rosco p i c a p p e n d ecto my may be req u i re d .

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C l o s u re

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If the i n c i s i o n was tra n s u m b i l i ca l , the u m b i l i cus s h o u l d be tacked back down to the fasc i a .

POSTOPERATIVE CARE •

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Patients with simple or uncomplicated appendicitis are usu­ ally discharged home after a 23-hour observation period, during which the patient is confirmed to tolerate oral intake and to have appropriate pain control.5•6 Recent studies advocate for same-day discharge for this pa­ tient population; discharge timing remains up to the discre­ tion of the surgeon. Patients with perforated or complicated appendicitis are generally admitted for IV antibiotics for 3 to 7 days or until they are afebrile and with a normal white blood cell count. Antibiotics are usually targeted toward gram-negative and anaerobic organisms. As with patients with simple appendicitis, discharge criteria include ability to tolerate oral intake and appropriate pain control. If patients continue to have abdominal pain, develop leu­ kocytosis, or become febrile after undergoing appendec­ tomy for perforated or complicated appendicitis, their symptoms may be signs of an intraabdominal abscess. Image-guided percutaneous drainage is usually needed for resolution. Pathology results should be concordant with the diagno­ sis of acute appendicitis. A negative appendectomy should prompt further workup as required. A pathologic diagnosis of appendiceal tumor or malignancy is present in 1 % of specimens removed for acute appendicitis.

OUTCOMES •

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Although long-term studies evaluating SILS appendectomy are not currently available due to the new nature of the approach, reviews and pooled analyses show no difference in complications and outcomes compared to traditional laparoscopic appendectomy_?-1 1 A recent prospective randomized controlled trial compar­ ing SILS appendectomy to traditional laparoscopic appen­ dectomy showed no difference in complications, outcomes, or cosmetic and pain results between the two approaches (follow-up of 14 days ) Y

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Further research, ideally as prospective randomized trials, will allow a better comparison of outcomes to traditional laparoscopic appendectomy. Although recent studies on SILS procedures show a possible increase in incisional hernias after the SILS procedure, cur­ rently available studies show no significant benefit or draw­ back for the SILS technique for appendectomyY· 1 4

COMPLICATIONS • • • • • •

Surgical site infection: superficial, deep, organ/space Hematoma Stump appendicitis/incomplete appendectomy Appendiceal stump leak/blowout Port site hernia Ileus and small bowel obstruction

REFERENCES 1 . Koh AR, Lee JH, Choi ]S, et al. Single-port laparoscopic appen­ dectomy during pregnancy. Surg Laparosc Endosc Percutan Tech. 2 0 1 2;22 ( 2 ) : e 8 3-e8 6 . 2 . Alvarado A. A practical score for the early diagnosis o f acute appendi­ citis. Ann Emerg Med. 1 9 8 6 ; 1 5 ( 5 ) : 5 5 7-564. 3 . Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg. 2008;32 ( 8 ) : 1 843-1 849. 4. Subramanian A, Liang MK. A 60-year literature review of stump appendicitis: the need for a critical view. Am J Surg. 2 0 1 2;203 (4): 503-507. 5 . Alkhoury F, Malvezzi L, Knight CG, et al. Routine same-day discharge after acute or interval appendectomy in children: a prospective study. Arch Surg. 2012;147(5) :443-446. 6. Dubois L, Vogt KN, Davies W, et al. Impact of an outpatient appen­ dectomy protocol on clinical outcomes and cost: a case-control study. JAm Coli Surg. 2 0 1 0 ;2 1 1 ( 6 ) : 73 1-737. 7. Rehman H, Rao AM, Ahmed I. Single incision versus conventional multi-incision appendicectomy for suspected appendicitis. Cochrane Database Syst Rev. 2 0 1 1 ; ( 7 ) : CD009022. 8 . St Peter SD, Adibe 00, Juang D, et al. Single incision versus standard 3 -port laparoscopic appendectomy: a prospective randomized trial. Ann Surg. 2 0 1 1 ;254(4 ) : 5 8 6-590.

C h a p t e r 8 APPE N D ECTO MY: Sing le-Incision Laparoscopic Surgery Technique

9. Gill RS, Shi X, Al-Adra DP, et al. Single-incision appendectomy is comparable to conventional laparoscopic appendectomy: a systematic review and pooled analysis. Surg Laparosc Endosc Percutan Tech. 2 0 12;22(4) : 3 1 9-32 7. 10. Rehman H, Mathews T, Ahmed I. A review of minimally invasive single-port/incision laparoscopic appendectomy. j Laparoendosc Adv Surg Tech A. 2 0 1 2;22 ( 7 ) : 64 1-646. 1 1 . Rehman H, Ahmed I. Technical approaches to single port/incision laparoscopic appendicectomy: a literature review. Ann R Colt Surg Engl. 20 1 1 ;93(7):508-5 1 3 .

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1 2 . Lee WS, Choi ST, Lee JN, e t al. Single-port laparoscopic appendec­ tomy versus conventional laparoscopic appendectomy: a prospective randomized controlled study. Ann Surg. 2 0 1 3 ;257(2) : 2 1 4-2 1 8 . 1 3 . Markar SR, Karthikesalingam A , Thrumurthy S , e t al. Single­ incision laparoscopic surgery (SILS) vs. conventional multiport cho­ lecystectomy: systematic review and meta-analysis. Surg Endosc. 2 0 12;26 ( 5 ) : 1 205-1 2 1 3 . 14. Van den Boezem P B , Siestes C. Single-incision laparoscopic colorec­ tal surgery, experience with 50 consecutive cases. J Gastrointest Surg. 2 0 1 1 ; 1 5 ( 1 1 ) : 1 9 89-1994.

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Chapter

9

Rig ht Hemicolectomy: Open Technique I

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�

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t

Soma/a Mohammed

DEFINITION •

Right hemicolectomy refers to the removal of the cecum, the ascending colon, the hepatic flexure, the proximal portion of the transverse colon, and part of the terminal ileum ( FIG 1 ) . I t i s the standard surgical treatment for malignant neoplasms of the right colon and involves ligation of the ileocolic, right colic, and right branch of the middle colic vessels.

DIFFERENTIAL DIAGNOSIS •

Various benign and malignant conditions require right hemi­ colectomy. The most common indication is a mass in the right colon. Other indications include neoplasms of the cecum or appendix. Benign conditions for which right hemicolectomy is performed include adenomatous polyps that cannot be removed endoscopically, cecal volvulus, inflammatory bowel disease, and right-sided diverticulitis, among others.

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A thorough history and physical examination is mandatory. Findings such as ascites or diffuse adenopathy may result in additional diagnostic workup to rule out metastatic

Extended

FIG 1 • Vasc u l a r a n atomy of a r i g h t h e m i c o l ectomy. (Pri nted with permission from Baylor College of M e d i c i ne.)

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Eric J. Silberfein

disease and this may alter the overall care plan for the patient. A baseline nutritional and functional status should also be ascertained in the preoperative setting. Previous abdominal surgeries should be noted. A thorough family history, including history of colonic polyps and cancers, should be obtained.

IMAGING AND OTHER DIAGNOSTIC STUDIES

PATIENT HISTORY AND PHYSICAL FINDINGS •

Kathleen R. Liscum

•

A full colonoscopy should be obtained to examine the re­ mainder of the colon, which has up to a 5% chance of syn­ chronous disease. Colonoscopy can also allow for India ink tattooing of the lesion to facilitate accurate intraoperative localization ( FIG 2 ) . Preoperative imaging also includes high-quality dual phase computed tomography ( CT) imaging of the abdomen and pelvis to not only assess for metastatic disease but also to evaluate the primary tumor's relationship to nearby struc­ tures such as the kidney, ureter, duodenum, and nearby ves­ sels such as the vena cava, superior mesenteric vessels, and middle colic vessels. Tumors that involve adj acent organs require additional preoperative planning and consultation with ancillary services may be necessary. Attempts at en bloc resection should be made in cases where the tumor involves adj acent organs or structures. Additional workup includes a CT of the chest, complete blood cell count, and comprehensive metabolic paneL A baseline carcinoembryonic antigen ( CEA) level should be obtained to assist with postoperative surveillance for recurrence. Positron emission tomography (PET)-CT is not routinely indicated.

FIG 2

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Tattooed lesion i n the cec u m .

C h a p t e r 9 R I G H T H E M ICO LECTOMY: Open Technique

SURGICAL MANAGEMENT Preoperative Planning •

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Preoperative bowel preparation is not mandatory but it may make manipulation of the colon more manageable. If intra­ operative colonoscopy is required, a prepped colon would also be preferred. Preoperative antibiotic prophylaxis for skin and bowel flora is recommended. Intravenous broad-spectrum antibiotics that contain second- or third-generation cephalosporins (such as cefoxitin or ceftriaxone) or fluoroquinolones (such as ciprofloxacin) along with metronidazole will adequately cover gram-negative and anaerobic pathogens. Alternatively, ertapenem, a carbapenem with activity against gram-positive, gram-negative, and anaerobic flora, can be used. Prophylac­ tic antibiotics should be at therapeutic bloodstream levels at the time of incision. Redosing the antibiotic should be considered when taking into account the length of the op­ eration, the estimated blood loss, and the half-life of the antibiotic. Venous thromboembolic prophylaxis for patients undergoing right hemicolectomy includes both mechanical interventions,

ANESTH ESIA AND PAT I E NT POSITI O N I N G

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G e n e ra l e n d otrach e a l a n esth esia is p refe rred for r i g h t h e m i c o l ectomy. H owever, s p i n a l a n esthesia a l o n e is fea­ s i b l e if necessa ry. The patient is p l aced s u p i n e with or without the a r m s tucked.

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such as pneumatic compression devices, and pharmacologic interventions, such as low-molecular-weight heparin or un­ fractionated heparin. These agents should be delivered prior to induction of anesthesia as the dramatically decreased level of vascular tone associated with anesthesia results in venous stasis and risks thrombosis. Patients on preoperative warfa­ rin should be transitioned to either low-molecular-weight or unfractionated heparin. Preoperative thoracic epidural placement for postoperative pain control should be offered to patients without contra­ indications to this form of analgesia. Epidural pain control reduces narcotic requirements postoperatively and decreases risk of postoperative ileus and pulmonary complications. Otherwise, patient-controlled analgesia is preferred. Intrave­ nous nonsteroidal antiinflammatory drugs (NSAIDs) should also be considered in the perioperative period to decrease the use and side effects of narcotic analgesia. Ancillary surgical services may be required to assist in the patient's care for procedures such as preoperative placement of ureteral stents or assistance in resection or reconstruction of involved adj acent organs, such as the kidneys, ureters, or the duodenum.

After i n d uction of a n esthesia, the b l a d d e r is cathete rized and a n orogastric tube is p l aced . The entire a b d o m e n is prepped a n d d raped . The s u rgeon sta n d s on the patient's rig ht a n d the fi rst assista nt on the l eft.

I N CISION • •

R I G HT COLON MOBI LIZATI O N •

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to the i l eoceca l valve. The colon a n d rect u m s h o u l d be i n s pected and p a l pated . The o m e n t u m and perito n e u m s h o u l d be eva l u ated f o r t u m o r i m p l a nts o r carci n o m ato­ sis. In wo men, the ova ries s h o u l d a l so be i n spected for a b n o r m a l ities.

A m i d l i n e l a p a rotomy is m a d e . U po n enteri n g the a b d o m i n a l cavity, i n spect for evidence of m etastatic d isease. The l iver s h o u l d be p a l pated for masses and b i o psied as needed, and the sma l l bowel evisce rated and i n s pected from the l i g a m ent of Tre itz

Placement of self-reta i n i n g retracto rs, such as a B a lfour, may be used to i m p rove expos ure. Otherwise, the ab­ d o m i n a l wa l l is retracted with h a n d h e l d i n st r u m e nts. The cecu m and asce n d i n g colon a re freed from the perito n e a l reflection by i n c i s i n g a l o n g the wh ite l i n e of To ldt (FIG 3) . The term i n a l i l e u m is a l so freed from the retroperito n e u m a n d m o b i l ized by incising the perito­ neum a l o n g the root of the mesentery. As the colon a n d term i n a l i le u m a re refl ected anteriorly a n d m ed i a l ly, the r i g ht gonadal vesse l s a n d r i g h t u reter s h o u l d be i d e ntified in the retroperito n e u m and not m o b i l i zed a nteriorly so as to avo i d i n j u ry.

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98 5

The l atera l d i ssect i o n is carried s h a rply up and a r o u n d the h e p a t i c flexure i n the avasc u l a r, e m b ryo l o g i c p l a n e betwee n the mesoco l o n a n d the d u o d e n u m . The seco n d a n d t h i rd port i o n s o f the d u o d e n u m a re i d e ntified n e a r the hepatic flexure a n d i nj u ry to t h i s struct u re m ust b e avo i d e d . The h epatoco l i c l i g a ment is transected (FIG 4) . The gastroco l i c l i g a m e nt, exte n d i n g from t h e g reater c u rvatu re of the sto mach to the transverse colon, is d ivided from l eft to right to co m p l ete the m o b i l i zation of the hepatic fl exu re (FIG 5) .

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

Right colon

Right colon

Right paracolic gutter

FIG 3

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Asce n d i n g colon m o b i l izat i o n . The s u rgeon retracts the ascen d i n g co l o n m ed i a l ly. D i ssection proceeds a l o n g the r i g ht p a raco l i c g utter by tra n sact i n g the wh ite line of To ldt.

Hepatocolic ligament • H e patic fl exu re m o b i l izati o n . Gentle traction o n the hepatic flexure of the colon exposes t h e h e patoco l i c l i g a m ent, which i s then tra nsected with e l ectrocautery.

FIG 4

FIG 5 • F u l ly m o b i l ized term i n a l i l e u m a n d r i g ht co l o n . The tattooed a rea can be s e e n o n the su rface o f the cecu m .

VASCULAR PEDICLE TRANSECTION

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For a right h e m icol ectomy, the vasc u l a r a rcades of i nter­ est i n c l u d e the i l eocol ic, the right co l i c, and the right branch of the middle co l i c vesse l s . An avasc u l a r w i n d ow betwee n the right branch of the m i d d l e co l i c a n d the right or i l eoco l i c vesse l a rcade is m a d e (FIG 6) . The right branch of the m i d d l e co l i c is d o u b ly c l a m ped, d ivided, and tied w h i l e the l eft branch i s spa red . The rig ht co l i c a rcade, if prese nt, is a lso taken at its orig i n to e n s u re a d e q u ate resect i o n o f lym p h atics. T h i s a rcade, h owever, rarely branches d i rectly off the s u perior mes­ enteric vessels. It is m ost often a branch of the i l eoco l i c a rca d e .

The i l eoco l i c a rcade i s therefore l i g ated a t its o r i g i n i n the majo rity of ci rcu m st a n ces (FIG 7). The lym p h atic drainage patte rn m i rro rs that of the vas­ c u l a r syste m . There a re two possi b l e paths of lym p h atic sprea d : parai ntesti n a l (a l o n g the i ntest i n e) a n d centra l (a l o n g the vesse ls). To red uce the risk of recu rrence, a n adeq u ate lym p h node h a rvest s h o u l d be attem pted by l i gating the req u i red mesenteric vesse l s at t h e i r orig i n . A m i n i m u m of 1 2 resected nodes is req u i red for American J o i nt C o m m ittee o n Cancer for a d e q u ate sta g i n g of colorecta l can cer. I ntra m u ra l sprea d i n g of ca ncer beyo n d 2 em i s ra re, but a n oncologic resection s h o u l d a i m for proxi m a l and d i st a l m ucos a l m a r g i n s of at least 5 to 7 em to e n s u re a d e q u ate h a rvest of para i ntest i n a l and mesen­ teric nodes.

C h a p t e r 9 R I G H T H E M ICO LECTOMY: Open Technique

• Avasc u l a r w i n d ow adjacent to r i g h t b r a n c h o f t h e m i d d l e co l i c vesse ls (arrow).

FIG 6

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An exte nded r i g h t h e m i c o l ectomy may be perfo rmed for lesions l ocated at the hepatic fl exu re or tra nsverse co l o n . T h i s p roced u re i nvolves tra n sect i o n o f the m i d d l e co l i c vesse l s a t t h e i r o r i g i n a n d a n a n asto mosis o f t h e d ista l i l e u m with the d i sta l transverse co l o n , relyi n g on the m a rg i n a rtery of Drummond for blood s u p p ly. If the in­ teg rity of t h i s blood vessel i s q u estio n a b l e, the resect i o n m u st be exte nded to i n c l u d e the s p l e n i c flexure a n d the d ista l ileum is a n a stomosed to the desce n d i n g co l o n .

•

For an exte n d ed r i g ht h e m icol ecto my, m o b i l ization of the s p l e n i c fl exu re is req u i re d . In order to m o b i l ize the splenic fl exu re, the s p l enocol i c, p h renoco l i c, a n d g a stro­ co l i c l i g a me nts m u st be d ivided (FIG 8) . The s p l e n i c fl ex­ u re is then ca refu l ly d i ssected of the ta i l of the pancreas. Ca re m u st be taken to avo i d i n j u ry to the spleen a n d the asce n d i n g branch of the l eft co l i c a rte ry.

• Tra nsect i o n of the i l eoco l i c ped i c l e . The i l eoco l i c vesse l s a re transected at t h e i r orig i n of the superior m esenteric vesse ls. SMA, superior mesenteric a rte ry.

FIG 7

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

• S p l e n i c flexure m o b i l ization (for exte nded r i g ht h e m i c o l ecto m i es). After med i a l a n d l atera l m o b i l ization of t h e splenic flexure atta c h m e nts, the s u rgeon hooks his or h e r right i n d ex f i n g e r under the s p l e n o c o l i c l i g a m ent, provi d i n g good exposu re and a l lowi n g for a safe transection of t h i s l i g a ment.

FIG 8

Left colon

S plenocolic ligament

BOWE L TRANSECTI ON •

The colon is c l e a red of e p i p l o i c fat at t h e pro posed site of a n asto mosis to a l l ow the bowe l wa l l to be visu a l ­ ized, thereby fac i l itat i n g precise p l acement o f sutu res or sta p l e rs. The tra n sverse co l o n is then tran sected to the right of the m i d d l e co l i c vesse l s with a l i ne a r 7 5 - m m b l u e load sta p l e r (FIG 9) .

• C o l o n tra n sect i o n . The c o l o n i s d ivided to the right s i d e of the middle co l i c vesse l s with a l i n ear sta p l e r.

FIG 9

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The d i sta l i l e u m is d ivided a p p roximately 10 em proxi­ mal to the i l eoceca l va lve with a l i n ear 75-mm b l u e load sta p l e r (FIG 1 0) . If adjacent o r g a n s a re i nvolved, every atte m pt at a com­ p l ete e n b l oc resection m ust be made. The spec i m e n s h o u l d be a ssessed w i t h the path o l o g ist to e n s u re t h a t the d iseased s e g m e n t i s acq u i red a n d that a d e q u ate m a r g i n s h ave been o bta i n e d . If there i s a ny d o u bt a bout m a rg i n status, a n i ntrao perative frozen section eva l u a ­ t i o n s h o u l d be co n d u cted .

FIG 1 0 • I l e a l transect i o n . The term i n a l i l e u m is d ivided with a l i n ear sta p l e r.

C h a p t e r 9 R I G H T H E M ICO LECTOMY: Open Technique

I LEOCOLO N I C ANASTOMOSIS •

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After resection, reco nstruct i o n p roceeds with an a n a sto­ mosis betwee n the i l e u m and the transverse co l o n . A p r i m a ry i leoco l i c a nasto mosis is a l m ost a lways poss i b l e . E i t h e r a hand-sewn o r a sta pled a n astomosis can be per­ formed in an end-to-end, end-to-side, side-to-side, or side­ to-end fash i o n . The via b i l ity of the p roxi m a l a n d d ista l seg m ents o f bowel s h o u l d be assessed a n d further resec­ tion to we l l-perfused bowel s h o u l d be perfo rmed if there is any q u estion reg a r d i n g the via b i l ity of the bowe l . Atra u m atic bowe l c l a m ps s h o u l d be p l aced prox i m a l a n d d i sta l to the a n astomotic s i t e to p reve nt s p i l l a g e o f bowel contents. G a uze pads s h o u l d a l so be p l aced i n t h e a b d o m e n to p rotect su rrou n d i n g structu res a n d the s k i n f r o m conta m i nation d u r i n g the p rocess of transect i n g the colon a n d creat i n g the a n asto m osis.

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The i l e a l a n d tra nsverse colon seg ments should be brought i nto a p position to a l l ow a tension-free anastomosis. For the sta pled tec h n i q ue, the a n t i m esenteric borders of the bowel seg m e nts a re a p p roxi m ated with i nter­ ru pted 3-0 s i l k sutures. A sma l l ente rotomy is m a d e o n t h e a n t i m esenteric border o f both the i l e u m a n d t h e transverse c o l o n (FIG 1 1 ) to a l l ow i n sertion o f a sta­ p l i n g device (FIG 1 2) . The sta p l e r i s a l l owed to gently c lose, b r i n g i n g together the ileum a n d transverse co l o n (FIG 1 3) . O n ce it i s assu red t h a t the m esentery is c l e a r a n d the sta p l e r is i n g o o d position, the sta p l i n g device is fi red a n d t h e n slowly remove d . This f u s e s the t w o previous ente rotom ies i nto a s i n g l e ente rotomy. T h i s n e w enterotomy can be cl osed either with a sta p l e r, p l aced at a r i g ht angle to the p revi ous sta p l e line (FIG 1 4), o r with sutu res, i n o n e o r two layers (FIGS 15 and 1 6).

• Sta p l e d i l eoco l o n i c a n asto mosis. Scissors a re u s e d to m a k e a s m a l l ente rotomy o n the a n t i m esenteric border of the bowe l . (Pri nted with permission from Baylor College of M e d i c i n e . )

FIG 11

FIG 12 • Sta p l e d i l eoco l o n i c a n a stomosis: i n se rt i n g the sta p l i n g device i nto the enterotomy.

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

• Sta p l e d i l eoco l o n i c a n asto mosis. The sta p l e r is i nserted i n the ileum a n d tra n sverse colon a n d is t h e n closed. (Pri nted with permission from Baylor Col lege of M e d icine.)

FIG 1 3

FIG 1 4 • Sta pled i l eoco l o n i c anastomosis: closi n g the com m o n enterotomy w i t h a sta pler. (Pri nted w i t h permission from Baylor Co l l ege of M e d i c i ne.)

• Sta pled ileocolonic anastomosis: closi ng the outer layer of the common enterotomy with i nterru pted Lembert sutures. (Pri nted with permission from Baylor College of Medicine.)

FIG 16

FIG 1 S • Sta pled i leocolonic anastomosis: closing the i n ner layer of the common enterotomy with a n a bsorba ble running suture. (Pri nted with permission from Baylor College of M ed icine.)

C h a p t e r 9 R I G H T H E M ICO LECTOMY: Open Technique

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The co m p l eted a n a stomosis is visu a l ly i n s pected to e n s u re that it i s we l l perfused a n d is p a l pated to check fo r patency (FIG 1 7) . Alternatively, a h a n d-sewn a n a stomosis ca n be per­ formed in either o n e or two layers. The type of suture (monofi l a m e nt, braided, a bsorba b l e), type of stitch (inte r r u pted, conti n u o us, Le m b e rt), o r confi g u ration used is probably n ot a s i m porta nt as a re t h e p r i n c i p l es of a p p roxi m a t i n g we l l -perfused bowe l without t e n s i o n . The a u t h o rs p refer a two-l ayer, s i d e-to-s i d e a n a stomosis using a n outer layer of i nterru pted Lembert silk sutu res and an i n ne r conti n u o u s r u n n i n g layer of m o n ofi l a m ent a bsorb a b l e suture. C l o s u re of the mesenteric defect is opti o n a l a n d is based o n s u rgeon p refe rence. Ofte ntim es, the o m e n t u m can be p l aced a r o u n d the a n asto mosis.

991

FIG 1 7 • The co m p l eted i l eotransverse colon side-by-si d e sta pled a n asto mosis. Pal pation of the a n asto mosis betwee n the t h u m b a n d i n d ex fi n g e r s h ows that the a n asto mosis is patent. N otice that both the i l e a l a n d co l o n i c seg ment a re we l l perfuse d . C l o s u re of the mesenteric d efect is opti o n a l a n d is based o n s u rgeon p reference.

CLOSURE •

O nce h e m ostasis is e n s u red a n d the a b d o m e n is i rri­ gated, the a b d o m i n a l fascia a n d s k i n a re cl osed i n sta n ­ d a rd fash i o n . D r a i n s a re n o t routi nely req u i red, a lt h o u g h i n cases of i nfect i o n o r a bscess, a d ra i n may be placed.

PEARLS AND PITFALLS Colon m o b i l ization

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The plane betwee n the m esoco l o n and the retroperito n e u m is a n avasc u l a r e m b ryo l o g i c p l a n e t h a t s h o u l d be d i ssected s h a r p ly. Excess b l ood l o s s d u r i n g t h i s d i ssection a l e rts the s u rgeon t h a t t h e i nco rrect p l a n e w a s entered .

Vasc u l a r d issection

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D u ri n g d issect i o n of the m i d d l e co l i c vessels, avulsion of t h e l a rg e co l l atera l branch that co n n ects t h e i nfe rior p a ncreaticod u o d e n a l ve i n w i t h the m i d d l e co l i c ve i n a n d su perior mesenteric ve i n ca n res u l t i n b l eed i n g that is d iffi c u l t to control beca use the vein retracts a n d ca n n ot be isol ated easi ly. Avo i d i n g excess u pward a n d m e d i a l traction of the right colon w h i l e m o b i l i z i n g the hepatic fl exu re best p revents this. Tra n s i l l u m i n ation of the mesoco l o n a n d t h e m esentery of the term i n a l ileum can h e l p to i d e ntify vasc u l a r a rcades to m i n i m i ze iatrog e n i c i nj u ry in patie nts with t h i c k mese ntery a n d ca n assure good b l ood s u p p ly to the a n asto mosis.

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Anastomosis

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A we l l -vasc u l a rized, tensio n-free a n asto mosis m i n i m izes the risk of a n asto motic breakdow n . If there i s a n y d o u bt reg a rd i n g the i nteg rity of t h e a n asto mosis, the bowe l seg m e nts s h o u l d b e f u rther resected to healthy, vasc u l a rized bowe l . B l ood s u p p ly t o the a n asto mosis ca n a lso be fu rth er assessed with D o p p l e r u ltraso u n d if n ecessa ry.

POSTOPERATIVE CARE •

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In the absence of intraabdominal infection, antibiotic therapy does not need to be continued postoperatively. A nasogastric tube is not routinely placed. The patient should begin ambulating on postoperative day 1 . The Foley catheter can usually b e removed o n postoperative day 1 or 2 unless an epidural remains in place.

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The patient can be started on a liquid diet. The diet can be advanced based on clinical progress. Deep venous thrombosis (DVT) prophylaxis should be continued until the time of discharge and can be considered as an outpatient in certain subsets of patients. The patient should be counseled about the initial changes in bowel habits including more frequent, loose stools and the possi­ ble appearance of blood clots in the first few bowel movements.

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P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

COMPLICATIONS •

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Intraoperative complications include inj ury to the ureter, duodenum, nearby bowel or colon segments, nearby blood vessels such as the inferior pancreaticoduodenal vessels or the superior mesenteric vessels, or an anastomosis that is poorly vascularized or under tension. Early postoperative complications include wound infection, anastomotic leak, or intraabdominal abscess formation Late postoperative complications include development of colocutaneous fistulas, recurrence of cancer, anastomotic stricture, incisional or internal hernia, or ureteral stricture from ureteral devascularization. An extended right hemicolectomy adds the potential compli­ cation of splenic injury, as the splenic flexure must be mobi­ lized to achieve a tension-free anastomosis. Because most of the proximal colon absorbs fecal water, an extended right hemicolectomy also predisposes to postoperative diarrhea.

SUGGESTED READINGS 1. 2.

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6.

Larson DW. Right colectomy: open and laparoscopic. In: Evans SRT, ed. Surgical Pitfalls. Philadelphia, PA: Elsevier; 2009:257-264. Morris A. Colorectal cancer. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2 0 1 0 : 1 090-1 1 1 9 . Rosenberg B L , Morris AM. Colectomy. I n : Minter RM, Doherty GM, eds. Current Procedures: Surgery. New York, NY: McGraw-Hill; 2 0 1 0 : 1 80-1 9 1 . Wolff BG, Wang JY. Right hemicolectomy for treatment o f cancer: open technique. In: Fischer JE, ed. Fischer's Mastery of Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2 0 1 2 : 1 698-1703. Silberfein EJ, Chang GJ, You YN, et al. Cancer of the colon, rectum, and anus. In: Feig BW, Ching CD, eds. The MD Anderson Surgical Oncology Handbook. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:34 7-4 1 5 . Sonoda T, Milsom JW. Segmental colon resection. I n : Ashley SW, Cancer WG, Jerkovich GJ, et al, eds. A CS Surgery: Principles and Practice. Ontario, Canada: Decker Publishing Inc; 2012:92 1-932.

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Laparoscopic Rig ht Hemicolectomy 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Craig A. Messick

Right hemicolectomy is defined as the resection of a portion of the terminal ileum, cecum, ascending colon, and portion of the transverse colon. When performed for neoplastic disease, it includes resection of the vascular pedicles including the ileocolic, right colic (when present), and sometimes right branch of the middle colic artery and their associated veins. An extended right hemicolectomy is one in which the middle colic vessels are ligated. Laparoscopic right hemicolectomy has been shown to be a preferred alternative technique in the resection of benign and malignant diseases of the colon and in experienced hands has been shown to have equivalent oncologic outcomes with improvements in speed of recovery when compared to open resection. 1-3

PATIENT HISTORY AND PHYSICAL FINDINGS •

INDICATIONS •

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Right hemicolectomy may be performed for either benign or malignant indications, but the underlying principles of surgical resection apply to both open and laparoscopic ap­ proaches. A thorough preoperative workup to define the underlying disease plays a critical role in determining the nature of the operative intervention and optimizing the sur­ gical treatment. Benign pathology (common etiologies) Crohn's disease: most frequently occurs in the terminal ileum and may include the ascending colon with associ­ ated an associated inflammatory phlegmon or fistula. Right hemicolectomy for Crohn's is performed when the disease is refractory to medical therapy. Right-sided diverticulitis: occurs uncommonly in the U.S. population and it is felt to arise as a congenital lesion oc­ curring more commonly in Asian patients. It is commonly misdiagnosed as acute appendicitis. Ischemic colitis: uncommonly affects the right colon in isolation owing to its collateral blood supply; however may present with abdominal pain, bloating due to stric­ ture, or hematochezia. Cecal volvulus: caused by a twist (typically clock-wise) of the terminal ileum and colonic mesentery around fixed retroperitoneal attachments, presents with acute abdomi­ nal pain and obstructive symptoms. Neoplastic pathology Endoscopically unresectable polyps should be treated with colectomy. As they have potential to harbor malig­ nant foci not detected on biopsy, they should be managed according to oncologic principles. Right-sided polyps in­ clude high-risk adenomas with high-grade dysplasia or villous components, large hyperplastic polyps, or sessile serrated adenoma/polyps (SSA/Ps) . Malignancy i s the most common indication for laparo­ scopic right hemicolectomy. Equivalent outcomes to open resection have been demonstrated in large multi-center

George J. Chang

randomized controlled trials. 2-6 A bulky cancer or one that has invaded into adj acent organs should be resected en bloc with associated tissues and may be considered for open resection. Adenocarcinoma: The location with respect to the anatomy of the blood supply determines the extent of bowel resection. Carcinoid: Right colectomy is indicated for carcinoid tumors of the terminal ileum or appendix when 2 em or greater. Colectomy is also indicated for adverse features such as gob­ let cell carcinoid histology or presence of lymphovascular or perineural invasion.

DEFINITION •

Joshua 5. Hill

�

•

•

•

•

Adenocarcinoma patients are commonly asymptomatic but can present with anemia, melena, altered stool patterns ( diar­ rhea), pain, and weight loss. A thorough history and physical examination is essential for identifying candidates for laparoscopic surgery. Several patient factors that can affect the feasibility of laparoscopic resection are shown in Table 1 . Patient characteristics or underlying dis­ ease issue may preclude safety of the laparoscopic approach or greatly increase the operative difficulty and time and these factors should be considered when making the decision to pro­ ceed with laparoscopy and during operative planning. Obesity poses unique challenges during laparoscopic hemi­ colectomy. The ease of finding the correct plane and the cen­ tral vascular anatomy is greatly diminished in obese patients. Patient positioning may also be impacted by obesity as obese patients may not tolerate extreme Trendelenburg, reverse Trendelenburg, or side to side positioning. In addition, obesity has been associated with a higher risk for conversion to open surgery. Despite these challenges, patients who are obese have increased risk for morbidity such as wound infection when compared to nonobese patients and thus may derive significant benefit from laparoscopic surgery. Patients with decreased cardiac output may not tolerate increased intraabdominal pressures resulting in decreased venous return secondary to pneumoperitoneum. Intraabdominal adhesions caused by prior surgery may pre­ clude laparoscopy. Laparoscopic lysis of adhesions may be

Table 1: Patient Factors that Can Affect the Feasibil ity of Laparoscopic Resection

Obesity Prior a b d o m i n a l surgery Cardiac dysfu nction P u l m o n ary dysfu nction Large tumor b u rd e n Pote ntial l o c a l involvement of adjacent vita l o r g a n s Abnormal i ntraa bdom i n a l a n atomy

993

994

•

P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

performed, although surgeon experience and the extent of adhesions should be considered. Patients with nutritional deficiencies and impaired healing, such as those on high-dose steroids, recent immunomodula­ tors, or systemic chemotherapy, are at higher risk for anasto­ motic failure. In those patients with ongoing life-threatening illnesses, ileocolonic anastomosis should be deferred in favor of end ileostomy. An ileocolostomy should not be performed in patients with hemodynamic instability.

DIAGNOSTIC STUDIES •

•

•

Colonoscopy: All tumors should be localized, biopsied, and tattooed prior to embarking on laparoscopic surgery. Tattooing allows for intraoperative localization of the tumor, although it may be faint when localized to the mesenteric border (FIG 1 ) . The tattoo can also be o n the retroperitoneal surface and not seen (FIG 2) . Synchronous tumors (present in 3% to 5% of patients with colon cancer) and unresected polyps should be noted and considered in the treatment plan? Colonoscopy may not be possible in patients with a complete obstruction. In these patients, intraoperative palpation of the entire colon should be performed to assess for secondary lesions. After re­ covery from surgery, a short interval completion colonoscopy should be performed. CT colonography/enterography: Can be useful in patients not amenable to colonoscopy. Use of CT enterography pro­ vides additional information of the small intestines in pa­ tients with Crohn's disease that may alter surgical strategy. CT scan of the abdomen and pelvis: In inflammatory bowel disease patients, CT scan provides information pertaining to the extent is of colitis, presence of a fistula, and/or abscess. In patients with malignancy, CT scans of the chest, abdo­ men, and pelvis should be performed to assess for pulmo­ nary, hepatic, and lymphatic metastasis as well as infiltration of the primary tumor into adj acent structures. 8

• Tatto o i n g the target. I n s o m e i n st a nces, a tattoo p l a ced with i n the mese ntery i s n ot v i s i b l e u n t i l d i ssect i o n i nto the retroperito n e u m . H e re, the d i ssect i o n of To l dt's fascia (anterior) h a s been perfo rmed a n d the retroperito n e u m exposed, revea l i n g the l ocat ion o f the tattoo with i n the retro perito n e u m o f t h e asce n d i n g co l o n .

FIG 2

We use mechanical bowel preparation because i t lightens the colon, thus facilitating laparoscopic manipulation of the colon. Patient Positioning •

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SURGICAL MANAGEMENT

The patient is positioned supine and secured with Trendelen­ burg straps on the ankles ( FIG 3 ) . If an extended right hemi­ colectomy will be performed, the patient may be placed in a lithotomy position to facilitate the mobilization of the splenic flexure, if necessary. Gravity is the single greatest facilitator of exposure during colectomy. During the course of the case, the patient may be placed in steep Trendelenburg, reverse Trendelenburg and rotated right side up. For this reason, the patient must be secured to be operating table and a variety of devices have been used to secure the patient. We prefer to use ankle and chest straps, but commercially available foam pads placed under the patient to prevent slippage may also be used. We avoid using pads of beanbags placed above the shoulder that can cause brachial plexus injuries. Both arms should be padded and tucked at the patient's side. If the patient is too wide for the table, the right arm may

Preoperative Planning •

•

Appropriate preoperative antibiotic coverage before incision has been shown to decrease the risk of surgical site infec­ tions, but courses of antibiotics greater than 24 hours are actually associated with worse outcomes.9 The need for a pre-operative mechanical bowel preparation in patients undergoing right hemicolectomy is controversiaJ.l0•1 1

__,.....,.;:::,_ ::.., - Heel foam padding ..,_""T"_ Foot end of table 11!!!"'=----:-- End table-to-an kle secure strap "'"7"""'l•- Velcro ankle straps ...----'+-- Sequential compression device Lateral table-to-ankle secure strap

Transverse colon Velcro ankle straps lntramesenteric tattoo Ascending colon mesentery Duodenum

•

Tatto o i n g the target. Tattoos p l aced with i n the co l o n i c mesentery may n o t be visi b l e u p o n i n it i a l i nspect i o n . As s h own i n t h i s operative p h otogra p h , the d i st a l asce n d i n g colon at the hepatic flexure h a s been a nteriorly reflected to reve a l the l ocati o n of a previ ously p l aced i ntra mesenteric tattoo .

FIG 1

':-'-!"--+-- Heel foam padding

FIG 3 • Sec u r i n g the patient to the ta b l e . Ve lcro stra ps a re secu red to the patie nt's a n k les, t h e n attached to the operat i n g r o o m ta b l e to p rotect the patie nt's legs f r o m s l i d i n g l atera l ly off t h e ta b l e's sides with extreme l eft-right positi o n i n g a n d to assist in kee p i n g the patient from s l i p p i n g toward the head of t h e t a b l e when i n p l aced i n steep Tre n d e l e n b u rg posit i o n .

C h a p t e r 1 0 LAPAROSCO P I C R I G H T H E M I COLECTOMY

be left out so that the operative team standing together on the patient's left side still has sufficient working space. The patient's hands should be turned such that their palms face medially with the thumbs anterior and fingers should be positioned so that they are in a neutral position.

•

PORT PLACEMENT •

A va riety of methods may be e m p l oyed for the entry i nto the a b d o m e n d u r i n g l a p a rosco pic s u rg e ry. Two com­ m o n ly used options a re the use of a Ve ress need l e o r the a ut h o rs' p refe rred tech n i q u e of a d i rect fasc i a l cutdown (Hassa n tec h n i q ue). P n e u m o perito n e u m is esta b l ished with carbon d i ox i d e to 15 mmHg as t o l e rated .

0

2 1

"

() 3

0

0 ()

VASCULAR TRANSECTION AND M E D IAL

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I LEOCOLIC ME SE NTERY

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•

Ensure that intravenous (IV) lines are working after posi­ tioning and prior to the start of the case. A second IV is recommended because the patient's arms will be inaccessible during the operation, thus making the establishment of an­ other IV difficult.

Sta n d a rd port p l a cement i n c l udes a 1 0- to 1 2- m m u m ­ b i l ical port (ca m e ra port), 5 - m m wo r k i n g po rts i n the l eft u p p e r q u a d ra nt, a n d either a 5-mm or 1 0- to 1 2- m m port i n the l eft lower q u a d ra nt . A fo u rth port is used i n either the suprapubic o r r i g ht lower q u a d ra nt positions. An op­ tional 5-mm port is p l a ced i n the patie nt's r i g h t u p per q u a d ra nt to assist with the d ista l transverse colon o r s p l e n i c f l e x u r e m o b i l ization as n e e d e d f o r a n extended right h e m i c o l ecto my (FIG 4) .

FIG 4 • Port p l acement. T h i s d i a g r a m s h ows the sta n d a rd a n d a d d i t i o n a l l a p a rosco p i c port sites for a l a p a rosco pic r i g h t h e m i c o l ecto my. Sta n d a rd p l acement i n c l udes a 1 0- to 1 2- m m u m b i l i ca l port (1), 5-mm l eft u p p e r q u a d ra n t port (2), a n d either a 5-mm o r 1 0- to 1 2- m m left lower q u a d ra n t port. A fou rth port is used in t h e o pt i o n a l locat i o n s (o), either s u p ra p u b i c or r i g h t l o w e r q u a d ra n t p o s i t i o n s . An opti o n a l 5-mm port is p l aced in the patie nt's right upper q u a d ra n t to assist with the d ista l transve rse colon or s p l e n i c flexure as needed for an extended right hem icol ectomy.

TO LATERAL MOBI LIZATI O N OF T H E

•

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The a b d o m e n s h o u l d be t h o ro u g h ly i n spected to r u l e out metastatic sites o r synchronous pathology with eva l u a ­ t i o n o f the perito n e u m , l iver, retro perito n e u m , a n d a d ­ n exa l struct u res i n wo m e n . The patient is positioned with the left side down a n d i n s l i g ht Tre n d e l e n b u r g . The o m e n t u m is retracted ce p h a l a d ove r the transverse colon i nto the u pper a b d o m e n . In an o bese patient with a b u l ky omentum, an assista nt can h o l d retract i o n of the o m e n t u m t h r o u g h the l eft u pper q u a d ra n t port.

•

995

The s m a l l i ntest i n e is swept to the l eft l ower q u a d ra nt, a l lowi n g for com p l ete visu a l ization of the mesenteric atta c h m e nts to the r i g h t colon a n d the superior mes­ enteric a rtery (SMA). The i l eoco l i c vessels ( I CV) can be i d e ntified as they cross ove r the t h i rd portion of the duo­ denum. The fo l d of Treves is g rasped a n d retracted later­ a l ly to d e m o n strate the cou rse of the I CV a n d to i d e ntify t h e i r o r i g i n from the S M A a n d the confl u e n ce of t h e i l eoco l i c ve i n i nto t h e superior mesenteric vei n (S M V) (FIG S) . T h e perito n e a l su rface is scored o n the d o rs a l s u rface of the ICV n e a r the SMA (FIG 6) . W h i l e e n s u r i n g that the lymph node-bea r i n g tissue is d i ssected i nto the i l eoco l i c mese ntery (spec i m e n s i d e), the retro perito n e a l attach­ m ents to the co l o n i c m esentery a re d ivided.

996

P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

• Exposu re of the i l eoco l i c ped icle. After the s m a l l bowe l has b e e n p l aced i n the patie nt's l eft h e m i a bd o m e n expos i n g the right colon mesentery, the i l eoco l i c ped i c l e is often seen p u lsat i n g with i n its mesentery. The d u o d e n u m is often s e e n t h ro u g h a t h i n l a y e r of c o l o n mesentery; the ICV can be i d e ntified as they cross the t h i rd portion of the duod e n u m . I n t h i s i m age, the SMV, i nferior ve n a cava, a n d rig ht co l i c a rtery a n d v e i n a re see n . IVC, i nferior vena cava; SMV, s u perior mesenteric ve i n .

FIG 5

I leocolic vein I leocolic artery Duodenum IVC Right colic lymph node Right colic artery and vein SMV

I CV Duodenum Right colic lymph node SMV

•

•

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The correct, avasc u l a r p l a n e can be deve l o ped with a combi nation of s h a r p a n d b l u nt d issect i o n . The sma l l retro perito n e a l vesse l s can act a s a g u i d e a n d s h o u l d be d i ssected downward, away fro m the co l o n i c mesentery. If these a re b l u ntly torn, m i n i m a l , yet bot h e rso m e b l eed i n g can e n s u e . T h i s ca refu l m e d i a l to latera l d i ssect i o n o f t h e i l eoco l i c mesentery is c a r r i e d ce p h a l a d to t h e orig i n o f the I CV, w i t h c a r e taken not to i n a dverte ntly i nj u re the d u o d e n u m , a n d l atera l ly relea s i n g the co l o n i c m esentery from retroperito n e a l atta c h m e nts without i nj u ry to the u reter or gonadal vesse ls. The d i ssect i o n plane should be a nterior to the d u o d e n u m and p a n creatic head, ta k i n g care to avoid i n a dverte nt d u o d e n a l m o b i l ization o r d issection betwee n the d u o d e n u m a n d p a n creas (FIG 7) . The I CV can then be d ivided at the orig i n from the S M A/ SMV with either an e n d osco p i c G IA sta p l e r with a vascu­ lar load (our prefe rence; see FIG 8), with a n e n ergy de­ vice, or between e n d oc l i ps . N ode-bea r i n g tissue s h o u l d be k e p t w i t h the speci m e n . N ext the d i ssection is taken up a l o n g the SMA to identify the right co l i c a rtery a n d ve i n (when p resent) (FIG 9) as

•

•

•

we l l a s t h e m i d d l e co l i c vesse ls (M CV) a n d their bifurcation (FIG 1 0). This step is fac i l itated by a nterior a n d cep h a l a d traction o n the tra nsverse co l o n to t e n t the mesentery. By fo l l owing the SMA from the point of I CV l igation, the va riably present right co l i c a rtery is id entified to a rise from the SMA between the I CV a n d the M CV where it s h o u l d be d ivided at i t s o r i g i n w i t h a n ene rgy-sea l i n g device. The ve n o u s d r a i n a g e of the right colon is a lso h i g h ly vari­ able and the right co l i c ve i n is m i ssi n g i n u p to 50% of patients. It can be fo u n d j o i n i n g the right g a stroe p i p l o i c a n d su perior p a ncreaticod u o d e n a l ve i n s at the g a stro­ co l i c tru n k of H e n l e . I n cases of more d i stal asce n d i n g colon or hepatic flexure t u m o rs, tra n sact i o n of either the right branch or the en­ tire tru n k of the middle co l i c a rtery (M CA) should be per­ formed after expos i n g the orig i n of these vesse ls from the SMA. Tea r i n g the ve i n at this level w i l l res u lt i n ra pid b l eed i ng; t h e refore, it i s i m portant to ca refu l l y a n d com­ p l etely ide ntify the vasc u l a r a n atomy of the right colon prior to d ivid i n g the mesentery.

Duodenum I leocolic artery and vein

...

---�=-· . . -· ,,..,.. � J.�l '

Caudad

FIG 6 • D i ssect i o n of the I CV. Sco r i n g of the perito n e u m a l o n g the i nferior s u l c u s of the I C V a l l ows f o r a posterior d i ssection to the I CV. Gentle l ifti n g of the ped icle will a l l ow for d issection of the tissue to the orig i n of the I CV at the S M A a n d SMV. I CV, i l eoco l i c vesse ls; S M V, s u p e r i o r mesenteric ve i n .

-- . .

� .,.....i !J. ; Cephalad

-1 ·:

�: -_.., rF . :

; ':4

Transverse colon Ascending colon Duodenum Head of pancreas (anterior)

FIG 7 • M e d i a l to l atera l d i ssect i o n . The m ed i a l to latera l d i ssection of the i l eoco l i c mesentery is conti n ued both latera l l y and s u periorly a nterior to the d u o d e n u m and head of p a n creas along the course of the S M A a n d SMV to the origin o n the middle co l i c vesse l s .

Stapler Right colic artery/vein lymph node Right colic artery and vein SMV

FIG 8 • Tra nsect i o n of the I CV. O n ce the i l eoco l i c a rtery a n d v e i n h ave b e e n cleared o f t h e i r s u rrou n d i n g fat a n d lym p h atic tissue, they can be tra nsected at t h e i r origins off the S M A and SMV. This can be perfo rmed with a 3 0 m m sta p l e r (as s h own) or with a n e n e rgy device as a p p ropriate. The vesse l s ca n be separated a n d l i g ated either sepa rately o r together, a s per s u rgeon p refere nce.

C h a p t e r 1 0 LAPAROSCO P I C R I G H T H E M I COLECTOMY

I leocolic pedicle (transected) Duodenum Right colic vein Right colic artery SMV

Transverse colon Transverse colon mesentery Right branch of middle colic artery and vein Left branch of middle colic artery and vein Duodenum Middle colic artery and vein

LATERAL COLON MOBI LIZATI O N •

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P l a c i n g the patient in Tre n d e l e n b u rg position a n d re­ tract i n g the sma l l bowe l out of the pelvis i nto the u p per abdomen fac i l itates t h i s ste p . The asce n d i n g c o l o n is m o b i l ized i n a n i nferior to su pe­ rior fas h i o n by l ifti n g the cecu m away from the retroperi­ to n e u m and sco r i n g the base of the ceca l and term i n a l i l e a l mesenteries u n t i l the m ed i a l to l atera l d issection i s met (FIG 1 1 ) . C a r e s h o u l d be taken to a v o i d i n advertent d issect i o n and i nj u ry of the u rete r and g o n a d a l ve i n . T h e l atera l atta c h m e nts a l o n g To ldt's fascia a re t h e n i n cised u p to the l e v e l of the h e p a t i c f l e x u r e . W e p refer an inferior to s u p e r i o r a p p roach a s t h i s m i n i m izes the risk for kid ney m o b i l ization o r d uo d e n a l Kocherization d u r­ i n g bowel m o b i l ization (FIG 1 2) . After the asce n d i n g c o l o n h a s b e e n m o b i l ized, the m o ­ b i l ization o f the transverse c o l o n a n d hepatic flexure i s perfo r m e d . W i t h the p a t i e n t i n reverse Tre n d e l e n b u rg posit ion, the l esse r sac is opened by relea s i n g the o m e n ­ t u m f r o m the transverse co l o n . A t t h i s l e v e l the o m e n t u m is fre q u e ntly f u s e d to the transverse mesoco l o n so c a r e s h o u l d be taken to a v o i d i n a dvertent mesenteric vasc u l a r i nj u ry. The p roxi m a l tra n sve rse co l o n i c atta c h m e nts a l o n g the h e patoco l i c l i g a ment can then be d ivided with a n e n e rgy device to m eet the p l a n e over the d u o d e n u m p revi­ ously esta b l ished d u r i n g the m e d i a l to l atera l d i ssect i o n (FIG 1 3) . The previous expos u re of the d u o d e n u m m i n i­ m i zes the risk of i n a dvertent Kocherization a n d/o r i n j u ry to the d u o d e n u m at t h i s sta g e .

FIG 9 • Tra nsection of the right colic vessels. A right colic a rtery a n d vei n a re shown originating from the superior mesenteric a rtery a n d vei n . This is often discovered o n ly after tra nsection of the i leoco lic a rtery and vei n has been com p l eted . These vesse ls a re typica l ly smaller than the i leoco lic a rtery and vei n and may be ligated with sta ples, endoc l i ps or an energy device. SMV, superior mesenteric vei n . • Exposu re o f t h e middle c o l i c vessels. T h e co lon mesentery is i ncised a long the border of the su perior m esenteric vessels to the bifurcation of the right and left branches of the m iddle colic a rtery and vei n as shown here, ensuring that a l l lym phatic tissue wit h i n t h e d istri bution ofthe right a n d proximal tra nsverse colon is removed with the speci men. This dissection is performed a nteriorly to the d uoden u m and head of pa ncreas. The right branch of the m i d d l e colic a rtery and vei n a re typica lly sma l l enough to tra nsect with a sea l i n g energy device.

FIG 1 0

Terminal ileum Right pelvic sidewall Small bowel mesentery Right ureter Right common il iac artery Right common il iac vein

FIG 1 1 • Expos u re of the right pelvic i n let. With the patient positioned i n stee p Tre n d e l e n b u rg and the s m a l l i ntest i n e rem oved f r o m the pelvis, the p roxi m a l l atera l p e l v i c a n d a b d o m i n a l atta c h m e nts o f the term i n a l i l e u m a n d cec u m a re i d e ntified. I m portant a n atomy is a p p reci ated in t h i s p h oto: right co m m o n i l i ac a rtery a n d ve i n a n d the right u reter. These perito n e a l atta c h m e nts m ust be i n c ised a n d freed to a l l ow co m p l ete m o b i l ity of the sma l l i ntest i n e .

Right abdominal wall Toldt's fascia (right} Ascending colon Lateral retroperitoneal attachments to ascending colon Right ureter

FIG 12 • Late ra l m o b i l ization of the ascen d i n g co l o n . O n ce t h e latera l pelvic a n d i n it i a l a b d o m i n a l atta c h m e nts a re i n cised, gentle traction o n the cecu m a n d asce n d i n g c o l o n toward t h e patie nt's l eft u p p e r q u a d ra n t w i l l assist i n the d i ssection o f To ldt's fasc i a . The d a r k p u rple-a p p e a r i n g tissue towa rd the bottom of t h i s operative p h oto reve a l s the retroperito n e u m p revi ously d i ssected d u ri n g the i n it i a l m e d i a l to latera l d i ssect i o n . The u reter m a i nta i n s a c l ose a p proximation to the d issect i o n p l a nes.

997

998

P a r t 4 OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

FIG 13 • M o b i l ization of the hepatic flexure. With the patient i n reverse Tre n d e l e n b u rg position a n d the tra n sverse colon with its omentum refl ected i nferiorly, the superior portion of the previous med i a l to lateral d issection is easily visual ized and is seen here i n the middle of the photo. I ncision i nto this thin tissue connects with the p revi ous d i ssection p l a n e and the dissection conti n ues l atera l l y to i ncise a n d release the hepatoco l i c l i g a m ents co m p l eting the m o b i l ization of the right co l o n . After this has been com p l eted, the right colon should be a b l e to be m e d i a l ized across the m i d l i n e of the a bdomen.

Ascending colon Gall bladder Stomach Transverse colon (inferiorly reflected) Pancreas visualized through previous issection plane) Duoden um (visual ized through previous dissection plane)

J

ENTEROCOLO N I C ANASTOMOSIS •

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I l eoco l o n i c a n asto mosis may be pe rformed either i ntra­ corporea l ly o r extraco rpo rea l ly. We p refer an extracorporea l a n a stomosis t h ro u g h a peri­ u m b i l ical extraction s ite, i ncorporat i n g the s u p ra-u m b i l ­ ica l port site. An advantage o f t h i s a p p roach is t h a t the a n asto mosis may be perfo rmed accord i n g to sta n d a rd open tec h n i q u e . I n cancer patients, t h e extracti o n site m u st be s uffi ciently l a rg e to a l l ow for the passage of the t u mor-bea r i n g

EXTRACORPOREAL TRAN SECTI ON AND

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ENTEROCOLO N I C ANASTOMOSIS •

•

•

O n ce the right colon a n d term i n a l i l e u m have been d e l iv­ ered t h r o u g h the wound p rotector, attention i s turned to the bowe l resect i o n . I nvestigation of the vascu l a r s u p p l y to the p l a n ned resection s ites prior to d ivision a n d a n astomosis is para m o u nt. The mese ntery s h o u l d be ca refu l ly i n s pected a n d the ter­ m i n a l vessels s h o u l d be visu a l l y assessed for p u l sations o r p u lsat i l e b l ood flow should be confirmed by D o p p l e r i nterrog atio n . If n o p u lsations a re p resent, then a n other site for resect i o n and a n asto mosis i s chose n . The term i n a l i l e u m a n d the tra n sverse colon (typ ica l ly to the right side of the M CV) a re tran sected with a l i n e a r sta p l e r. The i nterve n i n g m esentery is transected with a n e n e rgy device.

• Creati o n o f a n extraco rporea l s i d e-to-s ide sta pled i l eoco l o n i c a n asto mosis with a l i n e a r sta p l e r.

FIG 14

•

•

seg m e nt. A wound protector is p l aced i nto the i n cision to red u ce i nfect i o n . If the term i n a l i l e a l or colon mesenteries h a v e n ot been co m p l etely m o b i l ized, or the mesenteries have not been properly l i g ated, bowe l exteriorization may be d iffi c u l t a n d associ ated w i t h a risk f o r avu lsion i nj u ry to the mes­ enteric vesse ls. D u ri n g bowel exte riorization, it is h e l pf u l to i n it i a l ly m a i nta i n the reverse Tre n d e l e n b u rg position with the ta b l e s l i g htly rotated l eft-side d own to keep the s m a l l bowel from fa l l i n g over t h e c o l o n a n d entra p p i n g it.

There a re m u lt i p l e methods to create a n a n asto mosis . We sugg est that s u rgeons use the method with which they a re m ost comforta b l e . O u r p referred a p p roach is to perform a side-to-s ide, a n t i m esenteric, functi o n a l end-to­ end, sta pled a n astomosis i n cont i n u ity to avoid potenti a l f o r twist i n g o f the bowe l . T h i s is d o n e w i t h a colotomy a n d a n enterotomy o n t h e a nti-mesenteric s i d e o f the spec i m e n a b o u t 1 em or 2 e m away p roxi m a l to t h e p l a n ned transection sites. A l i n ear sta p l e r is p l a ced i nto the enterotomy a n d colotomy and a p p roxi m ated at t h e i r a nti mesenteric sides. After e n s u r­ i n g that the i l e a l a n d co l o n i c mesenteries a re free from the c l osed sta p l e r, it is fi red creat i n g the s i d e-to-side en­ terocol osto my a n asto mosis (FIG 1 4) . T h e c o m m o n enterocol ostomy is cl osed b y u s i n g a n 8 5 - to 1 00-mm l i ne a r sta p l e r (re load), avo i d i n g n a rrow­ i n g the a n a stomosis (FIG 1 5) .

• C l o s u re of t h e c o m m o n enterocol ostomy a n a sto­ mosis open i n g with a l i n er sta p l e r.

FIG 1 5

C h a p t e r 1 0 LAPAROSCO P I C R I G H T H E M I COLECTOMY

•

The a n asto mosis is i n s pected fo r g ross d efects o r b l eedi n g , both of w h i c h can be oversew n . The corners a n d i ntersect i o n s o f the sta p l e l i nes m a y be i m b ri cated o r rei nforced w i t h Le m b e rt sutu res.

•

CLOSURE •

The a b d o m e n s h o u l d be i n s pected for h e m ostasis a n d to e n s u re that there h a s been no i n a dvertent avu l s i o n i nj u ry to the mese ntery or twist i n g of the mesentery. The mes­ enteric d efect wi l l be l a rg e after col ecto my with prox i m a l

•

999

An a ltern ative tech n i q u e i n c l udes bowe l d ivision a n d i ntracorporea l a n asto mosis with a va riety o f opti o n s for spec i m e n extract i o n . One advantage of this a p p roach is the a b i l ity to avo i d a peri u m b i l ical i n cision with its associ­ ated risk for hernia i n favor of a Pfa n n e n st i e l i n c i s i o n .

vasc u l a r l i gation; the refo re there is neither the need to c l ose the mesentery, n o r is it g e n e ra l ly poss i b l e to d o so. Any 12 m m port sites a re cl osed a n d t h e extract i o n site can be cl osed with i nterru pted suture o r accord i n g to the s u rgeon's p refere nce.

PEARLS AND PITFALLS Patient sel ect i o n

• •

Preope rative planning

• • •

•

Patient position i n g a n d portplacement

•

Proced u re

• • • • • •

O r i e ntat i o n

• •

Patie nts who m eet criteria for h e red ita ry n o n polyposis colorecta l c a n c e r (H N PCC) o r Lynch syn d ro m e s h o u l d be consid ered for a s u btota l colectomy. Pat i e nt s h o u l d be a ssessed to e n s u re they w i l l tolerate p n e u m o perito n e u m a n d c h a n ges in positi o n i n g d u r i n g s u rg e ry. E n s u re a com p l ete colonoscopy was perfo r m e d . As m a ny as 1 i n 20 patie nts w i l l have syn chronous p r i m a ry cancers. Loca l ize the tumor with CT i m a g i n g for l a rger lesions and colonoscopic tattoo o r m eta l l ic clip for s m a l l e r ones. Ca refu l review p reoperative CT i m a g i n g i d e ntifies loca l ly adva n ced d isease, d ista nt m etastases, o r a berrant vasc u l a r a n atomy. Secu ring the patient to the bed with chest a n d leg straps is key a n d a l l ows for extremes in patient positi o n i n g . P l a c i n g ports i n e i t h e r the m i d l i n e o r contra latera l to the target fac i l itates o r i e ntation a n d maxi m i zes i nstr u m e n t range of m ot i o n . C o m p l e t i n g the m ed i a l to l atera l d i ssection f r o m the r i g h t b r a n c h of t h e m i d d l e co l i c a rtery d own to t h e cecu m is k e y to the d issect i o n a l l ow i n g e a s i e r d i ssect i o n of the l atera l asce n d i n g colon off of To l dt's fasc i a . Ca refu l atte ntion to the d u o d e n u m a n d pancreatic head s h o u l d be m a i nta i n e d wh i l e free i n g t h e trans­ verse mesoco l o n . The d u oden u m a lso se rves as a l a n d m a r k for p roxi m a l l i gation of the I CV. Antici pate va riations i n the vasc u l a r a n atomy of the hepatic flexure. The cou rse of t h e r i g ht co l i c ve i n i n p a rticu l a r is h i g h ly va r i a b l e a n d it is the refore at r i s k for avu l s i o n i n j u ry especi a l ly at t h e tru n k o f H e n l e . M o b i l ization a l o n g the base o f the term i n a l i l e a l m esentery over the i nfe r i o r v e n a cava a n d towa rd t h e l i g a m e n t o f Treitz ensu res a d e q u ate m o b i l ization f o r bowel exte riorization a n d tensio n-free a n asto mosis. Swee p i n g the asce n d i n g c o l o n a n d term i n a l i l e u m to the l eft s i d e of the patie nt's abdomen is a good test to e n s u re co m p l ete m o b i l ization of the entire right a n d transverse co l o n . E n s u re a n a p p ro p r i ate o n c o l o g i c resect i o n is performed d u ri n g a l l ste ps o f the proce d u re n ot leavi n g beh i n d i l eoco l i c a n d m i d d l e co l i c lymph nodes. Prior to closu re, i n s pect the o r i e ntati o n of the sma l l bowel a n d its m esentery to e n s u re that n o twists in the bowe l were i ntrod uced. C l o s u re of the mese nte ric d efect to p reve nt i ntern a l hernias i s n ot necess a ry if the d efect is l a rg e .

at least 24 hours. A narcotic minimizing regimen improves recovery.

POSTOPERATIVE CARE •

•

•

•

Following the procedure, principles of early mobilization and oral intake are observed. Early ambulation is encouraged to assist in return of bowel function and any invasive lines or catheters are also removed within 4 8 hours. Diet is initiated with clear liquids on the day of surgery and advanced as tolerated. Discharge criteria include ( 1 ) ability to maintain oral hydra­ tion, (2) adequate pain control without the need for IV nar­ cotics, ( 3 ) signs of bowel function (flatus) , and (4) afebrile for

OUTCOMES •

•

Laparoscopic procedures, when compared to traditional open surgery, have been shown to have quicker return of bowel function, less requirement of IV narcotics, earlier pa­ tient ambulation, fewer surgical site infections, and earlier discharge from the hospital. Most importantly, randomized control trials comparing lapa­ roscopic and open colectomies, when performed adequately,

1 000

P a r t 4 OPERATIVE TECH NIQUES I N COLON AND RECTAL SURGERY

provide equivalent oncologic outcomes with no differences in tumor recurrence and patient survival.

COMPLICATIONS • • • • •

Surgical site infection (superficial, deep, and organ space) Wound dehiscence Hemorrhage Anastomotic leak/breakdown Bowel obstruction

REFERENCES 1.

Kuhry E, Bonjer HJ, Haglind E, et al. Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic can­ cer. Surg Endosc. 2005; 1 9 ( 5 ) : 6 8 7-692. 2. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Eng/ I Med. 2004;350(2) :2050-2059. 3 . Jayne DG, Guillou P], Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. I Clin Oneal. 2007;25 (2 1 ) : 306 1-3 0 6 8 .

4. Bohm B, Milsom JW, Fazio VW. Postoperative intestinal motility fol­ lowing conventional and laparoscopic intestinal surgery. Arch Surg. 1 9 9 5 ; 1 3 0 ( 4 ) : 4 1 5-4 1 9 . 5 . Fleshman JW, Fry R D , Birnnaum EH, e t a l . Laparoscopic-assisted and minilaparotomy approaches to colorectal diseases are similar in early outcome. Dis Colon Rectum. 1 996;3 9 ( 1 ) : 1 5-22. 6. Weeks JC, Nelson H, Gelber S, et al. Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs open col­ ectomy for colon cancer: a randomized trial. }AMA. 2002;2 8 7 ( 3 ) : 321-328. 7. Latournerie M, Jooste V, Cottet V, et al. Epidemiology and prog­ nosis of synchronous colorectal cancers. Br J Surg. 2008;95 ( 12 ) : 1 528-1 5 3 3 . 8 . Pihl E, Hughes E S , McDermott FT, et a l . Lung recurrence after curative surgery for colorectal cancer. Dis Colon Rectum. 1 9 8 7; 3 0 ( 6 ) : 4 1 7-4 1 9 . 9 . Mahid S S , Polk HC Jr, Lewis JN, et a l . Opportunities for improved performance in surgical specialty practice. Ann Surg. 2008;24 7(2): 3 8 0-3 8 8 . 1 0 . Pineda CE, Shelton AA, Hernandez-Boussard T, e t al. Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature. I Gastrointest Surg. 200 8 ; 1 2 ( 1 1 ) :2037-2044. 1 1 . Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of sur­ gical site infection following colectomy: the role of oral antibiotics. Ann Surg. 2 0 1 0;252 ( 3 ) : 5 14-5 1 9 ; discussion 5 1 9-520.

I

Chapter

11

Rig ht Hemicolectomy: Hand-Assisted Laparoscopic Surgery Technique

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

,_ ----------------------------------------------------

Matthew Albert

DEFINITION •

Hand-assisted laparoscopic surgery (HALS) is a hybrid tech­ nique, which allows the surgeon to insert his or her hand into the abdominal cavity through a relatively small incision while preserving the ability to work under pneumoperito­ neum. This approach aids in tactile feedback, retraction, and dissection by hand assistance in turn eliminating the techni­ cal challenges of conventional laparoscopy while maintain­ ing nearly all of its benefits. 1•2

INDICATIONS • • • • •

Colon cancer Colon polyps not amenable to colonoscopic removal Inflammatory bowel disease Angiodysplasia Recurrent right colonic diverticulitis

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

A thorough history should be taken, including a detailed past medical history, past surgical history, present medica­ tions and allergies, and a personal and family history of colon and rectal cancer. A detailed family history to assess the risk of hereditary polyposis syndromes is critical in selecting the optimal pro­ cedure for the patient. Suspected patients should be offered genetic counseling and testing. A detailed physical examination of the patient should be per­ formed to identify any prior surgical incisions and palpable masses to plan for the operation. The location, histopathology, and the clinical stage of the lesion is crucial prior to any planned procedure.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

Colonoscopy remains the investigation of choice for localiz­ ing the target lesion, for obtaining tissue for histopathology, and for tattooing for intraoperative localization. This is also helpful in identifying synchronous lesions in the remaining colon. Computed tomography ( CT) scan of the chest/abdomen/pel­ vis with IV and oral contrast is recommended as the primary staging tool to assess for local organ invasion and for distant metastasis. 3

•

•

�

Harsha Polavarapu

Serum carcinoembryonic antigen ( CEA) level is a valuable marker for postoperative surveillance. Bone scan and brain imaging should be reserved for symp­ tomatic patients only.

SURGICAL MANAGEMENT •

•

The goal of surgery is an en bloc resection of the involved segment of bowel and to perform a high ligation of the vascular pedicle permitting adequate removal of associated lymphatics and lymph nodes. At least 12 lymph nodes must be harvested to adequately stage the patient and to avoid risk of understaging.3

Preoperative Planning •

•

• • •

Routine use of mechanical bowel preparation is not recommended. 4 Deep vein thrombosis prophylaxis with sequential compres­ sion devices and subcutaneous heparin dosing before induc­ tion of anesthesia is administered. A Foley catheter is placed prior to the operation. Nasogastric/orogastric tube is placed prior to the operation. Preoperative antibiotics covering skin and bowel flora are administered prior to induction of anesthesia.

Positioning •

•

•

•

•

Patient is positioned in a supine position. In order to prevent the patient from sliding during the case, the arms are tucked to the sides, the feet are placed against a padded footboard, and a strap is placed over the thighs ( FIG 1 ) . Alternatively, the patient can be placed i n the low lithotomy position to avoid instrument conflict with the lower extremi­ ties. The knees should be slightly flexed and the feet firmly planted on the stirrups to prevent undue pressure on the calves and on the lateral peroneal nerves. Depending on the location of pathology and body habitus, a 5- to 7-cm incision is made for the hand port in an epigas­ tric, periumbilical, or Pfannenstiel location ( FIG 2 ) . Location o f the trocars can b e variable based o n surgeon's preference. In general, it is best to triangulate all ports to en­ hance visualization and to prevent instrument conflict inside the abdomen. A traditional port placement includes ( FIG 2 ) A GelPort hand port through a 6-cm epigastric incision A 5-mm infraumbilical camera port A 5-mm left lower quadrant instrument port A 5-mm left upper quadrant/left anterior flank

1001

1 002

P a rt 4

/

OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

Pillow

/

Arm wrap Safety strap

A Padded foot board Heel padding

I I I B I

FIG 1 • Patient positi o n i n g . In order to p reve nt t h e patient from s l i d i n g d u r i n g the case, the arms are tucked to the s i d es, the feet a re p l a ced a g a i n st a padded footboa rd, a n d a stra p is p l a ced over the t h i g h s .

c D

FIG 2 • Port p l acement. The h a n d access port is p l aced t h ro u g h a 5- to 7-cm epig astric i ncision (A). Alternative ly, it ca n be p l a ced t h r o u g h a Pfa n n enstiel o r peri u m b i l ical i ncision (dotted lines). A 5-mm c a m e ra port is p l a ced i nfra u m b i l ica l ly (B) . Two 5-mm worki n g po rts are p l aced i n the l eft u p pe r (C) a n d l eft lower (D) q u a d ra nts.

EXPOSURE •

•

•

•

•

•

•

After p l acement of t h e h a n d po rt, the a b d o m e n is explored to l ocate the lesion, to a ssess the extent of s p read, a n d to p a l pate the l iver and perito n e a l cavity for d ista nt m etastatic s p rea d . I n fe m a l e patie nts, the ova ries s h o u l d be exa m i ned for m etastatic s p read o r p r i m a ry neoplasms. P n e u m o perito n e u m is created with carbon d i oxide (C0 2 ) a n d a d d i t i o n a l trocars a re i nserte d . Patient i s p l aced i n a l eft l atera l t i l t a n d s l i g ht Tre n d e l e n ­ b u rg posit i o n . The sma l l bowe l is fa n n ed out a l o n g its m esentery to a i d in the exposu re of the right co l o n . The g reater o m e n t u m a l o n g with the transverse colon is retracted cepha l a d . The cec u m is g rasped with the h a n d a n d retracted towa rd the a nterior a b d o m i n a l wa l l u s i n g gentle trac­ t i o n to i d e ntify the i l eoco l i c vesse ls. The i l eoco l i c ped i c l e is g rasped a n d retracted towa rd the a nterior a b d o m i n a l wa l l (FIG 3) .

• T h e i l eoco l i c ped icle (ICP), identified at its o r i g i n off the i nfe rior mesenteric vessels at the root of the m esentery (A), is g rasped a n d retracted towa rd the a nterior abdom i n a l wa l l .

FIG 3

C h a pt e r 1 1

R I G H T H E M ICO LECTO MY: Hand-Assisted Laparoscopic Surgery Technique

•

DIVISION OF I LEOCOLIC PEDICLE •

With t h e i l eoco l i c ped i c l e on stretc h , a p a ra l l e l i n c i s i o n i s m a d e o n t h e p e r i to n e a l l ayer u n d e r n e a t h t h e p e d i c l e (FIG 4) exte n d i n g to t h e root of t h e m esentery a n d t h e s u pe r i o r mesenteric ve i n , u s i n g m o n o p o l a r e l ectro c a u t e ry.

"a''\e e

ed

Tr n sv rs

.As c n ing colon

�·

I

Caudab,.'"'

r �

. ..

'f .1

.

J!!(f

' , -.6. ...-��-

' '

'

•

A w i ndow is created u n d e r the i l eoco l i c pedicle i n t h e avasc u l a r p l a n e that sepa rates the ped icle from t h e retro­ perito n e u m (FIG 5) . The i l eoco l i c pedicle is isol ated a n d d ivided cl ose to its orig i n off the superior mesenteric vesse l s u s i n g an e n ergy d evi ce, a l i n ear vascu l a r sta p l e r, or s u r g i c a l c l i ps based on s u rgeon's p refere nce (FIG 6) .

-� /�Cephalad -�W' > · ·:·: r.

-A#l' .r- . ,

·.

.U · �

..

:. _ ·

_;. -

• With the i l eoco l i c ped icle (ICP) on stretch, a para l l e l i ncision has been m a d e o n the perito n e a l l ayer u n d e rneath the ICP exte n d i n g to the root of the m esentery. The su rgeon, with the l eft hand now h o l d i n g the ICP a nteriorly, is now ready to open a wi ndow t h r o u g h the mesoco l o n latera l to the ICP.

FIG 4

FIG 5 • The i l eoco l i c ped icle (ICP) has n ow been co m p l etely e n c i rcled and is n ow ready for transect i o n . N otice that the ped icle h a s been com p l etely separated from the d u o d e n u m a n d o t h e r retroperito n e a l structu res.

Ascending colon

\ Ileocolic pedicle

I

Su perior mesenteric vein A B FIG 6 • A. The i l eoco l i c ped i c l e (I CP) is isol ated and d ivided i n between vasc u l a r c l i ps with a 5-mm e n e rgy device cl ose to its orig i n off the s u perior mesenteric vesse l s (SMV). B. I l l u strati o n of t h i s step .

1 003

1 004

P a rt 4

OPERATIVE TECH N I QUES IN COLON AND RECTAL SURGERY

MOBI LIZATION OF R I G H T M ESOCOLON •

•

U s i n g b l u nt d issect i o n with a 5-mm e n e rgy device, t h e asce n d i n g mesoco l o n is m o b i l ized off the retro perito­ n e u m (d uode n u m and G e rota's fascia) u s i n g a m e d i a l to l atera l d i ssection a p proa c h . To fac i l itate exposu re, the s u rg eon's l eft h a n d s h o u l d be p ro n ated a n d p l aced u n derneath the m esoco lon, g i v i n g u pwa rd traction for the retro perito n e a l d issect i o n

(FIG 7) . •

•

M o b i l ization of the right mesoco l o n is carried out l atera l ly to the a b d o m i n a l wa l l (FIG SA), s u periorly to the h e patore n a l recess (FIG 88), and m ed i a l ly expos i n g the t h i rd port i o n of the d u o d e n u m (FIG SC) . At t h i s poi nt, critica l structu res i n c l u d i n g the r i g h t u reter, the r i g h t g o n a d a l vein, a n d the d u oden u m a re i d e ntified a n d p rese rved i ntact in t h e retrope rito n e u m

• T h e ascen d i n g mesoco l o n is m o b i l ized off t h e retrope rito n e u m (d uod e n u m a n d G e rota's fa scia), u s i n g a m e d i a l to latera l d issection a p proa c h . To fac i l itate exposu re, the surgeon's l eft h a n d s h o u l d be pronated a n d p l aced u n d e rneath t h e mesoco lon, g i v i n g u pwa rd traction for the retrope rito n e a l d i ssect i o n .

FIG 7

(FIG 9) .

c

•

A. The m e d i a l to latera l d i ssection, pe rfo rmed b l u ntly with a 5-mm e n e rgy device, sepa rates the asce n d i n g mesoco l o n f r o m the retro perito n e a l structu res (Ge rota's fascia a n d d u o d e n u m) u n t i l reach i n g the l atera l a b d o m i n a l wa l l . B. The d i ssection is carried s u periorly u n t i l the h e patore n a l recess. C. The t h i rd portion of the duodenum is exposed m e d i a l ly. FIG 8

Retroperitoneum

Duodenum

I • After c o m p letion of the med i a l to latera l m o b i l ization of the asce n d i n g m esoco l o n , critica l structu res i n c l u d i n g the right u reter, the right g o n a d a l ve i n , a n d the d u o d e n u m a re i d e ntified a n d preserved i ntact i n t h e retroperito n e u m .

FIG 9

Right ureter

Right gonadal vein

C h a pt e r 1 1

R I G H T H E M ICO LECTO MY: Hand-Assisted Laparoscopic Surgery Technique

LATERAL MOBI LIZATI O N OF THE ASCE N D I N G COLON •

•

•

•

With the patient in a steep Tre n d e l e n b u rg posit ion, the small bowel is retracted out of pelvis, a n d the base of cecu m i s g rasped a n d retracted a nteriorly toward the a b d o m i n a l wa l l . With the i l e u m on stretch, a perito n e a l i ncision is created from the cec u m m ed i a l ly a l o n g the root of the i l e a l mes­ e ntery (FIG 1 0) to com m u n i cate with the retroco l i c space previ ously created by the m ed i a l to l atera l m o b i l ization of the asce n d i n g mesoco l o n . The rig ht u reter a n d the right g o n a d a l ve i n are m ost easily i d e ntified at t h i s phase of the operation co u rs i n g over the r i g h t i l iac vessels a n d i nto the p e l v i s (FIG 1 1 ) . Late ra l a n d a nterior to the psoas m u scle, the l atera l fe m ­ oral cuta neous n e rve is a l so freq u e ntly i d e ntified. The wh ite l i ne of To ldt is i ncised (FIG 1 2), d ivid i n g the o n ly rem a i n i n g atta c h m e nts of the asce n d i n g colon if the medial to latera l d i ssection was carried out adeq uately d u r i n g the previous ste p .

FIG 1 0 • With the patient i n a steep Tre n d e l e n b u rg position, the sma l l bowel is retracted out of pelvis, a n d the base of cec u m is g rasped a n d retracted a nteriorly towa rd the a bdom i n a l wa l l . With the i l e u m o n stretch, a peritoneal i ncision is created from the cec u m med i a l ly a l o n g the root of the term i n a l i l e a l mesentery.

Right ureter

Right gonadal vein

FIG 1 1 • After m o b i l ization of the cecum a n d term i n a l i l e u m, the right g o n a d a l vei n a n d the right u rete r a re seen in the retro perito n e u m cross i n g over the right i l iac a rtery a n d i nto the pelvis.

FIG 12 • With the s u rgeon retract i n g the colon m e d i a l ly, the l atera l atta c h m e nts of the asce n d i n g colon (wh ite l i ne of To l dt) a re tra n sected with an e n e rgy device i n a ce p h a l a d d i rect i o n .

MOBI LIZATION OF THE HEPATIC FLEXURE AN D THE PROXI MAL TRAN SVERSE COLON •

•

The patient is positioned in reverse Tre n d e l e n b u rg posi­ tion a n d the hepatic flexure ca n easily be exposed by g rasp i n g the colon in you r p a l m a n d p u l l i n g it downward and med i a l ly, as one wou l d d o d u ri n g open surgery. The h e patoco l i c l i g ament is transected with a 5-mm e n ergy device. The s u rgeon can fa c i l itate t h i s step by h o o k i n g h i s i n d ex f i n g e r u n d e r the h e patoco l i c l i g a ment

(FIG 1 3) .

• Tra nsection of the he patoco l i c l i g a m e nt. T h e hepatoco l i c l i g a ment is tran sected w i t h a 5-mm e n e rgy device. The s u rgeon can fa c i l itate this step by h o o k i n g h i s i n d ex fi n g e r u n d e r the hepatoco l i c l i g a ment as shown.

FIG 1 3

1 00 5

1 006

P a rt 4

•

•

OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

By p u l l i n g the transverse colon now d ownward, the gas­ troco l i c l i g a m e nt is rea d i ly expose d . The g a stroco l i c l i g a ment is transected u p to the m i dtrans­ verse co l o n with a 5-mm e n ergy device, and the lesser sac ente red .

BOWE L RESECTION AND ANASTOMOSIS •

•

O n ce the co l o n is co m p l etely m o b i l ized, the p n e u m o peri­ to n e u m is desuffl ated, and the r i g h t colon a n d term i n a l i l e u m a re exte riorized t h ro u g h t h e h a n d port site with the wo u n d p rotector i n p l ace to p reve nt oncologic a n d i nfectious conta m i nation o f the w o u n d (FIG 1 4). The extraco rporea l m o b i l ization of the rig ht colon a n d term i n a l i l e u m s h o u l d be feasi b l e without a n y tens i o n . S h o u l d t h e r e be a n y t e n s i o n d u r i n g the extra corpo rea l d e l ivery of the spec i m e n , reintroduce it i nto the a bdo­ men, reins uffl ate the p n e u m o perito n e u m , a n d m o b i l ize the right colon furt h e r to avo i d potent i a l ly tro u b l esome mesenteric tears that co u l d lead to s i g n ificant bleed i n g .

F I G 1 4 • Extracorporea l m o b i l izat i o n . T h e r i g ht c o l o n a n d the term i n a l i l e u m a re exte r i o r i zed t h r o u g h the h a n d port site with the wo u n d p rotector in p l ace.

•

•

•

•

•

•

The extent of m o b i l ization is d i ctated by the l ocat i o n of the pathol ogy, body h a b itus, a n d extract i o n site. With the hepatic fl exu re and the asce n d i n g colon n ow fu l ly m o b i l ized, we a re n ow ready for the extra corpo rea l m o b i l ization of the speci m e n .

The rema 1 n 1 n g m esentery o f the sma l l bowe l a n d t h e l a rg e bowe l is d ivided fo l l owed b y the d iv i s i o n o f t h e term i n a l i l e u m a n d m i dtra nsverse colon w i t h a l i n e a r sta p l e r device (FIG 1 5) . T h e resected r i g h t c o l o n is opened o n a s i d e ta b l e t o confi rm co m p l ete resect i o n o f the target l e s i o n a n d t h e spec i m e n is s e n t fo r f i n a l pathology. A side-to-side ileocolic anastomosis is performed (FIG 1 6A) . The completed anastomosis is i ntroduced back i nto the abdom i n a l cavity (FIG 1 68). Surgeons may choose from either a sta pled or a hand-sewn tech nique for the i l eocol ic anastomosis. The a b d o m e n is re i n sufflated to assure that there i s good hem ostasis as we l l as a correct bowel ori entat i o n .

FIG 1 5 • Extracorporeal transect i o n . The term i n a l i l e u m a n d the transverse co lon h ave b e e n tra nsected w i t h a l i near sta pler.

C h a pt e r 1 1

A FIG 1 6

R I G H T H E M ICO LECTO MY: Hand-Assisted Laparoscopic Surgery Technique

1 00 7

B •

Extra corpore a l a n a stomosis. A. A sta pled s i d e-to-si d e i l eotra nsverse colon a n asto mosis tech n i q u e is shown. B. The co m p l eted a n asto mosis will be i ntrod uced back i nto the a b d o m e n .

•

CLOSURE •

•

The po rts, the h a n d-assist d evice, a n d the wo u n d p rotec­ tor a re removed u n d e r d i rect v i s i o n . S u r g i c a l g l oves a re c h a n g e d to m i n i m ize the c h a n ce of a wo u n d i nfect i o n .

•

The h a n d-port fasc i a l i n c i s i o n is cl osed with a r u n n i n g a bsorba b l e m o n ofi l a m e nt sutu re ( n o . 1 polydioxa n o n e [PDS]). A l l w o u n d s are i r r i g ated and closed with s u bcuticu l a r 4-0 PDS sutu res.

PEARLS AND PITFALLS Preope rative loca l i zat i o n

•

Preoperative loca l ization of the lesion with a tattoo is crucial, especi a l ly f o r po lyps, as th ese can be d iffi c u l t to i d e ntify even with tact i l e feed back.

I d e ntification of t h e i l eoco l i c ped i c l e

•

The i l eocecal j u n ction should be e l evated to i d e ntify the i l eoco l i c vesse l s as the superior m esenteric vessels can easily be m i staken for the i l eoco l i c vesse ls.

Avo i d the s u pe r i o r mesenteric ve i n

•

When d issect i n g high o n the i l eoco l i c vessels, care should be taken to avoid the s u pe r i o r mesenteric ve i n .

I d e ntifyi n g t h e r i g h t u reter

•

T h e r i g ht u reter s h o u l d b e i d e ntified a n d preserved as i t c a n b e easily i n j u red i f y o u a re i n the wrong plane. Stay i n the loose a re o l a r plane located betwee n the asce n d i n g mesoco l o n a nteriorly and the retroperito n e u m poster i o rly.

S m a l l bowel orientation

•

B efore perform i n g an i l eoco l i c a n a stom osis, the o r i e ntat i o n of the sma l l bowel s h o u l d be ch ecked, a s the s m a l l bowe l can easily get twisted o n itself d u r i n g the extracorpore a l m o b i l izati o n .

POSTOPERATIVE CARE • •

• •

Patients are monitored on a surgical floor bed. Start a clear liquid diet on postoperative day 1 and advance diet as tolerated. Foley catheter is removed on postoperative day 1 . Most o f the patients are discharged home o n postoperative days 2 and 3 .

OUTCOMES •

•

Hand-assisted colectomy has been shown t o decrease the total operative time and conversion rate compared to con­ ventional laparoscopy.Z·5 The long-term survival of patients with colon cancer corre­ lates with the American Joint Committee on Cancer (AJCC) stage published guidelines.

1 008

P a rt 4

OPERATIVE TECH N I QUES I N COLON AND RECTAL SURGERY

COMPLICATIONS • • • • • •

Surgical site infection Anastomotic leak Postoperative bleeding Postoperative ileus Intraabdominal infection Incisional hernia

REFERENCES 1 . Naitoh T, Gagner M, Garcia-Ruiz A, et al. Hand-assisted laparoscopic digestive surgery provides safety and tactile sensation for malignancy or obesity. Surg Endosc. 1 99 9 ; 1 3 ( 2 ) : 1 5 7-1 60.

2 . Marcello PW, Fleshman JW, Milsom JW, et a!. Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial. Dis Colon Rectum. 2 0 0 8 ; 5 1 ( 6 ) : 8 1 8-826. 3 . NCCN clinical practice guidelines in oncology: colon cancer (Version 3 . 2 0 1 4 ) . http://www. nccn .org/professionals/physician_gls/f_gu ide! i nes .asp#site. Accessed January 7, 2014. 4. Mutch M, Cellini C. Surgical management of colon cancer. In: Beck DE, Roberts PL, Saclarides TJ, et al, eds. The ASCRS Textbook of Colon and Rectal Surgery. 2nd ed. New York, NY: Springer; 2 0 1 1 :71 1-720. 5 . Aalbers AG, Biere SS, van Berge Henegouwen MI, et a!. Hand­ assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis. Surg Endosc. 2 0 0 8 ;22 ( 8 ) : 1 769- 1 7 8 0 .

I

Right Hemicolectomy:

Chapter

Single-Incision Laparoscopic Technique

· ---------------------------------------4----------------------------------------------------- · I

Theodoros Voloyiannis

with the exception of the avoidance of use of multiple

DEFINITION •

Single-incision laparoscopic right hemicolectomy is a refined technique of conventional laparoscopy where a single mul­

laparoscopic ports. •

abdominal wall or other organs may be a contraindication

tichannel laparoscopic port is used via a 2.5- to 5-cm total

to single-incision laparoscopy, although excision en bloc

incision length. •

tiport laparoscopic technique. •

with soft tissue abdominal wall is still possible via a single

The goal is to keep the procedure simple, safe, and cost­ effective with comparable outcomes to hand-assisted or mul­ Although

single-incision

laparoscopy

differs

from

incision in some cases. •

petent ileocecal valve and small intestinal dilation may

conventional laparoscopy, it follows the same steps and

also suggest contraindication to laparoscopic approach

oncologic principles. It can be completed without difficulty

due to difficulty establishing a safe working space with

with an extracorporeal anastomosis. An intracorporeal

pneumoperitoneum. Anastomosis may be contraindicated

anastomosis can be performed as well; however, it requires scopic Endo GIA staplers.

in this case. •

operatively. Ileocecectomy or right hemicolectomy for neo­ plasia may require formal lymphadenectomy with en bloc resection of the ileocolic vascular pedicle. Hepatic flexure

The procedure can be performed for benign or neoplastic

or proximal transverse colon lesions may require additional

diseases or condition, including the following: •

Appendectomy

•

Ileocecectomy

•

Formal right colectomy

•

Extended right colectomy

resection of the right colic vein or right branch or the middle colic artery and vein and further mobilization of the proxi­ mal transverse colon. •

kidney, duodenum, small intestine, omentum, liver, and gall­ bladder, may require a hand-assisted laparoscopy or open

FINDINGS

laparotomy. Potential intraoperative consultation to other subspecialties may be required in these cases. It is the pri­

A detailed history and phy sical exam is essential preopera­

mary surgeons' responsibility to communicate with the con­

tively to determine if the patient is suitable for laparoscopic

sulting service that a single-incision laparoscopic approach

single-incision right hemicolectomy. Potential contraindica­

is planned.

tions to laparoscopic single-incision right hemicolectomy are summarized in Table 1. •

•

Failure to identify the tumor extent preoperatively may lead to longer operative time if a single-port technique is used.

In case of underlying neoplasia, the size of the tumor

Conversion to hand-assisted or open approach is prudent in

determines if it can be extracted without tension via the

these cases.

single-port wound protector. In general, tumors up to 7 em can be extracted via a 5-cm maximum length sin­

Involvement of other organs or structures, such as right ovary, small intestine, abdominal wall, right ureter, right

PATIENT HISTORY AND PHYSICAL

•

It is important to define the underly ing pathology-benign versus malignant disease and the location of the lesion pre­

DIFFER ENTIAL DIAGNOSIS •

Signs and sy mptoms of obstructing neoplastic lesion with proximal distended right colon with or without com­

the

advanced laparoscopic skills and the addition of laparo­

A large palpable tumor preoperatively with fixation to the

•

Presence of preoperative umbilical or other incisional her­ nia does not preclude a single-incision approach; however, it

gle incision. The procedure can still be performed with

may require lengthier operative time, extension of the inci­

elongation of the incision for extraction of larger tumors.

sion, and possibly placement of a xenograft.

In that case, the benefit of the single port is eliminated, •

Previous abdominal surgeries with extensive abdominal or pelvic adhesions may increase the operative time. A single incision may actually facilitate a faster abdominal adhesioly­ sis as it can partially be performed open via the port's wound

Table 1: Absolute Contraindications to

protector with assistance of a retractor.

Single-Incision Laparoscopic Right Coledomy •

-Complex terminal ileal or right colonic inflammatory bowel disease -Abscess, fistula, obstruction, perforation -Colon tumor size of more than 7 em -Colon obstruction with proximal massive intestinal distention - Preoperative decision for complex en bloc resection -Midline incisional hernia longer than the maximum single incision-S em

Crohn's terminal ileitis or right colitis with a large phleg­ mon or perforation with complex fistulae or abscess may preclude a single-incision laparoscopic approach.

•

Previous appendectomy is not a contraindication to single­ incision laparoscopic right hemicolectomy, as adhesions may be the only intraoperative finding with minimal increase to operative time.

1009

1010

P a r t 4 OPERATIVE TECH NIQUES I N COLON AND RECTAL SURGERY

IMAGING AND OTHER DIAGNOSTIC STUDIES

•

•

•

•

•

•

•

•

•

•

•

•

Preoperative colonoscopy with India ink tattoo inj ec­ tion is of paramount importance for smaller nonpalpable benign or malignant lesions or polyps, which are not re­ sectable endoscopically. The surgeon must clearly identify the site of the tattoo at 5 em distal to the lesion preopera­ tively in the absence of other anatomic landmarks, such as the ileocecal valve or the appendiceal orifice and the cecum itself. India ink tattoo by different gastroenterologists has been reported to be placed proximally around the lesion, distal to the lesion, or both proximal and distal to the lesion, leading occasionally to a false distal colonic resection margin. Inadvertent extracolonic India ink injection may lead to inflammatory-diverticulitis type-reaction of the surround­ ing mesentery and omentum, thus making the single-incision laparoscopic colonic mobilization challenging. Absence of preoperative tattoo for smaller or nonpalpable lesions distal to the ileocecal valve may lead to failure to localize the lesion intraoperatively, lengthy procedure and possible need for intraoperative colonoscopy, and conver­ sion to laparotomy. This may lead to significant air insuffla­ tion of the colon and small intestine unless a carbon dioxide (C0 2 ) colonoscopic insufflation is available. Compressing the terminal ileum with a laparoscopic grasper during the intraoperative colonoscopy may prevent small intestinal distension. Computed tomography of the abdomen and pelvis with oral and intravenous ( IV) contrast helps determine the feasibility of a single-incision laparoscopic approach and identifies the exact location of larger right colonic neo­ plastic lesions, involvement of adj acent organs or struc­ tures, mesenteric adenopathy and possible metastatic lesions, hernia, and other abdominal nonrelated pathol­ ogy. Inflammatory disease of the terminal ileum or right colon is suspected by the presence of phlegmon, abscess, fistula, or obstruction. Magnetic resonance imaging (MRI) of the abdomen may assist with the identification of indeterminate liver lesions and with the assessment of metastatic lesions preoperatively. Positron emission tomography (PET) computed tomography is not generally needed preoperatively. Preoperative barium enema or small bowel follow-through contrast study has generally been replaced by colonoscopy. Ultrasound (US) of the abdomen has limited usefulness for the identification of colonic pathology. A carcinoembryonic antigen is obtained as baseline tumor marker for surveillance.

•

Preoperative medical or pulmonary cardiac clearance as necessary. Correction of preoperative anemia as needed. IV antibiotics, venous thromboembolism (VTE) prophylaxis, fLU-receptor antagonist (alvimopan) immediately preopera­ tively, correction of electrolyte abnormalities.

Instrumentation •

• •

• • • • •

•

•

A bariatric length, 1 0-mm 30-degree camera is used. Use a right-angle adaptor for fiberoptic attachment to the camera, if needed, to avoid conflict of the fiberoptic cord with other laparoscopic instruments. Use a preheated camera or other devices for camera lens cleansing. Repeated camera cleans­ ing requires frequent removal via the single port, which adds time to the procedure. Two bariatric length laparoscopic bowel graspers are used. Bariatric length laparoscopic energy device such as 43 -cm LigaSure, 5 mm with monopolar tip, Enseal, or similar is used. Energy devices that produce excessive moisture/fog may impair the visibility as most single-incision laparoscopic ports have a side port for smoke evacuation at the same level with the channel for air insufflation. Bariatric length laparoscopic 5-mm suction irrigation Laparoscopic smoke evacuator channel Laparoscopic scissors Laparoscopic 5-mm or 1 0-mm clip applier ( optional) Laparoscopic Endoloop polydioxanone (PDS) for the ileoco­ lic vascular pedicle Staplers: linear gastrointestinal anastomosis ( GIA) 75-mm, double, or preferably triple line, blue staple cartridges Second set of instruments for extracorporeal anastomosis

Patient, Team, and Operating Room Setup •

•

•

The patient is placed over a foam pad on supine position with the arms and legs tucked to the side and secured to the table with a Velcro safety strap or broad tape across the chest and lower extremities ( FIG 1 ) . Sequential compression devices (SCDs) are applied t o the lower extremities. A laparoscopic operating room (OR) table with steep tilt­ ing is used. Test maximum tilting prior to draping to assess patients' secure positioning on the table.

SURGICAL MANAGEMENT Preoperative Planning •

Full bowel preparation is administered the day prior to sur­ gery. Right colectomy without bowel preparation is equally safe but it may increase the weight and volume of the right colon and impair the laparoscopic handling of the colon. Furthermore, extraction of the specimen via a small 3 . 5-cm single incision may become challenging.

• Pat ient positi o n i n g . The patient is p l a ced over a foa m pad on s u p i n e position with the a rm s a n d legs tucked to the s i d e a n d secured to the ta b l e with a Ve lcro safety strap o r b r o a d t a p e across the ch est a n d l o w e r extre m ities.

FIG 1

C h a p t e r 1 2 R I G HT H E M I CO L ECTO MY: Sing le-Incision Laparoscopic Technique

•

•

•

•

•

1 01 1

Anesthesiologist

A Foley catheter is inserted and taped over the right thigh in order to avoid urethral trauma during patient position­ ing changes throughout the operation. A bear hugger or other thermal device is applied to the chest and legs. Protecting foam pad is placed over the head to protect from injury with laparoscopic instruments. The laparoscopic tower and energy devices are placed to the right of the patient's head. The surgeon stands to the patient's left side with the assistant standing to his right side ( FIG 2 ) . The scrub nurse stands by the patient's right leg. One or two high-definition monitors are placed to the patient's right side at eye level in front of the surgeon.

Assistant

Monitor Surgeon

N u rse

FIG 2 • Tea m positi o n i n g . The s u rgeon sta n d s to the patie nt's l eft s i d e with the assistant sta n d i n g to h i s r i g h t s i d e . The scr u b n u rse sta n d s by the patie nt's r i g ht l e g . O n e o r t w o h i g h-defi n i t i o n m o n itors a re p l aced to the patie nt's r i g h t s i d e at eye l eve l , i n front of the s u rg e o n .

DIAG N OSTIC LAPAROSCOPY-S I NG L E M U LTICHAN N E L PORT TECH N I Q U E •

•

•

•

After positi o n i n g a n d secu r i n g the patient, the a b d o m i ­ n a l field is prepped a n d d ra ped. W e reco m m e n d l a p a ro­ sco p i c d r a p i n g with side p l astic bags/pockets to a l l ow for bar iatric i nstru ment p l acement. A l l l a p a rosco p i c cords a re brought via the patie nt's u p p e r ch est s i d e a n d secu red with the d ra pe's Ve lcro. A 3 . 5-cm vertical m i d l i n e i n c i s i o n is performed with n o . 1 1 sca l pe l t h r o u g h the u m b i l i cus (FIG 3A,B) . Asse m b l e a l l c h a n n e l s o f the s i n g l e port o n the b a c k table to avo i d losi n g p a rts outside the ste r i l e f i e l d . Place the

•

l a p a rosco p i c m u lt i c h a n n e l s i n g l e port (fo r neoplasia, a single port with a wo u n d p rotector is req u i red) (FIG 4A,B) . I ns uffl ate C0 2 p n e u m operito n e u m to 1 5 m m H g . Perform a d i a g n osti c l a p a rosco py. T h e s u r g i c a l assista nt/ c a m e ra h o l d e r a n d the s u rgeon sta n d by the patie nt's l eft si de, with the assistant to the su rgeon's r i g ht s i d e . Ti lt the O R ta b l e to a stee p Tre n d e l e n b u rg position a n d a i rp l a n e it to the l eft f o r maxi m u m exposure of the i l eoco l i c ped i c l e a n d the m e d i a l m o b i l ization of t h e sma l l i ntest i n e . There i s n o need for p l a cement of sponges o r Ray-Tees i n the a b d o m e n for retract i o n . M i n i m i ze exc u rsio n/c l uster effect a r o u n d h a n d s a n d c a m e ra betwee n the s u r g i c a l assista nt a n d t h e operati n g

B

A FIG 3

•

S i n g l e - i n c i s i o n l a p a roscopic s u rgery (SI LS) port p l a cement. A. S k i n m a r k i n g s . B. S k i n i n c i s i o n .

1012

A

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

8 FIG 4 • S i n g le-incision l a p a rosco pic surgery (SI LS) port p l acement a n d confi g u ration. A. A wou n d p rotector is used. B. A m u lti port c h a n n e l with th ree wo rking ports a n d i nsufflation port a n d a smoke evacuator port is used . The port is asse m b led on a side ta b l e prior to i nsertion i n the patient.

•

s u rg e o n . Ad h e re to the p r i n c i p l e that t h e s u rgeon s h o u l d position h i s assist i n g ( n o n d o m i n a n t h a n d) i nstru­ ment d i sta l tip (fo r g rasp i n g , retract i n g , o r sucti o n i n g) a s c l ose as poss i b l e to h i s d o m i n a nt operati n g i n st r u m ent tip (i.e., e n e rgy device at the d i ssect i n g surgical p l a n e) . This d i stance s h o u l d be a bout 3 to 4 em betwee n t h e two i nstru m e nts' ti ps. F o r exa m p l e, h o l d the i l eoco l i c vasc u l a r ped i c l e j ust a b ove the site of the d ivision site rat h e r than h o l d i n g the cec u m itse lf which is fa r m o re d i stant from t h e ped i c l e . T h i s tech n i q u e a l l ows a c h i evi n g a wide a n g l e betwee n the two i n stru m e nts outs i d e t h e a b d o m e n as t h ey e x i t a n d cross via the s i n g l e po rt, t h u s lead i n g to no i n strument c l u ster effect betwee n the s u rgeon's h a n d s . The assista nt camera h o l d e r w i l l avo i d c l u ste r i n g with the s u rgeon's i nstr u m e nts outs i d e the a b d o m e n if h e o r she a b d ucts the camera a s fa r as poss i b l e from the su rgeons' h a n d s a n d uses the cam era 's 30-deg ree a n g u lation for side view as we l l a s the zoo m - i n option.

•

•

•

•

DIVISION OF THE ILEOCOLIC VASCULAR PEDICLE AND MEDIAL TO LATERAL

•

MOBILIZATION OF THE ASCENDING MESOCOLON

•

•

•

•

The patient is positioned i n a stee p Tre n d e l e n b u rg position with t h e t a b l e t i lted maxi m a l ly towa rd t h e patie nt's l eft s i d e . The s u rg e o n sta n d s o n t h e patie nt's lower l eft s i d e, u s i n g a g rasper i n t h e n o n d o m i n a nt h a n d a n d a n e n e rgy d evice on t h e d o m i n a nt h a n d . The assista nt sta n d s u p t h e s u rg e o n 's right s i d e h o l d i n g t h e ca m e r a . If the omentum is a d h e rent m ed i a l ly to the right co lon, we sta rt the p roced u re with the d i ssect i o n of the omentum off the colon or perform an o m e ntecto my to

•

M i n i m ize the need for freq uent i n strument exchange via the single port, such as for ca mera lens clea n i n g o r exchange of g raspers with monopolar laparoscopic scissors. Instead, consider using energy devices that p rovide both dissection and sea l i ng-cutti ng effect, thus a l lowi ng consta nt p rog ress in the operating field a n d sign ificant time savi n g . The s u rgeon a n d the assista nt ca n e i t h e r switch sides (ca u d a l a n d cep h a l a d to the patient's l eft side) d u ri n g the va rious ste ps of the p roced u re o r j u st rotate the s i n g l e port cl ockwise o r cou nterclockwise w h i l e the i nstruments stay in the abdomen u n d e r d i rect visual ization with the camera, thus achievi n g different a n g les with the ca mera, better exposu re, and visu a l izati o n . If t h e surgeon's h a n d s a re cross i n g , then rotati n g t h e port o r switc h i n g positions with the assista nt (ca u d a l­ cephalad) w i l l i m p rove expos u re . The O R table is a lso ti lted accord i n g ly d u r i n g the va rious steps of the proced u re to i n crease exposure a n d p revent i nstrument c l u steri n g .

a l low f o r maxi m u m exposure o f the i l eoco l i c ped icle a n d the asce n d i n g c o l o n mesentery. D i ssect the term i n a l i l e a l retro perito n e a l atta c h m e nts and m o b i l ize it m ed i a l ly toward the m i d l i n e . Ide ntify the i l eoco l i c vesse l s as they cross over the t h i rd portion of the d u o d e n u m (FIG S). Perform a m e d i a l to l atera l m o b i l ization of the asce nd­ i n g mesoco l o n (FIG 6) . D i ssect u nd e r (dorsa l) the i l eoco l i c vesse ls, ente r i n g the p l a n e betwee n the asce n d i n g m eso­ colon and the retro perito n e a l structu res (d uode n u m a n d G e rota's fascia). T h e transition between the fat p l a nes of the asce n d i n g m esoco l o n and G e rota's fa scia ca n be easily i d e ntified and aids to stay in the proper d issection plane. U s i n g a n e n e rgy device, we d ivide the i l eoco l i c vasc u l a r ped icle at its orig i n a s it crosses the t h i rd portion o f t h e

C h a p t e r 1 2 R I G H T H E M I CO L E CTOMY: S ingle-Incision Laparoscopic Technique

FIG 5 • I d e ntification the i l eoco l i c vesse ls (I CV) as they cross over the t h i rd portion of the d uoden u m .

FIG 7 • Tra nsect i o n of t h e i l eoco l i c vesse l s (ICV) . Using a n e n e rgy device, w e d ivide the i l eoco l i c vasc u l a r ped icle at its o r i g i n as it crosses the t h i rd port i o n of the d u o d e n u m .

• •

•

F I G 6 • Medial t o latera l dissection o ft h e ascending mesocolon. Dissect under (dorsa l) the i leoco l i c vessels, entering the plane between the ascending mesoco lon a n d the retroperitoneal structu res (d uodenum a n d Gerota's fascia). The transition between the two fat pla nes (mesocolon a n d Gerota's fascia) can be easily visu a l i zed (dotted line).

•

d u o d e n u m (FIG 7) wh i l e h o l d i n g t h e vesse l stu m p with a g rasper to avoid retract i o n or res i d u a l bleed i n g . P l a ce h e m ostati c c l i ps or E n d o l oo p PDS at the d ivided stu m p to secu re the h e m ostasis. There is no need for l a p a rosco pic sta p l e d ped i c l e d ivision u n less severe atherosc l e rosis o r vesse l s l a rg e r t h a n 7 mm i n size a re p resent, which prec l u d e usage of a l a p a ro­ sco p i c e n ergy device. I n that case, we may use an E n d o G I A sta p l e r w i t h a vasc u l a r l o a d . Co m p l ete the m e d i a l to latera l d issect i o n of the asce n d ­ i n g colon mesentery, off the retro perito n e a l atta c h m e nts without ente r i n g G e rota 's fascia, identify i n g a n d pro­ tect i n g the r i g ht g o n a d a l vesse l s and the right u reter. Cont i n u e the m ed i a l to l atera l d issect i o n of the asce n d ­ i n g colon mesentery i n a cep h a l a d d i rection, separat i n g it f r o m the seco n d a n d t h i rd portion o f the d u o d e n u m a n d the head of the p a n creas i n a n atra u matic fas h i o n . T h i s wi l l a l l ow f o r a n e a s i e r m o b i l ization o f the hepatic flexure later d u r i n g the case.

MOBILIZATION OF TERMINAL ILEUM, ASCENDING COLON, HEPATIC FLEXURE, AND PROXIMAL TRANSVERSE COLON •

•

D ivide the term i n a l i l e a l mesentery with e n e rgy device flush to the i l eoco l i c vasc u l a r ped icle up to t h e mesen­ teric border of the term i n a l i l e u m at t h e sel ected site of prox i m a l i ntest i n a l d ivision (FIG 8). I n a d d ition, t h e term i n a l i l e u m is m o b i l ized off the ret­ roperito n e a l atta c h m ents towa rd the m i d l i n e. T h i s w i l l a l l ow f o r a tension-free extract i o n v i a the s i n g l e port site for the extracorporea l d ivision without tension o r risk for avu l s i n g the mesentery. M o r b i d ly o bese patie nts req u i re generous term i n a l i l e u m m ed i a l m o b i l ization to a l l ow for a tension-free spec i m e n extract i o n via the single port.

FIG 8 • D ivision of term i n a l i l e u m mesentery. Tra n sect the term i n a l i l e u m mesente ry d own to the bowe l wa l l with the e n e rgy device, kee p i n g the i l eoco l i c vesse l s (I CV) i n the speci m e n side.

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FIG 9 • Late ra l m o b i l ization of the asce n d i n g mesoco l o n . Tra n sect the wh ite l i n e o f To ldt (dotted line) w i t h the e n e rgy device.

•

•

•

•

•

M o b i l ize the ascen d i n g colon m ed i a l ly by tra nsect i n g its l atera l perito n e a l atta c h m e nts (th e wh ite l i n e of To l dt) (FIG 9) . P l a ce the patient on a reverse Tre n d e l e n b u rg position a n d keep the O R t a b l e ti lted to the l eft. The s u rgeon is positioned n ow ce p h a l a d a n d t h e assista nt/camera h o l d e r is positioned to h i s or h e r l eft sid e. E nter the lesser sac via the anti mesente ric border of t h e prox i m a l transverse colon (FIG 1 0) a n d pe rfo rm a form a l hepatic flexure m o b i l ization u s i n g t h e e n e rgy device. E l ect the poi nt of d i stal d ivision of the right co l o n a n d d ivide the correspo n d i n g m esentery u p t o the site o f t h e d i sta l resection m a rg i n a n d t o the r i g ht o f the m i d d l e co l i c vesse ls (FIG 1 1 ) . A m o r e g e nero u s d i sta l m o b i l ization of the c o l o n is req u i red compa red to h a n d-assisted l a p a rosco py, by a p p roxi m ately a nother 5 em, to a l l ow for a tension­ free extract i o n of the spec i m e n a n d to avo i d mesenteric avu lsion during spec i m e n extract i o n .

FIG 1 0 • E ntrance to the lesser s a c . E n t e r the lesser sac v i a t h e a n t i m esenteric b o r d e r of the p roxi m a l transverse co l o n a n d perform a form a l hepatic fl exu re m o b i l izat i o n u s i n g the e n e rgy device.

FIG 11 • D ivision of the m i dtransverse colon mesentery. E l ect the point of d i stal d ivision of the r i g ht colon a n d d ivide the correspo n d i n g mesentery u p to t h e site of the d ista l resection m a rg i n a n d to the ri ght of the middle co l i c vesse ls.

EXTRACORPOREAL MOBILIZATION AND TRANSECTION OF THE SPECIMEN • •

•

•

•

G rasp the term i n a l i l e u m at the proxi m a l resect i o n site securely before evacuating the p n e u m o perito n e u m . P l a ce wet l a p sponges a r o u n d the wound p rotector a n d u s e a seco n d towe l f o r the i n st r u m e nts used f o r creat ion of the a n asto mosis i n order to avo i d feca l conta m i nation to the l a p a rosco p i c s u rg i c a l d ra pes. Extract the term i n a l i l e u m fi rst a n d d ivide it with a G IA l i n ear 75-mm, d o u b l e or t r i p le, b l u e sta p l e load (FIG 1 2) . Use a g rasper to h o l d i nto the term i n a l i l e u m sta p l e d stu m p l i n e a n d rei ntroduce i nto the a b d o m e n . Extract the r ig h t colon a n d d ivide it at the d ista l site with a G IA l i n e a r 75-mm, d o u b l e o r t r i p le, blue sta p l e load (FIG 1 3) . If the colon with t h e attached mese ntery is too t h i c k o r i n case of neoplasia the t u m o r is l a rg e r t h a n the i ncision, t h e n e l o n gate the i n c i s i o n superiorly u s i n g a n a rmy navy

FIG 1 2 • Extracorporea l tra nsection of the term i n a l i l e u m . Extract the term i n a l ileum fi rst a n d d ivide it with a G I A l i n e a r 7 5 - m m d o u b l e or t r i p l e b l u e sta p l e l o a d .

C h a p t e r 1 2 R I G H T H E M I CO L E CTOMY: S ingle-Incision Laparoscopic Technique

•

retractor to " hook" under the fascia a n d p rotect the wound p rotector from perforat i o n . Use a n o . 1 1 sca l pe l i n a sawi n g m o t i o n o r e l ectroca utery to e l o n gate the i n c i s i o n as necess a ry a n d extract the speci m e n . Divide t h e re m a i n i n g mese ntery a n d pass the spec i m e n to pathol ogy, o r open the spec i m e n at the back ta b l e to confirm a d e q u ate m a r g i n s in case of n e o p l a s i a .

FIG 1 3 • Extracorporea l tra nsect i o n of the m i dtra n sverse co l o n . Extract the righ t colon and d ivide it at the d ista l site with a GIA l i n e a r 75-mm, d o u b l e o r trip le, b l u e sta p l e l o a d .

EXTRACORPOREAL ANASTOMOSIS •

•

Perform an extracorporea l side-to-side, funct i o n a l e n d ­ to-en d , i l eotra n sverse a n a stomosis w i t h a G IA l i n e a r 75-mm, d o u b l e o r t r i p le, b l u e sta p l e load (FIG 1 4A,B) . I n s pect the i l e a l a n d co l o n i c seg m e nts to r u l e out tors i o n p rior to f i r i n g the sta p l e r. The s u rgeon can p a l pate with a f i n g e r a l o n g the mesenteric m a r g i n of the term i n a l i l e u m mesentery a n d t h e d ista l colon mesentery towa rd the base at the retroperito n e u m a n d e n s u re that there is n o i ntest i n a l tors i o n .

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I n spect for b l eed i n g from the a n a stomotic l i n e . Approxi m ate the a n asto motic stu m p d efect w i t h a n other GIA l i n e a r 75-mm, d o u b l e o r t r i p le, blue sta p l e l o a d . Sometim es, a seco n d load is req u i red, t h u s e l i m i n ati n g the n e e d f o r a thoracoa bdom i n a l (TA) d o u b l e sta p l e l i ne, a l t h o u g h its use re m a i n s o n the s u rgeon's p refere nce. I ntroduce the a n asto mosis i nto the a bd o m e n ; i n s pect for b l eed i n g and feca l spi l l a g e . Cover the a n asto mosis with the rest of the omentum o r s m a l l i ntest i n e and e n s u re there is no torsion of the a n a stomosis. When i n d o u bt, p roceed aga i n with l a p a roscopic i n s pect i o n .

A B FIG 1 4 • Extraco rporea l a n asto mosis. A. An a n atomic side-to-side, f u n ct i o n a l end-to-e n d sta p l e d i l eoco l o n i c a n a sto mosis is constructe d . B. The a n asto mosis is tensio n-free a n d has exce l l ent b l ood s u p p ly.

WOUND CLOSURE •

•

It is advised to p l a ce an a n t i a d h esive s h eet poste rior to the m i d l i n e fasci a edges w h i l e avo i d i n g contact with the a n asto motic sta p l e l i nes. Rem ove the wo u n d p rotector and c l ose the fasc i a l i n c i s i o n with n o . 1 PDS suture. I r r i g ate the wound copiously with n o r m a l s a l i ne; o bta i n wound h e m ostasis.

•

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Approxi m ate the s k i n edges with sta p l es w h i l e leav­ ing the u m b i l i ca l skin edges opened and tucked with a Vase l i n e g a u z e with a cotton ba l l . T h e p roced u re is a c lea n conta m i nated o n e a n d l eav­ ing the u m b i l icus s k i n edges open may p rotect it from wo u n d i nfect i o n .

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PEARLS AND PITFALLS Preoperative wo r k u p

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Correct i d e ntificat i o n of the u n d e r l y i n g pathology a n d exte nt of the t u m o r i n re lation t o o t h e r organs a l l ows for ca refu l selection of the l a p a rosco p i c s i n g le-i ncision tech n i q u e .

Lesi o n loca l i zation

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India ink tattoo p l acement when i n d i cated for preoperative loca l i zat i o n of the lesion and the d i st a l resection margin is of paramount i m porta nce.

Patient positio n i n g, l a p a roscopic i n strume nts

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Secu r i n g the patient's position, use of O R table tilting, s i n g l e port rotation, and usage of bariatric l e n gth i nstr u m e nts and camera a re n ecessa ry for l a p a rosco pic s i n g le-i ncision s u rg e ry.

S u rgeon a n d assista nt position

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The s u rgeon s h o u l d change his o r h e r positi o n i n re lation to the assistant severa l t i m es d u r­ i n g t h e p roced u re i n order to a c h i eve a d e q u ate exposure a n d visu a l izat i o n .

La pa rosco p i c i n strument a n d tissue h a n d l i n g

• T h e t i p o f the assist i n g a n d d o m i n a n t l a p a rosco p i c i nstru m e nts a re positioned as cl ose as poss i b l e to each other i n the surgical field i n order to avo i d hand c l u ste r i n g outside the a bd o m e n .

POSTOPERATIVE CARE • A fast-track postoperative laparoscopic course is initiated. • The orogastric tube is discontinued in the OR upon comple­ tion of the procedure. • IV acetaminophen, alvimopan, and opioid patient-controlled anesthesia (PCA) or abdominal wall nerve block- " tap " is used as per surgeon's preference the day of surgery. Discon­ tinue the PCA within 36 hours and add IV or oral nonsteroi­ dal antiinflammatory drugs (NSAIDs) such as ketorolac to transition to oral analgesics. • Ice chips/water sips is introduced the day of surgery with the goal to advance to clear liquids within 24 hours and to a regular high-fiber diet within 48 hours postoperatively. • The Foley catheter is discontinued within 24 hours. • Perioperative antibiotics, VTE protocol-mechanical and pharmacologic-as well as early ambulation is initiated within 24 hours of surgery. • Incentive spirometer is initiated as per standard hospital policy. • Wound care need is minimal: Remove the umbilical dressing 2 to 3 days postoperatively. • The patient usually can be safely discharged home within 72 hours when passage of flatus is documented and regular diet is tolerated by at least two consecutive meals, and there are no other adverse postoperative findings such as signs of infection. • There is no need to wait until the patient has a bowel move­ ment prior to discharge. • No weight lifting more than 20 lb is recommended for 4 to 6 weeks postoperatively in order to avoid incisional hernia. OUTCOMES • Single-port laparoscopic hemicolectomy is considered to be an equally safe and cost-effective technique with better cosmesis, similar morbidity and operative time, possible less postoperative pain and faster return to full activities, possible shorter hospital stay, and comparable oncologic outcomes when performed for neoplastic diseases to con­ ventional hand-assisted or multiport laparoscopic approach. • It is achieved with equipment that the hospital already has available, with the exception of the single port which is not reusable, and requires no additional training for the opera­ tive room personnel while it is reproducible by surgeons who perform advanced laparoscopy.

• It does require one assistant to the surgeon who has advanced laparoscopic skills. • The laparoscopic single-incision right colectomy technique may contribute to decreased total hospital cost. COMPLICATIONS • The procedure has similar morbidity and mortality rates and comparable rates for conversion to laparotomy when compared to conventional laparoscopy. • Anastomotic leak rate is less than 2 % . • The single-incision laparoscopic technique for right hemico­ lectomy has the option for conversion to multiport or hand­ assisted Iaparoscopy. • Because a larger sized Ia paroscopic port is used, there is a slight increase in the incidence of incisional hernia ( 1 % o r more) compared to multiport laparoscopy. However, the incisional hernia rates are similar to the ones in hand­ assisted Iaparoscopy. • Single-incision laparoscopy may require a longer operative time during the early learning curve. This can complicate an already challenging operation especially for hepatic flexure or proximal transverse colon neoplastic lesions. • It is intrinsically a one-operating surgeon technique with less involvement of the assistant surgeon and with a potential negative impact on resident education during the learning curve period. SUGGESTED READINGS 1. Mufty H, Hillewaere S, Appeltans B, et al. Single-incision right hemicolectomy for malignancy : a feasible technique with standard laparoscopic instrumentation [Review]. Colorectal Dis. 2012;14( 1 1 ) : e764-e770. 2 . Chen WT, Chang SC, Chiang HC, et al. Single-incision laparoscopic versus conventional laparoscopic right hemicolectomy : a comparison of short-term surgical results. Surg Endosc. 201 1 ;25(6 ) : 1 8 87- 1 8 92. 3 . Chow AG, Purkayastha S, Zacharakis E, et al. Single-incision lapa­ roscopic surgery for right hemicolectomy. Arch Surg. 201 1 ; 146(2): 1 8 3-1 86. 4. Ramos-Valadez D I , Patel C B , Ragupathi M , e t al. Single-incision laparoscopic right hemicolectomy : safety and feasibility in a series of consecutive cases. Surg Endosc. 2 0 1 0;24 ( 1 0) : 26 1 3-26 1 6 . 5 . Chambers WM, Bicsak M , Lamparelli M , e t al. Single-incision lapa­ roscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis. Colorectal Dis. 201 1 ; 1 3 (4 ) : 3 9 3-3 9 8 .

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Chapter

13

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Transverse Colectomy: Open Technique ·

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Y. Na n cy Yo u

DEFINITION • The transverse colon is the segment of the abdominal colon between the hepatic and the splenic flexures. The transverse colon is an intraperitoneal organ of variable length, bound by the two flexures, which are second­ arily retroperitoneal areas of the colon typically fixed in position. • The main blood supply to the transverse colon is the middle colic vessels. The transverse colon, with transverse mesoco­ lon and middle colic vessels, lies in intimate proximity to the lesser sac, which is in turn bound by the quadrate lobe of the liver, the stomach, the pancreas, and the omentum. The operative surgeon must be fully familiar with these anatomic relations in order to avoid inj ury to these nearby structures. • Transverse colectomy is a relatively uncommon procedure, as pathology in the proximal transverse colon is often ad­ dressed by an extended right hemicolectomy, whereas pa­ thology in the distal transverse colon is often addressed by an extended left hemicolectomy. • Indications for transverse colectomy may be broadly divided into benign and malignant reasons. • Benign diseases with pathology focally located within the segment of the transverse colon represent the most natural indication for transverse colectomy. Examples may include focal inflammatory processes, localized trauma, or local perforation. • Transverse colectomy for primary malignancies of the transverse colon has been controversiaJ.l Because of the varying contributions to the lymphatic drainage of the transverse colon cancer from the ileocolic, the right colic, and the left colic blood vessels, extended right or extended left hemicolectomy has been preferred over seg­ mental transverse colectomy for primary tumors of the transverse colon. 2 • Transverse colectomy may be required as a part of a curative en bloc resection of a noncolonic malignancy arising from a nearby organ due to the close proximity of the transverse colon to other structures around the lesser sac. Surgeons must be cognizant of anatomic relations in order to safely carry out the intended operation.

Tissue diagnosis by biopsy should be secured in order to execute the optimal treatment regimen according to the primary malignancy. PATIENT HISTORY AND PHYSICAL FINDINGS • The goals of preoperative assessment should include deter­ mining whether urgent versus elective intervention is needed, facilitating intraoperative planning, and assessing the ben­ efits versus risks toward a sound surgical decision. • The patient should be examined for fitness to undergo an operation through a detailed assessment of patient's medi­ cal history, performance status, medication regimens, other medical needs, and psychosocial competency. • Symptoms such as abdominal cramping, difficulty with passage of stool or flatus, bleeding, or severe pain should be queried. Conditions that would necessitate urgent/ emergent rather than elective surgical intervention must be ruled out. Patients with an obstructing transverse colonic lesion and a competent ileocecal valve can rap­ idly develop a closed loop obstruction with high risks for ischemic colon and perforation and must be attended to emergently ( FIG 1 ) . • Elements o f prior surgical history that may present intraop­ erative difficulties such as previous stomach, pancreas, or colonic operations, and prior antecolic or retrocolic bowel bypass reconstructions, must be elicited. Prior operative reports should be obtained and reviewed. IMAGING AND OTHER DIAGNOSTIC STUDIES • All patients should ideally undergo both abdominal-pelvic cross-sectional imaging as well as endoscopic examination with possible biopsies.

DIFFERENTIAL DIAGNOSIS • Endoscopic tissue biopsy is a key step in the diagnostic workup of patients with both benign and malignant diseases involving the transverse colon. • In patients presenting with a locally advanced tumor mass that obliterates the lesser sac and involves adjacent organs such as the stomach, the pancreas, and the transverse colon, care must be undertaken to differentiate malignan­ cies of the colonic origin versus those that arose from adja­ cent organs but involves the transverse colon secondarily.

FIG 1 • CT sca n s h owi n g an obstruct i n g tra n sverse co l o n i c lesion (A) i n a patient with a com petent i l eoceca l valve. Cl osed loop obstruction ca u ses m assive d i lation of the cec u m (B). The h i g h risks fo r isc h e m i a a n d perforat i o n req u i re e m e rgent s u rg i ca l i ntervent i o n .

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SURGICAL MANAGEMENT • Thorough preoperative preparation, confirming that the diagnosis is correct, the indication is appropriate, and that possible intraoperative findings have been anticipated and planned for, is the basis for successful intraoperative man­ agement and the speedy postoperative recovery. FIG 2 • C o l o n osco p i c view of a mass l e s i o n i n t h e tra n sverse c o l o n , w h i c h i s recog n i zed by the t r i a n g u l a r s h a p e of the bowe l l u m e n and the a n c h o r i n g s p l e n i c and hepatic flexu res. H i sto l o g i c d i a g n o s i s c a n be o bta i n ed by e n d osco p i c b i o psy of the mass.

• Endoscopic examination of the colon should be undertaken preoperatively to confirm the location and the focality of the pathology within the transverse colon ( FIG 2 ) . Endoscopically, the transverse colon can be recognized by the triangular shape of the bowel lumen as well as by the anchoring landmarks of the splenic and hepatic flexure s . If there is any doubt as t o whether the lesion will be able to be localized with confidence intraoperatively, then the lesion should be marked with endoscopic tattooing. If there is any concern for involvement of adj acent organs, such as the stomach, an esophagogastroscopy should also be performed.3 • Cross-sectional imaging of the abdomen is performed through computed tomography (CT) or magnetic resonance imaging (MRI) scans. Imaging characteristics may supple­ ment histologic data and aid in the differential diagnosis. In addition, percutaneous biopsy may be needed. In cases of malignant disease, imaging will help differ­ entiate between colonic and noncolonic origin of the disease. Presence of distant metastatic disease and evidence of direct local invasion to adj acent organs should be assessed and appropriate intraoperative management plans should be made. Finally, any abnormal-appearing adenopathy along ves­ sels other than the middle colic vascular should be specifi­ cally assessed in order to determine whether the particular malignancy would be better managed through an extended right or extended left colectomy rather than a transverse colectomy.

INCISION AND ABDOMINAL EXPLORATION • •

A m i d l i n e i n c i s i o n exte n d i n g from the e p i g astri u m to below t h e u m b i l icus is m a d e . The a b d o m i n a l cavity is exp l o red for the presence of other pathology n ot i d e ntified by preoperative i m a g ­ i n g . I n cases of m a l i g n a nt d i sease, perito n e a l l i n i ng,

Preoperative Planning

• The operative surgeon should thoroughly review the patient's history and diagnostic workup to minimize any unexpected and unplanned for intraoperative finding. • Diagnostic biopsy and histologic results should be verified. A malignant diagnosis should be particularly noted in order to help determine the extent of the bowel resection and lymphadenectomy. • Documentation from preoperative endoscopy should be reviewed, particularly if the operative surgeon did not per­ form the procedure. The presence and location of a marking tattoo should be confirmed. • Preoperative imaging is used to help anticipate any involve­ ment of the adj acent organs and the possible need for en bloc resection intraoperatively. Any need for additional tech­ nical assistance from other surgeons should be planned for. • In cases of perforation and anticipated significant intraperi­ toneal contamination that may render bowel anastomosis unsafe, plans should be made for ostomy marking and edu­ cation preoperatively. • Preoperative bowel preparation, whether antimicrobial and mechanical, mechanical only, or no preparation, is a highly variable practice and is left to the discretion of the practicing surgeon. • Prophylactic intravenous antibiotics with coverage against gram-positive, gram-negative, and anaerobic flora of the skin and gut are typically administered prior to incision and continued for the first 24 hours. • Prophylaxis against deep venous thrombosis is typically administered prior to incision and during the hospital stay. Positioning

• Patients are usually placed in a supine position. If there is any possibility of extending the resection to the left colon or any possible need for intraoperative endoscopy, consid­ eration should be given for placing the patient in lithotomy position.

omentum, and hepatic and bowel s u rfaces a re i n s pected and p a l pated for any evidence of m etastatic d isease. I n women, the pelvic organs, i n c l u d i n g the ova ri es, s h o u l d be i n specte d . A n y s u s p i c i o u s n od u l e s h o u l d be b i opsied for pat h o l o g i c assessment as f i n d i n g s may affect the de­ cision of p roceed i n g to the re m a i n i n g of the p roce d u re .

C h a p t e r 1 3 TRANSVERSE COLECTOMY: Open Tech n i q u e

OMENTUM DISSECTION AND EXPOSURE OF THE LESSER SAC • •

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The relationsh i p betwee n the tra n sverse colon pathology a n d the lesser sac is assesse d . Exposure to the lesser sac is g a i ned i n o n e of two ways, d e pe n d i n g o n whether o m e ntecto my i s performed o r not. If d i sease p a t h o l o g y does not n ecessitate en b l o c o m e n ­ tectomy o r i f t h e r e i s d e s i re to p reserve a s m u c h of t h e o m e n t u m a s poss i b le, t h e n g reater o m e n t u m i s re­ tracted ce p h a l a d and the t r a n sve rse c o l o n i s retracted ca u d a d . T h i s reve a l s the avasc u l a r p l a n e between the g reater o m e n t u m and the t r a n sverse m esoco l o n (FIG 3) . The p a l e ye l l ow o m e nta l f a t i s d i st i n g u i s h e d from t h e f a t of t h e a p p e n d i ces e p i p l o i cae of t h e t r a n s ­ verse c o l o n (FIG 4) . As t h i s p l a n e i s d i ssected, t h e g reater o m e n t u m i s f r e e d from t h e t r a n sverse c o l o n a n d m esoco l o n a n d e nt r a n c e i nto t h e lesser sac i s g a i n e d . Th i s c a n be confi r m e d by v i s u a l i za t i o n of t h e poste r i o r wa l l of t h e sto m a c h d o rsa l ly a n d of t h e a n ­ t e r i o r s u rfa ces of t h e d u o d e n u m , p a n creas, a n d t r a n s ­ verse mesoco l o n ventra l ly. If t h e d i sease p a t h o l o g y n e cessitates en b l o c resect i o n of p a rt o r a l l of t h e o m e n t u m , t h e n t h e g a stroco l i c l i g a m e n t s h o u l d b e d i v i d e d . T h e g a stroe p i p l o i c a r­ t e ry a rc a d e is i d e nt i f i e d a l o n g t h e g reater c u rvature of t h e sto m a c h . D i ssect i o n of t h e o m e n t u m i s c a r r i e d o u t e i t h e r prox i m a l ( i n s i d e o f ) o r d i sta l (outs i d e of) t h e a rc a d e d e p e n d i n g on t h e extent of t h e d i sease,

F I G 4 • T h e p a l e ye l l ow cobblesto n e fat o f t h e omentum (A) is d isti n g u ished from the b r i g h t ye l l ow s m ooth fat of the a p p e n d i ces e p i p l o icae of the transverse colon (8).

t h e s u rg e o n p refe r e n ce, a n d t h e d e s i re to p reserve the g a stro e p i p l o i c a rc a d e (FIG S). The d e e p e r avascu­ lar p l a n e of t h e l esser sac, deep to t h e o m e n t u m b u t s u p e rfi c i a l to t h e t r a n sverse m esoco l o n , i s e ntered . T h e o m e n t u m is t h u s i s o l ated a n d d i v i d e d betwe e n c l a m ps .

Gastroepiploic vessels

FIG 3 • Retract i n g t h e g reater o m e n t u m ce p h a l a d a n d t h e t r a n sverse c o l o n c a u d a d h e l ps reve a l t h e avasc u l a r p l a n e betwee n t h e g reater o m e n t u m a n d t h e t r a n sverse m esoco l o n .

FIG S • D i ssection of the omentum is ca rried out either proxi m a l (inside of) o r d ista l (outs i d e of) the g a stroe p i p l o i c a rtery a rcade (dotted lines) d e pe n d i n g o n the extent of the d i sease, s u rgeon p referen ces, a n d the desi re to p reserve the g a stroe p i p l o i c a rcade.

MOBILIZATION OF THE HEPATIC FLEXURE

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AND THE SPLENIC FLEXURE •

I n order to g a i n e n o u g h m o b i l ity of the co l o n for i ntra­ operative m a n i p u lation and to a l low for a tensio n-free a n asto mosis after resection, it is often n ecessa ry to m o b i ­ l ize o n e o r b o t h of the flexu res•

To m o b i l ize t h e h e p a t i c flexu re, atte n t i o n is t u r n e d to t h e asce n d i n g co l o n . The c o l o n was retracted m e d i ­ a l ly to i d e n t ify t h e p e r i to n e a l refl ect i o n (w h ite l i n e o f To l d t ) . T h e cove r i n g peri to n e u m o f t h e p a r a co l i c g ut­ ter i s then i n c ised and d iv i d e d u s i n g e l ectroca utery. T h i s avasc u l a r t i s s u e p l a n e is fo l l owed i n a l a t e r a l to m ed i a l fash i o n , sepa rat i n g t h e co l o n i c mesentery from

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FIG 6 • A n a to m i c r e l a t i o n s for m o b i l i za t i o n of t h e h e p a t i c f l e x u r e : T h e ascen d i n g co l o n i s retra cted m ed i a l l y to i d e n t i fy t h e l atera l p e r i t o n e a l reflect i o n (wh ite l i n e o f To l d t); t h e cove r i n g p e r i to n e u m i s d iv i d e d t o free t h e h e p a t i c f l e x u r e . T h e h e p a t i c s u rface, t h e g a l l b l a d d e r, t h e d u o d e n u m , a n d t h e a nt e r i o r p a n creas' s u rface a re i n c l ose p r ox i m ity, and care m u st b e taken to a vo i d i n j u ry to these organs.

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t h e retro p e r i to n e u m . T h i s d i ssect i o n p l a n e i s t h e n c a r r i e d ce p h a l a d towa rd t h e h e p a t i c flexu re, where d iv i s i o n of t h e l a t e ra l p e r i to n e a l atta c h m ents w i l l free t h e h e pa t i c flexu re. As t h e d i ssect i o n i s c a r r i e d m e d i ­ a l l y, ca re m u st be t a k e n to avo i d i nj u ry to t h e ret r o p e r­ ito n e a l d u o d e n u m (FIG 6) . At t h i s t i m e, t h i s d i ssect i o n p l a n e s h o u l d be jo i n e d w i t h p r i o r d i ssect i o n p l a n e o f t h e o m e n t u m so t h a t co m m u n i c a t i o n to t h e l esser sac i s esta b l i s h e d . To m o b i l ize t h e s p l e n i c flexu re, atte n t i o n is t u rned to t h e d esce n d i n g c o l o n . The d esce n d i n g c o l o n is retracted m e d i c a l l y to i d e n t ify the l atera l perito n e a l atta c h m e nts in a s i m i l a r fas h i o n a s described in the m o b i l i zation of the asce n d i n g co l o n a bove. The avasc u l a r tissue p l a n e i s s i m i l a r l y fo l l owed a n d carried ce p h a l a d towa rd t h e s p l e n i c flexu re (FIG 7) . The s p l e noco l i c l i g a m e n t is e ncou ntered i n this p rocess and d ivided using e l ectro­ cautery. As the l ower pole of the s p l e e n comes i nto vi ew, care s h o u l d be taken to d iv i d e any a d h e s i o n be­ twee n t h e o m e n t u m and t h e caps u l e a s to avo i d u n ­ i ntended ca ps u l a r tea rs w i t h ret ract i o n a n d d i ssect i o n . Often, n u m e r o u s a d hesions between t h e o m e n t u m a n d t h e a p p e n d ices e p i p l o i c a e o f t h e c o l o n a re e n c o u n ­ tered, a n d c a r e m u st be taken to sepa rate t h ese e i t h e r by e l ectroca utery o r between c l a m p s to avoid b l eed i n g . F i n a l ly, a d d i t i o n a l avasc u l a r l i g a m e nts t o t h e sto m a c h a n d/o r t h e p a n c reas may be en co u ntered a n d s h o u l d b e d iv i d e d . After t h is, entry i nto t h e l e s s e r sac i s g a i n e d .

F I G 7 • M o b i l i z a t i o n of t h e s p l e n i c flexure. The s p l e n i c flexu re of t h e c o l o n (A) i s retracted m e d i a l l y to i d e nt i fy a n d release t h e l a t e r a l p e r i to n e a l atta c h m e nts. C a r e i s t a k e n t o avo i d i nj u ry to t h e s p l e e n (B). T h e renoco l i c l i g a m e n t (C), t h e s p l e n o co l i c l i g a m e n t (D), a n d t h e g a stroco l i c l i g a m e n t (E) a re i d e ntified a n d s u bseq u e nt l y d i v i d e d . T h i s a l l ows e n t ry i nto the l esser sac a n d frees the d i sta l t r a n sverse c o l o n and s p l e n i c flexure from poste r i o r retro peri to n e a l atta c h m e nts.

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The d i sta l tra nsverse co l o n a n d s p l e n i c flexu re a re now com p l etely free of poste r i o r retroperito n e a l atta c h ­ m e nts a n d a re f u l l y m o b i l e . After completing the d i ssecti ons outl i n e d i n t h i s step, the lesser sac is exposed co m p l etely, and the a nterior s u r­ faces of the tra n sverse m esoco l o n s h o u l d be in fu l l view (FIG 8) .

FIG 8 • After the lesser s a c i s exposed co m p l etely, poste rior wa l l of the sto mach (A) a n d a nterior s u rface of the p a n creas (B) a re v i s u a l ized. The a nterior s u rfa ces of the tra n sverse m esoco l o n with m i d d l e co l i c vesse l s (C) s h o u l d be in fu l l view.

C h a p t e r 1 3 TRANSVERSE COLECTOMY: Open Tech n i q u e

ISOLATION AND DIVISION O F THE MIDDLE COLIC VESSELS • •

The a n atomy of the m i d d l e co l i c a rtery can be h i g h ly va r i a b le, a n d often, it does n ot p resent as a s i n g l e vesse l . The m i d d l e co l i c vesse ls can usua l ly be i d e ntified by v i s u a l i n s pection o r p a l pation a l o n g the transverse mesoco l o n via the lesser s a c (FIG 9) . When prox i m a l l i gation is needed, as i s i n the case for m a l i g n a nt d isease, the over­ lyi n g perito n e u m is scored and the vesse l s s h o u l d be d issected u p to the lower border of the pancreas a n d l i gated a t t h i s l ocation (FIG 9) . Ca re s h o u l d be taken to avo i d avu lsion i n j u ry to the s m a l l e r co l l atera l venous branches from the p a n creaticod u o d e n a l a rcade a n d to

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avoid c l a m p i nj u ry to the pancreatic p a renchyma. When the root of the m i d d l e co l i c vesse l s is identified, the s u r­ rou n d i n g n o d a l -bea r i n g m esenteric tissue s h o u l d be swept toward the spec i m e n s i de. The vessels can then be isolated a n d contro l l ed with suture l i gature . If the m i d d l e co l i c vessels a n d the lesser sac a re i nvolved b y the d i sease path o l ogy a n d/or o b l iterated, then the m i d ­ d l e c oli c vessels ca n be a p p roached from the root o f t h e sma l l bowel m esente ry. After the transverse m esoco l o n is retracted ce p h a l a d , the root of the mesente ry is exposed. The overlyi n g perito n e u m is scored a n d d issected away to expose the a nterior s u rface of the superior mesenteric a rte ry. 5 The superior mesenteric a rtery is fo l l owed cep h a ­ l a d u n t i l the m i d d l e co l i c b r a n c h e s off, a n d the o r i g i n o f the m i d d l e c oli c vessels can be isol ated at t h i s location (FIG 1 0) . Extreme ca re m u st be u n d erta ken to p reve nt i nj u ry to the u n derlying superior mesenteric vesse ls.

FIG 9 • The middle co l i c vesse l s (A) a re i d e ntified i n the transve rse mesoco l o n (B) a n d then d i ssected a n d taken between c l a m ps . When proxi m a l l i g ation of the m i d d l e co l i c vessel is req u i red, the vessels a re transected at the i nfe r i o r b o r d e r o f the p a n creas.

FIG 10 • At the root of the s m a l l bowe l mesente ry, s u peri or mesente ric a rtery (A) is fo l l owed ce p h a l a d u n t i l the m i d d l e co l i c branches off (8).

BOWEL RESECTION AND ANASTOMOSIS

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•

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Aft e r d iv i s i o n of t h e m i d d l e co l i c vesse ls, t h e b l oo d s u p p l y to t h e tra n sverse c o l o n i s m a i nta i n ed by t h e m a rg i n a l a rte ry, w h i c h c a n be fo u n d a l o n g t h e e n t i re co l o n . The l e n g t h of t h e bowe l resect i o n is dete r m i n ed by t h e exte nt of d i sease p a t h o l o g y a n d by t h e extent of t h e vasc u l a r s u p p ly. I n cases of b e n i g n i n fl a m m at o ry d i sease, a m a rg i n of n o r m a l , h e a lthy c o l o n s h o u l d b e present for rea n a st o m o s i s . I n c a s e s of p r i m a ry m a l i g n a n cy of t h e tra n sverse c o l o n , a m i n i m u m g ross n e g a tive m a r g i n of 5 em p rox i m a l a n d d i sta l to t h e t u m o r s h o u l d b e p resent. O n ce the poi nts of prox i m a l a n d d i sta l bowe l resect i o n a re i d e ntified, the p resence of p u lsati l e b l ood s u p p l y t o the cut ends via the m a rg i n a l a rtery s h o u l d be verifi e d . If a d e q u ate b l ood s u p p ly ca n n ot be co nfirmed, the length of the resection m ust be exte nded to poi nts where blood s u p p l y i s p resent.

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In most cases, bowe l cont i n u ity is i m med iately reesta b­ l ished . H owever, i n cases of g ross perito n e a l conta m i ­ nation, g ross i n f l a m mation, g rave systemic i l l n ess, a n d others, the safety o f a bowe l a n astomosis m a y be q u es­ tioned, and creati o n of a n e n d col ostomy with either a m u cous fist u l a or a l o n g d i stal b l i n d l i m b may be wise. A seco nd-stage p roce d u re can be performed for d e l ayed rea n a stomosis. O n ce the decision for i m med iate bowel a n asto mosis i s m a d e, the mese nte ric orientation is checked to e n s u re that there is no twist i n g . The bowe l a n asto mosis can be performed in a va ri­ ety of ways, d e pe n d i n g o n the s u rgeon's p refe rence. The m ost co m m o n methods i n c l u d e a h a n d-sewn e n d ­ to-en d tech n i q u e o r a sta pled si de-to-s ide (fu nct i o n a l e n d-to-e nd) tec h n i q u e . • U s i n g the h a n d-sewn tech n i q ue, the d ivided e n d s of the colon a re a l i g n ed end-to-e n d . The a n a sto­ mosis is created i n two laye rs, with a n outer layer

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of i nterru pted sutu res p l aced i nto the seromuscu l a r layer o f the bowe l wa l l a n d a n i n n e r l ayer o f r u n ­ n i n g suture p l a ced fu l l t h i c k n ess, i n corporat i n g t h e bowel m ucosa (FIG 1 1 ) . I n t h e sta p l e d tech n i q ue, t h e e n d s of t h e bowe l a re d iv i d e d with a l i n e a r sta p l e r. These d i v i d e d e n d s of t h e c o l o n a re t h e n a l i g n e d s i d e-to-s i d e . S m a l l ente roto m i es a re m a d e typ ica l ly by exc i s i n g a c o r n e r off each sta p l e l i ne, a l l ow i n g t h e jaws of t h e l i n e a r sta p l e r to be i n se rted and t h e sta­ pler to b e fired (FIG 1 2) . The a rea of t h e ente rot­ omy t h r o u g h w h i c h the sta p l e r has been i n s e rted i s then c l osed e i t h e r by s u t u res o r by a second

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fi r i n g of t h e sta p l e r. Sta p l e l i n e s a re i n s pected for h e m osta s i s . Areas of cross i n g sta p l e l i n es m a y be i m b r icated with i nt e r r u pted s u t u re i n a La m b e rt fa s h i o n . • If there is we l l -vasc u l a rized omentum nea rby, it may be patched over the a n a stomosis to help future con­ ta i n a n y a n a stomotic leakage posto perative ly. The size of the mesenteric d efect between the r i g ht a n d l eft c o l o n s h o u l d be assesse d . S m a l l - a n d moderate-sized d efects s h o u l d be cl osed to p reve nt i ntern a l h e r n i a a n d any m esenteric twist i n g . Typical ly, if the m i d d l e co l i c ves­ sels had been l i g ated at t h e i r o r i g i ns, the defect i s l a rg e a n d c l o s u re is not n ecessa ry.

B

FIG 1 1 • I n a h a n d-sewn e n d-to-e n d coloco l o n i c a n asto mos is, the d ivided e n d s of the colon a re a l i g n e d (A); the a n asto mosis i s typ i ca l ly created i n two laye rs, w i t h a n o u t e r l ayer o f i nterru pted sutu res a n d a n i n n e r l a y e r of r u n n i n g suture (B-D) .

C h a p t e r 1 3 TRANSVERSE COLECTOMY: Open Tech n i q u e

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F I G 1 2 • I n a sta pled s i d e-to-si d e (fu nct i o n a l end-to-e nd) coloco l o n i c a na stomosis, the ends of the bowel a re a l i g n e d s i d e-to-s ide. S m a l l ente rotom i es a re m a d e by exc i s i n g a corner off each sta p l e l i ne, a l lowi n g the jaws of the l i n e a r sta p l e r to be i n serted i nto each l u m e n . The sta p l e r is fi red .

ABDOMINAL CLOSURE •

The a b d o m i n a l fascia is cl osed after p l a c i n g a ny re m a i n ­ i n g omentum betwee n the bowe l loops a n d the i n c i s i o n

if poss i b l e . The s k i n i n c i s i o n is cl osed u s i n g a bsorb­ able su bcuticu l a r sutu re o r sta ples. Abdom i n a l d ra i n is n o t p l a ced.

PEARLS AND PITFALLS D i a g n osti c a n d preopera­ tive a ssessm ents

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• • • • Omental d i ssection a n d exposu re o f the Jesser sac

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Any path o l ogy outside of the transve rse colon, transverse m esoco lon, a n d m i d d l e co l i c vesse l s s h o u l d be a ssessed o n p reope rative i m a g i n g , a n d a n exte nded ri ght o r a n exte nded l eft h e m i c o l ecto my s h o u l d be pe rfo rmed if n ecessa ry. In patients presenti n g with a l a rg e t u m o r m a ss, a n ato m i c relations to the p a n creas, d uo d e n u m , sto mach, a n d m esenteric vesse l s s h o u l d be ca refu l ly accessed. E n d osco p i c a n d/or percuta neous tissue b i o psy should be o bta i n e d to help d ifferenti ate m a l i g n a ncies of co l o n i c versus nonco l o n i c orig i n to a l l ow for opti m a l treatment p l a n n i n g . Patients presenti ng with a n obstructing transverse colonic lesion and a com petent ileoceca l valve req u i re emergent surgical attention to avoid perforation secondary to a closed loop l a rge bowel obstruction. The potenti a l need for a n ostomy i n cases where bowel a n asto mosis may not be safe s h o u l d be a ntici pated to a l l ow for preoperative osto my m a r k i n g and educatio n . Exposu re to the Jesser s a c ca n be g a i ned w i t h o r without a n omentecto my. The pale g ra n u l a r ye l l ow of the omental fat ca n be d isti n g u ished from the brig ht, sm ooth yel l ow of the fat of the co l o n i c a p p e n d i ces e p i p l o i cae to h e l p ide ntify the avasc u l a r d i ssection p l a n e .

M o b i l ization of the hepatic a n d/o r splenic flexure

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The s u rgeon s h o u l d n ot hes itate to m o b i l ize either o r b o t h of the flexu res, as it often g reatly fac i l itates i ntraoperative m a n i p u lation and fac i l itates a tension-free bowe l a n asto mosis.

Isolation a n d l i gation of t h e m i d d l e co l i c vesse l s

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When the root of the m i d d l e co l i c vessels i s a p p roached through the Jesser sac, i n j u ry to the s m a l l ve i n s at the i nfe rior border o f the pancreas s h o u l d be avo i d e d . When the root of the m i d d l e co l i c vessels i s a p p roached f r o m the root of the s m a l l bowe l mesentery, i n j u ry to the s u peri or mese nte ric vesse l s s h o u l d be avo i d e d .

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B o w e l resection a n d a n asto mosis

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A transverse col ecto my ca n be easily converted to a n extended right o r a n extended l eft h e m i co l ectomy if needed by i ntraoperative f i n d i ngs. I n some cases, i m m ed iate bowel a n a stomosis may not be safe, and a n e n d col osto my can be m a d e w i t h either a m u cous fistu l a o r a l o n g d i stal b l i n d l i m b for d e l ayed rea n a stomosis.

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POSTOPERATIVE CARE •

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Patients should receive routine postoperative care including adequate analgesia, aggressive pulmonary toilet, and early ambulation. Patients are typically kept on no more than a clear liquid diet the night of the operation in case there is a need for any emergency intervention and then advanced to a soft diet by the time of discharge. An occasional patient may experience diarrhea, which requires initiation of medicinal fiber and/or lmodium for symptom control.

OUTCOMES •

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Patients generally tolerate a transverse colectomy well. The risk of anastomotic complications requiring reoperation is less than 5 % , and a colostomy is not routinely required. Leakage from the colocolonic anastomosis may manifest as peritonitis, colocutaneous fistula, or localized intraperito­ neal abscess. Patients with clinical signs of sepsis and peritonitis should be managed by prompt return to the operation for reex­ ploration, washout, resection of the prior anastomosis, and creation of end colostomy and mucous fistula. Localized abscesses may collect in the subhepatic, sub­ phrenic, and lesser sac spaces. The diagnosis can be made by CT of the abdomen, and clinically stable patients may be managed by percutaneous drainage. Superficial wound infection occurs in 1 0 % to 1 5 % of the cases and should be managed by incision and drainage of any subcutaneous abscess.

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Transverse colectomy is not expected to significantly alter bowel function postoperatively.6 Although some patients may experience more frequent and looser stools during the immediate postoperative period, most patients reported an average of 1 to 2 stools per day and adapt to a normal bowel regimen over 6 to 12 months.

COMPLICATIONS • • • • •

Bleeding Wound infection Anastomotic leak lntraabdominal abscess Poor bowel function

REFERENCES 1. Hopkins JE. Transverse colostomy in the management of cancer of the colon. Dis Colon Rectum. 1971;14(3):232-236. 2. Gordon PH. Malignant neoplasm of the colon. In: Gorden PH, Nivat· vongs S, eds. Principles and Practice of Surgery for the Colon, Rectum and Anus. 3rd ed. New York: Informa; 2007:550-553. 3. Stamatakos M, Karaiskos I, Pateras I, et a!. Gastrocolic fistulae; from Haller till nowadays. Int J Surg. 2012;10(3):129-133. 4. Araujo SE, Seid VE, Kim NJ, et a!. Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study. Arq Gastroenterol. 2012;49(3):219-222. 5. Tajima Y, Ishida H, Ohsawa T, et a!. Three-dimensional vascular anat­ omy relevant to oncologic resection of right colon cancer. Int Surg. 2011;96(4):300-304. 6. You YN, Chua HK, Nelson H, et a!. Segmental vs. extended colec­ tomy: measurable differences in morbidity, function, and quality of life. Dis Colon Rectum. 2008;51(7):1036-1043.

I

Chapter

14

Laparoscopic Transverse Colectomy I

- --------------------------------------- �-----------------------------------------------------

G o vind Na n dakumar

DEFINITION •

Transverse colectomy refers to removal of the portion of the colon between the hepatic flexure and the splenic flexure­ the transverse colon. This portion of the colon derives its blood supply from the right and left branch of the middle colic vessels in addition to collateral flow from the ileoco­ lic, right colic, and left colic vessels. Transverse colectomy is commonly performed for tumors and/or polyps of this region. An alternative approach to these tumors is to per­ form an extended right or extended left colectomy. This chapter focuses on laparoscopic transverse colectomy.

PATIENT HISTORY AND PHYSICAL FIN DINGS •

• •

•

•

•

•

A complete history and physical focusing on the underlying pathology is essential. For patients with colon cancer and/or polyps, a detailed surgical history, personal cancer history, and family history is essential. Preoperative genetic counseling and testing may be indicated based on age and family history. Presence of an inherited cancer syndrome such as familial adenomatous polyposis or hereditary nonpolyposis colon cancer syndrome may require a total colectomy rather than a transverse colectomy. Prior abdominal surgery, distension, and obstruction are important to elicit in the history and physical examination prior to making a decision regarding open versus laparo­ scopic approach. History or physical examination suggestive of focal abdomi­ nal pain and tenderness are suggestive of abdominal wall invasion and more extensive or open surgical approach may be needed. History and physical examination should also evaluate the cardiovascular and respiratory systems to assess the ability to tolerate pneumoperitoneum. Nutritional status and recent history of maj or weight loss should be considered in performing primary anastomosis.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

• • • •

All patients with colon cancer and/or a polyp should have a complete extent of disease workup including carcinoem­ bryonic antigen (CEA), computed tomography (CT) of the abdomen and pelvic, chest X-ray, colonoscopy, and routine preoperative testing. The CT should be reviewed carefully to assess adj acent organ involvement, metastatic disease, and obstructive disease. Laparoscopic approach may not be feasible in the presence of massive distension and obstruction. Large bulky tumors with a tethered mesentery or adj acent organ involvement may also preclude laparoscopy. Colonoscopy and evaluation of the entire colon is important to ensure there are no synchronous lesions proximal or distal to the area of resection.

• • •

·

Sa ng W Lee

For small nonobstructing lesions, endoscopic tattoo marking should be performed prior to surgery. Endoscopic tattooing should be performed j ust distal to the tumor and in three quadrants. In general, tumors that are identified on CT scan can be readily identified laparoscopically and do not require a tattoo.

SURGICAL MANAGEMENT Preoperative Planning •

The patient receives a mechanical bowel preparation to facilitate handling of the colon and to facilitate intraopera­ tive colonoscopy if required. The need for bowel preparation is controversial. The consequences of a leak may be more significant without preparation. Laparoscopic handling of the colon is easier after mechanical bowel preparation. • The patient is seen and evaluated by the surgical and anesthesia teams in the preoperative area on the day of surgery. • Most patients are offered and elect to have an epidural or intravenous catheter for patient-controlled anesthesia. • A second- or third-generation cephalosporin or ertapenem is used for antibiotic prophylaxis within 1 hour of skin inci­ sion and redosed as needed. No antibiotics are administered postoperatively. • Venodyne boots and 5,000 units of subcutaneous heparin are used for deep vein thrombosis prophylaxis. Positioning •

The patient is positioned in a modified lithotomy position with both arms tucked to the sides. It is essential to ensure that all pressure points, fingers, and calves are padded adequately. • Use of a beanbag and cloth tape allows extreme positioning with decrease in possibility of patient sliding. • Alternatively, use of gel pads commonly available in the operating room ( OR) makes routine taping of patient not necessary. • Use of shoulder braces should be avoided as they can cause brachial plexus injury. • Prior to draping, the patient is placed in steep Trendelenburg and the table is rotated to ensure that the patient is secured well. • It is essential to ensure that both knees are in line with the torso in order to avoid collision of instruments to patient's thighs when working in the upper quadrants of the abdo­ men. The abdomen is prepped from the nipples to the mid thigh. • Access to the anus is always maintained for possible intra­ operative colonoscopy. • FIG 1 (laparoscopic setup) shows the OR setup for this procedure. Monitors are placed over the shoulders of the patient so that the surgeon, pathology, and monitors are situated in line.

1025

102 6

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

Anesthetist

FIG 1 • I l l u strates the patient set u p . A mod ified l ithotomy position a l l ows the s u rgeon o r assistant to sta n d betwee n t h e legs and to h ave a ccess to the anus for i ntraoperative colonosco py.

SKIN INCISIONS • •

A H a sson tech n i q u e is used to a c h i eve access to the a bdo­ m e n at the u m b i l icus. F o u r 5-mm trocars are p l aced-two on either side of the a b d o m e n latera l to the rectus with o n e hand b readth between the troca rs. An o pt i o n a l fifth trocar ca n be p l aced i n the s u p r a p u b i c a rea if req u i red for retraction. FIG 2 (troca rs) shows the typ i c a l trocar placem ent. 5 mm

0

5 mm

0

FIG 2 • We use t h i s sta n d a rd confi g u ration of troca r p l acement for the majo rity of l a p a rosco p i c colon a n d recta l operations.

1 0 mm

5 mm

5 mm

•

C h a p t e r 1 4 LAPAROSCO P I C TRANSVERSE COLECTOMY

LAPAROSCOPIC EXPLORATION •

• •

• •

The a b d o m e n is systematica l l y exp l o red in a l l fo u r q u a d ­ rants to look f o r m etastatic d i sease a n d/o r u n expected pat h o l ogy. Knowledge of t h e mesenteric a n atomy is essential for a successf u l l a p a rosco p i c a p proa c h . FIG 3 (co l o n a n ato my) s h ows the co l o n with its major vasc u l a r pedicles. Also d e p i cted is the gastroco l i c tru n k of H e n l e that can be a sou rce of b l eed i n g if not recog n ized d u r i n g the d i ssect i o n . T h e r i g ht co l i c vesse ls co m m o n ly o r i g i n ate f r o m the i l eo­ co l i cs (85 % ) . T h e m i d d l e co l i c a rteries co m m o n ly h ave m o re t h a n two branches ( 5 5 % ) .

Middle colic artery Middle colic vein

Gastro­ Colic trunk -f---:--��__:_�"-1

I leo colic

F I G 3 • S h ows the major vasc u l a r ped icles to the c o l o n a n d the m a rg i n a l a rtery t h a t m a i nt a i n s co l l atera l ci rcu lati o n .

PEDICLE LIGATION •

•

•

•

•

•

The i l eocol ic, m i d d l e col ic, a n d l eft co l i c vesse l s a re fi rst i d e ntified (FIG 4) . Identification of the vascu l a r pedicles is fac i l itated by tract i o n o n the colon to tent the mes­ e nte ry. Adeq u ate exposure is a c h i eved by g ra s p i n g each flexure and retract i n g su periorly and l atera l ly (FIG 5) . A w i n d ow is created i n the colon mesente ry betwee n the i l eoco l i c a n d middle co l i c vessels. With a p p ro p riate trac­ tion and cou ntertraction, the retromesenteric d issect i o n is cont i n ued s u perio rly, m e d i a l ly, a n d l atera l ly i nto the l esser sac (FIG 6) . Care is taken to p rotect the d u o d e n u m , head of the p a n ­ creas, a n d the s u pe r i o r mesente r i c a rtery (SMA) a n d ve i n d u r i n g t h e d i ssect i o n . The m i d d l e co lic vessels can be d ivided at the common tru n k or d ivided i n d ivid u a l ly after bifurcation (FIG 7). There is sig­ n ificant variation i n the a natomy of the middle co lic tru nk. O u r practice is to use a b i polar vessel-sea l i n g device to d ivide the pedicles, but clips and sta plers a re a l so options to d ivide the ped icles. It is i m portant to ensure that the SMA and vei n a re protected and that sufficient cuff o f t h e vascular ped icle is reta i ned to control bleed ing should the vessel sea lers fa i l . Stro n g a nterior traction on the tra n sverse colon mese n ­ tery opti m i zes m i d d l e co l i c d i ssection a n d decreases t h e l i ke l i hood of i n advertent i nj u ry to S M A .

F I G 4 • Appropriate traction o n the c o l o n i n the d i rect i o n of the arrows exposes t h e mesentery a n d a l l ows for identification of the major vasc u l a r pedicles.

102 7

Inferior mesenteric artery

102 8

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

FIG S • Ce p h a l a d a n d l atera l traction is used to v i s u a l ize the middle co l i c vesse ls.

F I G 6 • A w i n d ow i s created t o the r i g ht o f the m i d d l e co l i c vesse ls.

FIG 7 • After adeq uate m o b i l ization a n d p rotect i n g the d u oden u m a n d p a ncreas, the m i d d l e co l i c vessels a re d ivided.

RETROMESENTERIC DISSECTION •

R i g h t retrom esente ric d issect i o n Late ral ly, the d i ssection is carried to the wh ite l i n e o f To ldt a n d the hepatic flexure (FIG 8). • M e d i a l ly, the d issection is carried to the root of the middle co l i c vessels a n d a nterior to the head of the

•

FIG 8 • The latera l attach m ents of the colon a re taken down, ensuring there i s n o therm a l i nj u ry to the bowe l .

C h a p t e r 1 4 LAPAROSCO P I C TRANSVERSE COLECTOMY

FIG 9

•

•

D i ssection of the m i d d l e co l i c vesse ls.

pa ncreas a n d the d u o d e n u m (FIG 9) . The gastroco l i c ve n o u s tru n k is often encou ntered d u ri n g t h i s d issect i o n a n d can be a sou rce o f bleed i n g if not recog n i zed and contro l led (FIG 1 0) . • S u perio rly, the d i ssection is carried ce p h a l a d to the transverse colon wa l l . • The rema i n i n g atta c h m e nts to the l iver a re taken down (FIG 1 1 ) . Left retro m esenteric d issect i o n • A s i m i l a r d issect i o n is carried out on the l eft side, creat i n g a wi ndow between the left co l i c a n d m i d ­ d l e co l i c vesse l s (FIG 7) .

FIG 1 1 • Rem a i n i n g atta c h m e nts of the h e p a t i c flexure of the colon to the l iver a re taken down. The d i ssect i o n is fac i l itated by work i n g close to the co l o n .

•

•

•

FIG 1 0 • Early i d e ntificat i o n and control of the g a stroco l i c t ru n k p revents bleed i n g a n d i n j u ry t o t h e s u perio r mesente ric ve i n .

Late r a l ly, t h e d i ssect i o n is carried to t h e wh ite l i n e of To l d t and the s p l e n i c flexu re of the co l o n (FIG 1 2) . • M e d i a l ly, the d i ssect i o n is carried to the root of the middle co l i c vesse l s . S u perio rly, the d i ssection is carried to the i nfe rior border of the p a n creas a n d conti n u ed along the avasc u l a r p l a i n between the l eft c o l o n mesentery a n d the ta i l o f the pancreas (FIG 1 3) . At t h i s poi nt, the colon mese ntery s h o u l d be co m p l etely m o b i l ized. The transve rse colon is o n ly held by the latera l attac h m e nts, t h e omentum, a n d the ped icles.

F I G 1 2 • S p l e n i c flexure m o b i l ization req u i res takedown of the s p l e noco l i c l i g a ment.

102 9

1030

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

FIG 1 3 • To a c h i eve a d e q u ate m o b i l ization, the poste rior atta c h m e nts a l o n g the i nfe rior border of t h e pa ncreas n eed to be d issected with entry i nto t h e lesser sac.

RELEASE OF LATERAL ATTACHMENTS AND THE OMENTUM •

The omentum is n ext taken off the transverse colon (FIG 1 4) . The l atera l atta c h m ents a re taken d own o n both sides. The d i ssect i o n s h o u l d be started in the m i dtrans­ verse colon where the two l eaves of the g reater o m e n ­ t u m a re f u s e d together. Vis u a l ization of the poste rior wa l l of the sto mach ensu res that the s u rg i ca l d issection is i n t h e proper plane i nto the l esser sac. It is i m portant to p rotect the colon from t h e r m a l i n j u ry d u ri n g t h i s portion of the d i ssect i o n .

FIG 1 4 • The omentum is d i ssected off the transverse co l o n . T h e o m e n t u m i s left o n the co l o n a r o u n d the t u m o r t o e n s u re a n e n bloc resect i o n . E a r l y entry i nto the lesser s a c a n d i d e ntificat i o n o f the poste r i o r wa l l o f the sto mach fa c i l itates an effi cient d issect i o n .

•

I n a d d it i o n to m o b i l i z i n g the transverse colon, the r i g ht colon, with the hepatic flexu re, a n d the l eft colon, with the s p l e n i c flexu re, need to be fu l ly m o b i l ized. This w i l l a l low f o r speci m e n extraction a n d the creati o n o f a tension-free a n astomosis (FIG 1 S) .

FIG 1 S • Co m p l ete m o b i l ization o f the hepatic a n d s p l e n i c flexu res a l l ows for safe spec i m e n extract i o n a n d tensio n-free a n asto mosis.

C h a p t e r 1 4 LAPAROSCO P I C TRANSVERSE COLECTOMY

SPECIMEN EXTERIORIZATION AND

•

ANASTOMOSIS • •

The peri u m b i l i ca l i n c i s i o n is co m m o n ly exte nded as a n extraction site a n d a wo u n d p rotector is p l aced (FIG 1 6) . The m o b i l ized transverse colon i s exteriorized. Any re m a i n i n g mesentery is d ivided.

•

• •

• • • •

FIG 1 6 • Peri u m b i l i cal i n c i s i o n with wo u n d p rotector to extract speci m e n .

103 1

A l i n e a r sta p l e r is used to d ivide the colon proxi m a l to t h e h e patic flexure a n d d i sta l to the s p l e n i c flexure a s s h own (FIG 1 6) . The spec i m e n is either sent for g ross exa m i nation o r opened i n t h e O R to e n s u re that adeq u ate m a r g i n s (5 em for ca ncer) were o bta i n e d . lf the l e s i o n is l ocated latera l l y, a d d i t i o n a l pedicles can be taken as needed. A s i d e-to-s ide f u n ct i o n a l en d-to-e n d sta pled a n asto mosis o r a h a n d-sewn a n asto mosis can be fash ioned based o n the p reference o f the s u rgeon (FIG 1 7) . The colon is repl aced i n the perito n e a l cavity, a n d the ope rative a rea i s exa m i n ed for h e m ostasis. If there is concern fo r b l eed i n g , the p n e u mope rito n e u m can be reesta b l ished pri or to closure . Routi n e c l o s u re of the co l o n i c mese nte ric d efect is not necessary as co m p l ications a re m i n i m a l . ' The extraction site fascia is closed, the trocars a re removed u n d e r d i rect visu a l ization, a n d the skin is cl osed .

FIG 1 7 • S i d e-to-s ide f u n cti o n a l e n d -to-en d sta p l ed a n astomosis t h r o u g h a w o u n d p rotector i s i l l u strate d .

PEARLS AND PITFALLS I n d ication s

• •

Exte nded right o r l eft col ecto m i es may be m o re a p p ro p ri ate for t u m o rs l ocated closer to the fl exu res. Lapa roscopy may not be feasi b l e in o bstruct i n g t u m ors with massive bowe l d iste n s i o n o r t u m ors with exte n s ive loca l i nvas i o n . H i story of prior su rgeries is not a contra i n d ication to l a p a rosco py.

P l a cement of incisions (troca rs)

•

Late r a l to the rectus a n d at least 7-8 em betwee n each trocar to avo i d clas h i n g of i nstr u m e nts. The extract i o n i ncision is usua l ly at o r s u perior to the u m b i l i cus.

Posit i o n i n g

•

•

T h i g h s s h o u l d be p a ra l l e l to the f l o o r a n d k n e e s i n l i n e w i t h the torso to prevent co l l is i o n of the i n st r u m e nts with the knees.

103 2

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

Lapa rosco p i c retraction, m a n i p u lation, a n d d i ssection

•

• •

Care should be taken when d issect i n g over the p a n creas to avoid ca u s i n g b l eed i n g from the g a stroco l i c venous tru n k o f H e n l e . The s u perio r mese nte ric a rtery a n d vein s h o u l d be p rotected d u ri n g vesse l l i gati o n . B i po l a r e n e rgy devices may n o t be effective i n sea l i n g ca lcified vesse ls. E n d o loops s h o u l d be ava i l a b l e t o control u n expected bleed i n g . Vessel-sea l i n g devices c a n l e a d t o l atera l spread o f therm a l e n e rgy, a n d t h e c o l o n s h o u l d be p rotected d u ri n g d i ssect i o n . I ntraoperative colon oscopy is u sefu l if the exact location o f the t u m o r is u n c l e a r. A h a n d access port can se rve as a u sefu l a dj u n ct to co m p l ete d iffi cult a n d c h a l l e n g i n g d i ssections.

• • • •

Co m p l ete m o b i l ization of both flexu res is essential for a tensio n-free a n astomosis. I n a d e q u ate m o b i l ization of the splenic fl exu re can lead to traction i nj u ry of the splee n . I n cases where there i s tension, a n exte nded r i g h t col ectomy i s safer a s the s m a l l bowe l is freely m o b i l e . A w o u n d p rotector i s u sefu l i n m i n i m i z i n g conta m i nation a n d l i m it i n g the l e n g t h o f the extraction i n c i s i o n .

• • •

Anasto m osis

POSTOPERATIVE CARE • The patient is sent to the postsurgical unit and is usually given sips after recovery from anesthesia. Diet is advanced on post­ operative day 1 to clear liquids and solids after passing flatus. • The Foley catheter is removed on day 1 and oral pain medi­ cations started once the patient tolerates solid food. • The patient is usually discharged on day 3 or 4 when the patient is on oral pain medications, tolerating a diet, and passing flatus.

•

OUTCOMES • Large multicenter randomized trials have validated the onco­ logic safety and potential short-term benefits of laparoscopic surgery for colon cancer. 2 •3 Transverse colon cancers were not included in these maj or trials. • Smaller retrospective studies have concluded that the oncologic outcomes for laparoscopic treatment of transverse colon cancer are equivalent to the open approach. They also reported some potential short-term benefits.4-6 • There is limited data on laparoscopic transverse colectomy for benign lesions. • Laparoscopic transverse colectomy is technically challeng­ ing and may carry a higher incidence of conversion to open surgery during the procedure.7 • This procedure is best performed by surgeons experienced with open resections of the transverse colon and those with significant laparoscopic colorectal experience. COMPLICATIONS • Bleeding A medial to lateral dissection approach allows early identifica­ tion and control of the major vessels and may avoid bleeding. It is important to remain in the avascular plane between the mesentery and retroperitoneum. Significant oozing is a sign that the dissection may be too anterior into the mesen­ tery or too posterior into the retroperitoneum. Clips and endoloops are rarely required with modern energy and vessel-sealing devices but should be easily available to control bleeding, especially in patients with calcified vessels. Postoperative abdominal hemorrhage can be managed with repeat laparoscopic exploration. Postoperative intraluminal hemorrhage is best managed with carbon dioxide colonoscopy and endoluminal control. • Splenic inj ury It is safest to dissect toward the spleen rather than to retract the colon away from the spleen and cause a traction injury.

•

• •

Complete mobilization of the splenic flexure will avoid trac­ tion injury during the extracorporeal portion of the operation. Splenic inj ury can usually be managed with pressure and hemostatic agents. Occasionally, with uncontrollable bleeding or with injury to the hilum, splenectomy may be required. Anastomotic leak A tension-free anastomosis is facilitated by complete mobilization of both flexures. Pulsatile blood flow is confirmed at the mesenteric tran­ section line. If the proximal margin is devascularized, conversion to an extended right hemicolectomy with an ileocolonic anasto­ mosis may be safer. Small leaks may be managed nonoperatively. Larger leaks with peritonitis or contamination will likely require proximal diversion. In extreme cases, the anastomosis may need to be taken down and converted to an end stoma. Serosal or full-thickness injury to the bowel Careful dissection with attention to the possibility of lateral thermal spread is important. The duodenum should be completely dissected off the mesentery and protected prior to pedicle ligation. The small and large bowels are also at risk for puncture or shear inj ury during insertion of laparoscopic instruments. Deep and superficial surgical site infection Early and later incisional hernia formation

REFERENCES 1. Cabot ]C, Lee SA, Yoo ], et al. Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy. Dis Colon Rectum. 2010;53(3):289-292. 2. Bonjer HJ, Hop WC, Nelson H, et al. Laparoscopically assisted vs open col­ ectomy for colon cancer: a meta-analysis. Arch Surg. 2007;142(3):298-303. 3. Nelson H. Laparoscopic colectomy: lessons learned and future prospects. Lancet Oneal. 2009;10(1):7-8. 4. Kim HJ, Lee IK, Lee YS, et al. A comparative study on the short-term clin­ icopathologic outcomes of laparoscopic surgery versus conventional open surgery for transverse colon cancer. Surg Endosc. 2009;23(8):1812-1817. 5. Lee YS, Lee IK, Kang WK, et al. Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer. lnt ] Colorectal Dis. 2008;23(7):669-673. 6. Schlachta CM, Mamazza ], Poulin EC. Are transverse colon cancers suitable for laparoscopic resection? Surg Endosc. 2007;21(3):396-399. 7. Simorov A, Shaligram A, Shostrom V, et al. Laparoscopic colon resec­ tion trends in utilization and rate of conversion to open procedure: a national database review of academic medical centers. Ann Surg. 2012;256(3):462-468.

I

Chapter

15

Transverse Colectomy: Hand-Assisted Laparoscopic Surgery Technique , _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

Daniel A lb a

DEFINITION •

•

•

Transverse colectomy refers to removal of the portion of the colon between the hepatic and the splenic flexures. The transverse colon derives its blood supply primarily from the middle colic vessels. In addition, the transverse colon receives collateral blood flow from the left and right mar­ ginal arcades (marginal artery of Drummond and arch of Riolan, respectively) . Hand-assisted laparoscopic surgery ( HALS) i s a minimally invasive surgical approach that uses conventional laparo­ scopic-assisted (LA) surgery techniques but with the addi­ tion of a hand-assist device that allows for the introduction of one of the surgeon's hands into the surgical field. The hand-assist device is placed at the projected specimen extraction site. HALS in colorectal surgery retains all of the same advantages of conventional LA surgery over open surgery, including less pain, faster recovery, lower inci­ dence of wound complications, and reduction of cardio­ pulmonary complications, especially in the obese and in the elderly. HALS has significant advantages over conventional LA colorectal surgery, including Reintroduces tactile feedback into the field Shorter learning curves; easier to teach Shorter operative times and lower conversion to open rates Allows for insertion of multiple ports through the hand­ assist device Allows for the introduction of laparotomy pads into the field (helps keeping the small bowel and omentum out of the way, particularly in the obese) Higher usage rates of minimally invasive surgery

DIFFERENTIAL DIAGNOSIS • •

•

•

constipation ) . More advance tumors may present with a complete l arge bowel obstruction. If these patients have a competent ileocecal valve, they develop a closed loop large bowel obstruction and present with severe right lower quadrant abdominal pain and abdominal disten­ tion secondary to a massive colonic dilation proximal to the obstructing lesion. These patients should be taken to the operating room emergently. Unopposed, this will ulti­ mately cause an ischemic perforation of the cecum leading to a catastrophic fecaloid peritonitis and potential onco­ logic contamination of the abdominal cavity leading to carcinomatosis. A detailed personal and family history of colorectal cancer, polyps, and/or other malignancies should be elicited. Physi­ cal examination should include a routine abdominal exami­ nation, noting any previous incisions.

IMAGING AND OTHER DIAGNOSTIC STUDIES • A full colonoscopy with documentation of all polyps should be performed . Lesions that are unresectable en­ doscopically and/or are suspicious for cancer should be tattooed to facilitate localization during surgery. If there is any concern for involvement of adj acent organs, such as the stomach, an esophagogastroscopy should also be performed . • A computed tomography ( CT) scan of the chest, abdomen, and pelvis evaluates for potential metastases. In patients with a large bowel obstruction, the CT scan shows dilation of the right colon and cecum, collapse of the distal colon, and a paucity of fluid and gas in the small bowel ( FIG 1 ) . • A preoperative carcinoembryonic antigen level i s obtained.

Focal inflammatory processes, localized trauma, or local perforation Colon cancer located in the midtransverse colon. Can­ cers located at the flexures may necessitate extended right or left hemicolectomies in order to ensure adequate lymphadenectomy. Other tumors locally extending into the transverse colon (i.e., gastric, pancreatic, adrenal tumors, sarcomas) may necessitate en bloc transverse colectomy when resecting the primary tumor to achieve negative margins.

PATIENT HISTORY AND PHYSICAL FINDINGS •

Patients with colon cancer generally present with occult bleeding and anemia . Patients may also present with high­ grade obstructing symptoms ( crampy abdominal pain and

FIG 1 • CT sca n s h ows a l a rg e obstruct i n g colon cancer in the transverse colon (A) with d i lation of the cecu m (B) a n d a paucity of f l u i d a n d gas in the s m a l l bowe l (C ) .

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

SURGICAL MANAGEMENT Preoperative Preparation • • • •

Clinical trials have shown no need for mechanical bowel preparation. Intravenous cefoxitin is administered within 1 hour of skin incision. Use hair clippers if needed and chlorhexidine gluconate skin preparation. Preoperative time-out and briefing is performed.

Assistant

Surgeon

Equipment and Instrumentation • • • • • •

5-mm camera with high-resolution monitors 5-mm clear ports with balloon tips. They hold ports in the abdomen and minimize their intraabdominal profile during surgery. Atraumatic graspers and laparoscopic endoscopic scissors A blunt tip, 5-mm energy device 60-mm linear reticulating laparoscopic staplers with vascu­ lar and tan loads We use the GelPort hand-assist device due to its versatility and ease of use. This device allows for the introduction/ removal of the hand without losing pneumoperitoneum.

Scrub nurse

FIG 2

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Patient a n d tea m set u p .

Patient Positioning and Surgical Team Setup • •

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This is the single most critical determinant of success in lapa­ roscopic colorectal surgery (FIG 2 ) . Place the patient o n a supine position, with the arms tucked and padded (to avoid nerve/tendon injuries) . The patient is taped over a towel across the chest without compromising chest expansion. The surgeon starts at the patient's right lower side with the scrub nurse to the surgeon's right side. The assistant stands at the surgeon's left side.

•

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PORT PLACEMENT AND OPERATIVE

Align the surgeon, the ports, the targets, a n d the monitors in straight line. Place monitors in front of the surgeon and at eye level to prevent lower neck stress injuries. Avoid unnecessary restrictions to potential team move­ ment around the table. All energy device cables exit by the patient's upper left side. All laparoscopic (gas, light cord, and camera) elements exit by the patient's upper right side.

•

FIELD SETUP •

I n se rt a Gei Port through a 5- to 6-cm epigastric incision. This incision wi l l be a lso used for specimen extraction, tra nsection, a n d a n astomosis. Placement i n the epigastric a rea g reatly fac i l itates d i ssection of the m i d d l e co l i c ves­ sels through a s u p ra m esoco l i c a p proach (see step 7).

•

OPERATIVE STEPS •

I nsert th ree 5-mm work i n g po rts i n the right u p p e r, ri ght l ower, a n d l eft u p per q u a d ra nts. I nsert a 5-m m c a mera port a bove the u m b i l i cus. Tri a n g u late the ports so the c a mera port is at the a pex of the tria n g l e . Th is avoids confl ict between the i nstr u m e nts a n d p revents d isorien­ tati o n ("wo r k i n g o n a m i rro r " ) .

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O u r HALS transverse colectomy operat i o n is h i g h ly sta n­ d a rd i zed a n d it consists of nine ste ps: • Tra nsect i o n of the i nfe r i o r mesenteric ve i n (IMV) • M e d i a l to l atera l d i ssection of the desce n d i n g m esoco l o n • Tra nsect i o n of the l eft co l i c a rtery • M o b i l ization of the s i g m o i d off the pelvic i n let • M o b i l ization of the desce n d i n g colon • M o b i l ization of the s p l e n i c flexure

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M o b i l ization of the ri ght colon Tra nsect i o n of the m i d d l e co l i c vessels (su p r a m eso­ co l i c a p p roach) Extracorporea l tra n sect i o n a n d a na sto mosis

Step 1 . Transection of the Inferior Mesenteric Vein •

T h i s is t h e critical " po i n t of entry" i n t h i s operati o n . A t the level o f the l i g a m ent o f Tre itz, the I M V is easy to v i s u a l i z e a n d is fa r from critica l structu res that can be i n j u red d u r i n g its d i ssection (no i l i ac vesse l s o r l eft

C h a p t e r 1 5 TRANSVERSE COLECTOMY: Hand-Assi sted Laparoscopic Surgery Technique

FIG 3 • Step 1: Key a n atomy. Ligament of Treitz (A). I MV (B). Left co l i c a rtery (C) as it sepa rates from the I M V a n d goes toward the s p l e n i c flexure of the colon (D).

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•

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u reter nea rby) . T h i s w i l l be the o n l y t i m e when a true v i rg i n tissue plane is ente red . Every step will set u p the fo l l ow i n g o nes, o pe n i n g the tissue p l a nes seq uenti a l ly. The patient is p l aced o n a steep Tre n d e l e n b u rg posit i o n w i t h the l eft side u p . U s i n g the right h a nd, m ove the small bowe l i nto the right u p per q u a d ra n t ( R U Q) a n d the transverse colon a n d omentum i nto the u p p e r a b d o m e n . If n ecessa ry, p l ace a l a p a rotomy pad to h o l d the bowel out of the field of view especi a l ly in obese patients. T h i s pad can a l so be u s e d to d ry u p the field a n d to cl ean the scope t i p i ntracorporea l ly. M a ke s u re that the circulating n u rse n otes the l a p a rotomy pad i n the a b d o m e n o n the wh ite board. Identify the critical a n atomy: I M V, l i g a ment of Treitz, a n d l eft co l i c a rtery (FIG 3) . If t h e re a re atta c h m e nts betwee n the d u oden u m/root of mesentery a n d the m esoco l o n , transect them with l a p a ­ rosco p i c scissors. This w i l l a l l ow for a d e q u ate exposu re o f m i d l i n e struct u res. P i c k u p t h e I M V with t h e l eft h a n d . D i ssect u n d e r t h e I M V a n d i n f r o n t of G e rota's f a s c i a w i t h e n dosco p i c scisso rs, sta rt i n g at t h e l e v e l of t h e l i g a m e n t of Treitz and p roceed i n g towa rd t h e i nferior mesenteric a rtery (I MA). The assista nt p rovi des u pward tract i o n with a g ra s p e r. Tra n sect the I MV cep h a l a d of the l eft co l i c a rtery (wh ich m oves away from the I MV a n d towa rd the splenic flexure of the colon) with the 5-mm e n e rgy device (FIG 4}, t h u s p reservi n g i ntact t h e l eft-sided m a rg i n a l a rte r i a l a rcade a n d m a i nta i n i n g the b l ood supply to the desce n d i n g c o l o n segment.

Step 2 . Medial to Lateral Dissection of the Descending Mesocolon

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The s u rg e o n 's h a n d a n d t h e assista nt's g ra s p e r re­ tract t h e I M V/I eft co l i c ped i c l e at t h e cut edge of the

FIG 4 • Step 1 : Tra nsection of the IMV (A) ce p h a l a d of the l eft co l i c a rtery (B).

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desce n d i n g m esoco l o n u pwards towa rds t h e ente r i o r a b d o m i n a l wa l l . H e o r s h e t h e n d i ssects t h e p l a n e b e ­ tween t h e m esoco l o n a n d G e rota's f a s c i a (rea d i ly i d e n ­ t i f i e d by t h e t r a n s i t i o n between t h e two f a t p l a n es) with a 5 - m m e n e rgy device (FIG S) . We l i ke to d i ssect t h i s space by g e n t l y p u s h i n g the retro p e r i to n e u m down with t h e b l u nt tip of t h e 5 - m m e n ergy device. D i ssect ca u d a l ly u n d e r the I M V/I eft co l i c a rtery towa rd the takeoff of the l eft co l i c a rtery off the I M A. D i ssect l atera l ly u n t i l you reach the l atera l a b d o m i n a l wa l l . This will g reatly fa c i l itate step 5 . D i ssect superiorly between the s p l e n i c fl exu re and the ta i l of the p a n creas. This w i l l g reatly fac i l itate step 6 .

FIG S • Step 2 : M ed i a l to latera l d i ssect i o n of the desce n d i n g mesoco l o n . T h e s u rgeon is h o l d i n g the s p l e n i c fl exu re u pward. N otice that there i s a l a p a rotomy pad o n the field h o l d i n g the s m a l l bowe l o u t o f the w a y a n d h e l p i n g provide exce l lent expos u re . The l eft co l i c a rte ry is located i n the medial edge of t h e desce n d i n g m esoco l o n (A). I M A (B). G e rota's fascia (C) . Desce n d i n g colon (D) .

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

• •

l eft i l iac a rte ry a n d psoas m uscle, a n d m ed i a l to the go­ nadal vesse l s before transect i n g a nyth i n g (FIG 7A) . D i ssect with your t h u m b a n d i n d ex f i n g e r a r o u n d a n d beh i n d t h e I M A (FIG 78) Visu a l ize the Jetter "T" formed betwee n the I MA, t h e l eft co l i c a rte ry, a n d the S H A (FIG 7A) . Tra nsect the l eft co l i c a rtery as it takes off the I M A with the e n e rgy device (FIG 7C) . The s u rgeon ca n n ow co m p l ete the d i ssect i o n of the mesoco l o n off the retroperito n e u m i n a s u p e r i o r to i nfe rior d i rect i o n d o w n to the level of the p e l v i c i n let. This w i l l g reatly fac i l itate steps 4 and 5.

Step 4. Mobilization of the Sigmoid off the Pelvic Inlet

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FIG 6 • Step 3 : Critica l a n atomy. The l etter T formed between the IMA (A) and it's l eft co l i c a rtery (B) and SHA (C) term i n a l branches.

• Step 3 . Transection of the Left Colic Artery

•

•

Ide ntify the critical a n atomy: The " l etter T" formed betwee n the I M A and its l eft co l i c and s u perio r h e m o r­ r h o i d a l a rtery (SHA) term i n a l branches (FIG 6) . H o l d i n g the S H A u p w i t h the left h a n d , d i ssect the p l a n e a l o n g the p a l p a b l e g roove betwee n the S H A a n d the l eft i l iac a rtery u s i n g l a p a rosco p i c scissors a n d a 5-mm e n e rgy device. P rese rve the sym pathetic n e rve tru n k i ntact in the retro perito n e u m . Identify the l eft u rete r in front of the

A

c

The s u rgeon p u l l s the p roxi m a l s i g m o i d colon m ed i a l ly with the l eft h a n d a n d the assista nt p u l l s t h e d i stal sig­ m o i d co l o n med i a l ly with a g rasper (FIG SA) . Tra nsect the latera l s i g m o i d co l o n attachm ents to the pelvic i n let with l a p a rosco p i c scissors i n your right h a n d . Stay me­ d i a l ly, close to the s i g m o i d a n d mesos i g m o i d , to avo i d i nj u r i n g the l eft u reter (FIG 88) . You s h o u l d rea d i ly e nter the retroperito n e a l d issect i o n p l a n e d i ssected d u r i n g the p revio u s step . D i ssect ca u d a l ly u n t i l rea c h i n g the l eft s i d e of the D o u g l a s pouch.

Step 5 . Mobilization o f the Descending Colon

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Retract the desce n d i n g colon m ed i a l ly with your l eft h a n d . Tra n sect t h e wh ite l i n e of To ldt up to the s p l e n i c fl exu re u s i n g e n d osco p i c scissors o r e n e rgy device with yo u r right hand t h r o u g h the left-sided port. You s h o u l d rea d i ly e nter the retro perito n e a l d issect i o n p l a n e d is­ sected d u ri n g step 2 .

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FIG 7 • P a nel A: The " l etter T" d i ssected : I M A (A), left co l i c a rtery (B), S H A (C) . Notice the l eft u reter (D) i n the retroperito n e u m . P a nel 8: The I M A is n ow co m p l etely encircled. Panel C: Level of tra n section of the l eft co l i c a rtery (A) as it branches off the IMA (B). Notice the l eft u reter (C) in the retro perito n e u m . The d otted l i n e s h ows where the l eft co l i c a rtery w i l l be tran sected at it's o r i g i n off the I MA.

C h a p t e r 1 5 TRANSVERSE COLECTOMY: Hand-Assi sted Laparoscopic Surgery Technique

A B FIG 8 • Step 4. Pa n el A: M ed i a l tract i o n on the s i g m o i d exposes its latera l atta c h m e nts to the pelvic i n let. Pa n e l B: After the sigmoid m o b i l ization is co m p l eted, the l eft u reter is v i s u a l ized a s it crosses over the l eft i l iac a rte ry. Step 6. Mobilization of the Splenic Flexure

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P l a ce the patient on reverse Tre n d e l e n b u rg position with the l eft side up to help d i s p l ace the s p l e n i c flexure d own out of the l eft upper q u a d ra nt . W i t h the assista nt p u l l i n g the transve rse colon down­ ward with a g rasper, the s u rgeon l i fts the sto mach up with his l eft hand and transects the g a st roco l i c l i g a ment i n betwee n the sto mach a n d transverse colon using a

A

c

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5-mm e n e rgy device t h r o u g h the R U Q port site (FIG 9A) . T h i s a l l ows for entrance i nto the lesser sac a n d p rovides for a n exce l lent view of the s p l e n i c flexure. Tra n sect the g a stroco l i c l i g a ment (from m ed i a l to latera l) with t h e 5-mm e n e rgy device, stay i n g cl ose to the trans­ verse colon a n d avo i d i n g t h e spleen. Proceed l atera l l y to the s p l e n i c flexure. Because the d i ssection performed i n step 2 com p l etely sepa rated the splenic flexu re of the colon from the

B FIG 9 • M o b i l izat i o n of t h e s p l e n i c flexure. P a n e l A: The p a rt i a l ly tran sected g a stroco l i c l i g a m e n t i s visi b l e between t h e tra n sverse c o l o n (A) a n d t h e sto m a c h (B). N o t i c e t h e exce l l ent view of t h e l e s s e r sac l atera l ly t o w a r d t h e s p l e n i c flexure of t h e c o l o n (C) a n d t h e s p l e e n (D). P a n e l B : The s u rg e o n i s " h u g g i n g " t h e s p l e n i c flexu re with h i s h a n d a n d " h o o k i n g " h i s i n dex f i n g e r u n d e r t h e s p l e n o c o l i c l i g a m e n t a l lowi n g for a n exce l l ent exposu re a n d t ra n sect i o n of t h i s l i g a m e n t w i t h a n e n e rgy device. C: S p l e n i c flexu re m o b i l izat i o n . The s u rg e o n retracts the s p l e n i c flexure of the c o l o n (A) downwards a n d m ed i a l ly, expos i n g t h e atta c h m e nts o f t h e s p l e n i c flexure to t h e s p l e e n (B) . The p h renoco l i c (C) a n d s p l e n o c o l i c (D) l i g a m e nts a re tra n sected i n a n i nfe r i o r t o s u p e r i o r, a n d l atera l t o m ed i a l d i rect i o n . The g a stroco l i c l i g a m e n t (E) i s t h e n t r a nsected i n a m e d i a l to l atera l d i rect i o n , u n t i l both p l a nes of d i ssect i o n m eet and t h e s p l e n i c flexure i s fu l l y m o b i l ized .

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retroperitoneum, the s u rgeon can now slide h i s or her right h a n d u nder the splenic flexu re, holding the splenic flexu re up with the i n dex finger " h ooked" under the splenoco l i c l i g ament. This a l l ows f o r a n easy transection o f the spleno­ co l i c l igament with a n energy device (FIGS 98 and C). The left colon should be now fully m o b il ized to the m i d l ine.

Step 7. Mobilization of the Right Colon

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Sta n d i n g at the l eft side of the table, the s u rgeon com­ p l etes the t ra n section of the g a stroco l i c l i g a ment u n t i l rea c h i n g the h e p a t i c flexure of the colon u s i n g a 5-mm e n e rgy device. At t h i s poi nt, the hepatoco l i c l i g a m ent is rea d i ly v i s i b l e . S l i d e yo u r rig h t i ndex f i n g e r u n d e r it, h o l d it u pward, and transect it with a 5-m m e n e rgy d evice. Proceed i n g o n a s u p e r i o r to i nfe r i o r d i ssect i o n , t r a nsect to the r i g h t wh ite l i n e of To l d t with l a pa rosco pi c scis­ sors. F u l ly m o b i l ize t h e ascen d i n g colon off t h e retroper­ ito n e u m with t h e 5 - m m e n e rgy device. T h i s d i ssect i o n s h o u l d p roceed f r o m a l atera l to m e d i a l a s we l l a s from a s u p e r i o r to i nfe r i o r d i rect i o n . Stay in front of t h e d u o­ d e n u m , t h e head of t h e p a n c reas, and G e rota 's fasc i a .

Step 8 . Transection o f the Middle Colic Vessels ( Supramesocolic Approach )

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D i ssect i o n a n d tra nsection of the m i d d l e co l i c vesse ls can be o n e of the m ost d a u nt i n g m a n e uvers i n co l o recta l s u r­ g e ry. Tra d i t i o n a l ly, th ese vessels a re a p p roached i nframe­ soco l ica l ly by d i ssect i n g the root of the mesotra n sverse colon at the i ntersect i o n with the root of the m esentery where t h e ve n o u s a n atomy is extre mely va r i a b l e a n d co m p l ex. T h e s u perio r mesenteric ve i n (SMV) a n d its bra nches, a n d the g a stroco l i c ve n o u s tru n k of H e n l e a n d its branches, surround the m i d d l e co l i c vesse l s . Ve n o u s tea rs tend to travel d ista l ly to the n ext major tri b utary. I n terms of the SMV a n d the g a stroco l i c t ru n k of H e n le, this n ext "tributa ry" is the porta l ve i n confl u e n ce, w h i c h l i es i n a retroperito n e a l p l a n e for w h i c h you d o not h ave control at t h i s t i m e . I n order to p reve nt potent i a l ly d evastati n g b l eed i n g com­ p l ications d u ri n g t h e d i ssection and tra nsection of the middle co l i c vessels, we h ave deve l oped a s u p ra m esoco l i c a p p roach t o these vesse ls. T h e h a n d-assisted tech n i q u e g reatly fac i l itates the performa nce o f t h i s tech n i q u e a n d m a kes it very safe. The s u perior a spect of the transve rse mesoco l o n is n ow rea d i ly visib le, with the m i d d le co l i c vesse l s easily p a l ­ p a b l e as they cross the t h i rd portion of the d u o d e n u m i n the m i dtransverse c o l o n (FIG 1 0) . W i t h the assista nt p u l l i n g down o n the transverse colon d ownwa rd with a g rasper, the s u rgeon " p icks u p " t h e m i d d l e co l i c vesse l s s u p r a m esoco l i c a l l y w i t h h i s o r h e r rig h t t h u m b a n d i n dex f i n g e r. U s i n g his o r h e r l eft hand, t h e s u rgeon n ow d is­ sects u n d e r the m i d d l e co l i c vesse l s with the 5-mm e n ­ e rgy d evice, co m p l etely e n c i rcl i n g the m i d d l e co l i c vesse l s w i t h the t h u m b a n d i n dex f i n g e r. W i t h g reat exposure and control, the s u rgeon now transects the m i d d l e co l i c vesse ls w i t h the 5 - m m e n e rgy device.

FIG 10 • S u p ra m esoco l i c tra nsection of the m i d d l e co l i c vesse l s (M CV) . T h e M CV a re rea d i ly v i s u a l ized at t h i s point t h r o u g h a s u pram esoco l i c a p p roach as they cross over the t h i rd portion of the d u od e n u m . T h i s a l l ows for a safe d i ssection a n d tra nsection w i t h a 5-mm e n e rgy device. •

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D u r i n g t h i s a p p roach, t h e transverse mesoco l o n sepa­ rates the SMV and the gastroco l i c ve n o u s tru n k of H e n l e from the m i d d l e co l i c vesse l s s h i e l d i n g them a n d , t h u s, g reatly red u c i n g the potenti a l risk of serious ve n o u s i n ­ j u ries. It a lso a l l ows f o r a very h i g h tra nsection o f t h e m i d d l e co l i c vesse l s a n d, therefore, a g reat lym phatic n o d a l capture. Prior to the extracorporea l m o b i l ization, we tran sect the r i g ht co l i c vessels i ntracorpo rea l ly (FIG 1 1 ) . H o l d the transverse colon u p with the ri ght h a n d; while t h e as­ sista nt retra cts the ri ght colon a nteriorly a n d latera l ly,

FIG 1 1 • Tra nsection of the r i g ht co l i c vessels. The s u rgeon is h o l d i n g the transverse colon (with the rig ht-sided vasc u l a r a rcade a l o n g i t s mesente ric border) u p . T h e solid white line sh ows where to transect the right co l i c vesse l s (RCV) as they branch off the i l eoco l i c vesse l s ( I CV). Tra nsected m i d d l e co l i c vesse l s (M CV) .

C h a p t e r 1 5 TRANSVERSE COLECTOMY: Hand-Assi sted Laparoscopic Surgery Technique

103 9

FIG 1 2 • Extracorporea l m o b i l ization a n d transect i o n . The spec i m e n is exte rio rized without any tensi o n . The white solid lines show where to tran sect the colon p roxi m a l a n d d ista l to the hepatic a n d s p l e n i c flexu res, respectively. The tattooed target in the m idtra n sverse colon and the vasc u l a r a rcade (arch of R i o l a n) a re rea d i l y v i s i b l e .

expose the rig ht-s ided vasc u l a r a rcade that conn ects the right branches of the middle co l i c vesse l s with the right co l i c vesse l s (th e a rch of R i o l a n ) . You can n ow safe ly tr a n­ sect the right co l i c vesse l s at its orig i n f ro m the i l eoco l i c vesse ls.

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Step 9 . Extracorporeal Transection and Anastomosis

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D e l iver the transve rse co l o n t h r o u g h the e p i g astric i n c i ­ s i o n w i t h the wound p rotector i n p l ace to m i n i m ize the cha nce of wound i nfection a n d oncologic conta m i nation of the wo u n d . Should there be a n y tension, rei ntroduce the co l o n i nto t h e a b do m i n a l cavity a n d m o b i l ize the r i g ht a nd/o r l eft colon more l a p a rosco pical ly. Excessive traction d u ri n g t h i s step ca n lead to tro u b l esome vascu­ lar i n j u ries o n mese nte ric struct u res. Tra n sect the colon extracorporea l ly proxi m a l to the hepatic fl exu re a n d d i sta l to the splenic flexure with a

•

l i n e a r 60- m m e n d osta p l e r with tan loads (FIG 1 2) . The transverse colon spec i m e n conta i n s the m i d d le, rig ht, and l eft co l i c pedicles. At t h i s poi nt, we perform a n extracorporea l , a n ato m i c side-to-si d e, coloco l o n i c a n asto mosis with a 60-m m l i n e a r e n d osta p l e r u s i n g a vasc u l a r load (FIG 1 3) . W e avo i d u s i n g the sta p l ed co l o n i c e n d s i n the a n a stomosis to p re­ vent potenti a l isch e m i a at the sta p l e l i n es i ntersect i o n . The a n asto mosis s h o u l d be tensio n-free a n d h ave a n exce l lent b l ood s u p p ly. W e d o n ot close t h e a n a stomotic mesenteric gap to p reve nt potenti a l damage to its b l ood s u p p ly. The a n astomosis is rei ntroduced i nto t h e a b d o m i n a l cavity. After cha n g i n g g l oves, a l l p o rts a re remove d . Wo u n d s a re c l osed with a bsorba b l e sutu res a n d sea led off with D e r m a b o n d . We p l ace a b i latera l s u bcosta l n e rve b l o c k with b u p ivaca i n e for posto pe rative a n a l g e­ s i a p u rposes.

FIG 13 • Extracorporea l sta pled s i d e-to-side coloco l o n i c a n a stomosis. The a n asto mosis i s tensio n-free a n d h a s exce l l ent b l ood s u p p ly.

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

PEARLS AND PITFALLS Set u p

•

P r o p e r patie nt, t e a m , port, a n d i nstr u m entation set u p is critica l .

Operative tech n i q u e

•

P o i n t o f entry: I M V a t the l i g a ment o f Tre itz. Co m p l ete every step . Each step sets u p the n ext ones seq uential ly. Vascu l a r d issect i o n to v i s u a l ize the l ette r T of the I M A a n d its S H A a n d l eft co l i c branches; identify l eft u reter p r i or to l eft co l i c transect i o n . Supramesoco lic a pproach t o t h e m i d d l e c o l i c vessels is critica l t o prevent serious venous inju ries.

• • •

Pitfa l l : d i ssect i n g a nterior to the SHA

•

S o l u t i o n : Ide ntify " g roove " betwee n l eft c o m m o n i l i a c a rtery a n d S H A a n d d issect i n betwee n t h e t w o vesse ls.

Pitfa l l : tension d u ri n g extract i o n of the spec i m e n

•

Rei ntroduce the colon i nto the a b d o m i n a l cavity a n d m o b i l ize the ri ght a n d/o r l eft c o l o n f u rther. Te n sio n d u r i n g the extract i o n phase can lead to s e r i o u s b l eed i n g problems.

POSTOPERATIVE CARE

COMPLICATIONS

•

•

Postoperative care is driven by clinical pathways that includes the following: Pain control: Intravenous acetaminophen for 24 hours (start in the operating room) followed by intravenous ketorolac for 72 hours (if creatinine is normal) . The sub­ costal nerve block greatly reduces the need for narcotics. Deep vein thrombosis (DVT) prophylaxis with enoxapa­ rin starting within 24 hours of surgery No additional antibiotics, judicious use of intravenous fluids No nasogastric tube. Remove Foley catheter on postop­ erative day 1 . Early ambulation, diet a d lib, aggressive pulmonary toilet Targeted discharge: postoperative day 3

OUTCOMES •

•

•

HALS leads to improvements in short-term outcomes, in­ cluding less pain, faster recovery, shorter hospital stay, and lower incidence of cardiac/pulmonary complications when compared to open surgery. When compared to conventional laparoscopy, HALS results in higher usage rates of minimally invasive surgery, shorter learning curves, lower conversion rates, shorter operative times, and shorter hospital stays. For cancer resection, minimally invasive surgery onco­ logic outcomes are at least comparable to those of open surgery.

• • • •

Wound infections and hernias are markedly reduced versus open surgery. Anastomotic leak rates should be below 5 % . Ureteral injury: critical to identify the left ureter prior to vas­ cular transection DVT: low risk with use of DVT prophylaxis Cardiac and pulmonary complications: significantly reduced compared to the open surgery approach

SUGGESTED READINGS 1. Orcutt ST, Marshall CL, Balentine CJ, et al. Hand-assisted lapa­ roscopy leads to efficient colorectal cancer surgery. J Surg Res. 2012;177(2):e53-e58. 2. Orcutt ST, Marshall CL, Robinson CN, et al. Minimally invasive sur­ gery in colon cancer patients leads to improved short-term outcomes and excellent oncologic results. Am ] Surg. 2011;202(5):528-531. 3. Wilks JA, Balentine C], Berger DH, et al. Establishment of a minimally invasive program at a VAMC leads to improved care in colorectal can­ cer patients. Am ] Surg. 2009;198(5):685-692. 4. Marcello PW, Fleshman ]W, Milsom ]W, et al. Hand-assisted laparo­ scopic vs. laparoscopic colorectal surgery. A multicenter, prospective, randomized trial. Dis Colon Rectum. 2008;51:818-828. 5. Kim HJ, Lee IK, Lee Y S, et al. A comparative study on the short­ term clinicopathologic outcomes of laparoscopic surgery versus con­ ventional open surgery for transverse colon cancer. Surg Endosc. 2009;23(8):1812-1817. 6. Lee Y S, Lee IK, Kang WK, et al. Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer. Int J Colorectal Dis. 2008;23(7):669-673. 7. Schlachta CM, Mamazza J, Poulin EC. Are transverse colon cancers suitable for laparoscopic resection? Surg Endosc. 2007;21(3):396-399.

I

Chapter

16

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

Left Colectomy for Colon Cancer 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - .....

Sa ul J. Ruge/es

DEFINITION •

Left colectomy for cancer is defined as the resection of the left colon in which the extension must correspond to the distribution of the lymphovascular drainage of the tumor­ compromised segment, having as the result negative borders on histopathologic studies, along with in block extirpation of the lymphovascular tissue that nurtures that zone of the colon with a minimum number of 12 lymph nodes available to be evaluated by a histopathologic study. 1

Luis Jorge Lombana

• Total colonoscopy: Regardless of the primary localization of the tumor, every patient should have a complete colonos­ copy study whenever possible, because 2% to 9% of the patients may have synchronous tumors. 1 The colonic enema with double contrast may be used in those patients in whom the colonoscopy is not possible. • Tumor histologic studies that describe the cell differentiation and the extent of the invasion. SURGICAL MANAGEMENT

DIFFERENTIAL DIAGNOSIS

Preoperative Planning

• Most of patients with left colon tumors must have a cancer histologic diagnosis before being taken to surgery. • However, there are existing cases in which the biopsies taken by colonoscopy do not identify the presence of a neoplasia. In these cases, it is recommended to take another biopsy set. If a second set is not diagnostic, it is recommended to proceed with the colectomy and obtain the pathologic study from the surgical specimen. • The differential diagnoses for left colon cancer include com­ plicated diverticular disease with stenosis, intraluminal foreign bodies with an inflammatory reaction, neoplastic invasion from adjacent organs (especially ovaries), and colonic endometriosis.

• The extension and type of procedure must be thoroughly discussed with the patient and family. This includes the pos­ sibility of a temporary or permanent colostomy. • Left colectomy is a maj or surgery that has potential for post­ operative morbidity and mortality. It is desirable to discuss with the patient the local statistical rates for morbidity and mortality before obtaining the informed consent. • There is controversy about the effectiveness and need of mechanical preparation of the bowel before the colectomy. J-s I personally use a " mild " preparation with 2 days of liquid diet and polyethylene laxatives the day before the surgery, achieving the evacuation of large fecal residues. I do not demand a crystalline wash before the surgery. • In the operating room, before initiating the anesthetic act, it is desirable to follow a checklist in which every profes­ sional involved in the surgical act must participate. This list should include at least patient identification, type of surgery, type of anesthesia, expected events during the surgery, the need for blood components, prophylactic antibiotic, surgical devices availability, and potential adverse events and their prevention.

PATIENT HISTORY AND PHYSICAL FINDINGS • The patient's medical record must be complete, including a detailed description of signs and symptoms; medical history, with special attention to the evolution of symptoms; food intake and weight changes; and a thorough physical examina­ tion, including rectal examination. The abdomen must be care­ fully palpated, aimed to search for lumps, carcinomatosis, or ascites. The lymphatic nodal basin must be examined as well. • Family history of cancer is especially important, including two generations, and asking for the presence of colon, gastrointestinal, breast, endometrial, and prostate cancer. This will allow the identification of possible cases of familiar colon cancer. • The clinical evaluation must include a subj ective global assessment of nutritional status to identify the patients who may benefit from perioperative nutritional therapy. 2 • The physiologic risk of the patient must be evaluated accord­ ing to his or her age, intercurrent diseases, and type of surgery, following the institutional preoperative evaluation guidelines. IMAGING AND OTHER DIAGNOSTIC STUDIES •

• •

Carcinoembryonic antigen (CEA): The baseline preoperative result and postsurgical control must be obtained as an assess­ ment for complete tumor resection. On the other hand, the ab­ solute presurgical value is an independent variable for survival.1 Abdominal computed tomography is the most sensitive and specific test for detection of intraabdominal metastases.1 Chest computed tomography is the most sensitive and specific test to detect mediastinal and lung metastases. 1

Positioning •

•

The surgery is performed with the patient in a supine position. The arms should ideally be tucked to the sides, allowing freedom of movement for the surgical team. If one extended arm is required, it should be placed at an angle of 90 degrees and the right arm is preferred. If a colo rectal anastomosis with a circular stapler is assumed, the patient should be in the lithotomy position. In this case, one must ensure that the patient's thighs maintain a hori­ zontal plane with the patient's abdomen, for them not to interfere with the surgeon's arms ( FIG 1 ) . The lower extremi­ ties' position in the brackets must protect them from neuro­ praxias or vascular compressions.

• The surgical team setup is shown in FIG 2. • The surgical table must allow inclinations in every way, which will be necessary to expose regions with difficult access, such as the splenic flexure of the colon. • The patient must be secured to the surgical table adequately to prevent body displacements with position changes of the surgical table.

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

2nd Assistant 1 st Assistant 0-degree angle Anesthesiolog ist

FIG 1 • Correct position of the patient in the operat i n g ta b l e . N ote the h o rizontal posit ion of the t h i g h s to e n s u re free movement of s u rgeon's arms and h a nds.

3rd Assistant

FIG 2

LAPAROTOMY, REVISION OF PERITONEAL CAVITY, AND SURGICAL FIELD

•

PREPARATION •

•

A m e d i a l s u p ra- a n d i nfra u m b i l ica l l a p a roto my is per­ fo rmed, carry i n g the i ncision down to the p u bis, which will i m p rove pelvic expos u re . Once the abdom i n a l cavity is opened, it is advisa b l e to p rotect the wo u n d edges from bacte rial and cel l u l a r conta m i nation by p l a c i n g an Alexis® wo u n d p rotector o r s i m i l a r i nstrument (FIG 3A,B) . Fol lowi n g this, one s h o u l d exp lore the abdom i n a l cavity, emphasizing i n the search for l iver metastases a n d syn­ chronous co l o n tumors, especia l ly i n patients i n which the

A

•

•

Surgeon

S u rg i c a l tea m set u p .

tota l co lonoscopy w a s not poss i b l e d u e to a n o bstructive tumor. Next, the s m a l l bowe l is d i s p laced towa rd the ri ght u p per q u a d rant of the abdomen a n d conta ined using pads a n d a b d o m i n a l rolls. I perso n a l ly p refer not to eviscer­ ate the patient because t h i s i n c reases m a n i p u lation of the i ntesti nes a n d the refore i n c reases t h e poss i b i l ity of posto pe rative i l eus. I n order to a c h i eve good pelvic a n d d ista l desce n d i n g c o l o n exposu re, the patient is p l aced in a Tre n d e l e n b u rg posit i o n . A s l i g ht i n c l i nation of the s u rg i ca l t a b l e toward the r i g ht can be h e l pfu l . Placement of a Bookwalter retractor fa c i l itates operative exposu re. The exact location of the l eft colon tumor is identified and the extent of co l o n i c and lymp hovasc u l a r ped icle resection is defi ned (FIG 4) .

B F I G 3 • A,B. T h e A l exis® retractor h a s b e e n p l aced to p rotect the w o u n d f r o m feca l a n d t u m o r a l conta m i nati o n .

C h a p t e r 1 6 L E FT COLECTOMY FOR COLON CANCER

Line of

Line of proximal resection Tumors

----'.:::!.....L_

Tumors Vascular and lymphatic dissection

resection

-�'-----

FIG 4

•

Leve l s of colon a n d lym p h ovasc u l a r pedicle resection in acco rdance to t u m o r loca l i zati o n .

IDENTIFICATION O F THE LEFT URETER AND START OF LEFT COLON MOBILIZATION •

•

Line of distal resection

T h e s i g m o i d c o l o n is retracted toward t h e r i g h t s i d e, a n d t h e l atera l p erito n e a l fo l d is exposed u p to t h e pelvic ring. Perito n e a l section i n g is i n iti ated with the m o n o p o l a r e l ectroca utery i n a ce p h a loca u d a l d i rect i o n . The loose retro perito n e a l tissue is exposed and it can be sepa­ rated with a co m b i nation of b l u nt and sharp d i ssect i o n i n order to identify the g o n a d a l vessels, the l eft u reter, a n d the l eft c o m m o n i l iac a rte ry. It is usefu l to know that the l eft u reter is a l ways m ed i a l to the g o n a d a l ves­ sels, cross i n g over the common i l i ac a rtery p rio r to its bifu rcat i o n . The l eft u reter is m a rked with a vesse l loop,

FIG 5 • The l eft u reter, located m ed i a l to the g o n a d a l vesse ls, has been i d e ntified and m a rked .

•

b e i n g ca refu l of i n c l u d i n g its acco m p a n y i n g l o n g it u d i n a l vascu l a rization (FIG 5) . A t t h i s poi nt, a n avasc u l a r tissue p l a n e l ocated i n b e ­ twee n t h e u reter a n d t h e g o n a d a l vesse l s i n t h e b a c k a n d t h e mesentery of t h e s i g m o i d a n d desce n d i n g co l o n i n t h e front s h o u l d be searched for. U s i n g b l u nt d i ssect i o n , it is poss i b l e to sepa rate t h ese structu res i n a ce p h a l a d d i rect i o n , stayi n g i n front o f G e rota's fas­ cia, w h i c h s h o u l d be preserved i ntact. M e a n w h i le, the d esce n d i n g c o l o n m esentery i s e l evated . At t h e end of t h i s m a n e uver, the d esce n d i n g c o l o n mesentery w i l l be raised, conta i n i n g the i nfe r i o r m esente r i c a rtery ( I M A) a n d its b r a n c h e s a n d t h e i n f e r i o r mesente r i c ve i n a n d its tri b utaries (FIG 6) .

F I G 6 • T h e l eft co l o n mesentery h a s been raised. T h e retro­ perito n e a l structu res a re expose d .

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

LATERAL TO MEDIAL DISSECTION AND VASCULAR ISOLATION •

•

•

The s i g m o i d a n d desce n d i n g colon a re retracted latera l ly, a n d the perito n e u m is sectioned in a vertica l d i rection from the l i g a ment of Tre itz to the pelvic i n l et, a nterior to the a o rtic a rtery p u lse. At t h i s t i m e, it is poss i b l e to see a s l i g ht h e m atoma behind the root of co l o n i c mes­ ente ry, prod u ct of the previously described latera l d i ssec­ t i o n . Sect i o n i n g the loose tissue in the mesentery root ( u n d e r the s u perio r h e m o r r h o i d a l vesse ls) com m u n i cates the m ed i a l and l atera l d i ssection p l a nes (FIG 7) . Late ral to the fou rth portion of the d u o d e n u m a n d below the i nfe rior p a ncreatic border, it is possi b l e to i d e ntify the i nferior m esenteric ve i n . The i nfe rior mese nte ric ve i n is t h e n l i g ated a n d d ivided (FIG 8) . On t h i s a n ato m i c p l a ne, o n e s h o u l d cont i n u e secti on­ i n g the mesentery i n a ca u d a l d i rection, rem a i n i n g 1 em a head the a o rta i n order to preserve the a b d o m i n a l sym pathetic p l exus (hypogastric tru n k) . I n a l m ost every patie nt, it is possi b l e to observe the hypogastric tru n k as it traverses over the promontory. The hypogastric t r u n k d ivides i nto the rig h t a n d l eft hypogastric tru n k, w h i c h

FIG 8 • The i nfe rior mesenteric ve i n has been d i ssected a n d i s ready to be tra n secte d .

•

can be i d e ntified i n the ri ght a n d l eft poste rol atera l p e l ­ v i s , respectively (FIG 9) . T h e s e n e rves m ust be preserved in order to avo i d a ut o n o m i c dysf u n ction posto perative ly. The I M A, identified a few cent i m eters a bove the aortic bifurcation, is l i g ated a n d d ivided. I n p roxi m a l tumors, this d ivision can be performed at the o r i g i n of left co l i c a rtery i n o r d e r t o preserve the I MA, s i g m o i d a l vessels, a n d superior hemorrh o i d a l a rteries i ntact. T h i s ensures preser­ vation of a we l l -vasc u l a rized s i g m o i d co lon for the a nas­ tomosis, without co m p rom ising the oncological exte nt of the lym phadenectomy (FIG 4) .

FIG 7 • M e d i a l view o f d issection. T h e fo u rth portion o f d u o d e n u m is s e e n i n the s u rgeon's left a n d the assista nt is retracting the l eft co l o n l atera l ly. Notice the s l i g ht hematoma beh i n d the root of the co l o n i c mesentery i n the rig ht, i n d icating the zone of d i ssection u n d e r the su perior hemorrhoidal vesse ls.

F I G 9 • View o f sym pathetic p l exus a n d o r i g i n o f the l eft a n d r i g ht hypogastric n e rves.

MOBILIZATION OF THE SPLENIC FLEXURE

•

•

•

At t h i s t i m e, the o n ly re m a i n i n g step needed for a fu l l m o b i l ization o f t h e l eft colon is t h e m o b i l ization of the s p l e n i c flexure. This m a n e uver can be c h a l l e n g i ng, because t h e splenic flexure can have a very deep l ocation i n the l eft u p p e r q u a d ra n t of t h e abdomen. The latera l perito n e u m sect i o n i n g is conti n u e d from the i n it i a l i n c i s i o n i n a cep h a l ic d i rection a s fa r a s poss i b le, avo i d i n g excessive tract i o n of the s p l e n i c flexure in order to p revent splenic lacerations. T h i s d i ssection can be done with a m o n o p o l a r sca l pe l o r with a b i p o l a r vessel­ sea l i n g device.

•

The f i n a l a p p roach to the splenic flexure s h o u l d be com p le­ mented with a nother point of d i ssection that is i n itiated i n the transverse colon to the left of the m i d d l e colic ves­ sels. At t h i s poi nt, the gastroco l i c l ig a ment is transected, entering the lesser sac (FIG 1 0) . The gastroco l i c l i g a ment is then tra nsected from m ed i a l to l atera l with a monopolar sca l pe l o r with a b i p o l a r vessel-sea l i n g device, leavi n g the g reater omentum attached to the surgical speci m e n . W i t h a co m b i ned traction o f the tra nsverse a n d descend­ i n g colon, it is n ow easier to expose the splenocolic l i g a ­ me nt, a l l owing f o r i t s transection w i t h a m o n o p o l a r sca l pel o r w i t h a b i p o l a r vessel-sea l i n g device (FIG 1 1 ). T h e l eft co l o n is n o w fully m o b i l ized a l l the w a y to the m i d l i ne.

C h a p t e r 1 6 L E FT COLECTOMY FOR COLON CANCER

Gastroepiploic vessels Lienocolic ligament Ligament of the splenic flexure Standard mobilization

Omentum reflected down

FIG 10 • The gastroco l i c liga ment wi l l be transected, sta rting to the left side of the middle col i c vesse ls and proceed i n g from medial to latera l a n d around the splenic flexu re of the colon, until the latera l d i ssection spleen is reached.

/ Stomach /

Pancreas Omentum Spleen

A

FIG 1 1 • A-C. Exposu re of the splenoco l i c l i g a ment. Once the med i a l and latera l d issection pla nes a re con nected, the splenoco l i c liga ment is easily visual ized and is now ready to be transected. (continued)

1045

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P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

S pleen

S plenocolic ligament

Descending colon ----,+---=--=�i

c

8 FIG 1 1

•

(con tinued)

COLON EXTRACTION AND ANASTOMOSIS •

•

At t h i s t i me, a c o l o n seg m e n t from t h e d i sta l t h i rd of t h e tra n sverse c o l o n d ow n to t h e rectos i g m o i d j u n c­ t i o n co u l d be t a k e n to t h e m i d l i n e a n d exte rn a l i ze d t h r o u g h t h e l a pa rotomy i n c i s i o n (FIG 1 2) . The tra n sec­ t i o n p o i nts a re c h o s e n based o n the o n c o l o g i c m a rg i n s n e e d e d , e n s u r i n g a n a d e q u ate captu re of t h e a p p ro ­ p r i ate lym p h ovasc u l a r p e d i c l e s (FIG 4) . I n t h i n p ati e nts, it i s possi b l e to feel the p u l s e of the m a rg i n a l a rtery n e a r t h e p o i nts of tra n sect i o n . I n m o re o bese p ati e nts, o r if the p u l s e i s n ot p a l p a b l e, the p resence of a n o r­ m a l c o l o r i n t h e co l o n is a g o o d i n d icator of a d e q uate p e rf u s i o n o n t h e co l o n i c seg m e nts to be used for the a n a st o m o s i s . If the exte n sio n of the resection a l l ows p reserv i n g t h e s i g m o i d colon, a side-to-si d e transverse colon-s i g m o i d a n asto mosis w i t h a mech a n ical sta p l e r is advisa b l e (FIG 1 3A1 ,A2) . If the s i g m o i d colon h a s to be i n c l u d ed i n the resection spec i m e n , then an e n d-to-e n d colorecta l a n asto mosis with c i rcu l a r sta p l e r via a tra n sa n a l route m ust be performed (FIG 1 381,82) . It is critica l that the a n asto mosis is tension-free; fu l l m o b i l ization of the s p l e n i c flexure ensu res that this is possi b l e .

FIG 1 2 • The l eft colon is n o w f u l l y m o b i l ized a n d is exte riorized t h ro u g h the s u r g i c a l i n c i s i o n . F u l l m o b i l ization of the splenic flexu re will e n s u re a tension-free a n asto mosis.

C h a p t e r 1 6 L E FT COLECTOMY FOR COLON CAN C E R

A1

A2

81 82 FIG 13 • Anasto mosis: A1 . S i d e-to-s i d e sta p l e d transverse colon-s i g m o i d a n a stomosis. A2. Co m p l et i o n of the a n a stomosis a n d resect i o n of the l eft co l o n spec i m e n with a t h o racoabd o m i n a l (TA) sta p l e r. 81 . E n d-to-e n d sta p l e d colo recta l a n a stomosis. 82. Co m p l eted colo recta l a n a stomosis tested u n d e r water. A i r b u b b l es i d entified d u r i n g i n suffl ation of t h e a n a stomosis i n d i cate an a n a stomotic l e a k .

FINAL REVIEW AND CLOSURE OF THE PERITONEAL CAVITY •

O n c e t h e a n asto m o s i s is co m p l eted, t h e s u rg i ca l bed m u st be reviewed to i d e ntify and control s m a l l b l ee d i n g retro p e rito n e a l p o i nts, w h i c h a re freq u e n t . T h e vessel

loop i s r e m oved from the l eft u reter and the a n a sto­ m osed colon i s l eft in t h e retro pe rito n e u m . The rest of t h e a b d o m i n a l cav ity i s ch ecked, t h e s u rg i c a l p a d s a re cou nted, a n d t h e a b d o m i n a l cav ity i s c l osed i n t h e u s u a l way.

1047

1048

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

PEARLS AND PITFALLS Patient posit i o n

•

An i m proper position w i t h h i p f l e x i o n w i l l make it d iffi c u l t to m a n euver d u ri n g the whole proced u re . Make s u re the patie nt's thighs a re co m p l etely h o rizonta l .

Left u reter i d e ntification

•

The l eft u reter m u st be ide ntified a l l the way through and n ot j u st at the entrance to the pelvis. At the a rte r i a l l i gation poi nt, t h i s organ ca n become m ed i a l a n d be i nj u re d . M a ke s u re to i d entify it d u r i n g the vasc u l a r isolati o n .

S p l e n i c flexure m o b i l ization

•

It is usua l ly the m ost cha l l e n g i n g step of this operati o n . It m ust be d o n e with patience, good l i g ht i n g , and u s i n g the d u a l (med i a l a n d l ateral) a p p roach p revi ously descri bed .

Te n s i o n -free a n asto mosis

•

F u l l m o b i l ization of the splenic flexure is critical fo r a tensio n-free a n a stomosis. Anastomotic tension ca n lead to a n astom otic lea ks.

POSTOPERATIVE CARE • • • • • • •

Fluid resuscitation with Ringer's lactate to maintain a uri­ nary output of 1 mL/kg!hr without overhydration Pain control with patient-controlled analgesia or epidural analgesia Early oral intake and patient mobilization Early removal of bladder catheter Venous thrombosis prophylaxis according to guidelines Routine use of nasogastric tube is not recommended. No postoperative antibiotics are needed.

OUTCOMES •

•

The patient's prognosis depends on the tumor staging, which is determined by the histopathologic study of the specimen (pTNM).6 Many patients will require adjuvant chemotherapy according to the tumor stage.7

COMPLICATIONS • • • •

Surgical site infection Hematomas Anastomotic leak Peritonitis

• •

Prolonged postsurgical ileus Incisional hernia

ACKNOWLEDGMENTS The authors thank Maria Angelica Botero, fifth year under­ graduate medicine student, who helped us with translation of the text and editing. REFERENCES 1. 2.

3.

4. 5. 6. 7.

Otchy D, Hyman N, Simmang C, et al. Practice parameters for colon cancer. Dis Colon Rectum. 2004;47:1 269-1 284. Weimann A, Braga M, Harsany L, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25: 224-244. Zhu QD, Zhang QY, Zeng QQ, et al. Efficacy of mechanical bowel preparation with polyethylene glycol in prevention of postoperative complications in elective colorectal surgery: a meta-analysis. Int J Colorectal Dis. 201 0;25(2):267-275. Fry DE. Colon preparation and surgical site infection. Am J Surg. 201 1 ;202(2):225-232. Ramirez JM, Blasco JA, Roig ]V, et al. Enhanced recovery in colorectal surgery: a multicentre study. BMC Surg. 201 1 ;1 1 :9. Link KH, Sagban TA, Miirschel M, et al. Colon cancer: survival after curative surgery. Arch Surg. 2005;390:83-93. Van Cutsem E, Oliveira J. Colon cancer: ESMO clinical recommenda­ tions for diagnosis, adjuvant treatment and follow-up. Ann Oneal. 2008;19(suppl 2):ii29-ii30. doi:10.1 093/annonc/mdn077.

I

Chapter

17

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

Left Hemicolectomy: Laparoscopic Technique 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

Erik Askenasy

DEFINITION • A "left hemicolectomy" can be a nebulous term because three colonic segments lie in the left abdomen: the splenic flexure, the descending colon, and the sigmoid colon. At times, this can lead to consternation during surgical plan­ ning or even intraoperatively. Remembering that the loca­ tion of the pathology guides the extent of colonic resection as well as the associated vascular and regional lymph nodes can provide much needed clarity. Additionally, understand­ ing the vascular anatomy of the left colon and its common variations is essential for a well-vascularized and tension­ free anastomosis. • The left colon develops embryologically from the hindgut and contains three segments: the splenic flexure, the de­ scending colon, and the sigmoid colon. The splenic flexure is located in the left upper quadrant and is supplied by an­ regrade flow from the left branch of the middle colic as well as retrograde flow from the left colic artery. Griffith's point is typically found in the splenic flexure and refers to the wa­ tershed area between these two arteries and represents a cir­ culatory communication between the superior and inferior mesenteric arteries. The descending colon lies in between the sigmoid colon and the splenic flexure and is supplied by the left colic artery. Finally, the sigmoid colon is located in the left lower quadrant and is supplied by the sigmoidal arteries, branches of the inferior mesenteric artery (IMA) after the takeoff of the left colic artery. In this chapter, we will focus on the splenic flexure and the descending colon. • A surgeon must be ready for " surprises " when entering the abdomen for a lesion in the descending colon, because there can be wide variation between the location of the target

lesion as reported during flexible colonoscopy and the actual location found during surgery. The exact type and extent of resection will be dictated by the lymphovascular pedicles associated with the location of the target lesion ( FIG 1 ) . • Laparoscopic surgery provides many advantages t o the patient, including the following: 1-4 Less pain Faster return to work Quicker return of bowel function Shorter hospital stay DIFFERENTIAL DIAGNOSIS • Common indications for laparoscopic left hemicolectomy Cancer of the splenic flexure or descending colon Diverticular disease and its sequelae, including colovesicu­ lar or colovaginal fistulas PATIENT IDSTORY AND PHYSICAL FIN DINGS • Most patients with early-stage colon cancer are asymptomatic, with lesions found on colonoscopy performed for screening purposes or secondary to a positive fecal occult blood test. • Late-stage colon cancer can present with abdominal pain, unexplained weight loss, melena, iron deficiency anemia, or a change in bowel habits. Obstructive symptoms are typi­ cally secondary to circumferential tumors. • Patients with uncomplicated diverticulitis report episodic pain in the left lower quadrant associated with fever, changes in bowel habits, and/or bloating. • The spectrum of symptomatology for complex diver­ ticulitis can be as benign as those for uncomplicated Line of

Line of proximal resection Tu mors

Tu mors �-=i-c-e--- Vascular and lymphatic dissection

resection

..!...11-

FIG 1

•

'-----

Line of distal resection

Extent of lymphovasc u l a r pedicle resection based on l ocation of the p r i m a ry t u m o r.

1049

1050

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

diverticulitis but can progress to localized or even general­ ized peritonitis . • Patients with neoplastic o r inflammatory erosion into adja­ cent organs, such as the bladder or vagina, can present with pneumaturia, fecaluria, or fecaloid vaginal discharge. • A thorough family history of colon or rectal cancer, polyps, and/or other malignancies should be elicited. • Physical examination should include the following: Abdominal examination, focusing on localized tender­ ness, masses, and previous scars Digital rectal examination to assess for blood as well as sphincter function IMAGING AND OTHER DIAGNOSTIC STIJDIES • A full colonoscopy is essential. If a lesion is identified and it is suspicious for malignancy, the area should be tattooed to aid in intraoperative localization. • In malignancy, a triple-phase computed tomography ( CT) chest/abdomen/pelvis scan is performed to evaluate for metastases and locoregional extent of disease as well as to delineate the vascular anatomy. A preoperative carcinoem­ bryonic antigen level should also be obtained. • In diverticulitis, a routine CT abdomen/pelvis scan with oral and intravenous (IV) contrast is obtained.

Anesthesiologist

SURGICAL MANAGEMENT Preoperative Preparation

• Although preoperative bowel preparation is controversial, we routinely use it, as it makes the bowel easier to handle. • Chlorhexidine shower the evening prior to surgery • Normothermia maintained with Bair Hugger ( 3 6 ° C to 3 7°C) perioperatively • Euglycemia maintained perioperatively • One gram of Rocephin and 500 mg of Flagyl are adminis­ tered within 1 hour of skin incision. • Hair clippers are used to clear the field. • Chlorhexidine is used for skin preparation; Betadine is used for perineal preparation. • Preoperative time-out and briefing Equipment and Instrumentation

• One Hasson trochar, one 1 2-mm port, and two 5-mm ports • A 1 0-mm, 45-degree camera (may use 5 mm if quality of camera is acceptable) • Atraumatic bowel gaspers, laparoscopic endoscissors, and a 5-mm energy device Patient Positioning and Surgical Team Setup

• For pathology proximal to the mid-descending colon, the patient is placed on a supine position. Otherwise, the patient is placed on a lithotomy position. • Both arms are tucked and padded. Wide silk tape is applied over two towels across the patient's chest in an "X" figure to secure the patient ( FIG 28) .

Assistant

Monitor B

Surgeon

Instrument table

A c FIG 2 • A. Patie nt, po rts, a n d team set u p . B. Wide s i l k tape is a p p l ied ove r two towe l s across the patie nt's ch est i n an X f i g u re to secure the patient. C. The t h i g h s a re positioned p a ra l l e l with the floor to m i n i m ize encroachment o n the su rgeon's right operati n g a r m .

C h a p t e r 1 7 L E FT H E M I COLECTOMY: Laparosco p i c Tec h n i q u e

• The patient is positioned such that the anus is easily accessible. • The legs are placed in Allen stirrups, making sure the heel is flush against the base. Pressure points are padded posteriorly and laterally. • The thighs are positioned parallel with the floor to mini­ mize encroachment on the surgeon's right operating arm ( FIG 2C) . • Thighs are wrapped with warm blankets t o minimize heat loss during surgery. • Draping is performed to allow for easy access to the perineum.

PORT PLACEMENT AND OPERATIVE FIELD SETUP •

A Hasson troc h a r is p l aced at as the ca me ra port as we l l a s pathology is l ocated i n the a 1 2- m m port is p l aced i n the

the u m b i l icus. This se rves the extract i o n site. If the d ista l desce n d i n g co lon, rig h t l ower q u a d ra n t and

•

• The surgeon starts at the patient's right lower side with the assistant to his or her left. The assistant drives the camera while the surgeon uses both working ports ( FIG 2A) . • A single monitor i s needed and located o n the patient's left side, across from the surgeon and at or slightly below eye level. • All laparoscopic cables should come in from the patient's upper left side. All energy devices, Bovie, and suction should come in from the patient's upper right side. This setup pre­ vents cluttering of the field and facilitates movement of the team around the table.

a 5-mm port is p l aced in the right m i d q u a d ra nt. If the pathology is m o re proxi m a l , then the two right a b ­ d o m i n a l ports a re s h ifted ce p h a l a d a few cent i m eters (FIG 2A) . A 5-m m port can be p l aced i n the left l ower q u a d ra n t to a i d with ta kedown of the wh ite l i n e of To ldt a n d with the s p l e n i c flexure m o b i l izat i o n .

OPERATIVE STEPS •

Alth o u g h s l i g ht a dj u stme nts may be n ecessa ry based o n t h e exact l ocat i o n o f the lesion, l a p a rosco p i c surgery for lesions in the s p l e n i c flexure o r in the desce n d i n g co l o n s h o u l d be sta n d a rd i zed to maxi m i ze operative efficiency, fo l l ow i n g th ese seq uenti a l ste ps: • Placement of the omentum a bove the transverse colon • Tra nsection of the s u perio r mesenteric ve i n (S MV) • Tra nsect i o n of the l eft co l i c a rtery or the I M A (depe n d i n g o n pathol ogy location) • M e d i a l to l atera l d i ssection of the desce n d i n g mesoco l o n • Tra nsection of the g a stroco l i c l i g a m e nt a n d entrance i nto the l esser sac • Tra nsection of the wh ite l i n e of To ldt • M o b i l ization of the s p l e n i c flexure • Extracorporea l resect i o n a n d a n asto mosis • C l o s u re of a b d o m i n a l wounds

• Step 1 . Placement of Omentum above the Transverse

c�� •

The patient is p l aced i n a steep Tre n d e l e n b u rg a n d rotated t o the r i g ht. Omental atta c h m e nts t o the pelvis a re taken down with a n e n e rgy device. The omentum i s then p l aced over the transverse colon a n d i nto t h e l eft u p p e r q u a d ra n t (FIG 3) .

Step 2 . Transection o f the Inferior Mesenteric Vein

•

The i nfer i o r m esenteric ve i n ( I M V) se rves as the g ateway to the retro perito n e u m . E nteri n g t h i s p l a n e in the cor­ rect location wi l l fac i l itate the rest of the operati o n . The s m a l l bowe l is swept to the rig h t a n d the l i g a ment of

•

• • •

105 1

Treitz is expose d . If n ecessa ry, a Ray-Tee sponge can b e p l aced i n to the a b d o m e n t h r o u g h the 1 2- m m port t o assist w i t h expos u re . The I M V, l ocated latera l to the l i g a ment of Tre itz, a n d the l eft co l i c a rtery a re identified (FIG 4A) . Sta rt b y p i c k i n g u p the I M V j u st latera l to the l i g a m e n t of Tre itz a n d d issect u n d e r it with either hot scissors or a n e n e rgy device. E n c i rcle t h e I M V and transect it with either a sta p l e r o r a n e n e rgy device (FIG 48) . Lift u p o n the c u t I M V a n d beg i n exposu re of the retro­ perito n e a l p l a n e (FIG 4C) . There is a " ba re a re a " of mesentery between the l eft co l i c a rtery a n d the m i d d l e co l i c a rte ry. U s i n g a n e n e rgy devi ce, take this mesentery 1 em from the latera l edge of the d u o d e n u m as fa r latera l a s it is safe. Care m ust be taken here to avoid a n g l i n g u p towa rd the colon and risk injuring the m a rg i n a l a rte ry (FIG 40) .

1052

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

B

A

uJ=---'P 5 m m-20 mm > 2 0 m m-25 mm >25 mm

CC-1 CC-2

CC-3

The two classification systems i n use are the R status of resection and the completeness of cytoreduction (CC) score. Complete cytoreduction of all gross disease is designated RO or R 1 or CC-0.

HYP ERTHERMIC INTRAPERITONEAL •

If d u r i n g the p roced u re the s u rgeon feels com p l ete cytoreduction i s not possi b l e or carries u n d u e risk for the patient, the operation is aborted or ta i l o red to delay bowel obstruction, as i ncom p l ete CRS offers no s u rviva l advantage i n colon cancer-i n d u ced PSD. If a bowel resect i o n i s req u i red, n o d ata exist reg a rd i n g t h e t i m i n g o f creati n g a n a n asto m o s i s; t h u s, a n y a n as­ tomosis req u i red co u l d be made prior to o r fo l l ow i n g H I P E C . Req u i red ost o m i es a re created fo l l owi n g H I P E C . W e encourage the u s e o f d ivert i n g loop i l eosto mies i n cases where a low a nterior resection (LAR) with p r i m a ry a nastomosis is performed.

•

•

effects. The d e s i red tem p e ratu re of t h e perfusate i n t h e a bd o m e n ranges f r o m 4 o • c to 4 2 " C . D u r i n g H I P E C, t h e p a t i e n t is coo led to p revent system i c hyperthe r m i a . Lowe r i n g t h e r o o m te m p e rature a n d u s i n g r o o m tem­ pe ratu re i ntraven o u s fl u i d s acco m p l ish this passive coo l i n g . Perfusion for colon p r i m a ries a t o u r i nstituti o n is gen­ era l ly m a i nta ined for 1 20 m i n utes with MMC o r oxa l i ­ p l ati n . Perfusion ti mes m a y be decreased t o avoid system i c a bsorption i n patients deemed to be particu­ larly suscept i b l e . Factors that may m a ke a patient more

Table 2 : Chemotherapeutic Agents Used in Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer

Agent Floxuridine M itomycin C Oxali platin

Molecular Weight

Peritoneal Fluid Concentration to Plasma Concentration

246 Da 3 3 4 Da 3 9 7 Da

2000 : 1 75:1 25:1

C h a p t e r 48 CYTO RED UCTIVE SURGERY AND HYPERTH E R M I C I NTRAPE RITONEAL CHE MOTHERAPY

•

•

suscept i b l e to drug toxicity i n c l u d e extensive peritonec­ tomy, poor performa nce status, o r old a g e. The perfusate is d r a i ned fo l l ow i n g the desig n ated t i m e p e r i o d f o r perfu s i o n . The a b d o m e n is expl o red once a g a i n and a n a stomoses o r ostomies a re create d . We do not rout i n e ly p lace d ra i ns, with the except i o n of patients un de rgoi n g d i sta l pancreatectomy. The a b d o m e n is c l osed a n d the p roce d u re is concluded. Several techniques for perfusing with H I PEC have evolved. All consist of a closed circuit to maintain consistent hyperthermia and tem perature monitoring (FIG 6A.B). There is insufficient evidence to support one technique over another.

Hyperthermic Intraperitoneal Chemotherapy Delivery Modalities: T he Closed Abdominal Technique •

•

•

The c l osed tech n i q u e is o n e of the two most com mo n ly used H I PEC tech n i q ues. This tech n i q u e i nvolves the p l acement of i nflow a n d out­ flow catheters through the skin prior to sutu r i n g the s k i n closed i n a tempora ry yet watertight m a n n e r (FIG 7) . Tem porarily closing at the l eve l of t h e s k i n w h i l e leavi n g the fasci a o p e n a l l ows contact o f the perfusate to t h e l i kely conta m i n ated su bcuta neous tissue on e i t h e r side of the i n ci s i o n .

Video touch screen r---

Ro lle r pump Inflow catheter

A

FIG 6 • A. S c h e m a t i c of a H I PEC perfusion ci rcuit. B. Photog raph of the perfus io n c i rcuit. F l ow of

B

isoto n i c fluid is esta b l ished i nto the patient. Inflow a n d outflow temperatu res a re m o n itored a n d the perfusate i s titrated to a n outflow temperature of 40°( to 42"C. The chemotherapeutic agent is added at t h i s poi nt. The perfusate exits the patient, is fi ltered, and cycled back through the heat p u m p a n d i nto the patient f o r the set period o f t i m e .

1 3 53

1 3 54

P a r t 4 OPERATIVE TECH NIQUES IN COLON AND RECTAL SURGERY

Hyperthermic Intraperitoneal Chemotherapy Delivery Modalities: T he Open, or Coliseum Technique •

•

•

•

•

FIG 7 • A p h otog ra ph d e picti n g t h e closed abdom i n a l tech n i q u e . There a re two i nflow a n d two outflow ca n n u las that a l l ow the abdomen to be i n cont i n u ity with the perfusion c i rcu it. The abdomen has been closed temporarily with a r u n n i n g suture at the s k i n l eve l . •

•

•

The operating room personnel massage the abdomen (gen­ tly shaking it i n a back-a nd-forth rocking fashion) to help distribute the perfusate throughout the abdomen (FIG 8). The i ncreased pressu re i n the closed tech n i q u e theoreti­ ca l ly provides deeper penetrat i o n of the chemot h e ra py i nto tissues. For these reasons, the closed tech n i q u e is o u r p referred a p p roach to d e l ive r i n g H I PEC.

The open tech n i q u e is a lso a com m o n l y used H I PEC tech n i q u e . This H I PEC technique involves sutu ring p lastic sheeting circu mferentia l ly around the patient's skin i ncision and securing it to the fixed retractor (FIG 9). This expa nds the potentia l space with a "col iseum-l i ke" device, wh ich a l l ows the bowel to float freely in a larger vol u m e of perfusate. T h is tech n i q u e theoretica l ly i ncreases exposure of a l l s u r­ faces to the chemot h e ra py. The open tech n i q u e a l l ows the s u rgeon to m a n i p u late the i ntraabdo m i n a l contents a n d may fac i l itate a more even d istribution of heat and agent t h roughout the a b d o m e n . D u e to concern regard i n g exposure of operat i n g room person n e l to the chemotherapeutic agent with the open tech n i q ue, spec i a l i zed e d u cation a n d tra i n i n g of i nvolved person n e l is m a n d atory. Othe r safety efforts i n c l u d e restriction o f operati n g r o o m traffic, s m o ke evacuators, fi ltration masks, a n d waterproof gowns.

Hyperthermic Intraperitoneal Chemotherapy Delivery Modalities: Other Techniques •

•

Other modal ities of perfusion have been deve l o ped i n a n attem pt t o com b i n e t h e advantages o f both t h e open a n d cl osed tech n iq ues but a re not widely used. These tech n iques may p rovide m o re even d r u g a n d tem­ peratu re d istr i b ution; h oweve r, they a re g e n e ra l ly com­ p l ex and do not e l i m i nate all safety risks to operat i n g r o o m perso n n e l .

Smoke evacuator tubing

FIG 8

• D istribution of t h e perfusate. The o perati ng room person n e l massage the abdomen (gently s h a k i n g it i n a back a n d forth rocking fash ion) to help d istri b ute the perfusate throughout the a b d o m e n .

Self-retaining retractor

Perfusion cannulas FIG 9 • The open or "colise u m " H I PEC tech n i q u e i nvolves sutu r in g p lastic sheet i n g c i rcu mferentia l ly around the patient's s k i n i ncision a n d secu r in g it to the fixed retractor. This expa nds the potential space with a " co l ise u m - l i ke " device, wh ich a l l ows the bowe l to float freely in a l a rg e r vo l u m e of perfusate.

C h a p t e r 48 CYTO RED UCTIVE SURGERY AND HYPERTH E R M I C I NTRAPE RITONEAL CHE MOTHERAPY

1 355

PEARLS AND PITFALLS CRS/H I P E C goal

•

Patient selection

•

Com p l ete cytored uction prior to H I PEC i nfusion It i s critical to sel ect a p p ropriate ca n d i d ates. I m porta nt e l e m e nts to assess i n c l u d e the fo l l owi n g : Patient's performa nce status • Extent a n d d i stribution of d i sease Consider use of l a pa roscopy. •

•

CRS

• • • •

H I PEC

• • •

Posto perative care

• •

Remove everyt h i n g with tumor d eposits: (nonvital) organs and perito n e u m . If a bowel resection is req u i red, a n a nastomosis may be created p r i o r to o r fol l ow i n g H I PEC. Req u i red ostom i es a re created fo l lowi ng H I PEC. The two pred o m i nati n g cl assificati o n systems a re used : R status of resection a n d the CC score. Perfuse for 1 20 m i n utes at 40°C to 42°C. Tem p eratu re >42°C g reatly i n creases morbid ity/morta l i ty. The closed a b d o m e n a n d open (co l iseum) tech n iques a re most freq uently used. C l ose I C U m o n itoring is req u i re d . Postoperative com p l ication rates a re h i g h : A h i g h i ndex of c l i n ica l s u s p i c i o n is req u i re d .

POSTOPERATIVE CARE •

•

•

•

•

•

•

•

•

•

•

The goal is for extubation in the operating room, followed by hemodynamic support and close fluid monitoring in the intensive care unit (ICU ) . Seventy-five percent o f our patients require close monitoring in ICU postoperatively for a median stay of 1 day, whereas 2 5 % are admitted directly to the floor. Total parenteral nutrition is not routinely initiated postop­ eratively. A nasojejunal feeding tube is often but not always placed in the operating room for early initiation of trophic feeds. Broad-spectrum intravenous antibiotics are not continued postoperatively. Patients are kept NPO until exhibiting return of bowel func­ tion. Nasogastric tubes are used as necessary. The Foley catheter is removed within 4 8 hours; however, it is kept for 5 days in cases where an LAR was performed and for 10 days in cases of a cystectomy or bladder repair. Patient-controlled analgesia (PCA) or thoracic epidural analgesia is used postoperatively at the discretion of the surgeon. Mechanical and pharmacologic DVT prophylaxis is started on the day of the operation. Aggressive chest physical therapy is instituted. Early ambu­ lation is encouraged. The median hospital stay for our first 1 ,000 CRS/HIPEC patients is 8 days. Postdischarge follow-up: Patients are discharged home with 2 weeks of prophylactic enoxaparin and are initially seen for a postoperative checkup 2 weeks following dis­ charge from the hospital . Follow-up thereafter includes an examination, tumor markers, and CT imaging every 3 months.

COMPLICATIONS •

Given the extent of the surgical resection required to achieve adequate cytoreduction, morbidity is significant. Maj or morbidity over the last 5 years for our institution is 27% with 3 . 8 % mortality.

•

•

•

•

•

•

•

•

Complications are frequently divided into two groups: secondary to the operation itself or toxicity from the chemo­ therapeutic agent. The complications of CRS essentially depend on the com­ bination of organs resected and are similar with that de­ scribed in the general surgery literature. The gravity of the complication may be significantly worse and depends on the physiologic reserves of the patient (which are com­ monly depleted), the extent of CRS, ECOG, and impact of chemotherapy. Twenty-three percent of patients are likely to require a blood transfusion at some point during their operation or hospitalization. Predictors of morbidity include older age, higher PCI, greater number of visceral resections, poorer performance status, and higher drug dose. Morbidity rates are related to the experience of the center performing CRS/HIPEC. Common causes of death are bowel perforation, respiratory failure, bone marrow suppression, thromboembolic events, and sepsis. Preoperatively, diabetes, the presence of ascites, bowel obstruction, and poor performance status are predictors of increased mortality rates. Despite the significant rates of morbidity and mortality, CRS/HIPEC remains the only hope many of these patients have for long-term survival. Therefore, any legitimate evaluation of the complications following CRS/HIPEC must be compared to the inherent complications of PSD and its natural history without such treatment.

OUTCOMES •

•

The CC has been shown to be an important independent predictor of survival. The average rate of complete cytore­ duction among high-volume centers is about 60% to 75 % . Predictors o f incomplete cytoreduction include poor perfor­ mance status, disease outside of the peritoneal cavity, more than three hepatic metastases, biliary or ureteral obstruction, multifocal bowel obstructions, the presence of malignant ascites, and extensive disease in the gastrohepatic ligament.

1 3 56

•

•

•

•

•

•

P a r t 4 OPERATIVE TECH NIQUES I N COLON AND RECTAL SURGERY

A consensus statement on the locoregional treatment of colorectal PSD recommends CRS/HIPEC as the treatment of choice for patients without distant metastatic disease and in whom complete cytoreduction is deemed feasible. CRS/HIPEC in our institution has a median survival of 3 3 . 6 months in colorectal cancer patients who achieved a complete CRS and 2 1 .2 months if CRS/HIPEC is performed with synchronous hepatic resection of limited liver disease. This has to be compared with the 10 to 1 4 months median survival obtained with second-line chemotherapy and the 3 months median survival obtained with third-line chemo­ therapy for stage IV colorectal cancer patients. It is important to mention that systemic chemotherapy and CRS/HIPEC are complementary treatment and not in lieu of each other. These patients should be treated in a multidisciplinary fash­ ion. Multiple lines of chemotherapy result in decrease in ECOG functional status, which is a well-documented pre­ dictor of increased postoperative morbidity and mortality. Conversely, upfront CRS/HIPEC resulting in major morbid­ ity will deprive the patient from timely administration of systemic chemotherapy. Despite these results, HIPEC for this cohort has not been universally accepted in the oncology community and contro­ versy remains. Patient quality of life is another key outcome following CRS/ HIPEC. Our quality-of-life data indicate that patients return to their baseline between 3 and 6 months postoperatively. The expected decrease in quality of life immediately follow­ ing such therapy and its duration should be communicated to patients considering CRS/HIPEC.

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offers no survival benefit in patients with PSD from colonic primary lesions. Many factors influence the efficacy of HIPEC. There are also many ways to perform HIPEC, each with their own advan­ tages and disadvantages. Close monitoring is required postoperatively, as complica­ tion rates are high. Clinicians should maintain a high index of suspicion for complications. CRS/HIPEC may offer a survival benefit in low-volume patients with colon cancer-induced PSD when a complete cytoreduction is obtained. This treatment modality should be offered in addition to systemic chemotherapy.

SUGGESTED READINGS 1.

2.

3.

4.

5.

6.

MAIN POINTS OF CYTOREDUCTIVE SURGERY/HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY FOR

7.

PATIENTS WITH PERITONEAL SURFACE DISEASE FROM COLON CANCER •

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CRS/HIPEC involves surgical resection of all seeded organs and peritoneal surfaces followed by heated chemotherapy within the abdomen. When planning CRS/HIPEC for patients with PSD from co­ lonic primary lesions, appropriate patient selection hinges on the feasibility of obtaining a complete cytoreduction and the patient's ability to undergo the procedure. The sensitivity of preoperative CT in determining distribu­ tion of disease is small. The goal of CRS/HIPEC is the removal of all visible disease prior to perfusion with HIPEC. Incomplete cytoreduction

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Levine EA, Stewart JH, Sherr P, et al. Intraperitoneal chemotherapy for peritoneal surface malignancy: experience with 1 000 patients. I Am Coil Surg. 2014;2 1 8 ( 4 ) :573-5 8 5 . Stewart J H , Shen P , Levine E A . Intraperitoneal hyperthermic chemo­ therapy for peritoneal surface malignancy: current status and future directions. Ann Surg Oneal. 2005; 1 2 ( 1 0 ) : 765-777. Esquivel ] , Elias D, Baratti D, et al. Consensus statement on the loco regional treatment of colorectal cancer with peritoneal dissemination. I Surg Oncol. 2008;9 8 ( 4 ) :263-267. Sarnaik AA, Sussman ]], Ahmad SA, et al. Technology of intraperito­ neal chemotherapy administration: a survey of techniques with a re­ view of morbidity and mortality. Surg Oncol Clin N Am. 2003 ; 1 2 ( 3 ) : 849-8 6 3 . Verwaal VJ, v a n Ruth S , d e Bree E, e t a l . Randomized trial o f cytoreduction a n d hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with perito­ neal carcinomatosis of colorectal cancer. I Clin Oncol. 2003;2 1 (20): 3737-3743. Glehen 0, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive sur­ gery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. I Clin Oncol. 2004;22 ( 1 6) : 3 284-3292. Verwaal VJ, Bruin S , Boot H , et al. 8 -year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinoma­ tosis of colorectal cancer. Ann Surg Oncol. 200 8 ; 1 5 ( 9 ) :2426-2432. Elias D , Lefevre JH, Chevalier ] , et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for perito­ neal carcinomatosis of colorectal origin. ] Clin Oncol. 2009;27 ( 5 ) : 6 8 1-6 8 5 . Newman N A , Votanopoulos K L , Stewart J H , e t a l . Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer. Minerva Chir. 2012;67(4):309-3 1 8 . Hill AR, McQuellon RP, Russell GB, e t al. Survival and quality o f life following cytoreductive surgery plus hyperthermic intraperitoneal che­ motherapy for peritoneal carcinomatosis of colonic origin. Ann Surg Oncol. 2 0 1 1 ; 1 8 ( 1 3 ) :3673-3679. Randle RW, Swett KR, Swords D S , et al. Efficacy of cytoreductive sur­ gery with hyperthermic intraperitoneal chemotherapy in the manage­ ment of malignant ascites. Ann Surg Oncol. 2014;2 1 ( 5 ) : 1 474-1479.

5

O p e rat i ve Te c h n i q u es i n B re a st, E n d o c r i n e, a n d O n co l o g i c S u rg e ry

F i n e N e e d l e As p i rat i o n of a B re a st M a s s 1 3 63 J u dy C. Pa n g a n d Cla ire W. Mich a e l

W i re Loca l i ze d B re a st B i o p s y 1 3 70 Micha e l S. Sa b e l

S u ba re o l a r D u ct E xc i s i o n

13 78

A m y C . D e g n im

C r y o a b l a t i o n of B re a st F i b ro a d e n o m a s 1 3 8 6 Ca ry S . Ka u fm a n

L u m p e ct o m y f o r B re a st Ca n c e r 1 3 94 Micha e l S. Sa b e l

O n co p l a st i c B re a st S u rg e r y 1 4 03 Kristin e E. Ca lh o u n a n d B e nja m in 0. A n ders o n

B ra c h y t h e r a p y C a t h e t e r I n s e rt i o n f o r B re a s t C a n ce r 1 4 1 4 Peter D . B e itsch

S e n t i n e l Ly m p h N o d e B i o p s y f o r B re a st Ca n c e r 1 42 1 A n e e s B. Ch a gp a r

I n te r n a l M a m m a r y S e n t i n e l N o d e B i o p s y 1 424 A . Ma rilyn L e itch

S i m p l e M a ste cto m y 1 432 Micha e l S. Sa b e l and L isa N e wm a n

S k i n - S pa r i n g a n d N i p p l e/A re o l a r- S p a r i n g M a stectom y 1 442 Ele n i To usim is and Rache Sim m o n s

M o d i f i e d R a d i ca l M a stecto m y 1 4 5 1 Tiffa ny A . To rste n s o n a n d J u dy C. B o u g h ey

Te c h n i q u e s f o r Co rrect i n g L u m p e c t o m y D efe cts 1 4 62 Ju lie E. Pa rk, Jo n a th a n B a n k, a n d Da vid H. S o n g

D i rect-To- I m p l a n t B re a st Reco n st r u ct i o n

1471

A m y S. Co lwell

Two - S t a g e I m p l a nt B re a st Reco n st r u ct i o n

1 4 76

Eric G. H a l vo rs o n

P e d i c l e d L a t i s s i m u s D o rs i F l a p B re a s t Reco n s t r u ct i o n a fte r M a stecto m y 1 4 88 Fra n k Fa n g a n d A d eyiza 0 . M o m o h

P e d i c l e d Tra n sv e r s e R e ct u s A b d o m i n i s M yo c u t a n e o u s F l a p B re a s t R e c o n st r u ct i o n 1 4 9 6 D a le Collins Vida l a n d Em ily B . R idg way

F re e Tra n sv e r s e Rect u s A b d o m i n i s M u s c u l o c u t a n e o u s F l a p R e c o n st r u ct i o n afte r M a stectom y 1 502 Ma urice Y. Na h a b e dia n a n d K e ta n M. Pa tel

D e e p I n fe r i o r E p i g a str i c P e rf o r a t o r F l a p B re a s t R e c o n st r u ct i o n Aft e r M a ste cto m y 1 5 1 2 A deyiza 0. M o m o h

N i p p l e-Areo l a r R e c o n s t r u ct i o n 1 522 A n ita R . Kulka rn i, A my K . A lderm a n, a n d A n drea L . Pusic

R e d u ct i o n M a m m o p l a st y 1 52 8 S e b a s tia n Win o c o u r a n d Va le rie L e m a in e

W i d e E xc i s i o n of P r i m a r y C u t a n e o u s M e l a n o m a 1 53 5 R ussell S. B e rm a n a n d Je ffrey E . G e rsh e n wa ld

Adva n c e m e n t a n d Rotat i o n a l F l a p s 1 54 6 Je ffrey H . Kozlo w

S k i n G rafts 1 555 Da vid L . B ro wn

D i g i t A m p utat i o n s 1 560 Ste ve n C . H a a s e

R e s e ct i o n of H e a d a n d N e c k M e l a n o m a 1 5 6 7 Scott A . Mcle a n

S e n t i n e l Ly m p h N o d e B i o p s y f o r M e l a n o m a 1 5 78 M e rrick I. R oss a n d Mich a e l Kim

Ax i l l a r y Ly m p h N o d e D i s s e ct i o n f o r M e l a n o m a 1 594 Micha e l S. Sa b e l

I n g u i n a l Ly m p h N o d e D i s s e ct i o n ( l n g u i n ofe m o ra l a n d I l i o i n g u i n a l ) f o r M etastat i c M e l a n o m a 1 6 0 5 A m o d A . Sa rn a ik a n d Ve rn o n K . S o n da k

M i n i m a l l y I n va s i ve I n g u i n a l Ly m p h N o d e D i s s e ct i o n f o r M e l a n o m a 1 6 1 5 Ja m es W. Ja k u b

S e l e ct i ve N e c k D i ss e ct i o n f o r M e l a n o m a 1 62 6 Vasu D ivi

P o p l i t e a l D i s s e ct i o n

1 634

G l e n da G. Ca lle n de r a n d Ke lly M. McMas ters

I s o l a t e d L i m b I n f u s i o n 1 64 1 Je ffrey J. Sussm a n a n d Joseph S. G ig lia

I s o l a t e d L i m b P e rf u s i o n 1 64 7 O m g o E . Nieweg, Osca r E. Im h o f, a n d B in B . R. Kro o n

T h y ro i d L o b e cto m y 1 656 A my C . Fox a n d Pa u l G. G a u g e r

Tota l T h y ro i d e c t o m y 1 6 63 Sa ld C. Azo ury A n d Ma rth a A. Ze iger

T h y ro i d e cto m y f o r S u bste r n a l G o i te rs 1 6 73 A n dre w G. S h u m a n a n d Ash o k R. Sh a h a

S u btota l T h y ro i d e cto m y f o r G ra v e s ' D i s e a s e 1 6 79 Edwin L. Kap la n a n d Raym a n H. Gro g a n

M i n i m a l l y I n va s i ve V i d e o - As s i st e d T h y ro i d ecto m y 1 68 6 Pa o lo Miccoli a n d G a b rie le Ma terazzi

Ly m p h N o d e D i s s e ct i o n i n T h y ro i d Ca n c e r 1 694 G e ra rd M. D o h e rty

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1 10 0

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S u btota l Pa rath y ro i d e c t o m y o r Tota l w i t h A u to l o g o u s G ra ft 1 1 1 1 B ria n D. Sa u n ders

M i n i m a l l y I n va s i ve P a r a th y ro i d e c t o m y 1 723 Peter A n g e lo s a n d Raym a n H. Gro g a n

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Ad re n a l e c t o m y, O p e n : A n te r i o r 1 74 7 B a rb ra S. Miller

Ad re n a l ectom y, Open: Thoracoabdom i na l 1 755 Ba rb ra 5. Miller

Ad re n a l e c t o m y : O p e n Poste r i o r 1 763 Ba rb ra 5. Miller

La p a ro s co p i c R e tro p e r i t o n e a l Ad re n a l e c t o m y 1 769 Mich a e l G. Joh nston and Ja m es A . L e e

La p a ro s co p i c A d re n a l e c t o m y - L a t e ra l A p p ro a c h 1 7 75 G e o ffrey B. Th o m p s o n a n d A n n a K u n d e l

l n s u l i n o m a s 1 782 D o u g la s L. Fra k e r

S u rg e r y for G l u c a g o n o m a 1 79 1 Rich a rd A . Prinz a n d Ca th e rin e A . M a d o rin

I

Chapter

1

Fine Needle Aspiration of a Breast Mass

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Judy C. Pa ng

DEFINITION •

Fine needle aspiration (FNA) biopsy is a percutaneous proce­ dure that uses a fine gauge needle with or without a syringe to sample fluid from a cyst or extract cells from a solid palpable mass for cytologic analysis.

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A focused history should be obtained from the patient including duration of the mass, changes in size, associated pain, or fluctu­ ations of the mass with menstrual cycle. Prior history of trauma or malignancies should also be ascertained. On physical exami­ nation, localizing the mass as within the breast parenchyma, lower axilla, or subcutaneous/cutaneous tissue of the chest wall is important. The differential diagnoses may be different. In ad­ dition, noting any skin changes such as redness, warmth, or edema is also helpful. Determining the size and quality of the mass as well as depth and relation to other structures is essen­ tial for an adequate sample while minimizing complications. There are no absolute contraindications to FNA.

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Mammographic and ultrasound findings can be helpful in arriving at an accurate diagnosis. Knowing whether a lesion is solid or cystic can help select the appropriate needle and syringe. For lesions that are nonpalpable or difficult to palpate, image-guided (i.e., ultrasound) FNA is recom­ mended to ensure proper sampling of the mass.

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Benign (i.e., fibroadenoma, cyst) Malignant (i.e., carcinoma, lymphoma) Atypical (core biopsy or surgical excision required for definitive diagnosis)

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Alcohol pads to cleanse the sk i n a n d ga uze pads to a p p ly pressu re after com p l et i o n of the proce d u re Local a n esthetic is optio n a l . B eve led hypodermic need l es • A 23-g a u g e needle is preferred a n d typica l ly the o n e to start w i t h . If i n a d eq uate mate r i a l is o bta ined, a 22-g a u g e needle can be used especia l ly for lesions with m i n i m a l stroma (i.e., lymphoma, m e l a noma) or a 25-g a u g e need l e for r u b bery or f i b rous masses (i.e., fibroadenoma). • The length of the needle is typica l ly 5/8 i n to 1 % in, which is j u st long enough to reach the target. Shorter

The patient may be upright or supine depending on the loca­ tion of the mass. The patient should be positioned to opti­ mize palpation and sampling of the mass.

Approach •

EQUIPMENT •

Prior to the FNA, the location of the palpable mass should be confirmed with the patient. The mass should be examined in the upright and supine position to determine the ideal position for the biopsy.

Positioning

DIFFERENTIAL DIAGNOSIS •

Alternative procedures to FNA biopsy are core needle biopsy and surgical excision of mass. For solid masses, FNA biopsy provides cells for cytology, whereas core needle biopsy obtains tissue. In situations where an experienced cytopathologist is not available or tis­ sue architecture is necessary to make a diagnosis (e.g., differ­ entiating between in situ and invasive disease), core needle biopsy is preferred. Surgical excision should be reserved for cases where FNA or core needle biopsy was inconclusive. It may be considered for small breast masses where the patient is strongly desirous of excision.

Preoperative Planning

IMAGING AND OTHER DIAGNOSTIC STUDIES

•

For patients who opt not to undergo a biopsy, short-term follow-up (4 to 6 months) with repeat imaging and clinical examination to document stability or changes is recommended.

SURGICAL MANAGEMENT

FINDINGS

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Claire W. Michael

NONOPERATIVE MANAGEMENT

PATIENT HISTORY AND PHYSICAL

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FNA can be performed using ( 1 ) a needle, syringe, and syringe holder; (2) a needle and syringe; or ( 3 ) a needle only.

needles a re easier to m a n i p u late beca use they w i l l not bend. A s l i p-t i p syr i n g e is best as it is easy to handle a n d pro­ vides a good sea l . A Luer lock syr i n g e may a lso be used, but it can be d ifficult to remove the need l e . A 1 0- m l syri n g e is preferred as it a l l ows the h a n d to be c l o s e r t o t h e ta rget a n d o n l y 2 to 4 m l o f suction is n e e d e d for aspirati o n . For l a r g e r cystic lesions, a 20-ml syr i n g e may be advantageous. A syringe holder a l l ows for one-handed grip and appl ication of suction leaving the other hand free to sta b i lize the target. G l ass s l ides a n d cover s l i ps S l i d e h o l d e r for a i r-dried sl i d es

1363

1 364

P a r t 5 OPERATIVE TECHN IQUES IN BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

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N i n ety-five percent eth a n o l (EtO H) i n a j a r for fixati o n of s l ides or spray fixative. If the j a r is not slotted for separat i n g s l i d es, using paper c l i ps o n a lternati n g s l ides can a c h i eve the same goa l . There a r e d ifferent ra pid sta i n s that c a n b e used for ade­ q uacy checks i n c l u d i n g to l u i d i ne bl ue, ra p i d hematoxy l i n

•

a n d eosin, rapid Pa pan icolaou for fixed s l ides, and G iemsa a n d Diff-Qu i k for a i r-dried sl ides. Need l e ri nses can be performed i n R P M I (ce l l b l ock or flow cytometry for lym p h o m a), 1 0 % b uffered forma l i n (cel l b l ock), or Cytolyt (th i n prep).

FINE NEEDLE ASPIRATION USING NEEDLE, SYRINGE, AND SYRINGE HOLDER1 • 2 •

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Ca refu l ly pal pate the mass to estim ate the size a n d d e pth as we l l as assess the structu res nea rby to avoid (i.e., major blood vessels, bone, and lung especi a l l y with s m a l l b reasts) . Fix the mass firmly i n p l a ce with the f i n g e rs. • For l a rge lesions, use the t h u m b a n d opposing f i n g e r

(FIG 1 ) . For s m a l l e r lesio ns, p lace t h e forefi ng er a n d m i d d l e f i n g e r on t o p o f the m a s s a n d t h e n spread them a p a rt, stretc h i n g the sk i n (FIG 2) . P l a n t h e a n g l e o f the need le at the entra n ce p o i n t o f t h e s k i n a n d determ i n e the d e pth o f penetrat i o n . • If the need l e enters at 90 deg rees to the mass, the need l e s h o u l d pen etrate t h e s k i n o n top of the mass •

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FIG 2

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Fixation of s m a l l e r mass u s i n g forefi n g e r a n d m i d d l e

f i n g e r.

(FIG 3A,B) . •

If the need l e enters at a 30- to 45-degree a n g l e, which is oftentimes m o re comforta b l e a n d practical, co mpensate for the acute angle by penetrat i n g the s k i n adjacent to the mass a n d not on top of the mass

(FIG 4A,B) . When entering at 90 deg rees, penetrat i n g too deep with the need l e can potentia l ly res u l t i n a pneumo­ thorax. If t h i s is a concern (e. g . , mass nea r the chest wa l l), a 30- to 45-deg ree a n g l e is p referred. • To sta b i l ize the i nstr u m e nt, rest the barrel of the syri n g e o n the forefi n g e r of the p a l pat i n g h a n d or use the thumb to sta b i l ize the syr i n g e as you enter the mass. O n ce the need l e is i n the mass, the t h u m b ca n be removed (FIG 4A) . Extract i n g mate r i a l • For cystic lesions, applying suction without back a n d forth m ovement is sufficient. • For solid masses, 1 5 to 20 excu rsions a re made before suction is released and the need l e is removed from the m ass. If b l ood is seen at the h u b, the n u m be r •

•

B • A,B. Need l e ente r i n g 90 deg rees to the mass s h o u l d penetrate the s k i n o n top of the mass.

FIG 3 FIG 1

• Fixation of a l a rg e m a s s u s i n g the t h u m b a n d opposing f i n g e r.

C h a p t e r 1 F I N E NEEDLE ASPI RATION OF A BREAST MASS

B FIG 4

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A.B. Need l e entering 30 to 45 deg rees to the mass s h o u l d penetrate the s k i n adjacent to the mass

a n d not on top of t h e mass.

•

of excu rsions should be l i m ited a n d suction released before reach i n g 1 5 to 20. Always release the suction before p u l l i n g the needle out of the patient; othe r­ wise, a l l the materia l w i l l flow i nto the barrel of the syri n g e, which will be very d ifficult to extract (FIG S) . Adeq uate sa m p l i n g • To s a m p l e d ifferent a reas of a wel l-defi ned l a rg e l e s i o n , it i s preferable to m a ke sepa rate passes to

A •

s a m p l e d i fferent a reas. This is a lso p refera b l e in w e l l -defi ned lesions. In i l l-d efi ned ta rg ets, especia l ly f i brocystic c h a n g es of the breast, it is best to red i rect w h i l e sa m p l i n g in a fa n l i ke fas h i o n . To avo i d tea r i n g the t i s s u e a n d ca u s i n g b l e e d i n g , the need l e s h o u l d be retracted to t h e s u rface o f the ta rget ( b u t sti l l i n t h e patient) before red i rect i n g (FIG 6) . • Typical ly, two to th ree passes a re adequate. Addi­ t i o n a l passes a re performed if the ta rget is l a rg e or t h e sa m p l e is i n a d e q u ate. H owever, typica l ly more t h a n th ree passes is not reco m m ended as often times the yield of d i a g n ostic mate r i a l decreases with each s u bseq u e nt pass due to blood. The fi rst pass is traditio n a l ly the best. Zaj d e l a 's tech n i q ue, which uses only the need l e with­ out a syri nge or syri n g e holder (FIG 7A) . This tech n i q u e is ideal f o r sma l l ta rgets as it i ncreases sensitivity to t h e d ifference i n consistencies betwee n n o r m a l breast tissue and the lesion that ca n n ot be a p p reciated as wel l with a syri nge a n d syr i n g e h o l d e r. In a d d ition, it is less b loody. H owever, t h is tech n i q u e often yields l ess mate r i a l t h a n when suction is used, a n d there i s a risk of overfl ow o f material if the l e s i o n is cystic. A syri nge (without the p l u n g e r) can be used if needed (FIG 7B) .

c

FIG 5 • A. Need l e placed in mass. B. Withd raw p l u nger creating 2 to 4 m l of vacuu m/suction a n d perform 15 to 20 excursions. C. Release the p l u nger/suction before p u l l i n g need le o u t o f the patient.

F I G 6 • To s a m p l e d i fferent a reas, red i rect the need l e i n a fa n l i ke fash i o n .

1 36 5

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P a r t 5 OPERATIVE TECHN IQUES IN BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

FIG 7

• Zaj d e l a 's tech n i q u e u s i n g o n ly a need l e (A) o r a need l e a n d a syr i n g e without the p l u n g e r (B) .

PREPARING SLIDES1 · 2 •

Expu lsion of mate r i a l The needle is fi rst d i sconnected from the syr i n g e (FIG 8) . The p l u n g e r is then p u l led b a c k a l l the way before reatta c h i n g the needle (FIG 9A,B). If using the Zajdela tech n i q u e with the need l e a n d syri nge, d isco n n ect the needle from the syri n g e before putt i n g the p l u n g e r back i nto the syr i n g e . • With t h e t i p of t h e need l e on the s l i d e (bevel down), the p l u n g e r is forcefu l ly pushed so that all the mate­ rial is on one s l i d e (FIG 1 0A,B). If there is a b u n d a n t mate r i a l , the p l u n g e r can be pushed s l owly so that o n l y a s m a l l a m o u nt of mate r i a l is p l a ced on each s l i d e . The s l ides s h o u l d be l a b e l e d with patient iden­ tifie rs (i.e., n a m e a n d b i rth d ate) with a penci l . • If there is rema i n i n g mate r i a l in t h e h u b, it can be ri n sed for cytocentrifugation ( i n Cytolyt) or cel l block ( 1 0 % buffered forma l i n o r R P M I ) (FIG 1 1 ) . I f a d d i t i o n a l smears a r e desired, t h e fl i p tech n i q u e can be used where the need l e is secured i n the rubber top of a Vacuta i n e r tube. The hub is then fl icked

•

A

"

B FIG 1 0

• A.B. With the t i p of the need l e on the s l i d e (beve l down), the p l u n g e r is forcefu l ly pushed so that a l l the mate r i a l is on o n e s l i d e . If there is a b u ndant material, the p l u ng e r ca n be pushed slowly so that o n l y a s m a l l a m o u nt of mate r i a l is pl aced o n each s l i d e . -

D isco n n ect need l e f r o m syri n g e .

repeatedly o nto a s l i d e . Droplets o f the mate r i a l on the s l ides can t h e n be smeared. (FIG 1 2) . S m e a r i n g tech n i q ues • Rest the edge of a second s l i d e on top of the s l i d e t h a t conta i n s the a s p i rate mate r i a l (FIG 1 3) .

F I G 9 • A,B. The p l u ng e r is p u l led back a l l t h e way (A) before reatta c h i n g the need l e (B) .

FIG 1 1 • The need l e can be ri nsed i n R P M I , 1 0 % b uffered forma l i n, o r Cyto lyt.

•

FIG 8

•

A

B

C h a p t e r 1 F I N E NEEDLE ASPI RATION OF A BREAST MASS

FIG 12 • Secure the needle i n the rubber top of a Vacuta i n e r t u b e . F l i c k the h u b repeatedly o nto a s l i d e .

FIG 1 5 • Apply l i g ht p ressure a n d s l i d e the top s l i d e over the bottom s l i d e .

FIG 1 3 • Rest a s l i d e on t o p o f the s l i d e t h a t conta i n s t h e aspi rate m ateri a l .

r

FIG 1 6

FIG 14

• Rotate the t o p s l i d e s o t h a t it is para l le l to t h e bottom s l i d e . •

•

•

Rotate the top s l i d e so that it is level with the bot­ tom s l i d e (FIG 14) . Kee p i n g both sl ides l evel, a p p ly l i g ht pressure a n d s l i d e the t o p s l i d e over the bottom s l i d e (FIG 1 5) . The e n d product s h o u l d be a s l i d e with material i n a n ova l confi g u ration o f even t h i ckness (FIG 1 6) . Virt u a l ly, a l l the mate r i a l s h o u l d be on the bottom s l ides. M icroscopical ly, the cel l s s h o u l d be we l l pre­ served with i ntact cytop l a s m . If too much p ressure is a p p l ied, t here w i l l be crushed n u c l e i and few

•

•

r

E n d product with mate r i a l i n a n ova l confi g u rati o n .

ce l l s with p reserved cytop l a s m . If the slides a re n ot m a i ntained l evel to each oth e r, the mate r i a l w i l l be scra ped and lost and d i stort io n w i l l be present. Other tech n i q ues • Place a clean s l i d e exactly para l l e l to t h e bottom s l i d e conta i n i n g the aspi rate mate r i a l a n d s l i d e a p a rt. The mate r i a l w i l l be p resent on both sl ides (also p roduces good smea rs) (FIG 1 7A,B) . • For b l oody aspi rates, tilt the s l i d e a n d a l low the b l ood to d ra i n i nto col l ecti n g media (FIG 1 8A,B). The par­ ticulates rem a i n i n g on the s l i d e is then scraped with the edge of a nothe r s l i d e and then smeared onto a sepa rate s l i d e (FIG 1 8C,D) . Alternatively, the par­ ticulates on the o r i g i n a l s l i d e ca n be smeared d i rectly with a sepa rate clean s l i d e (FIG 1 8E) .

FIG 1 7

• A.B. P l a c e a c l e a n s l i d e exactly para l l e l to the bottom s l i d e conta i n i n g the aspi rate mate r i a l a n d s l i d e a p a rt.

1 367

1 368

P a r t 5 OPERATIVE TECHN IQUES I N BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

r

A

B

FIG 1 8 • A. B l oody aspirate. B. Tilt the slide and a l low the blood to drain i nto col l ecting media. C. Scrape rema i n i n g particulates on the slide with the edge of another slide and then smear onto a separate slide (D) or smear the particulates on the orig i n a l slide d irectly with a separate clean slide (E).

D

FIX SLIDES •

The s l ides s h o u l d be i m mersed i n 9 5 % EtOH or fixed by spray fixation (FIG 1 9) . Thi s s h o u l d be d o ne as q u ickly as possi b l e after smea r i n g the s l i des to p revent a i r-d ry a rti­ fact. Alternative ly, sl ides may be l eft to air d ry without fixat i o n . I d e a l ly, both air d ried a n d fixed s l ides s h o u l d be made for cyto l o g i c eva luation.

FIG 1 9

•

spray fix.

Fix sl ides i m med iately i n 9 5 % l i q u i d EtOH or

C h a p t e r 1 F I N E NEEDLE ASPI RATION OF A BREAST MASS

1 369

PEARLS AND PITFALLS3 I n d ications

• • •

Major d i a g n ostic pitfa l l s

•

•

Major l i m itations

• • • • • •

Pa l p a b l e m asses: A brief h i story a n d focused physica l exa m i nation s h o u l d be performed . D i a g n ostic: p r i m a ry neoplasms (be n i g n vs. m a l i g n a nt), tumor recu rre nce, seco n d a ry or m etastatic tumors, infl a m m atory d iseases (uncom m o n), atypical e p ith e l i a l lesions (req u i re add itional stu d ies) Therapeutic: evacuation of s i m p l e cysts False negative: sma l l focus of carci n o m a a r i s i n g in a backg round of a pred o m i n a ntly ben i g n lesion (i.e., fib rocystic c h a n g e), carc i n o m a a r i s i n g i n a com p l ex proliferative lesion (i.e., pa p i l loma), we l l ­ d ifferentiated carc i n o m as, ra re t u m o r types, extensively necrotic or cystic ca rci n o mas, sa m p l i n g error, i n a d e q u ate smears False positive: f i b roadenoma, pa p i l l om a/pa p i l l a ry lesions, atypical d ucta l hyperplasia, p reg n a n cy­ associated/l actati o n a l c h a n g es, fat necrosis, col l agenous spherulosis, s k i n ad n exa l t u m o rs I n a b i l ity to d isti n g u ish betwee n i nvasive a n d i n situ carci noma Accu racy i s often dependent on the size of the lesion (less sensitive if < 0 . 5 em). Low accu racy i n tumors with a p red o m i nant necrotic/cystic component Lack of specific d i a g nosis for majority of benign lesions Need fo r b i o psy (core o r excisional) of all lesions with a n " atypica l " d i a g nosis A b i l ity to perform hormone receptor a n d HER-2/neu a n a lysis can o n l y be d o n e with accu racy if a n adequate sa m p l e is obta i n e d .

POSTOPERATIVE CARE •

Pressure should be applied to the site for a few minutes to assure hemostasis, and then a sterile dressing is applied.

OUTCOMES • • •

8 0 % to 1 0 0 % sensitivity, with a specificity of over 9 9 % 3 % t o 5 % false-negative a n d 0 . 5 % t o 2 % false-positive rate Implementing the "triple test" is essential (correlation of clinical, radiologic, and cytologic findings)

COMPLICATIONS • • • •

Low complication rate and most complications are minor Pain Bleeding/hematoma Infection

• • • •

Vasovagal reaction Pneumothorax Epithelial displacement/tumor seeding Artifacts occurring after aspiration may interfere with ra­ diographic interpretation and histologic evaluation of sur­ gical resection ( epithelial displacement can mimic invasive carcinoma ) .

REFERENCES 1.

Dusenbery D . The technique of fine needle aspiration of palpable mass lesions of the head and neck. Otolaryngol Head Neck Surg. 1 9 9 7; 8 ( 2 ) : 6 1-67. 2. Ljung BM. Pathology FNA technique video. PathLab.org Web site. http:// www. pa thlab.org!FNA_Cytology_Techniq ue_Pa thla b.org_Patho logy_ Ul(_Video_Cytology_Books_Media_News.hnnl. Accessed February, 2008. 3 . Ali SZ, Parwani AV. Breast Cytopathology. New York, NY: Springer; 2007.

-

Chapter

2

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Wire Localized Breast Biopsy

I

�

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I

·

Micha el S. Sabel

DEFINITION •

•

The wire-localized excisional biopsy (or needle-localized biopsy) is used to obtain tissue for the diagnosis of a non­ palpable, image-detected abnormality. There are various methods for localizing breast lesions for excision, including wire localization, cutaneous markers, and radiocolloid oc­ cult lesion localization (ROLL ) . Wire localization is the most frequently used method and is described in this chapter. It is preferable to use image-guided biopsy as a first step (ste­ reotactic biopsy or ultrasound or magnetic resonance imag­ ing [MRI] -guided biopsy), as this avoids surgery in patients with benign disease and allows for a definitive oncologic op­ eration in patients with malignant disease. Thus, the wire­ localized excisional biopsy should be limited to patients who failed image-guided biopsy or are not suitable candi­ dates. Wire-localized lumpectomy is a similar procedure for patients who have already been diagnosed with breast cancer, where the goal is a complete excision of the cancer with an adequate margin of surrounding normal tissue. For wire-localized lumpectomy, often, two wires are needed to " bracket" the cancer in order to assure complete removal.

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

A bilateral breast exam should be performed in all patients for whom wire-localized breast biopsy is being contemplated for two reasons. First, to assess whether or not the lesion is truly nonpalpable. If the abnormality is palpable, then wire local­ ization will not be necessary. If an abnormality is palpated, it is critical to review with the radiologist to be sure that the palpable abnormality corresponds to the imaging abnormal­ ity being recommended for biopsy. The second reason for bi­ lateral breast examination is to make sure there are no other palpable occult abnormalities that may also require biopsy. For patients with biopsy-proven cancer who are to un­ dergo wire-localized lumpectomy, a thorough history and physical examination is necessary to make sure they are suitable candidates for breast conservation therapy (BCT ) . Contraindications t o BCT include prior radiation, colla­ gen vascular disease, first or second trimester of pregnancy, multicentric cancer, or widespread calcifications (see Part 5, Chapter 5, Lumpectomy) .

IMAGING AND OTHER DIAGNOSTIC

SURGICAL MANAGEMENT Preoperative Planning •

•

•

The preoperative imaging is essential to the procedure. Prior to the decision to perform a wire-localized breast biopsy, the breast imaging should be reviewed to determine whether the patient is a suitable candidate for an image-guided biopsy, as this is the preferable first step. The patient's allergies, medica­ tions (specifically aspirin or anticoagulants) , or the presence of a bleeding diathesis should be reviewed. Contraindications

1370

Performing a breast exam after the localization will be diffi­ cult, as the wire will be secured by a variety of methods that will preclude physical exam. These should not be removed until the patient is positioned in the OR to minimize the chance of dislodging the wire during transport. Prior to taking the patient back to the OR, the localization films should be reviewed. Specifically, the surgeon should note the proximity of the abnormality to the wire, the direc­ tion of the wire from the point of skin entry, and how far the lesion is from the skin, as this may impact the degree of sedation (if any) . Although the risk of infection after breast surgery is low, it tends to be higher than average for a clean surgical proce­ dure, and several studies have shown that antibiotic prophy­ laxis significantly reduces the risk of postoperative infection. 7

Positioning •

STUDIES •

to stereotactic core needle biopsy include an inability to ad­ equately visualize the target lesion or an inability of the pa­ tient to remain in the position required for the procedure. Some patients may exceed the weight limit for the stereotactic table. Other factors that may preclude stereotactic core nee­ dle biopsy include higher breast density; lesions close to the skin, chest wall, or axilla; or the presence of breast implants. Prior to coming to the operating room (OR), the patient un­ dergoes needle localization under image guidance. After local anesthesia, a rigid introducer needle with a hooked wire within it is directed toward the site of the abnormality using bipla­ nar mammography ( FIG 1 A) or ultrasound ( FIG 1 8) . The rigid needle is then removed, leaving the wire secured by the hook so it is not easily withdrawn or redirected ( FIG 2A.B) . I n many cases, a wire-localized excision i s recommended after an image-guided core needle biopsy-demonstrated atypia (lobular carcinoma in situ [LCIS], atypical ductal hy­ perplasia [ADH] , atypical lobular hyperplasia [ALH], or flat epithelial atypia [FEA] ) . It is also often recommended after a needle biopsy of papilloma or radial scar. In these cases, a fraction may upstage to in situ or invasive cancer. 1-6 It is good to review the pathology and indications for the biopsy prior to the procedure.

•

The patient should be positioned supine. Often, the localiza­ tion wire is placed laterally, so the ipsilateral arm may need to be at 90 degrees. Once the patient is on the OR table and positioned, the tape and dressings securing the wire should be removed carefully as not to dislodge the wire. A gentle breast exam can be per­ formed at this point to see if the lesion is palpable. In addi­ tion, light palpation while watching the external portion of the wire can give the surgeon an idea of what direction the wire is heading.

C h a p t e r 2 WIRE LOCALIZED BREAST B I O PSY

1 371

U ltrasound transducer

Abnormality

B

Introducer needle with wire

FIG 1 A

• Placement of the r i g i d need l e u s i n g b i p l a n a r m a m m o g raphy (A) or u ltraso u n d (B) .

B

Rigid needle withdrawn

• A. B. T h e r i g i d need l e is withd rawn, leavi ng t h e w i re in the locati o n of the a b n o r m a l ity.

FIG 2 A

Localization wire

1 3 72

P a r t 5 OPERATIVE TECHN IQUES IN BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

•

The localization wire is often quite long and with a signifi­ cant portion outside of the skin. The case will be facilitated by cutting the wire to a more workable length. Care must be taken not to advance the wire or pull the wire back (or out ) . It is also important not to cut the wire so close to the skin that it disappears. Secure the wire at the level of the skin prior to cutting with a wire cutter ( FIG 3) .

FIG 3

• The w i re is secured a t t h e l eve l o f t h e s k i n w h i l e excess w i re is cut. It is i m porta nt not to dislodge the w i re as w e l l as to l eave a n adequate a m o u nt.

ANTICIPATING THE LOCATION OF THE ABNORMALITY •

•

After the d ress i n g s h ave been removed, the s u rgeon uses the site and d i rection of the w i re a l o n g with the cra n ia­ ca u d a l (CC) and lateral-m e d i a l (LM) views to determ i n e the l ocation o f the a b n o r m a l ity i n the breast. A sma l l B B is usua l ly pl aced at the s i t e w h e r e the w i re enters t h e skin, so it i s possi b l e to est i m ate how far t h ro u g h the breast tissue the w i re extends. Remember, the b reast is compressed during the m a m m og raphy but not o n the O R ta b l e, so the measurement on the f i l m may not be exact. It is often h e l pful to identify the n i p p l e on the m a m mogram as a n a d d i t i o na l l a n d m a rk . The CC view (FIG 4A) demonstrates both the a nterior­ posterior a n d the l ateral-m e d i a l l ocation of the ab­ normal ity but g ives no i nformation reg a r d i n g the

•

•

superior-inferior locat i o n . With a l atera l ly p l aced wi re, the CC view ca n be used to est i m ate how deep the lesion is a n d how med i a l (especia l ly when a lso using the n i p p l e as a n additional l a n d m a rk) . T h e LM view (FIG 4B) demonstrates t h e a nterior-posterior orientation as wel l as the superior-inferior but g ives no i nformation rega rd i n g the lateral-m e d i a l l ocatio n . Aga i n , w i t h a latera lly placed wi re, the deviation f r o m the skin B B to the hook of the w i re can be used to assess whether the w i re is heading superiorly or i nferiorly. U s i n g both v iews, t h e s u rg e o n s h o u l d a lso n ote w h e re t h e a b n o r m a l ity is in relation to t h e w i re . Typ i c a l ly, t h e r a d i o l o g i st atte m pts to p l a ce t h e rei nforced portion o f t h e w i re i n cl ose prox i m ity to t h e l e s i o n . It i s cruci a l t o k n ow t h e relative proxim ity o f t h e w i re t o t h e le­ s i o n a n d i n what d i rect i o n t h e w i re sits re l ative to t h e lesi o n .

FIG 4

A

B

• T h e loca l i zation f i l m s show t h e relatio n s h i p between the s k i n , the wi re, a n d the a b n o r m a l ity. I n the CC view (A), the dot shows t h e entry point i n t h e s k i n . The fi l m shows the l e s i o n to be posterior a n d lateral, b u t this fi l m d o e s n o t reve a l the a nterior-posterior posit i o n . The hook a n d rei nforced portion of the w i re a re d ista l (med i a l) t o t h e lesi o n . I n t h e LM view (B), y o u c a n a g a i n s e e t h e lesion is posterior, b u t n o w you c a n s e e that it sits superio rly. It may seem l i ke the w i re trave ls through the b reast for some d i stance but most of that is externa l . The white dot shows where it enters the s k i n .

C h a p t e r 2 WIRE LOCALIZED BREAST B I O PSY

SKIN INCISION AND IDENTIFICATION OF THE WIRE •

•

Using both the preoperative i m a g i n g a n d exa m i nation of the breast, the su rgeon ca n est i m ate the d i rection of the w i re a n d the d ista nce to the rei nforced portion of the wi re. Using a water-sol u b l e ma rker, a n i ncision should be ma rked out (FIG S). For lesions close to where the w i re enters the skin, the i ncision ca n be planned at the entry site. Otherwise, the i n cision s h o u l d be placed d i rectly over the pred icted site of the m a m mogra p h i c a b n o r m a l ity. When m a r k i n g the i ncision, it s h o u l d be kept in m i n d t h a t if this lesion is m a l i g n a nt, y o u m a y be retu r n i n g for a reexcision l u m pectomy o r a mastectomy. Therefore, the i ncision s h o u l d be p laced in a way that does not

FIG S • An i ncision is ma rked out over the antici pated site of the a b n o r m a l ity, keep i n g i n m i n d a reexcision l u m pectomy or mastectomy s h o u l d the pathology ret ur n as m a l i g nant.

•

FIG 6 • A small incision is m a d e i n t h e s k in after i nfi ltration of local a n esthesia.

lesion is deep to the i ncision, the d i ssection is cont i n u e d posteriorly so as to avoid removi ng excessive tissue a nte­ rior to the lesion and w i re (FIG 7A) . For m o re superfi c i a l lesions, f l a ps s h o u l d be e l evated shortly after incision but kept thick enough to avoid concavity at the site (FIG 7 B) .

EXCISION •

comprom ise that. For lesions near the n i p p l e-areo l a r com p l ex, a c i rcu m a re o l a r i ncision is cosm etica l ly appeal­ ing, but excessive tunneling is d i scouraged as t h is will a lso com p l i cate a reexcision l u m pectomy if cancer is present. The incision s h o u l d be kept s m a l l at fi rst, as it can be l e n gthened later if need be (FIG 6) . As these a re typica l ly performed with j ust loca l a n esthesia or l ight sedation, t h e skin is a n esthetized prior to any i n c i s i o n .

The g o a l of the wi re-loca l ized excisio n a l b i o psy is to make the d i a g nosis w h i l e removing as l ittl e breast tis­ sue as poss i b l e . If the CC and LM views suggest that the

Abnormality Abnormal ity

A FIG 7

Local ization wire

B

Localization wire

• The s u bcuta neous fat a n d breast parenchyma a re d ivided with cautery. For deep lesions (A), d issect a fa i r d i stance to avo i d ta k i n g excessive tissue a nterior to the lesion (ca u s i n g concavity) . For superfic i a l lesions (B), t h i c k f l a ps s h o u l d be e l evated shortly after i n c i s i o n .

1 373

1 3 74

P a r t 5 OPERATIVE TECHN IQUES I N BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

Abnormality

FIG 8

The w i re is i d entified p roxi m a l to the antici pated site of the a b n o r m a l ity. •

•

If the incision does not pass through the entry site of t h e wi re, the next step is to i d entify the shaft of the w i re prox i m a l to the lesion. D issection is carried d own to the wi re, ta k i n g care not to l a n d o n top of the abnormal­ ity but rat h e r on the w i re proxi m a l to the a b n o r m a l ity

•

Once the w i re is identified, it is g rasped with a h e m o­ stat on the spec i m e n s ide, a n d t h e shaft of the w i re is retracted i nto the wou n d . Ta ke care to secu re the w i re adequately so it is not d islodged (FIG 9A,B) . At the point where the wire enters the b reast, g rasp the tissue with a n Allis clamp. B e ca refu l to g rasp a bove or below the w i re a n d not the w i re d i rectly, as retraction o n the c l a m p may d islodge t h e w i re (FIG 1 0) . D i ssection then cont i n ues para l l e l t o t h e wi re, m a i nta i n ­ i n g a ci rcu mfere n ce of a p p roximately 1 em of breast tis­ sue around the wire. Thi s is mod ified based on the size of the a b n o r m a l ity and the relatio n s h i p between the w i re a n d the lesion. For exa m p le, for a lesion sitt i n g a p p roxi mately 1 em a n t e r i o r to the w i re, a larger m a r­ g i n is taken a nteriorly, whereas a s m a l l e r m a r g i n can be taken deep to the wire. For m a m m o g ra p h i c masses, p a l pation a lo n g the w i re w i l l often a l low the s u rgeon t o i d entify t h e a b n o rm a l ity a n d proceed w i t h excision, s i m p l ifyi n g the p roce d u re. D i ssection conti n ues until you a re confident you a re past the location of t h e a b n o r m a l ity a n d the spec i m e n can be transected (FIG 1 1 ) . Often, the w i re w i l l be encou ntered d u r i n g this step, so take care not to d ivide the wi re, po­ tenti a l ly leavi ng the hooked end in the patient. If the wire is identified at this poi nt, visu a l ize where o n the w i re you a re. If you a re at the hook and the f i l m s show the hook is d ista l to the lesion, you s h o u l d be fine. If you encou ntered the rei nforced portion of the wi re, g rasp the rem a i n i n g tissue i n t h e d i rection of the w i re a n d con­ tinue the d i ssection until you a re past the hook.

Localization wire

A

(FIG 8) .

•

•

•

•

B FIG 9 • A. The w i re is secured at the b reast with a h e m ostat. B. Forceps a re then used to p u l l the exter n a l portion of the w i re through the s k i n a n d out of the wound .

Abnormality

Localization wire

Bovie dissecting underneath

FIG 10 • An A l l i s c l a m p is used to g rasp the breast tissue (do n ot grab the wi re) and d i ssection cont i n ues p a ra l l e l to the w i re i n a l l d i rections.

C h a p t e r 2 WIRE LOCALIZED BREAST B I O PSY

Abnormality

Localization wire

Bovie dissecting underneath

FIG 11 • Once the ci rcumferentia l d i ssection is past where you est i m ate the lesion to be, the speci m e n i s transected, ta k i n g care not to divide the w i re (a nd l eave the hook).

•

ORIENTATION •

I m m ed i ately u p o n remov i n g the l esion, m a i nta i n the ori­ entation a n d p l a ce 2-0 silk sutures for the patho l o g i st. If this returns as cancer, this a l l ows for s i m p l e reexcision of any i nvolved m a r g i n as opposed to a reexcision of t h e entire cavity. It is often p refera b l e to p lace one or two orienting sutu res before com p l ete remova l of the speci m e n .

Long stitch

=

•

Th ree sutu res a re reco m m ended to orient the mass cor­ rectly for the patholog ist a n d avoid errors.8 We recom­ m e n d placing a short sutu re s u periorly, a long suture lateral ly, a n d a double sutu re deep posteriorly (FIG 1 2) . It is a lso often benefi c i a l t o p l a ce radiopaque c l i ps on t h e speci m e n t o a l l ow f o r orientation o f the lesion o n t h e speci m e n m a m mograms. F o r exa m p l e, if the w i re enters lateral ly, p l a c i n g a s i n g l e c l i p superiorly a n d a d o u b l e c l i p posteriorly a l lows y o u to orient t h e speci men on the f i l m s (FIG 1 3A,B) . I n the case o f a wi re-loca l ized l u m pectomy for cancer, t h i s a l l ows for reexcision of a potent i a l ly close m a rg i n . For a b i opsy, if the a b n o r m a l ity is not with i n the speci men, this may help the s u rgeon identify i n what d i ­ rection additional tissue s h o u l d be s a m p l e d .

lateral

FIG 1 2

• The l e s i o n is oriented w i t h th ree m a r k i n g sutures prior to sen d i n g to rad io l ogy for spec i m e n m a m mography.

1 375

1 376

P a r t 5 OPERATIVE TECHN IQUES I N BREAST, ENDOCRI NE, A N D ONCOLOG IC SURGERY

A

B FIG 1 3

•

A. B. Spec i m e n m a m m o g raphy sh ows the c l i p a n d w i re to be com p l etely remove d .

SPECIMEN RADIOGRAP HY AND ADDITIONAL TISSUE •

•

Spec i m e n rad io g raphy is performed to confi rm that the a rea of concern has been removed (FIG 1 3A,B) . The spec­ i m e n m a m mogram s h o u l d demonstrate the presence of the m icroca lcifications of concern or the p resence of a c l i p pl aced with i n the spec i m e n . It s h o u l d a lso show that the entire w i re has been removed. If the w i re becomes sepa rated from the speci men, send both to rad i o l ogy to document its remova l . If the lesion is i d e ntified on speci m e n radiography, the wou n d can be closed. If the lesion is n ot present, t h e n a d d i t i o n a l t issue s h o u l d be excised a n d sent to rad i o l ­ ogy. It may be c l i n ica l ly evident w h a t a rea n e e d s further

•

CLOSURE •

•

O n ce the b i o psy is com p l ete, h e m ostasis is assu red a n d the w o u n d i s irrigated with sa l i n e . For an exc i s i o n a l b i opsy, the s u rgeon s h o u l d not try to rea p p roxi mate the b reast tissue. The cavity w i l l fi l l with

•

excision based on exposure of t h e w i re d u r i n g the d i ssec­ t i o n . The use of rad iopaque c l i ps on the spec i m e n , as we l l as othe r l a n d m a rks on t h e orig i n a l m a m m o g ra m s, may also help identify where to excise add itional tissue. If a second speci m e n fa i l s to i d entify the lesion, it be­ comes a j u d g m e nt ca l l whether to cont i n u e or a b a n d o n the p roced u re . For u ltraso u n d -visi b l e lesions, i ntraopera­ tive u ltraso u n d may be able to i d entify the a b n o r m a l ity. In the case of a c l i p that s h o u l d have been in the speci­ men, someti mes these can get d islodged and suctioned out. F i lteri n g a n d x-raying t h e fluid i n the suction can is­ ter can sometimes reve a l a d islodged c l i p . Oth e rwise, it may be prudent not to cont i n u e and plan on re i m a g i n g and, if n ecessa ry, retu r n i n g to the O R rath e r t h a n t a k i n g a n excessive a m o u nt o f b reast tissue.

seroma a n d fibrin, a n d u lt i m ately, fibrous tissue, which will m a i nt a i n the normal conto u r. The incision is closed with a bsorba b l e deep d e r m a l su­ tu res, fo l l owed by either a su bcuticu l a r stitch or tissue a d h esive. Drains should not be used.

C h a p t e r 2 WIRE LOCALIZED BREAST B I O PSY

1 377

PEARLS AND PITFALLS I n d ications

•

Image-g u ided b i o psy is the preferred a p p roach to the n o n p a l p a b l e a b n o r m a l ity. Review the case with the radiolog ist to confi rm whether t h is is a n opt i o n .

Placement of i n c i s i o n

•

K e e p i n m i n d that if m a l i g n a nt, the patient may n e e d a reexcision l u m pectomy or mastectomy. Orient you r incision with t h i s in m i n d .

I d entifyi ng the w i re

•

Ta ke care not to m ove or dislodge the w i re d u r i n g the position i n g, prepping, a n d d ra p i n g of the patient. I d entify the w i re early a n d secure it while b r i n g i n g it i nto t h e wound so that it does not become d islodged d u ri n g the proced u re .

•

Excision

• •

Spec i m e n m a m m og ra p h y Closure

G rasp the tissue, not the w i re, while excising the lesion so as not to accidently pull the w i re out. D u r i n g d i ssection, p a l pate the a rea to identify t h e mass or if you a re too close to the wire.

•

Th ree orientation sutu res a re necessa ry to a v o i d error. C l i ps can h e l p orient the spec i m e n on the m a m mography so as to g u i d e a reexcision.

•

Do n ot try to rea pproxi mate the breast tissue or place a d r a i n .

•

POSTOPERATIVE CARE •

After a breast biopsy, the patient should be placed in a breast binder or supportive brassiere. This helps sustain hemosta­ sis and relieves tension on the skin closure imposed by the weight of the breasts. The patient should be encouraged to wear the support bra day and night for 1 week after surgery.

OUTCOMES •

In experienced hands, the failure rate of wire-localized biopsy is low, although published reports suggest the wire localiza­ tion failure rate can range from 0% to 2 0 % . Factors associ­ ated with failure include lesion type and size, distance from the wire, breast shape and size, and volume of excised tissue.9-11

COMPLICATIONS • • • • • •

Seroma Hematoma Infection (cellulitis or abscess) Pneumothoraces (rare) Retained wire fragments Failure to identify abnormality

REFERENCES 1.

Lewis JA, Lee DY, Tartter Pl. The significance of lobular carcinoma in situ and atypical lobular hyperplasia of the breast. Ann Surg Oneal. 2 0 1 2 : 1 9 ( 1 3 ) : 4 1 24-4 1 2 8 .

2 . Nguyen CV, Albarracin CT, Whitman GJ, e t a l . Atypical ductal hyperplasia in directional vacuum-assisted biopsy of breast micro­ calcifications: considerations for surgical excision. Ann Surg Oneal. 2 0 1 1 ; 1 8 : 752-76 1 . 3 . Peres A , Barranger E, Becette V, e t al. Rates o f upgrade t o malignancy for 271 cases of flat epithelial atypia (FEA) diagnosed by breast core biopsy. Breast Cancer Res Treat. 2 0 1 2 ; 1 3 3 ( 2 ) : 659-666. 4. Douglas-Jones AG, Denson JL, Cox AC, et al. Radial scar lesions of the breast diagnosed by needle core biopsy: analysis of cases contain­ ing occult malignancy. J C/in Pathol. 2007;60:295-2 9 8 . 5. Jaffer S , Nagi C , Bleiweiss I J . Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy. Cancer. 2009 ; 1 1 5 :2837-2843. 6. Cheng TY, Chen CM, Lee MY, et al. Risk factors associated with conversion from nonmalignant to malignant diagnosis after surgi­ cal excision of breast papillary lesions. Ann Surg Oneal. 2009; 1 6 : 3 3 75-3 3 79 . 7. Bunn F , Jones D J , Beli-Syer S . Prophylactic antibiotics t o prevent surgical site infections after breast cancer surgery. Cochrane Database Syst Rev. 2 0 1 2; ( 1 ) :CD005360. doi: 1 0 . 1 002/1465 8 5 8 . CD005360 .pub3 . 8. Molina MA, Snell S, Franceschi D, et al. Breast specimen orientation. Ann Surg Oneal. 2009 ; 1 6 : 285-2 8 8 . 9. Jackman RJ, Marzoni F A Jr. Needle-localized breast biopsy: why do we fail? Radiology. 1 9 9 7;204 ( 3 ) : 677-684. 10. Abrahamson PE, Dunlap LA, Amamoo MA, et al. Factors predicting successful needle-localized breast biopsy. Acad Radio/. 2003 ; 1 0 ( 6 ) : 601-606. 1 1 . Kouskos E, Gui GP, Mantas D , et al. Wire localization biopsy of non­ palpable breast lesions: reasons for unsuccessful excision. Eur J Gynaecol Oneal. 2006;27(3 ):262-366.

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Chapter

3

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Subareolar Duct Excision

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Amy C. Degnim

DEFINITION •

•

Subareolar duct excision is defined as the surgical removal of lactiferous ducts in the immediate subareolar space. The terms " major duct excision" or " central duct excision" refer to excision of the entire bundle of ducts contained within the central nipple stalk; microdochectomy refers to selective excision of a single abnormal duct.

ANATOMY •

•

•

•

•

The lactiferous ducts drain converging ducts from lobes of the breast gland and serve as a conduit for milk egress via the nipple during lactation ( FIG 1 ) . Most women have approximately 7 to 20 ducts that are distinct and functional sources of milk during lactation. At the base of the nipple, the lactiferous ducts widen centrally in a spindle shape over a short distance. This region is called the lactiferous sinus and can expand in lactation to 8 mm as a reservoir for milk. Surrounding the lactiferous ducts is a system of smooth muscle fibers that contract in response to nipple stimula­ tion and oxytocin release, facilitating milk flow through the nipple . 1

•

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

Subareolar duct excision is undertaken in cases of abnormal nipple discharge for two purposes: To obtain diagnostic biopsy tissue and rule out malignancy To provide resolution of the bothersome discharge Abnormal, or "pathologic," nipple discharge is characterized by the following features: Discharge from a single duct Spontaneous discharge Clear or bloody discharge

The history should be focused on questions to determine the laterality and quality of the discharge as well as whether it is spontaneous or only occurs with manual expression. Physical exam should include a thorough examination of both breasts and axillae. In addition, a detailed examination is necessary for both nipple-areolar complexes and the subareolar tissues. Inspect the nipples for crusting, bloodstained ducts, or any visible protuberances or nodules. The deep tissue of the areolae should be palpated carefully for any small nodules and to determine if subareolar pressure results in nipple discharge. The nipple itself should be palpated by rolling the nipple between the thumb and forefinger in order to best detect any small nodules located centrally within the nipple stalk. This should be performed first for the breast without discharge to set a normal comparison to the breast that is symptomatic. If no discharge has been identified up to this step of the examina­ tion, then attempt should be made to elicit discharge from both nipples, by applying pressure to the areola at the base of the nipple, then grasping the base of the nipple between the thumb and forefinger and drawing upward with gentle pressure. Throughout the examination, for any nipple discharge observed, its location (o'clock position) and quality of the fluid should be noted.

IMAGING AND OTHER DIAGNOSTIC STIJDIES •

•

•

All women with abnormal nipple discharge should undergo diagnostic mammogram and ultrasound. Prior to the imag­ ing studies, the imaging team should be informed about the symptom of nipple discharge and which breast is affected. Because nipple discharge can be associated with underlying malignancy, the primary purpose of diagnostic imaging is to look for possible signs of malignancy. Another goal of imaging is to evaluate the subareolar tissues for any findings that would explain the presence of nipple discharge. Generally, subareolar ducts are not visible with ultrasound unless they are abnormally dilated. A small nodule visualized within a dilated subareolar duct indicates a likely diagnosis of intraductal papilloma ( FIG 2 ) .

Lactiferous duct

FIG 1 • N o r m a l a n atomy of s u b a reo l a r lactiferous d u cts a n d s i n uses.

1378

FIG 2

•

U ltraso u n d o f a s u b a reo l a r n o d u l e .

C h a p t e r 3 SUBAREOLAR DUCT EXCI S I O N

•

•

•

Evaluation with magnetic resonance imaging (MRI) is con­ troversial. It detects more lesions than standard imaging for women with nipple discharge but is imperfect in ruling out malignancy associated with nipple discharge. 2 Ductography can be considered as a diagnostic test. This is a radiographic procedure that entails cannulation of the duct with abnormal discharge, then injection of contrast dye with immediate mammographic imaging. This procedure can identify and map out abnormal ducts and identify some intraductal filling defects, but it does not provide diagnos­ tic tissue. For these reasons, it is not a required component of the evaluation and is intentionally avoided in some prac­ tices. Although it may help to localize the etiology of the discharge, it cannot reliably exclude malignancy or eliminate need for duct excision.3 Another approach to diagnostic evaluation is via ductos­ copy, a microendoscopic procedure to directly visualize the duct ( s ) with discharge. This requires special equip­ ment and skill, with a learning curve for technical success. D uctoscopy can help to identify lesions and guide excision but has not been proven in large numbers of women to improve diagnosis to the point that duct excision can be avoided. 4•5

SURGICAL MANAGEMENT •

•

•

•

• • •

Intraductal papilloma Duct ectasia Carcinoma, either invasive or ductal carcinoma in situ Paget's disease

NONOPERATIVE MANAGEMENT •

•

Nonoperative management can be considered for cases of nipple discharge when The discharge occurred on only one occasion and was not reproducible on examination Both mammogram and ultrasound show no abnormalities. 6 •7 In this case, 3-month follow-up history and physical exami­ nation is recommended. Alternately, if imaging identifies a benign-appearing lesion and percutaneous core biopsy confirms a benign intraductal papil­ loma with complete or near complete removal by imaging, then observation is also appropriate with follow-up imaging in 3 months.

INCISION PLANNING • •

I n general, i ncisions a re pl aced at the a reo l a r edge . An i ncision at t h e i nfer i o r a r e o l a r edge is preferred if poss i b l e for bette r cosmesis, espec i a l l y if the i nvolved d u ct i s l ocated centra l ly o n t h e n i p p l e su rface a n d t h e i m a g i ng d o e s n o t d e m onstrate any a b n o r m a l ities

(FIG 3) . •

Otherwise, i ncisions can be p laced a long the a reo l a r border i n the o'clock position o f the a b n o r m a l ity, for either a periphera l ly located d uct with d ischarge o r if there is a n i m a g i n g abnorma l ity a few cent i m eters from the n i pp l e .

Subareolar duct excision removes the lactiferous ducts under the nipple, the primary connection between the nipple and the milk-producing lobules of the breast, so patients must be counseled that lactation from the operated breast should not be possible after surgery. Selective and focused excision of the single abnormal duct may be performed in an attempt to preserve other ducts for future lactation, but due to the very close proximity of the remaining ducts, scar tissue from the operation may still impair future lactation. In women who are past childbearing age, a plan to remove the entire bundle of subareolar ducts is preferred because future lactation is not needed, and this approach reduces the chance of recurrent discharge from another duct and need for repeat operation in a field of scar tissue. The patient should be informed of the possibility of a diag­ nosis of malignancy yet reassured that benign findings are most likely.

Preoperative Planning •

DIFFERENTIAL DIAGNOSIS •

1 3 79

•

For subareolar mass lesions that are nonpalpable and identi­ fied only by imaging, preoperative localization with either a wire or a radioactive seed should be performed to ensure intraoperative guidance to the target. Before surgery, patients should be counseled that they may experience continued discharge in the first few weeks post­ operatively, as postoperative fluid in the subareolar space may discharge via the nipple duct until healing is complete. This should resolve completely by 4 to 6 weeks.

Positioning • •

The patient should be positioned supine. The ipsilateral arm is generally positioned at approximately 90 degrees, although the arm could also be tucked based on the patient's body habitus and preferences of the anesthesia team.

Approach •

The general approach is to dissect under the areola toward the nipple, isolate and excise the central duct bundle, and follow any abnormal ducts to complete removal, along with simultaneous excision of any nonpalpable lesions identified on preoperative imaging.

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P a r t 5 OPERATIVE TECHN IQUES I N BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

•

The length of the incision s h o u l d be l a rg e e n o u g h that the s u rgeon has adequate visua l ization of the su bare o l a r s p a c e without req u i r i n g excess retraction a n d ische m i a of the a reo l a r edge. Depen d i n g on the a r eo la r size, the i ncision m a y go u p t o 5 0 % o f t h e c i rcu mference o f the

•

a reola, but a shorter i ncision i s p refe rred when possi b l e to h e l p preserve b l ood s u p p l y to the n i p p l e a n d a reo l a r dermis. Prior to i ncision, correct surgica l site a n d p l a n s h o u l d be confi rmed with the operative tea m .

DUCT CANNULATION •

•

•

•

•

Once t h e field is prepped a n d d ra ped, attem pt s h o u l d be made to ca n n u late the i nvolved d uct. A fi ne lacri m a l d uct p robe (4-0) s h o u l d be h e l d ready i n t h e d o m i n a nt h a n d f o r ca n n u lation prior t o expressi n g the n i p p l e d isch a rg e . The n i p p l e should be g rasped between the t h u m b a n d forefi nger o f the nondom i n a nt ha nd at the n i p p l e base and d rawn u pward g ra d u a l ly (FIG 4) . If no d ischarge is seen, i ncreasing pressure can be a p p l ied to a reasonable degree. The goal is to e l i cit a s i n g l e tiny d rop of f l u i d at the skin su rface; a smaller d rop of fluid will be more h e l pful i n identifying t h e location o f t h e abnormal duct (FIG 5). The n i p p l e s h o u l d be p u l led away from the breast gently i n order to e l o ngate the s u ba reo l a r lactiferous sinus a n d i m p rove the chance o f ca n n u l ation (FIG 6) . The lacri m a l d u ct probe s h o u l d be gently p robed a long the nipple s k i n su rface at the site of the expressed fl u i d . T h e g o a l is to f i n d t h e o pe n i n g rather t h a n m a k e a fa lse passage; the probe w i l l s l i d e easily i nto the d uct once it is i n the r i g ht location (FIG 7) .

FIG 4

•

FIG 6

•

•

•

Ca n n u lation tech n i q u e .

M a n u a l expression o f n i p p l e d ischarge.

FIG 7

FIG 5

•

Visi b l e tiny d rop of f l u i d at n i p p l e s u rface.

•

Ca n n u lated d uct w i t h p robe advanced.

The p robe s h o u l d be gently advanced as fa r as it w i l l easily go. If it does n o t pass g reater t h a n 1 em beyond the nipple s k in su rface, then the depth of the ca n n u la­ tion should be noted as a s i g n that there may be a very superfic i a l obstruct i n g m ass lesion. If no d ischarge is id e ntified or if the d u ct can not be can­ n u l ated despite several attem pts, the proce d u re s h o u l d proceed to i n c i s i o n .

C h a p t e r 3 SUBAREOLAR DUCT EXCI S I O N

INCISION •

•

•

Prior to incision, loca l a n esthetic can be used but s h o u l d n o t be i nj ected d i rectly i nto the a rea of the s u b a reo l a r d u cts. If used, it s h o u l d be i njected i ntraderma l ly d i rectly at the p l a n ned incision site (no m o re than 1 m L) and ad­ dition a l ly in a peripheral fas h i o n i nto the fou r q u a d ra nts of the b reast to create a local field b l ock. The s k i n s h o u l d be i ncised sharply with a sca lpel, ta k i n g c a r e to m a i nta i n a b l a d e a n g l e t h a t is perpend icu l a r t o the ski n . The incision s h o u l d be deepened a few m i l l i m eters i nto the su bcuta neous fatty tissue ( FIG 8) .

FIG 8

•

I ncision i nto s u bcuta neous tissue.

ELEVATION O F T H E AREOLAR SKIN FLAP •

•

•

The areolar s k i n edge is then retracted superiorly (sk i n hooks or sutures cou l d be used), a n d d issection p roceeds in t h e d i rection of the n i p p l e toward the centra l d u ct b u n d l e ( FIG 9) . Care s h o u l d be taken to perform t h e d i ssect i o n at a d e pth to preserve some su bcuta n e o u s fatty tissue u n d e r t h e a re o l a r s k i n , as t h i s w i l l h e l p to p rotect t h e via b i l ­ ity o f t h e a re o l a r s k i n a n d n i p p l e . S i m i l a rly, t h e latera l edges of t h e d i ssect i o n f i e l d s h o u l d n a rrow as t h e cen­ tral d uct b u n d l e i s a p p roached (FIG 1 0) . Attention s h o u l d be p a i d to t h e l ocati o n of d i ssect i o n a n d i t s prox i m ity to t h e n i p p l e, l o o k i n g c l o s e l y for the d u cts, w h i c h a p p e a r as na rrow vert i c a l t u b u l a r or stra n d - l i ke struct u res. The d u cts may be v i s i b l y d isco l ­ ored ( FIG 1 1 ) .

FIG 10

FIG 9

•

Retract i o n of the s k i n flap.

FIG 1 1 fl u i d .

•

•

N a rrow i n g the d i ssect io n field towa rd t h e n i pp l e .

A v i s i b l y a b n o r m a l d uct w i t h d i scolored i ntra l u m i n a l

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P a r t 5 OPERATIVE TECHN IQUES I N BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

ISOLATION AND EXCISION OF THE CENTRAL DUCT BUNDLE •

(FIG 1 2) . •

•

•

D i ssect i o n t h e n proceeds i n vert i c a l fas h i o n on t h e latera l sides of t h e d uct b u n d l e u n d e r t h e n i p p l e . T h i s s h o u l d p roceed to t h e far s i d e o f t h e n i p p l e The d u ct b u n d l e s h o u l d be p a l pated betwee n the t h u m b a n d fi n g e r to confirm the presence o f the d uct p robe a n d any other s m a l l p a l p a b l e no d u les. The centra l d u ct b u n d l e s h o u l d then be transected at t h e deep aspect of the n i p p l e d er m i s. If u s i n g e lectroca utery, the "cutt i n g " mode s h o u l d be chosen at a low e n e rgy

sett i n g to m i n i m ize thermal d a m a g e to the n i p p l e dermis. As t h e d u ct b u n d l e i s t r a n sected, t h e ca n n u l a t i n g probe wi l l be i d e ntifi e d . It may be w i t h d rawn if it becomes d iffi c u l t to m a i nta i n its posit i o n i n t h e d u ct

(FIG 1 3) . •

T h e d u ct b u n d l e s h o u l d be retracted away from t h e breast, d i ssect i n g c i rc u m fe r e n ti a l ly a ro u n d the d u ct b u n d l e to a d e pth of a p proxi m a t e l y 4 to 5 em o r fa rth e r along a p a rt i c u l a r g rossly a b n o r m a l d u ct

•

The tissue speci m e n s h o u l d b e transected a t its base a n d oriented f o r the path o l o g i st (FIG 1 S) . T h e o p e n w o u n d s h o u l d be p a l pated f o r any a b n o r m a l i ­ ties, a n d the n i p p l e d e r m i s s h o u l d be pal pated between the thumb a n d finger to e n s u re that t h e re a re n o any superfic i a l nodu les present that were n ot excised. I n the event of a sma l l nodule with i n the n i p p l e derm is, a tiny s k i n incision i n the n i p p l e ca n be m a d e to remove the lesion.

(FIG 1 4) .

•

FIG 1 3

•

Tra nsection of the d u cts j ust deep to the n i p p l e

dermis.

FIG 1 2 bundle.

•

Vertica l d issection a l ong both sides of the d u ct

FIG

14 • D issect io n of d u cts deeper i nto the breast p a re nchyma .

C h a p t e r 3 SUBAREOLAR DUCT EXCI S I O N

fJ GHT

5 L{ Bf\REDLAR D LlCTS

�T -

FIG 1 5

CLOSURE •

Aft e r h e m osta s i s, t h e pa renchym a l a n d s u bcuta n e o u s tissue d efect in t h e s u b a re o l a r reg i o n m u st be c l osed i n o r d e r to avo i d n i p p l e retract i o n i n t h e h ea l i n g p h a s e . I f t h e re i s a so l i d b uttress of tissue u n d e r l y i n g t h e

•

•

•

A

FIG 1 6 • Closure of the deep tissue. A. Media l-to-latera l closu re, (B) superior-to-inferior closure.

•

Orientation o f the speci m e n .

n i p p l e-areo l a r co m p l ex, t h e n i p p l e w i l l be l e s s l i ke l y t o retract. T h e parenchym a l c l o s u r e m a y be p e rfo r m e d as a s i m ­ p l e d i rect a p proxi m a t i o n of tissu es, i n w h ateve r o r i ­ entat i o n resu lts i n l e a st t e n s i o n a n d a bsence of s k i n d i m p l i n g ( FIG 1 6) . If t h e d efect i s l a rg e r, it may req u i re a s m a l l l o c a l t i s s u e a d v a n c e m e n t fl a p or u n d e r m i n i n g o f t h e breast g l a n d from t h e s k i n . I n t h a t case, it i s p refe ra b l e to avo i d further d i ssect i o n u n d e r t h e a reo­ lar skin and o bta i n donor tissue from t h e other side of the cavity. If the n i p p l e is effaced, it may be h e l pful to p l a ce a pu rse­ str i n g stitch in the deep d e r m i s around the n i p p l e base to recreate the normal n i p p l e shape and prevent n i p p l e retraction i n the h e a l i n g p hase ( FIG 1 7) . The s k in s h o u l d be c l osed in two layers, with buried i n ­ terru pted sutu res i n the deep d e r m i s a n d su bcuta neous tissue, fol l owed by a ru n n i n g i ntra d e r m a l stitch i n the s k in edge. Care s h o u l d be taken to place the deep d e r­ m a l sutu res so that the a reo l a r s k in edge is at or s l i g htly a bove the b reast s k in edge (but not lower) ( FIG 1 8), or the n i p p l e-a reo l a r com p l ex will have a sunken-in appear­ a nce. If the a reola is sma l l, resu lting in an incision with g reater c u rvatu re, the final layer of skin closure s h o u l d u s e m u lt i p l e shorter b ites ( FIG 1 9) .

FIG 17

•

Pu rse-string suture i n the deep d e r m i s of the n i p p l e .

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P a r t 5 OPERATIVE TECHN IQUES IN BREAST, ENDOCRI NE, AND ONCOLOG IC SURGERY

FIG 1 8 • Appeara nce after closure of the deep d e r m a l layer of i ncision, with the a reo l a r edge at or a bove the breast s k i n . •

Adhesive d ressings on the dermis of the n i pple itself should be avoided. If an incision was req u i red in the n i pple dermis for a n i ntraderm a l nod u l e, t h e n i p p l e incision should be closed with fine i nterru pted nona bsorba b l e sutu res.

FIG 19

•

•

I ntra d e r m a l suture for final layer of closure.

D ress i n g s t h a t create excess p ressure o n t h e n i p­ p l e s h o u l d a l so be a vo i d e d . If a p ress u re d ress i n g i s d e s i red, it s h o u l d h ave a " d o n ut " o p e n i n g f o r t h e nipple.

PEARLS AND PITFALLS Preoperative counse l i ng

•

Preoperative counse l i ng s h o u l d a d d ress Focused d u ct excision versus excision of the entire d uct b u n d l e • I n a b i l ity to l a ctate after su rgery from the operated b reast • Li kely patho l o g i c fi n d i ngs • Poss i b l e nipple d ischarge i n the postoperative h ea l i n g period •

Incision p l a n n i n g

•

I nferior a reo l a r e d g e is preferre d .

S u b a reo l a r d i ssection

•

B e ca refu l to preserve su bcuta neous fat u n d e r the a reo l a r s k in a n d to l i m it d i ssection to as n a rrow a field as possi b l e to red uce risk of skin necrosis.

Closure

•

Proper closure of the deep a n d superfic i a l tissues u n d e r the n i p p l e-areolar com p l ex is critical to avoid n i p p l e retraction with h e a l i ng, a n d consider a pu rse-string stitch to reesta b l ish n o r m a l n i p­ p l e project i o n .

POSTOPERATIVE CARE • •

• •

The incision should be kept clean and dry. Clothing that creates excess pressure on the nipple should be avoided, and p atients may choose to use a donut-type foam dressing to relieve any pressure on the nipple. Showering is permitted. If any nonabsorbable sutures were placed in the nipple skin, they are removed at 1 week.

•

COMPLICATIONS •

•

OUTCOMES •

•

Subareolar duct excision for abnormal nipple discharge is highly successful, with resolution of discharge in the vast maj ority. Recurrent discharge is reported in the range of less than 5 % . 8 Pathology findings are most often benign (papilloma or duct ectasia ) , but malignancy is found in the range of 0% to 2 0 % .8,9

The likelihood of successful lactation after duct excision is not well characterized.

Bleeding and infection are possible complications after every sur­ gical procedure but are rare with this procedure. Avoidance of antiplatelet therapies and anticoagulants per surgical routine will help to minimize risk of bleeding, and a single preoperative dose of intravenous antibiotics is recommended prophylactically. Skin necrosis is also rare but devastating if it occurs; for this reason, careful attention should be paid to preserving blood supply to the areolar tissue and limiting the extent of dissection under the areolar skin, with focused excision of the central ductal tissue.

ACKNOWLEDGMENTS

Sincere thanks to Marilyn Churchward for assistance with manuscript preparation.

C h a p t e r 3 SUBAREOLAR DUCT EXCI S I O N

REFERENCES Fritsch H , Ki.ihnel W. Color Atlas of Human Anatomy: Internal Organs. Vol 2 . 5th ed. New York, NY: Thieme; 2008:4 1 8 . 2 . Morrogh M , Morris EA, Liberman L, e t a l . The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 2007; 1 4 ( 1 2 ) : 3 3 69-33 77. 3 . Dawes LG, Bowen C , Yenta LA, et al. Ductography for nipple discharge: no replacement for ductal excision. Surgery. 1 9 9 8 ; 124: 6 8 5-6 9 1 . 4. Fisher CS, Margenthaler JA. A look into the ductoscope: its role in pathologic nipple discharge. Ann Surg Oncol. 201 1 ; 1 8 : 3 1 8 7-3 1 9 1 . 1.

1 38 5

5 . Khan SA, Mangat A, Rivers A, e t a l . Office ductoscopy for surgical selection in women with pathologic nipple discharge. Ann Surg Oncol. 20 1 1 ; 1 8 :3 785-3 790. 6. Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg. 2007; 1 94:850-855. 7. Sabel MS, Helvie MA, Breslin T, et al. Is duct excision still necessary for all cases of suspicious nipple discharge? Breast]. 2 0 1 2; 1 8 (2 ) : 1 57-162. 8 . Morrogh M , Park A, Elkin EB, et al. Lessons learned from 416 cases of nipple discharge of the breast. Am J Surg. 201 0;200:73-8 0. 9 . Kooistra BW, Wauters C, van de Yen S , et al. The diagnostic value of nipple discharge cytology in 6 1 8 consecutive patients. Eur J Surg Oncol. 2009;35:573-577.

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Chapter

4

Cryoablation of Breast Fibroadenomas

r

· r

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

t

CRYOABLATION TREATMENT FOR BREAST FIBROADENOMAS-OVERVIEW •

•

•

•

•

•

Cryoablation is a minimally invasive, innovative treatment for breast fibroadenomas. The treatment is performed in an office setting rather than an operating room, resulting in a cost-effective and patient-friendly procedure with little to no scarring. Published reports demonstrate that cryoablation as primary treatment for breast fibroadenomas is safe and effective and at long-term follow-up, demonstrates progres­ sive resolution of the treated area, with excellent patient and physician satisfaction (Table 1 ) . About 8 0 % o f the approximately 1 . 3 million biopsies per­ formed annually in the United States reveal benign condi­ tions, primarily benign tumors or fibrocystic change. The most common benign breast tumor is a fibroadenoma. 1-3 Although not life threatening, benign breast tumors can cause fear, anxiety, and discomfort in the patient, and defini­ tive treatment is often desired.3-5 Fibroadenomas consist of a proliferation of epithelial and connective tissue elements within the lobular region of the breast. They are usually sharply demarcated from the adj a­ cent breast tissue and give the clinical and imaged appear­ ance of being encapsulated.5 They often grow to a size of 2 to 3 em and are multiple in 2 0 % of women.4• 6-9 Approximately 1 0 % of women will experience a fibroad­ enoma in their lifetime. Although most common in young women, fibroadenoma occurs in every age-group from ado­ lescents to octogenarians.1•2 •7•10•1 1

DIFFERENTIAL DIAGNOSIS •

•

•

These benign breast tumors have a classic physical examina­ tion: rubbery texture, smooth and well defined, circular to oval, and freely moveable within the breast. Other breast lesions that may have similar clinical presen­ tations include phyllodes tumors, j uvenile fibroadenomas, breast cancer (particularly medullary carcinomas) , or breast cysts. Diagnosis is resolved by imaging and core needle biopsy. Cryoablation has only been proven effective for biopsy­ proven fibroadenomas (Table 2 ) . 1 2-1 6

Table 1: Potential Advantages for Cryoablation in the Treatment of Fibroadenoma Reaso n s to consider a b lation tech n i q ues: Small p u n cture incision A proce d u re not surgery Less scarri ng M in i mal d iscomfort Less i nvasive Less expensive

1386

�

Ca ry 5. Ka ufman

PATIENT IDSTORY AND PHYSICAL FINDINGS •

•

•

•

•

•

Patients with small- to medium-sized single tumors that are not too close to the skin or nipple are appropriate candi­ dates for cryoablation. Indications and contraindications are listed in Table 3 . The target lesion must b e clearly visible with ultrasound and not be within 1 em of the skin or immediately deep to the nipple. A histologic diagnosis using a core biopsy should demon­ strate a classic fibroadenoma without atypia. Other histo­ logic lesions are not appropriate for cryoablation. Tumors should be measured in three dimensions and the longest dimension used to calculate freezing time ( FIG 1 ) . I t i s important t o discuss with the patient the process of cryoablation and the progressive resorption of the residual necrotic debris over time ( FIG 2 ) . The candidate should not currently have breast cancer i n the ipsilateral breast and be otherwise healthy. She should not be pregnant, breastfeeding, or have breast implants.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

•

If the patient is in the mammography screening age-group, a pretreatment screening mammogram should be obtained and be normal except for the fibroadenoma ( FIG 3 ) . There are classic imaging findings o f fibroadenoma o n both ultrasound and mammography, but histology is needed for an accurate diagnosis1•3•9•17 ( FIGS 3 and 4A,B, ultrasound and mammogram of a fibroadenoma) . The differential diagnosis includes the larger and faster growing j uvenile fibroadenomas and phyllodes tumors. 1•7•9 Large-core needle biopsy is the diagnostic method of choice because of the need to differentiate between benign and ma­ lignant tumors in general and fibroadenoma from phyllodes tumor in particular. 1 •9

MANAGEMENT OPTIONS •

•

There are three treatment options for a confirmed fibroade­ noma: ( 1 ) serial observation ( "watchful waiting " ) , (2) surgi­ cal removal, and ( 3 ) cryoablation. Surgery for fibroadenoma provides definitive treatment while confirming the diagno­ sis and eliminating patient anxiety and future monitoring. Drawbacks to surgical excision include patient discomfort, anesthetic and surgical recovery, skin incision and potential scarring as well as operating room costs . 1 8 On the other hand, many women choose serial observation with the advantages of no surgical pain, avoidance of the operating room and anesthesia, less cost, and only a mini­ mal scar from the large-core needle biopsy. Drawbacks to conservative management include ongoing patient anxiety regarding the presence and potential growth of a lump, the inconvenience of serial office visits, and the confusion of physical examination and mammography evaluations caused by the mass effect. 7•19

C h a p t e r 4 CRYOABLAT I O N OF BREAST F I B ROAD E N O MAS

1 387

Table 2 : Published Reports o f Cryoablation for Fibroadenomas

Author

Fibroadenomas (n)

Mean Size (em)

Freeze Time (min)

Skin Injury

Any Growth @1y

Stil l Palpable @1y

Volume Deer (%) @1y

Cosmesis by Patient @1y

Satisfied Patient @1y

310 444 23 70 847

1 .8 1 .8 2 m m ) N o EIC or LVI Any Unifoca l Pas

Nodes Histo logy Marg ins

" Cautionary"

Pas I L C or DC I S C l ose (3 em E I C/DC I S

Neg

/DC. invasive ductal carcinoma; ILC. invasive lobular carcinoma; DC/5, ductal carcinoma i n situ; EIC. extensive intraductal component; LVI, /ymphovascular invasion; ER, estrogen receptor.

•

•

Brachytherapy devices are routinely placed in the surgeon's office. Cavity evaluation devices ( CEDs ) ( FIG 5) can be inserted at the time of the lumpectomy as a " space holder" until ex­ changed in the office for the brachytherapy device.

Preoperative Planning •

•

Preoperative consultation with the radiation oncologist will be helpful in facilitating postoperative treatment scheduling. Postlumpectomy placement in the office begins with the preoperative plan for the lumpectomy including Location of incisions (do not perform sentinel lymph node biopsy through the lumpectomy incision) Use of oncoplastic techniques (minimal flap rearrange­ ment is okay but maj or flap movement with obliteration of the lumpectomy cavity negates the use of APBI) Thicker wound closure if possible (more tissue between skin and cavity may require skin resection and multilayer closure)

Positioning • •

Operative: No changes needed for CED placement. Office: Generally, brachytherapy devices are placed from lat­ eral to medial to minimize the nontherapeutic radiation that other parts of the body receive as the brachytherapy seed travels into and out of each of the catheters.

FIG 5

•

Cavity eva l u ation device.

OPERATIVE PLACEMENT OF A CAVITY E VALUATION DEVICE First Step •

After l u m pecto my but before closu re, a s m a l l s k i n n i ck i s m a d e latera l l y o r i nfer i o r l y a n d the C E D is t u n n e l e d from the skin n ick i nto the l u m pecto my cavity (FIG 6) .

Lum pectomy cavity

Second Step •

I nf l ate the ba l l oo n with e n o u g h sa l i n e to fi l l the cavity

(FIG 7) . Third Step •

Deflate the ba l l oo n a n d c l ose the l u m pecto my wo u n d .

Fourth Step •

Reinflate the b a l l o o n a n d n ote the vo l u m e used . T h i s w i l l assist i n choosi n g t h e correct s i z e o f b ra chytherapy de­ vice to be p l aced i n the office. •

T h e re is no n eed to suture the C E D to the s k i n as the i n f l ated b a l l o o n will h o l d it i n p l ace.

FIG 6

•

O p e rative p l acement of C E D .

1416

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

Sal ine inflated baloon Saline

1. FIG 7

OFFICE EXCHANGE OF CAVITY

Third Step

E VALUATION DEVICE FOR

•

Review the pat h o l ogy to e n s u re neg ative m a r g i n s a n d

Fourth Step •

oncolog ist that the patient i s a ca n d i date for APB I .

Second Step •

Prep a n d d ra p e the CEO a n d the s u r ro u n d i n g b reast tis-

Defl ate t h e CEO (not i n g the vo l u m e used) a n d remove it, the s a m e t r a c k i nto the l u m pecto my cavity (FIG 9) .

First Step negative senti n e l node(s) a n d confirm with t h e radiation

I nf l at i n g the C EO.

i m m ed i ately p l a c i n g the b ra chyt h e ra py device t h r o u g h

BRACHYTHERAPY DEVICE

•

•

I nf l ate the b a l l o o n with the same a m o u nt of sa l i n e o r expa n d the struts u n t i l they e n g a g e the cavity wa l l s.

Fifth Step •

Ste r i l e l y d ress the entrance s ite of the device.

sue with Betad i n e o r c h l o rhexi d i n e and ste r i l e d ra p e o r towe l s (FIG 8) . I nj ect local a n esthetic a r o u n d the s k i n n i c k .

•

Brachytherapy device

Lum pectomy cavity

FIG 8

•

P r e p a n d d ra pe the CEO a n d s u r r o u nd i n g b reast.

FIG 9 • Exc h a n g e of brachytherapy device for CEO t h r o u g h s a m e t r a c k without n eed for u ltraso u n d .

C h a p t e r 7 BRACHYT H E RAPY CAT H E T E R I N S E R T I O N FOR B R EAST CANCER

OFFICE PLACEMENT OF BRACHYTHERAPY DEVICE WITH ULTRASOUND GUIDANCE First Step •

Review the pat h o l ogy to e n s u re n e g ative m a rg i ns a nd negative senti n e l node(s) a n d co n f i r m with the radi ation o n c o l o g i st that the patient i s c a ndidate for APB I .

Second Step •

Exa m i n e the l u m pecto my cavity with u ltraso u nd to de­ term i n e the best size of brachyt h e ra py device and the best a p proach to p l ace t h e device (FIG 1 0) . The a p p roach is p a rt ic u l a rly i m portant for the strut­

•

based device because it is e l l i ptica l and s h o u l d be

FIG 11

p l a ced a l o n g the long axis of the l u m pecto my cavity

•

Loc a l a n esthetic a t the i nsert i o n site.

(ba l l oon devices w i l l expa n d and m a k e the l u m pec­ tomy cavity conform to the ba l l oo n ) . P l a n i n ci s i o n -2 em from the edge of the cavity.

•

Third Step •

I nject local a n esthetic i nto the s k i n n i ck site a nd the track

Seventh Step •

Fourth Step •

Steri l e l y prep a n d drape the site a n d p l a ce the u ltraso u nd

Eighth Step •

If a ste r i l e tra nsducer cove r is n ot ava i l a b le, you can clean the tra nsducer with a lco h o l swa b a n d use ster­ i l e g e l , but the h a n d u s i n g the u ltraso u nd w i l l no l o n ­

I nfl ate the b a l l o o n u nt i l you m eet resista nce or deploy the struts u nt i l they engage the cavity wa l l s (FIG 1 5) .

tra nsducer i nto a ste r i l e drape onto the field. •

I n se rt the brachyt h e rapy device t h ro u g h the troca r track i nto t h e l u m pectomy cavity (FIG 14) .

that l eads to the l u m pecto my cavity (FIG 1 1 ) .

Ninth Step •

Exa m i n e the device p l acement with u ltraso u n d (FIG 1 6) .

g e r be ste r i l e a n d therefore t h a t h a nd ca n n ot touch a ny of the i nstru m e nts o r brachytherapy device.

Fifth Step •

•

Rem ove the center stiffe n e r rod a n d replace with a cath­ ete r ca p to keep f l u i d out of the catheter (FIG 1 7) .

Use a n o . 1 1 b l ade a n d m a k e an a p p roxi m ately 1 2- m m i n c i s i o n (FIG 1 2) .

Sixth Step •

Tenth Step

Eleventh Step •

Ste r i l e ly dress the device entrance s ite (FIG 1 8) .

The troca r is i n se rted i nto the cavity u nde r u ltraso u nd g u ida nce (th e l u m pecto my seroma may p a rt i a l ly evacu­ ate at this t i m e) (FIG 1 3A,B) .

FIG 1 0

•

U ltraso u n d exa m i nation of the l u m pecto my cavity.

FIG 1 2

•

S k i n i n c i s i o n at i n se rt i o n site.

1417

1418

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

A FIG 13

•

Lumpectomy cavity B A,B. Troc a r i n se rt i o n i nto l u m pecto my cavity u nder u ltraso u n d g u ida nce.

• B ra chyt h e rapy device p l acement i nto cavity u nder u ltraso u n d g u ida nce.

FIG 1 4

FIG 16 • U ltraso u n d exa m i nation of the b rachyt h e ra py device p l acement.

FIG 1S

•

I nflati n g the brachyt h e ra py device b a l l o o n .

FIG 1 7

•

R e p l a c i n g the center cath ete r c a p .

C h a p t e r 7 BRACHYT H E RAPY CAT H E T E R I N S E R T I O N FOR B R EAST CANCER

FIG 18

•

1419

Ste r i l e dress i n g a ro u nd the b ra chytherapy device.

PEARLS AND PITFALLS Poor confo r m a nce of ba l l oo n device to cavity wa l l

•

If t h e re is a pocket o f f l u id o r a i r betwee n t h e b a l l o o n a nd l u m pecto my cavity wa l l (as seen by u ltraso u nd), gently massage the b reast to evacuate the f l u i d/a i r.

D ra i n a g e t h ro u g h track

•

There is often fluid that will dra i n out t h ro u g h the track of the C E D o r device. Wa r n i n g your pa­ tient a bout t h i s will often save a phone ca l l at bedt i m e (usu a l ly occ u rs w h e n patient l ays down for bed) .

Delay in device p l acement after l u m pecto my

•

As the l u m pecto my wo u n d h e a l s, the cavity w i l l become f i b rotic and eve ntu a l ly o b l iterates. T h i s ca n v a ry between patie nts, but it is g e n e ra l ly best to p l a ce t h e device with i n 4 w e e k s of the l u m pectomy.

Avo i d i n g radi ation reca l l

•

If t h e patient is g o i n g t o b e rece i v i n g c h e m ot h e ra py, i t i s best t o wa it a m i n i m u m o f 3 weeks afte r t h e l a st APB I treatment to p revent radi ation reca l l (poorly u nderstood p h e n o m e n a of n o n ­ i nfect i o u s e ryt h e m a overlyi n g the l u m pecto my cavity) .

M i n i m i z i n g s k i n radiation

•

Alth o u g h the newer devices h ave m u lt i p l e catheters that a l low m u c h bette r ta i l o r i n g of t h e ra­ diation to m i n i m ize radiation to n o r m a l str u ct u res (sk i n , l u ngs, ri bs, h e a rt, pecto ra l m uscle), it i s sti l l best to create as m u c h dista nce between the s k i n a n d the brachyt h e ra py device as poss i b l e, so you may need to excise s k i n overlyi n g the b reast cancer a n d close t h e cavity i n m u lt i p l e l ayers.

POSTOPERATIVE CARE •

•

•

Postinsertion care includes daily dressing changes, no show­ ering ( sponge baths only until device removed) . Most surgeons place the patient o n antibiotics while the device is in. Cephalexin, Bactrim DS, and ciprofloxacin are commonly used. Typically, the radiation oncologist will remove the device after the last treatment and Steri-Strip the opening.

OUTCOMES •

•

•

APBI has local recurrence rates of 2% to 5 % at 5 years­ similar to WBI.4-7 Overall survival and breast cancer-specific survival are also equivalent to similarly staged patients who receive WBI. True recurrences (tumor bed) are usually treated with mas­ tectomy, but elsewhere, recurrences (presumably new prima­ ries ) may be treated with lumpectomy and APBI.

COMPLICATIONS •

•

Early complications4 Infections-� 9 % (no catheter explant due to infection) Seromas-� 3 0 % Painful seromas-� 1 3 % Late complications Cosmesis-excellent/good, 9 0 % ; and fair/poor, 1 0 % Fat necrosis-� 2 %

REFERENCES 1.

American Society of Breast Surgeons. Consensus statement for acceler­ ated partial breast irradiation. https://www.breastsurgeons.org/state­ ments/PDF_Statements/APBI.pdf. Accessed July 2 8 , 2 0 1 3 . 2. Keisch M , Arthur D, Patel R , e t al. American Brachytherapy Society Breast Brachytherapy Task Group. American Brachytherapy Society Web site. http://www.americanbrachytherapy.org/guidelines/abs_breast_ brachytherapy_taskgroup.pdf. Accessed July 2 8 , 2 0 1 3 . 3 . Smith B D , Arthur OW, Buchholz TA, et a l . Accelerated partial breast irradiation consensus statement from the American Society

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

for Radiation Oncology (ASTRO ) . lnl } Radial Oneol Bioi Phys. 2009;74 ( 4 ) : 9 8 7-1 0 0 1 . 4. Vicini FA, Beitsch P, Quiet C , e t al. Five-year analysis o f treatment efficacy and cosmesis by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated par­ tial breast irradiation. lnl} Radial Oneol Bioi Phys. 201 1 ;79( 3 ) :808-8 17. 5. Shah C, Antonucci JV, Wilkinson JB, et al. Twelve-year outcomes and patterns of failure with accelerated partial breast irradiation versus

whole-breast irradiation: results of a matched-pair analysis. Radiolher Oneal. 2 0 1 1 ; 1 00:2 1 0-2 14. 6. Swanson TA, Vicini FA. Overview of accelerated partial breast irradia­ tion. Curr Oneol Rep. 2 0 0 8 ; 1 0 : 54-60. 7. Polgar C, Fodor J, Major T, et al. Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast car­ cinoma-S-year results of a randomized trial. Inl J Radial Oneal Bioi Phys. 2007;6 9 ( 3 ) :694-702.

I

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Chapter

8

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Sentinel Lymph Node Biopsy for Breast Cancer -t t

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DEFINITION •

Preoperative Planning

Sentinel node biopsy is a minimally invasive means to accu­ rately stage the axilla in breast cancer patients.

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

As always, a complete history and physical exam is war­ ranted. If the patient has obvious clinically enlarged axil­ lary lymph nodes on physical exam, ultrasound, and/or fine needle aspiration ( FNA) or core needle biopsy may provide diagnostic information. If the biopsied node is positive, one could proceed to neoadjuvant chemotherapy and/or axil­ lary dissection if primary surgery is planned. Alternatively, if the biopsied node is negative, sentinel node biopsy is still indicated for definitive evaluation.

Timing of sentinel node biopsy vis-a-vis neoadjuvant che­ motherapy is controversial; some opt to perform this pro­ cedure prior to initiation of neoadj uvant chemotherapy so as to most accurately stage the axilla, whereas others will do a sentinel node biopsy after completion of neoadjuvant chemotherapy so as to potentially spare patients who have had a pathologic complete response to the morbidity of a complete axillary dissection.

Positioning •

IMAGING AND OTHER DIAGNOSTIC STUDIES •

·

An ees B. Chagpar

•

Lymphoscintigraphy is commonly performed in conj unction with sentinel lymph node (SLN) biopsy for breast cancer, although it is not absolutely necessary. 1 Depending on how the radionucleotide tracer is injected, lymphoscintigraphy may show drainage to the internal mammary nodes (see Part 5 , Chapter 9 ) . If patients have had previous sentinel node biopsy and/or axillary node dissection, repeat sentinel node biopsy may be considered for staging ipsilateral recur­ rent or new primary disease. In this circumstance, alternative drainage patterns are possible, and therefore, preoperative lymphoscintigraphy may be useful.2

Patients are positioned supine. A roll may be placed under the ipsilateral shoulder so as to elevate the latissimus dorsi muscle. Care should be exercised to ensure that the arm is supported on folded sheets so as to avoid a brachial plexus stretch injury ( FIG 1 ) . Intravenous lines, pulse oximeter devices, and blood pressure cuffs should be placed on other extremities if possible.

SURGICAL MANAGEMENT •

Sentinel node biopsy is indicated for staging of patients with invasive breast cancer or those with ductal carcinoma in situ undergoing mastectomy.

FIG 1 • Patient positi o n e d with ro l l u n d e r i p s i latera l latiss i m u s a n d fo l d e d sheets to s u p po rt a r m .

i n d u ct i o n of a n esthes i a . The rad i otracer ca n b e

INJECTION OF RADIOACTIVE TRACER

i nj ected peritu m o r a l , intra d e r m a l ( i n t h e s k i n over

AND/OR BLUE DYE •

the locat i o n of the ca n ce r), o r periareo l a r (fo u r i n ­

Use of d u a l tracer has been s h ow n to be associated with

tra d e r m a l i njections a r o u n d the a reola). If i njection

h i g h e r i d e ntification and lower false-negative rates3;

is d o n e o n the same day as the operative procedu re, a dose of 0.5 mCi is a d e q u ate. If i njection is d o n e the

h owever, p a rt i c u l a r l y in patie nts u n d e rg o i n g ski n-spa r i n g mastecto my, surgeons may wish to forego b l u e dye, as the dye may d isco l o r the skin and m a ke it m o re d iffi c u l t to eva l u ate for s k i n isch e m i a o r necrosis. •

•

day p r i o r to surge ry, 2 . 5 m C i should be used . B oth isosulfan a n d methylene b l u e dye h ave been used for SLN b i opsy; they va ry i n their color, com­

I n g e n e r a l , the ra d i oactive tracer used is tec h n eti u m

p l i cation p rof i l e, and cost. lsosu lfa n blue is a more

Tc 9 9 m s u l f u r co l l o i d . F o r patie nts n ot u n d ergo i n g

a z u re blue (which is easier to d isti n g u ish from venous

lym p h osc i n t i g r a p hy, the tracer can be i nj ected i n

structu res) but is associated with less than 1 % risk

t h e p reoperative h o l d i n g a re a . H owever, i njection

of a n a p hylaxis4 a n d is sign ificantly m o re costly than

of t h i s mate r i a l is p a i n f u l , a n d a d e q u ate cou nts can

methylene b l u e . M ethylene b l u e is da rker, associated

often be o bta i n ed with i ntra d e r m a l i njection afte r

with a h i g her rate of skin necrosis, but is fa r chea per. 5

142 1

1422

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

In general, 5 mL of these tracers a re used; if methylene b l u e is chosen, it should be d i l uted 1 :2 with sa l i ne. •

B l ue dye may be i nj ected peritu m o r a l or u s i n g a s u b a reo l a r a p p ro a c h . T h e l atte r a l l ows for lym­ p h atic m a p p i n g of m u lt i p l e t u m o rs and t hose w h ich a re n ot easily i d e ntifi a b l e6 (FIG 2) . F o r patie nts u n d e r g o i n g b reast conservat i o n , the s u b a reo l a r a p ­ p r o a c h may l e a v e the p a t i e n t with a " b l u e b reast" for some t i m e .

FIG 2

•

S u ba reo l a r i nj ecti o n of b l u e dye.

PRE PPING AND DRAPING •

The a r m is prepped c i rcu mferent i a l l y a l o n g with the b reast. The a r m is d ra ped i nto the f i e l d a n d kept free such that the s u rgeon may move the arm in a steri l e fash­ i o n d u r i n g the case (FIG 3) .

FIG 3 • Patient d raped with breast and axi l l a in the f i e l d ; the i psi latera l a r m is d ra ped i n the ste r i l e f i e l d .

INCISION •

I d e ntification of the a rea of maxi m a l r a d i o a ctivity in the axi l l a u s i n g a h a n d h e l d gamma probe a l l ows o n e to posi­ t i o n the incision over the senti n e l n o d e .

•

La n d m a rks of the pectora l i s a n d latiss i m u s d o rsi m uscle a re used to fas h i o n a n incision for a n axi l l a ry d i ssect i o n of w h i c h the senti n e l node i n c i s i o n w o u l d be a seg ment

(FIG 4) . A l a zy S incision will a l low for opti m a l cosme­ sis and w i l l a l low for exten s i o n s u p e r i o r l y and i nfe riorly if needed for maxi m a l visu a l izati o n . Altern ative ly, i f a conventi o n a l m a stectomy is p l a n ned, the senti n e l node b i o psy can often be pe rfo rmed t h r o u g h the l atera l aspect of the s a m e i n c i s i o n . •

Loca l a n a esthetic may be used for preem ptive a n a l gesia . The i n c i s i o n is taken down t h ro u g h s k i n , su bcuta neous tissue, and clavi pecto r a l fasc i a .

FIG 4 • I nc i s i o n p l a n n i n g . The pectora l i s a n d latissi m us d o rsi m u scle borders a re identified. An "X" m a rks the a rea of maxi m a l r a d i o a ctivity. A l a zy S i n c i s i o n is fash i o n ed for a potentia l axi l l a ry d i ssect i o n g o i n g t h r o u g h the X. A s m a l l e r seg m e nt (ma rked b y the crosshatch l i n es) d e l i n eates t h e i n c i s i o n f o r the senti n e l n o d e b i o psy.

of whether they a re b l u e or h ot, a s tracers may n ot

IDENTIFICATION OF SENTINEL NODES •

with r a d i oactive cou nts g reater t h a n 1 0 % of the ex vivo cou nts of the h ottest n o d e . I n a d d it i o n , a l l b l u e nodes and t h ose at the e n d of a blue l y m p h atic c h a n n e l are a lso rem oved (FIG 5) . •

have trave l l ed to positive l y m p h n o d es if lym p h atics a re

Ca re is taken to remove the h ottest node, a n d a n y node

P a l pation is critica l t o i d e ntify a n y c l i n ica l ly suspicious l y m p h n o d es; t h ese should a l so be re m oved regard l ess

o bstructed with t u m o r. •

Alth o u g h some have a rg u e d that the p roced u re c a n be term i n ated afte r t h ree S L N s have been rem oved/ oth e rs have a rg u e d that a l l n odes that fit t h e e a r l i e r mentioned crite r i a be rem oved .8 O n average, h owever, two sent i n e l n o d e s a re identified.

C h a p t e r 8 S E N T I N EL LYM P H N O D E B I OPSY FOR B R EAST CANCER

FIG 5

•

1423

B l u e S L N at the e n d of a b l u e l y m p h atic c h a n n e l .

INTRAOPERATIVE E VALUATION •

I ntraope rative eva l u at i o n with e i t h e r touch preparat i o n cytology o r frozen sect i o n has been fo u n d to h a v e a h i g h specificity a n d fa i r l y h i g h sensitivity (FIG 6) .

•

Some s u rgeons may opt to forego i ntraoperative eva l u ation i f they d o not i nte n d to co m p l ete t h e axi l l a ry n o d e d i ssect i o n at the s a m e operative sett i n g g iven the f i n d i n g s of the s e n ­ t i n e l node b i o psy. F o r patie nts w h o fit the American Co l l ege of S u rgeons O n c o l ogy G ro u p Z00 1 1 criteria, c o m p l et i o n axi l ­ l a ry n o d e d i ssect i o n may be avoided if o n l y o n e to t w o s e n ­ t i n e l nodes a re positive a n d w h o l e b reast i rra d i ation after p a rt i a l mastectomy i s p l a n n e d . 9

FIG 6

I ntraoperative frozen sect i o n resu lts.

Steri-Strips. If, h owever, a n axi l l a ry d i ssect i o n is i n d i cated,

CLOSURE •

•

the i ncision can be exte nded (as p l a n ned i n the e a r l i e r

In g e n e r a l , if axi l l a ry node d i ssect i o n is not pe rformed, n o

d iscuss i o n ) .

d r a i n s a re req u i re d . The i nc i s i o n is cl osed i n sta n d a rd fash­ i o n with s u b d e r m a l and su bcuticu l a r sutu res fo l l owed by

POSTOPERATIVE CARE •

After sentinel node biopsy alone (i.e., without axillary dis­ section) , patients can go back to usual activities. No special exercises are required nor is there any need for lymphedema compression garments.

OUTCOMES •

Outcomes after sentinel node biopsy alone are outstanding, with no detriment in survival or local recurrence. Morbidity is low, especially compared to axillary dissection.

COMPLICATIONS • • • • • • • •

Bleeding/hematoma Infection Seroma Numbness/paresthesia Lymphedema Allergic reaction to isosulfan blue dye " Blue breast" from blue dye inj ection Skin or fat necrosis from methylene blue dye

REFERENCES 1.

2.

3. 4.

5.

6.

7. 8. 9.

McMasters KM, Wong SL, Tuttle TM, et al. Preoperative lymphoscin­ tigraphy for breast cancer does not improve the ability to identify axil­ lary sentinel lymph nodes. Ann Surg. 2000;2 3 1 : 724-73 1 . Port ER, Fey J , Gemignani ML, e t al. Reoperative sentinel lymph node biopsy: a new option for patients with primary or locally recurrent breast carcinoma. I Am Coil Surg. 2002; 1 9 5 : 1 67- 1 72. Chagpar AB, Martin RC, Scoggins CR, et al. Factors predicting failure to identify a sentinel lymph node in breast cancer. Surgery. 2005 ; 1 3 8 :56-63. Alba D, Wayne JD, Hunt KK, et al. Anaphylactic reactions to isosul­ fan blue dye during sentinel lymph node biopsy for breast cancer. Am I Surg. 200 1 ; 1 82:3 93-3 9 8 . Simmons RM, Smith SM, Osborne MP. Methylene blue d y e as an al­ ternative to isosulfan blue dye for sentinel lymph node localization. Breast I· 2 0 0 1 ; 7: 1 8 1-1 8 3 . Chagpar A , Martin RC III, Chao C , et a l . Validation of subareolar and periareolar injection techniques for breast sentinel lymph node biopsy. Arch Surg. 2004; 1 3 9 : 6 14-6 1 8 . Zakaria S , Degnim AC, Kleer CG, e t al. Sentinel lymph node biopsy for breast cancer: how many nodes are enough? I Surg One. 2007;96:554-559. Chagpar AB, Scoggins CR, Martin RC, et al. Are 3 sentinel nodes suf­ ficient? Arch Surg. 2007; 142:456-459. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sen­ tinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American College of Surgeons Oncology Group Z001 1 randomized trial. Ann Surg. 201 0;252:426-432.

-

Chapter

9

Internal Mam mary Sentinel r

Node Biopsy

r

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

· t

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

DEFINITION •

Internal mammary node dissection is performed for both diagnostic and therapeutic purposes. This surgery is gener­ ally performed in conjunction with breast cancer surgery as part of nodal staging. In modern times, this usually involves removal of lymph nodes from one or two parasternal inter­ spaces as part of a sentinel node staging procedure. In the first descriptions of internal mammary node dissection, the entire internal mammary nodal chain was resected including the adj acent ribs. 1 With the advent of sentinel lymph node mapping, it is possible to perform a more minimally invasive procedure to resect in a directed fashion internal mammary nodes that are demonstrated to have lymphatic drainage from the breast. Internal mammary sentinel node drainage is identified on lymphoscintigraphy in 1 0 % to 22% of map­ ping studies. Internal mammary drainage is more likely to be identified if the radionucleotide is inj ected in the peritumoral region rather than subareolar. The technique described here to retrieve sentinel nodes can also be used to surgically bi­ opsy small suspicious internal mammary nodes identified on preoperative imaging with computed tomography ( CT) scan or breast magnetic resonance imaging (MRI ) .

•

•

PATIENT IDSTORY AND PHYSICAL FINDINGS •

•

The breast cancer patient should have a careful evaluation with a complete history and physical examination as well as appropriate imaging studies. The patient's history should focus on specific breast complaints including how long the patient has been aware of the cancer in her breast, associ­ ated symptoms and signs, and focal chest wall pain. It is important to ascertain the patient's medical history to assess the patient's risk for surgery related to intercurrent medical conditions. Prior surgery such as sternotomy, coronary artery bypass graft, thoracotomy, and breast augmentation should be noted, as these may complicate the performance of inter­ nal mammary node dissection. Past history should include annotations about prior radiation to the chest wall such as mantle radiation for Hodgkin's disease. The patient should be queried about prior trauma to the anterior chest wall. Physical examination includes the full examination of the breast to document any palpable mass lesion, including the size and location with respect to the quadrant of the breast and its distance from the nipple. The nodal basin should be care­ fully examined including the cervical, supraclavicular, axillary basins, as well as the palpation of the parasternal region. If there are any evident abnormal nodes, these should be further evaluated with imaging including mammography and ultra­ sound. Needle biopsy of suspicious nodes can be undertaken preoperatively in order to plan the therapeutic intervention.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

The standard imaging workup for a newly diagnosed breast cancer patient would include mammography and ultrasound

1424

�

A. Ma rilyn L eitch

of the breasts. Many patients will have an MRI performed as well. This study permits visualization of the internal mam­ mary nodal chain. If an abnormal lymph node is identified, it can be biopsied with a needle or targeted for excision at the time of surgery ( FIG 1 A,B ) . C T scanning o f the chest i s not routine for the workup o f that early-stage breast cancer. However, if a CT scan of the chest or positron emission tomography (PET)-CT is performed for other indications, internal mammary node enlargement may be identified ( FIG 2A,B) . If the patient has palpable fullness in the parasternal region, a CT scan should be ordered to evaluate for internal mammary nodal metastases. In order to identify the internal mammary nodal drainage in the sentinel node procedure, it is critical to inject a ra­ diolabeled tracer for mapping of the pathways to the inter­ nal mammary nodes. To maximize the chance of identifying internal mammary lymphatic drainage, it is important to perform the injections of technetium sulfur colloid in the peritumoral region rather than performing a subareolar in­ j ection only. Lymphoscintigraphy can be performed to have a visual representation of the location of the internal mam­ mary drainage ( FIG 3A-D) . The area of radioactivity in the parasternal region can be marked on the skin by the nuclear medicine technician at the time of scanning ( FIG 4A,B ) . This increases the efficiency o f identifying the appropriate interspace for exploration for the sentinel node. Most com­ monly, there will be one interspace that demonstrates a hot spot. However, more than one interspace may demonstrate a radioactive focus. The most common areas of drainage are the 2nd and 3rd interspaces.

SURGICAL MANAGEMENT Preoperative Planning •

The lymphoscintigraphy should be reviewed prior to going into the operating room. It is important to consent the pa­ tient specifically for the internal mammary exploration. Knowing from the lymphoscintigraphy that there is internal mammary lymphatic drainage, the surgeon can convey to the patient that this pathway can be pursued if the patient is agreeable. If it is the practice of the surgeon not to perform lymphoscintigraphy prior to surgery, then the interspaces can be examined intraoperatively with the gamma probe to identify foci of increased radioactivity in the parasternal in­ terspaces. It remains important to consent the patient for the possibility of an internal mammary exploration with its potential complications.

Positioning •

The patient is positioned supine with the arms abducted to 90 degrees on padded arm boards. The skin prep of the chest wall should cross to the contralateral breast so that the sternum and parasternal regions are draped into the field of operation.

A B A. Abnorm a l right internal m a m m a ry lym ph node and right axi l l a ry lym phadenopathy seen on breast M R I axia l T1 postcontrast subtraction series. B. B reast M R I . Sag itta l T1 reconstruction demonstrating the abnormal i nternal m a m m a ry node. (Cou rtesy of Stephen Seiler, FIG 1

•

MD, U n iversity of Texas Southwestern Medical Center.)

B

A FIG 2

•

A. Chest CT sca n demonstrat i n g e n l a rged left i ntern a l m a m m a ry node. B. PET sca n i m a g e shows f l u o rod eoxyg l u cose (FDG) u ptake

i n the l eft i nternal m a m m a ry node. (Cou rtesy of Stephen Seiler, M D , U n iversity of Texas Southwestern Medical Center.)

A

c

RT

ANT

TRAN SMISSION L T ANTERIOR OBLIQUE

LT

B

D

RT

TRANSMISSION ANTERIOR

LT

FIG 3 • A. Lym p h osci ntigraphy of b i l atera l breasts d e m o n strat i n g i nte r n a l m a m m a ry n o d a l d r a i n a g e o n the r i g h t i n the a nterior p roject i o n . B. Ante r i o r p roject i o n of lym p h osci ntigraphy show i n g rad i oactive u pta ke i n two i nterspaces with fa i nt u ptake base of neck. In t h i s vi ew, the axi l l a ry node is fa int. C. Left a nte r i o r o b l i q u e p roj ect i o n s h ows the axi l l a ry u pta ke more i ntense ly. D. Lym p h osci n t i g r a p hy (ante r i o r p roj ect i o ns) w i t h l y m p h atic d r a i n a g e to m u lt i p l e i nte r n a l m a m m a ry nodes.

142 5

1426

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

-- 1 M AX --

A

B A. Lym p h oscintigraphy d e m o n strat i n g i ntense r a d i o activity i n the r i g ht axi l l a ry node b a s i n a n d very fa i n t r a d i oactivity i n the i nt e r n a l m a m m a ry basi n . B. N ote X m a rks p l aced by the n u c l e a r FIG 4

•

"

"

m e d i c i n e tech n i c i a n to g u i d e g a m m a probe exa m i n a t i o n .

operat i n g roo m . Lym p h a z u r i n b l u e a l o n e w i l l not be

INCISION AND INITIAL IDE NTIFICATION

successf u l i n i d e ntifyi n g the i nte r n a l m a m m a ry sent i n e l

OF AREA OF INTERNAL MAMMARY

n o d e s . H owever, o n c e the a rea of ra d ioactivity i s identi­

SENTINEL NODE •

fied a n d exp l o ration is beg u n , blue lym p h atics o r sta i n ­ i n g o f the sent i n e l nodes may be i d e ntified but n o t with

P l acement of the i n c i s i o n is governed by the p roced u re

the fre q u e n cy that it is seen i n the axi l l a ry nodes. As with

p l a n ned for resect i o n of the breast t u m o r. F o r patients

the r a d i oactive tracer, the blue dye is m o re l i ke l y to be

h a v i n g b reast-co nserv i n g s u rg e ry, the i n c i s i o n for the

i d e ntified in the i nte r n a l m a m m a ry n odes if the i nject i o n

p r i m a ry t u m o r is p l aced overlyi n g the p r i m a ry l e s i o n . If the p r i m a ry lesion is n e a r to the a rea of i nte r n a l m a m ­ m a ry d r a i n a g e, t h e n it may be feasi b l e to exp l o re t h e

is peritu m o ra l . •

exp l o ration is then beg u n . (Refer to Part 5, C h a pter 8 for

i nterspaces v i a the p a rt i a l mastecto my i n c i s i o n . H owever,

m o re i nformation o n senti n e l node d i ssect i o n .) I n m ost

if the p r i m a ry lesion is d ista nt from the pa raste r n a l re­

cases, there w i l l be an axi l l a ry sent i n e l node i dentified i n

g i o n , then the i n c i s i o n for exp l o ration of the i nterspace i s p l aced overlyi n g the a rea of foc a l r a d i o a ctivity. •

If the patient is u n d e r g o i n g a mastecto my, the sta n d a rd

After t h e b l u e dye is injected, t h e axi l l a ry sent i n e l node

those pati ents w h o a lso have i n te r n a l m a m m a ry d r a i n a g e . •

The m a stectomy o r p a rt i a l m a stectomy i s t h e n pe rfo rmed .

mastecto my i n c i s i o n is used for access i n g the pa raster n a l i nterspaces (FIG 5). When reconstruct i o n is p l a n ned, t h e mastecto my i n c i s i o n i s g e n e ra l ly m o re l i m ited w i t h t h e s k i n -spa r i n g tech n i q u e . H oweve r, the pa raster n a l reg i o n can be g e n e ra l ly accessed v i a t h ese i n ci s i o n s w i t h retrac­ tion of s k i n f l a ps, u n l ess t h e re is n i p p l e preservati o n with the i n c i s i o n p l aced in the i nfra m a m m a ry l i ne . In this c i r­ c u m st a n ce, the i n c i s i o n locat i o n wo u l d be d ete r m i ned i n a s i m i l a r fas h i o n as patie nts havi n g breast-co nservi n g s u rg e ry. •

It is m u c h easier to i d e ntify the a rea of foc a l r a d i oactiv­ ity i n the i nterspaces after the breast is removed or after the p a rt i a l m a stecto my i s co m p l eted . T h i s redu ces the a m o u nt of backg r o u n d r a d i o a ctivity, w h i c h i ncreases the ease of i d e ntifyi n g r a d i oactivity i n a n i ntern a l m a m m a ry n o d e . In order to f i n d an i ntern a l m a m m a ry sent i n e l n o d e , it is i m perative to h ave a stro n g s i g n a l t h a t c a n be p i c k e d u p b y the g a m m a p r o b e to d i rect the i n c i s i o n p l acement.

•

Lym p h a z u r i n b l ue, w h i c h is ofte n i njected for i d e ntifi­ cation of the senti n e l nodes i n the axi l l a, should be in­ jected p r i o r to beg i n n i n g a n y resective p roced u re i n the

FIG 5 • S k i n spa r i n g mastecto my i n c i s i o n with edge retracted to expose pa raste r n a l i nterspace.

C h a p t e r 9 I NTERNAL MAMMARY S E N T I N EL N O D E B I OPSY

EXPLORATION OF THE PARASTERNAL INTERSPACES •

•

F o r the p a rt i a l m a stecto my patie nts, the i n it i a l exa m i n a ­ t i o n w i t h a g a m m a p robe may h a v e to be d o n e t h ro u g h the s k i n overlyi n g t h e i nterspaces if t h e p a rt i a l m a stec­

U s i n g the g a m m a probe, the parasternal i nterspaces

tomy i n c i s i o n is away from t h i s a re a . Because the s k i n s u r­

a re exa m i ned in seq u e n ce from s u p e r i o r to i nfe r i o r. I n

face is fart h e r from the node, it can be m o re tech n i ca l ly

patie nts h a v i n g a sta n d a rd o r ski n-spa r i n g m a stecto my

d iffi c u l t to i d e ntify the hot spot. Each i nterspace is exa m ­

i nc i s i o n , the skin edges ca n be retracted with a R i c h a rd ­

i n e d a n d cou nts taken as d e s c r i b e d for the m a stectomy.

son retractor o r w i t h L o n e Sta r hoo ks, w h i c h c a n obviate

When the foca l hot spot is i d e ntified, the i n c i s i o n is m a d e

the need for a n assista nt to retract. With the pectora l i s

overlyi n g the i nterspace a l o n g the a x i s of the r i b s (FIG 6) .

m uscle exposed, the g a m m a p robe is t h e n p l aced d i rectly

The i n c i s i o n is ca rried t h r o u g h the s k i n , the su bcuta ne­

o n the m uscle after p a l pati n g the i nterspace. When an

ous tissue, and a n y u n d e r l y i n g breast tissue d own to the

a rea of foca l r a d i oactivity is i d e ntified, cou nts a re taken

pectora l i s m uscle. A self-reta i n i n g retractor is p l aced to

for 1 0 seco n d s, two o r th ree t i m es with a backgro u n d

expose the pectora l i s m u scle w i d e ly. Lone Sta r h o o k re­

taken a ce n t i m eter away t o confirm t h a t it is a foc a l hot

tracto rs may be used if the t h i c kn ess of the tissue in t h i s

spot. Cou nts a re taken at each i nterspace.

port i o n of the b reast i s t h i n .

A FIG 6

•

B A. Pa raste r n a l i n c i s i o n i n conserved b reast with exposu re of pectora l i s m u sc l e . B. Lo n e Sta r h o o k retractors p l aced to

retract s k i n to expose m uscle.

DISSECTION THROUGH THE CHEST WALL •

O n ce the pectora l i s major m u scle is exposed overlyi n g t h e ra d i oactive i nterspace, the fi bers of the pectora l i s m uscle a re s p l i t a l o n g t h e i r axis. A s m a l l self-reta i n i n g retractor o r Lone Sta r h ooks a re p l aced t o h o l d t h e fi b e rs a p a rt (FIG 7) . Exa m i nation is performed a g a i n with the gamma probe to confirm that the r a d i o a ctivity is per­ sistent deep to t h e pectora l i s m uscle (FIG 8) . If there i s persistent r a d i o a ctivity, t h e n the i nte rcosta l m u scles a re i ncised with e l ectroca utery over a 3- to 4-cm length ex­ te n d i n g from the ste r n a l edge latera l l y (FIG 9A) .

• Pecto ra l is m u scle fi bers s p l it a n d retracted t o expose i ntercosta l m u scl e .

FIG 7

1427

1428

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

FIG 8 • Exa m i nation is performed a g a i n with the g a m m a p robe t o confi rm t h a t the r a d i oactivity is persistent d e e p to the pectora l i s m uscle.

Pectoralis muscle

muscle

A FIG 9

B

Exposure of i nte rcosta l space i n b reast conserv i n g s u r g e ry with i nte rcost a l m uscle d ivided (A) . Two i nterspaces exposed by d ivid i n g i ntercost a l muscle a bove and b e l ow the rib v i a this l i m ited i n c i s i o n . The i ntern a l m a m m a ry vesse l s a re m ed i a l ly l ocated i n t h e i nterspace (B) . •

tissue to expose the n o d e s . S m a l l tita n i u m c l i ps c a n be

DISSECTING IN THE INTERSPACE TO

used to l i gate fine ca p i l l a ries. It i s critica l to avoid a n y

RETRIE VE THE SENTINEL NODE •

•

b l e e d i n g , w h i c h c a n o b s c u r e t h e s m a l l o p e rative f i e l d . The lym p h n o d es m a y be i nt i m ately rel ated with t h e

A t h i n , f i l m y fasc i a is i n cised deep to the i nte rcosta l m us­ cles to expose a t h i n p l a q u e of fatty tissue that l i es j ust

i ntern a l m a m m a ry vesse l s, so a ny b r a n c h es m u st be se­

a nte r i o r to the p l e u r a . Ag a i n, the g a m m a p robe is used

c u re l y l i g ated in d issect i n g the node away from th ese

to loca l ize the node that w i l l be i n fatty tissue deep to

vesse l s . The p l e u ra w i l l be exposed a s the fatty tissue

the i nte rcosta l m uscles. The i ntern a l m a m m a ry vesse l s

i s teased away with t h e move m e n t of t h e l u n g v i s i b l e

a re m ost m e d i a l i n the i nterspace (FIG 1 0)

t h r o u g h t h e t h i n p l e u ra (FIG 1 1 ) .

T h e sent i n e l n o d es a re often q u ite s m a l l a n d a re ye l l ow to ye l l ow t a n i n co l o r. Th us, t h e i r i d entificati o n m a y be

•

W h e n the n o d e is removed, g a m m a cou nts a re taken o f the n o d e t o confirm its r a d i o a ctivity (FIG 1 2) . The i nter­

somewhat ted i o u s . F r e q u e n t use of t h e g a m m a probe

space is a g a i n exa m i ned with the g a m m a probe to con­

h e l ps to d i rect t h e d i ssecti o n . Fine i n stru m e nts a re used

f i r m t h e re is n o res i d u a l r a d i o a ctivity. If t h e re is res i d u a l

to tease out t h e fat around the nodal tissue. A s m a l l

a ctivity, f u rt h e r exp l o ration is d o n e t o i d e ntify a n y other

Kitt n e r m a y b e used t o g e ntly tease away t h e fatty

senti n e l nodes i n the i nterspace.

C h a p t e r 9 I NTERNAL MAMMARY S E N T I N EL N O D E B I OPSY

• R i g h t mastecto my proced u re with expos u re of i nterspace showi n g i nte r n a l m a m m a ry vesse l s m ed i a l ly and ye l l ow sent i n e l n o d e l atera l to vesse ls.

FIG 10

FIG 12 • I ntern a l m a m m a ry node ex vivo o n g a m m a probe to confirm r a d i oactivity i n resected spec i m e n .

• M a stecto my site with pectora l i s m uscle retracted and p l e u ra v i s i b l e afte r remova l of senti n e l n o d e .

FIG 11

T h i s is m o re i m po rtant i f the t e a r is l a rg e . A s m a l l red

EXAMINATION OF THE INTERSPACE FOR

r u b b e r catheter can be put in the o pe n i n g with repa i r

A PLEURAL TEAR •

performed u p t o i t . P r i o r t o tyi n g t h e sutu re, t h e t u b e c a n

The wound is i rrigated to clear a l l b lood a n d loose fat tissue

be a s p i rated with the a n esthesiolog i st g i v i n g a susta i n e d

that may obscure the f i e l d . Then, i rrigation f l u i d is i nsti l l ed

breath to the patient to i nfl ate the l u n g . The t u b e i s re­ m oved and the suture tied down.

and left to pool i n the i nterspace. The a n esth esiolog ist can then d e l iver a susta ined breath i nto the endotracheal tube. T h e i nterspace is observed f o r a i r b u b b l es. If a i r b u b b l es a re •

•

If the tea r if q u ite s m a l l , atte m pt i n g repa i r may e n ­ l a rg e the h o l e . F l u i d c a n be p l aced i n the i nterspace a n d

seen, a pleural tea r can be assumed.

wo u n d c l o s u re beg u n with the a n esth esiolog ist m a i n ­

O n e ca n a s p i rate the f l u i d a n d l o o k for the tea r. If the tea r

ta i n i n g l u n g i nf l at i o n .

can be i d e ntified, it can be repa i red with a 5-0 suture.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

WOUND CLOSURE •

The i ntercosta l m uscles ca n n ot be re l i a b ly c l osed, as the sutu res tea r t h r o u g h the m u scl e .

•

C l ose the poste r i o r fasc i a of the pectora l i s m u scl e in a

•

Then, cl ose the a nterior pectora l i s m u scle or m uscle fas­

•

With m a stecto my, a d r a i n is p l a ced ove r l y i n g t h e c h est

r u n n i n g fas h i o n with 3-0 Vicryl suture. cia, if p resent, with a ru n n i n g 3-0 sutu re (FIG 1 3) . wa l l in the u s u a l fash i o n . C l osed s u ct i o n b u l b i s at­ tach e d . S k i n c l o s u re i s t h e n p e rfo r m e d . The d e r m i s is c l osed with i nterru pted 3-0 or 4-0 a bsorba b l e s u t u r e . T h e s k i n i s c l osed with a r u n n i n g m o n ofi l a m e n t a bsorb­ able s u t u r e . •

Wo u n d closu re i n the p a rt i a l mastecto my c i r c u m st a n ce s h o u l d i n c l u d e c l o s u re of the d ivided b reast tissue a nte­ r i o r to the i nterspace to avo i d a soft tissue d efect over the i nterspace. T h i s i s performed with either a ru n n i n g o r a n i nterru pted 3-0 a bsorba b l e suture. T h e d e r m i s a n d s u bcuta n e o u s tissue is c l osed w i t h i nterru pted 3 - 0 o r

FIG 1 3 • C l o s u re of the a nterior pectora l i s m uscle or m uscle fascia, if p rese nt, with a ru n n i n g 3-0 suture.

4-0 a bsorba b l e suture. T h e s k i n is c l osed w i t h a ru n n i n g m o n ofi l a m e n t a bsorba b l e suture.

PEARLS AND PITFALLS Preoperative planning

•

T h e i nj ecti o n s o f t h e ra d i o n u c l i d e f o r lym p h atic m a p p i n g s h o u l d be p e rformed i n t h e peritu m o r a l reg i o n rat h e r t h a n s u b a reo l a r a l o n e i n order t o i d e ntify the lym p h atic pathways to the i ntern a l m a m m a ry nodes.

P l a ce m e nt of incision and expos u re

•

M a k i n g exposu re easier-If free f l a p breast reco nstruct i o n is b e i n g d o n e with a n asto m osis of vesse l s to t h e i nte r n a l m a m m a ry vesse ls, wait to rem ove the i nt e r n a l m a m m a ry senti n e l node u n t i l the vessel exposu re i s d o n e w i t h remova l of the costo c h o n d r a l c a rt i l a g e w h i c h g ives m u c h w i d e r expos u re (FIG 1 4) . I f the patient has b reast i m p l a nts, p re pectora l, o r s u b pecto ral, be certa i n that the i m p l a nt is we l l retracted from the i nter­ space to perm it a d e q u ate expos u re but a l so to avo i d i m p l a nt i n j u ry. There w i l l be a f i b ro u s c a ps u l e to be d is­ sected t h ro u g h to g et to the i nte rcosta l m uscle.

Exploration of the pa raster n a l i nterspaces

•

Perfo r m i n g exa m i nation w i t h the g a m m a p r o b e after the breast o r b reast l e s i o n is rem oved w i l l m a k e i d e n ­ tification of the a rea of r a d i o a ctivity i n t h e i nt e r n a l m a m m a ry n o d a l c h a i n easier, because of red u ct i o n o f backgro u n d r a d i o a ctivity.

D i ssect i o n t h r o u g h the ch est wa l l

•

Reexa m i n e with the g a m m a probe at each layer t h ro u g h the ch est wa l l to be certa i n there i s pers i stent r a d i o­ activity i n the n ext layer. There c a n be a n i nt ra m a m m a ry n o d e m ed i a l ly that p icks up r a d i oactivity or back­ g r o u n d radioactivity may h ave co m p l i cated the exa m .

D i ssect i n g i n the i nterspace

•

Avo i d excessive b l e ed i n g . D i ssect i o n m ust be ca refu l a n d d e l i berate with sec u r i n g o f even very sm a l l vesse l s . An obscu red f i e l d w i l l i ncrease c h a nce of p l e u r a l t e a r s o r more major vasc u l atu re i nj u ry. When b i o psy is b e i n g pe rfo rmed for a n a b n o r m a l i nte r n a l m a m m a ry n o d e i d entified o n preoperative i m a g i n g , it may be n ecessa ry to rem ove the costo c h o n d r a l carti l a g e to expose a n d s uccessfu l ly remove the e n l a rged n o d e .

C l o s u re

•

K n ow w h e n to sto p . When perfo r m i n g the s u rg e ry for sta g i n g , d o not risk major vasc u l a t u re i n j u ry if you a re n ot a b l e to f i n d the n o d e with u s u a l m a n e uvers. Place a tita n i u m c l i p to m a rk t h e a rea of i n c reased r a d i oac­ tivity, which can i nform radiation p l a n n i n g .

FIG 1 4

•

Rem ova l of the costoc h o n d r a l c a rt i l a g e .

C h a p t e r 9 I NTERNAL MAMMARY S E N T I N EL N O D E B I OPSY

survival of approximately 54% compared to 3 0 % if both internal mammary and axillary nodes were positive. 8 This indicates the equivalent significance of knowing the inter­ nal mammary nodal status as well as the axillary, if there is lymphatic drainage to the internal mammary nodal basin. In a modern series, patients with internal mammary nodal metastases had an overall survival of 97% at 5 years with multimodality therapy.9

POSTOPERATIVE CARE •

•

•

•

•

•

In the recovery room, a chest x-ray should be performed if a pleural tear occurred to be certain there is no significant pneumothorax. If the surgeon is early in experience, a chest x-ray may be done as routine postoperatively. A small pneumothorax will generally not require therapy, as there is no intrinsic lung inj ury with ongoing air leak. If there is a large pneumothorax causing symptoms, then a chest tube can be placed, which can usually be removed in 1 to 2 days. Usual postoperative pain management is acceptable for these patients. They generally do not complain of focal pain in the area of the internal mammary node resection. Patients having breast-conserving surgery can be discharged home on the same day if there is no pneumothorax.

COMPLICATIONS • •

Pleural inj ury with or without pneumothorax Bleeding from inj ury to internal mammary vessels

REFERENCES 1.

OUTCOMES •

•

•

•

•

Success in identification of the internal mammary sentinel node at surgery varies from 70% to 1 0 0 % .2 Complications from internal mammary node biopsy are rare, ranging from 0% to 5 % . Even when a pleural injury occurs, chest tube drainage is rarely required. Recovery from this procedure is similar to that of the mas­ tectomy or breast-conserving surgery performed at the same time. Patients who undergo lymphoscintigraphy and biopsy of in­ ternal mammary nodes that demonstrate lymphatic drainage have more accurate staging of their breast cancer, which can result in treatment changes. The rate of internal mammary sentinel node positivity ranges from 1 0 % to 24% . Among five series of internal mammary sentinel node biopsy, in approximately 3 7 % of cases, the internal mammary senti­ nel node was positive when the axillary sentinel node was negative.3-7 The 1 0-year survival for patients who are internal mammary node positive and axillary node negative is similar to those who are axillary node positive alone as reported by Veronesi and colleagues. 8 In this study, patients with either axillary or internal mammary node metastasis only had a 1 0-year

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2.

3.

4.

5.

6.

7.

8.

9.

Urban JA, Baker HW. Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain; a new pro­ cedure for primary operable cancer of the breast. Cancer. 1 952;5: 992-1 0 0 8 . Chen R C , Lin NU, Golshan M, et a l . Internal mammary nodes in breast cancer: diagnosis and implications for patient management-a systematic review. ] Clin Oneal. 2008;26:498 1-498 9 . Caudle A S , Y i M, Hoffman K E , e t a l . Impact of identification o f internal mammary sentinel lymph node metastasis i n breast cancer patients. Ann Surg Oneal. 20 14;2 1 : 60-65. Gnerlich JL, Barreto-Andrade JC, Czechura T, et al. Accurate staging with internal mammary chain sentinel node biopsy for breast cancer. Ann Surg Oneal. 2014;2 1 : 3 6 8-374. Estourgie SH, Tanis PJ, Nieweg OE, et al. Should the hunt for internal mammary chain sentinel nodes begin? An evaluation of 1 5 0 breast cancer patients. Ann Surg Oneal. 2003 ; 1 0 :935-941 . Heuts EM, van der Ent FWC, Hulsewe KWE, e t al. Results o f tailored treatment for breast cancer patients with internal mammary lymph node metastases. Breast. 2009 ; 1 8 :254-2 5 8 . Carcoforo P, Sortini D, Feggi L, e t a l . Clinical a n d therapeutic importance of sentinel node biopsy of the internal mammary chain in patients with breast cancer: a single-center study with long-term follow-up. Ann Surg Oneal. 2006; 1 3 : 1 3 3 8-1343. Veronesi U, Cascinelli N, Greco M, et al. Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes. Ann Surg. 1 9 85;202: 702-70 7. Dellapasqua S, Bagnardi V, Balduzzi A, et al. Outcomes of patients with breast cancer who present with ipsilateral supraclavicular or internal mammary lymph node metastases. Clin Breast Cancer. 2 0 1 4 ; 1 4 :53-60.

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Chapter

10

Simple Mastectomy 1

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Micha el S. Sa bel

DEFINITION •

A simple mastectomy, also commonly referred to as a total mastectomy, is the surgical removal of all breast tissue, in­ cluding the nipple-areolar complex and enough overlying skin to allow closure. A simple mastectomy does not include removal of the axillary contents; when the breast tissue and axillary lymph nodes are removed en bloc, this is referred to as a modified radical mastectomy (MRM) ( see Part 5, Chapter 12). Variations of the simple mastectomy, typically performed in concert with immediate reconstruction include the " skin-sparing mastectomy, " where the nipple-areolar complex is removed but the overlying skin is preserved; and the "nipple-areolar sparing mastectomy, " where the native skin and nipple-areolar complex are preserved. These are described in Part 5, Chapter 1 1 .

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

In clinically early-stage breast cancer, survival is largely driven by risk of distant organ micrometastatic disease and ability to control/eliminate this aspect of the cancer with ad­ j uvant systemic therapy. Locoregional manifestations of dis­ ease in the breast and axilla can usually be controlled with surgery and radiation. Multiple prospective, randomized clinical trials have therefore documented survival equiva­ lence between breast-conserving and mastectomy surgery for invasive breast cancer as well as for ductal carcinoma in situ (DCIS ) . Lumpectomy for a diagnosis of breast cancer is usually followed by breast radiation to sterilize microscopic/ occult foci of disease in the remaining breast tissue, thereby reducing the incidence of ipsilateral breast tumor recurrence. Many women will nonetheless undergo total mastectomy as the primary breast surgical option either because of personal preference, medical contraindication to breast radiation, or because of disease features suggesting inability to achieve a margin-negative lumpectomy with a cosmetically acceptable result (e.g., diffuse suspicious-appearing microcalcifications on mammogram, multiple breast tumors not amenable to resection within a single lumpectomy, unfavorable tumor­ to-breast size ratio) . It is important for the clinician to re­ member that aesthetic acceptability must be defined by the patient. Total mastectomy is also the conventionally ac­ cepted surgical approach for breast cancer prophylaxis in high-risk women such as those with hereditary susceptibility. A detailed history and physical examination is imperative on the first consultation with these patients. In addition to the details of their breast cancer diagnosis, the history should cover medical comorbidities, medications, surgeries, aller­ gies, and also any musculoskeletal issues, which could affect operative positioning and/or radiation treatment planning. Prior chest wall irradiation (such as for Hodgkin's lymphoma or as part of breast-conserving treatment for a past ipsilat­ eral breast cancer) is a contraindication to reirradiation and

1432

•

•

•

·

Lisa Ne wm a n

breast conservation for a new or recurrent breast cancer. Connective tissue disorders such as Sj ogren's syndrome or scleroderma can result in severe radiation-related toxicity and patients with these medical conditions will typically re­ quire mastectomy for management of breast cancer, even if the tumor is detected at a small size that would otherwise have been amenable to breast-conserving surgery. Patients that are unable to raise the arm above shoulder level may have difficulty tolerating the breast radiation tangents. All breast cancer patients should have a detailed family can­ cer history, focusing on both the maternal and paternal sides of the family. Patients with a strong family history, partic­ ularly of breast and ovarian cancer, should receive genetic counseling. These patients may want to consider bilateral mastectomies for prevention of second cancers. A bilateral breast and lymph node examination, includ­ ing the axillary, cervical and supraclavicular lymph nodes, is critical. Any patient with clinically evident lymph nodes should undergo further evaluation, including axillary ultra­ sound and fine needle aspiration ( FNA) biopsy. Breast examination should focus on the size and location of the tumor, fixation to the underlying musculature or over­ lying skin, and skin changes, particularly those consistent with inflammatory breast cancer ( erythema, swelling, peau d'orange) or locally advanced disease (bulky tumors, tumors with secondary inflammatory changes, or cancers associated with matted nodal disease) . These patients may require neo­ adjuvant chemotherapy in order to downstage the cancer and to improve resectability. A coordinated multidisciplinary approach, including input from medical and radiation on­ cology specialists promptly following the breast cancer diag­ nosis, is important for efficient management planning and is vital to the successful treatment of these patients. Early-stage breast cancer patients with a clinically negative axillary exam undergoing total mastectomy require axil­ lary staging, which can usually be performed as lymphatic mapping and sentinel lymph node (SLN) biopsy. Mastec­ tomy patients with axillary metastases documented by either needle biopsy or SLN dissection require standard levels 1 and 2 axillary lymph node dissection (ALND ) or MRM, and postmastectomy locoregional radiation needs are then deter­ mined by the full pathologic extent of disease identified in the breast and axillary contents. All patients planning mastectomy should be presented the option of immediate reconstruction and a consultation with a plastic surgeon. Patients who opt for immediate recon­ struction may be candidates for a skin-sparing or nipple­ areolar sparing mastectomy. If postmastectomy radiation is being considered, this might impact the patient's options and eligibility for immediate reconstruction. Because the axillary nodal status is a strong predictor of postmastectomy radia­ tion benefit, it may therefore be helpful to perform the SLN biopsy prior to the mastectomy surgery in cases where im­ mediate breast reconstruction is planned.

C h a p t e r 1 0 S I M PL E MASTECTOMY

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

•

Breast imaging plays a vital role in the screening and diag­ nostic workup for breast cancer. Imaging can define the ex­ tent of the disease and help assess for any abnormalities in the contralateral breast. Bilateral mammography is essential for any patient with breast cancer. Any suspicious contra­ lateral lesions should be worked up before making the final surgical decision. Axillary ultrasound can be performed in many patients with a biopsy-proven invasive cancer to identify suspicious nodes suggestive of regional involvement. Suspicious nodes on ax­ illary ultrasound should undergo an FNA biopsy with ultra­ sound guidance. It should not be assumed that any axillary node that is pal­ pable or suspicious on ultrasound is malignant, as often they may be reactive. They should always be interrogated with FNA biopsy; and if the FNA is negative, then definitive ax­ illary staging should be performed by SLN biopsy. At the time of lymphatic mapping and sentinel node dissection, it is important to excise any palpable/suspicious node, regardless of whether or not the node has any appreciable radiocolloid or blue dye uptake. If local resources permit, intraoperative evaluation of the sentinel node ( s ) with frozen section analy­ sis can also be useful so that the patient can proceed onto im­ mediate completion of the ALND if metastatic nodal disease in confirmed. When frozen section analyses are available and planned, the patient must be consented preoperatively for possible conversion from total mastectomy to MRM. The use of magnetic resonance imaging (MRI) is controver­ sial. For patients undergoing mastectomy, MRI may detect contralateral cancers that were not visualized on mammog­ raphy. For patients that hope to pursue breast-conserving surgery, a preoperative breast MRI may detect suspicious foci of disease in the breast such that mastectomy may be recom­ mended. MRI usage has therefore been associated with in­ creased rates of bilateral mastectomies. However, MRis are sensitive but not specific and may lead to false-positive find­ ings that necessitate additional biopsies. Furthermore, the natural history of MRI-detected multifocal/multicentric le­ sions in the cancerous breast is unclear, as these areas of oth­ erwise occult disease would typically be radiated following

CHOICE OF INCISION •

The sta n d a rd i n c i s i o n for a s i m p l e m astecto my is the clas­ s i c Stewart i n ci s i o n , a n e l l i pse o r i e nted m e d i a l to latera l, encom pass i n g the n i p p l e-areo l a r co m p l ex and a n y p r i o r b i o psy sca r (FIG 1 ) . Alternative l y, the m o d ified Stewart i n c i s i o n is a n g l e d toward the axi l l a . It has been s u g gested that the modified Stewa rt i nc i s i o n , by exc i s i n g m o re of the d e r m a l l y m p h at i cs r u n n i n g toward the axi l l a, may prov i d e bette r local contro l .

•

I n a d d it i o n to the Stewa rt a n d mod ified Stewa rt, t h e re a re a lternate options for a s i m p l e m a stectomy. The p l ace­ m e nt and o r i e ntati o n of the i n c i s i o n m ust be based o n the locat i o n of the b i o psy s c a r a n d/o r the l ocation of the t u m o r. For a p a l p a b l e t u m o r, p a rticu l a rly o n e c l ose to the

•

1433

lumpectomy for the known cancer. Retrospective and pro­ spective studies of outcome following breast-conserving sur­ gery in patients whose breast-conserving surgery eligibility was planned with versus without breast MRI have failed to demonstrate any significant differences in cancer-related out­ comes.1-3 We do not recommend routine MRI but rather its use should be on a patient by patient basis. In the absence of locally advanced disease (skin or muscle involvement, multiple matted nodes) , routine staging tests, such as computed tomography ( CT) scan of the chest, abdo­ men and pelvis, or bone scan, are not indicated.

SURGICAL MANAGEMENT Preoperative Planning •

•

In the preoperative area, the breast to be removed should be clearly marked and confirmed with the patient. Prophylactic antibiotics have been shown to reduce postop­ erative infections and are indicated.4 Sequential compression devices should be placed prior to initiation of general anes­ thesia for venous thromboembolism (VTE) prevention.

Positioning •

•

•

•

The patient should be positioned supine with the arm out laterally, taking care not to abduct the arm greater than 90 degrees as this may cause an inj ury to the brachial plexus. For a simple mastectomy, it is not necessary to prep and drape the ipsilateral arm into the field. However, if an SLN biopsy with frozen section and possible ALND is planned, it may be reasonable to include the arm using a sterile stocki­ nette and Kerlix wrap. The endotracheal tube should be po­ sitioned toward the contralateral side of the mouth from the side of the mastectomy. Position the table and lights to allow enough room above the arm for an assistant to stand. If an SLN biopsy is to be performed and blue dye is to be injected, this can be done at this time. Either isosulfan blue dye or dilute methylene blue dye can be injected subareolar, periareolar, or peritumoral, according to surgeon preference. The chest wall, axilla, and upper arm are prepped into the field. Be sure to prep widely, extending across the midline and onto the abdomen and neck.

s k i n , the s k i n over the t u m o r s h o u l d be i n c l u d ed in the excised skin. P l a n n i n g of the s k i n i n c i s i o n i n conj u n ct i o n w i t h the p l a stic su rgeon can be q u ite h e l pf u l i n patie nts u n d e r g o i n g s k i n -spa r i n g m a stecto my a n d i m med iate re­ construct i o n . I f the patient has a s u r g i c a l cancer b i o psy i nc i s i o n , t h i s scar s h o u l d be resected with the u n derlyi n g m a stecto my speci m e n . I n cisions l ocated i n p roxi m ity to the n i p p l e-a reo l a r com p l ex can be resected with i n the centra l skin e l l i pse that is being sacrificed . I nc i s i o n s that a re l ocated remote from the centra l n i p p l e-areo l a r s k i n can sometimes be resected as a sepa rate e l l i pse o f sacri­ fi ced skin, as long a s the rema i n i n g s k i n bridge is wide e n o u g h to re m a i n v i a b l e . The o ri g i n a l surgical cancer bi­ o psy scars s h o u l d n ot be left i ntact i n the m a stecto my skin f l a ps because of the o n c o l o g i c concern that this s k i n

1434

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

, --- - - - - .....

- - - - -

I

.,... .... - ", ' I ,. ../ I / I , I _,

� - - -

FIG 1 • Sta n d a rd i n c i s i o n s for a s i m p l e mastectomy. The Stewa rt i n c i s i o n (left) i nvolves a horizontal e l l i pse that encom passes the n i p p l e-a reo l a r com p l ex and adeq u ate skin to a l low a flat closure. The modified Stewa rt i n c i s i o n is a n g led towa rd the i psi latera l axi l l a .

may potent i a l ly h a rbor cancer ce l l s (a n d the m a stecto my skin is u s u a l ly n ot b e i n g r a d i ated, as is the case fo l l ow i n g l u m pectomy); a n d f r o m a wo u n d h ea l i n g perspective, t h e s u bcuta neous f a t deep to the tra u m atized i n c i s i o n a l s k i n w i l l be l ess hea lthy a n d m o r e l i ke l y to n ecrose. O l d s u r g i ­ c a l b i o psy scars that a re u n related to the ca ncer d i a g n o­ sis ca n be l eft i n p l a c e . Al so, percuta neous n e e d l e b i o psy scars can be l eft i ntact on the s k i n f l a ps, a s th ese have not been s h ow n to co ntrib ute to risk of local rec u rrence. •

It is i m portant to rem ove e n o u g h s k i n so that there is no re­ d u n d a n cy but n ot so m u c h that there is u n d u e tension on the incision. A usefu l method to determ i n e the p l a cement of the superior a n d i nferior incisions is to h o l d a m a r k i n g pen i n the a i r o v e r the n i pp l e a n d retract the breast i nferi­ o rly. M a rk this site o n the skin and then retract the b reast

A

superiorly to m a r k the i nferior extent (FIG 2A,B) . •

When desi g n i n g the e l l i pse, c l o s u re w i l l be fac i l itated by m a k i n g s u re the s u p e r i o r and i nfe r i o r i n c i s i o n s a re of e q u a l l e n gth (FIG 3) . This c a n easily be assessed u s i n g a 3-0 s i l k suture.

B • With a m a r k i n g p e n h e l d over t h e n i p p l e, t h e b reast is retracted i nfe riorly (A) a n d the extent of the s u pe r i o r f l a p is m a rked . The b reast is t h e n retracted s u p e r i o r l y ( B ) a n d t h e i nferior exte nt is m a rked . T h i s a l l ows the s u rgeon to est i m ate how much s k i n s h o u l d be excised to e l i m i nate red u n d a n cy without u n d u e tensi o n .

FIG 2

• Confi r m i n g the superior and i nfer i o r i n cisions a re of e q u a l length w i l l fac i l itate closu re.

FIG 3

C h a pt e r 10

•

B efore m a k i n g t h e i n c i s i o n , m a rk the b o u n d a ries of the

S I M PL E MASTECTOMY

d i ssected off the pecto ra l i s major m uscle e n b l o c with the

breast tissue. Alth o u g h the b reast is a n obvious exter­

pectora l i s fasc i a . The conventi o n a l ly a cce pted peri p h e ra l

n a l featu re of the h u m a n a n atomy, its b o u n d a ries deep

m a stecto my f l a p bou n d a ries a re a s fo l l ows: s u p e r i o r m a r­

to the s k i n a re less we l l defi n e d . Lack i n g a n y c l e a r-cut

g i n-c lavicle or 2 n d r i b (identified by p a l pation); i nfer i o r

c a ps u l e to d e l i neate b reast tissue from s u rrou n d i n g

m a r g i n-infra m a m m a ry fold ( I M F);

fat a n d s u bcuta neous tissue, t h e s u rg e o n m ust i d e ntify

latera l border of the ste r n u m ( i d e ntified by p a l pation);

m ed i a l

m a rg i n­

a n ato m i c l a n d m a rks that se rve as reaso n a b l e a n d rela­

latera l m a rg i n-th e l atera l exte nt of the breast tissue can

tively constant structu res, beyo n d w h i c h it is u n l i ke l y to

be m a rked exte rn a l ly o n the s k i n su rface a n d the edge of

f i n d s i g n ificant a m o u nts of breast tissue. These ra d i a l

the latiss i m u s d o rsi m uscle is a usefu l vertical b o u n d a ry

bou n d a ries f o r t h e s k i n f l a ps essent i a l ly se rve a s a p i ct u re

that can be visua l l y i d e ntified from with i n the m a stec­

fra m e; a n d once t h ese f l a p s a re co m p l eted, the breast i s

tomy s u r g i c a l f i e l d ( FIG 4) .

Superior margin: C lavicle or 2nd rib

Lateral margin: Lateral extent

Inferior margin: l nframammary fold

FIG 4 • To assu re rem ova l of all b reast tissue, the d i ssection is performed to the clavicle o r 2 n d r i b superiorly, the I M F i nferiorly, the lateral border o f t h e ste r n u m med i a l ly, a n d the late r a l extent of t h e breast tissue o r edge of the latiss i m u s d o rsi m uscle l atera l ly.

SKIN INCISION AND CREATION OF FLAPS •

Once the s k i n i nc i s i o n has been m a pped out on the breast, a sca l p e l is used to cut t h r o u g h the s k i n a n d d e r m i s . Cau­ tery is used to then o bta i n h e m ostasis. It is i m portant to g et i nto the r i g ht plane to raise f l a ps at the sta rt. The i n it i a l i n cision should extend through f u l l -t h i c k n ess s k i n , j u st barely expos i n g the s u bcuta neous fat, a n d n o f u rther. I nc i s i n g t h ro u g h deeper l ayers of su bcuta neous fat w i l l res u l t i n a s p l a y i n g o u t o f those fatty p l a n es, a n d th ese deeper tissues w i l l spu riously a ppear as a nterior m a r g i n

s u rfaces w h e n a n a lyzed a n d i n ked in the path o l ogy l a bo ratory. The a ct u a l anterior m a rg i n of the mastecto my spec i m e n (beyo n d the centra l e l l i pse of sacrificed n i p p l e­ a re o l a r s k i n ) s h o u l d be defi ned by the s u rgeon v i a d is­ section of the a p propriate-th ickn ess s k i n f l a ps. Fa i l i n g to leave a s m a l l a m o u nt of tissue beneath the d e r m i s can lead to isch e m i a a n d wo u n d co m p l i cations, a n d t h i s can be p a rtic u l a rly concern i n g i n cases i nvo l v i n g i m m e d i ate reco nstruct i o n . Conversely, an excessively t h i c k s k i n f l a p l eaves the patient at r i s k for resid u a l breast tissue o n t h e ch est wa l l , th e re by i n crea s i n g risk o f l o c a l recu rrence.

1435

1436

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

• The s u r g e o n 's o p posite h a n d is used to prov i d e a d e q u ate te n s i o n o n the b reast t i s s u e to a l l ow e l evat i o n o f the s u pe r i o r f l a p i n the correct p l a n e .

FIG 7 • If d o n e correctly, t h e re w i l l be a sma l l a m o u nt o f s u bcuta neous f a t beneath the d e r m i s so t h a t the b l o o d s u p p l y i s p reserve d .

Sta rt i n g with the s u p e r i o r f l a p, s k i n h ooks a re used to

view of the d i ssect i o n . H owever, t h i s c a n l e a d to expos­

FIG S

•

e l evate the s k i n a n d p rovide a p p ro p r i ate te n s i o n for

ing the d e r m i s and poss i b l y a b utto n h o l e i n j u ry to t h e

e l evat i o n of the flap (FIG S) . The key to e l evat i n g a n a p -

s ki n .

propriate f l a p is t h e te n s i o n o n t h e b reast tissue. I n it i a l ly,

•

•

T h e correct p l a n e w i l l leave a s m a l l a m o u nt of s u bcuta­

a forceps can be u s e d t o g e t i nto the r i g ht p l a ne; b u t

neous fat beneath t h e d e r m i s so that t h e b l ood s u p p l y i s

o n c e t h a t p l a n e is i d e ntified, tract i o n w i t h the contra­

p reserved w h i l e n ot leavi n g a n y breast t i s s u e . T h i s p l a n e

l atera l hand of the s u rgeon using a l a p a roto my p a d on

is often avasc u l a r (FIG 7) . I nterm itte ntly i n spect i n g a n d

the b reast tissue w i l l be critica l . As the flap e l evati o n p ro­

p a l pati n g t h e f l a p w i l l assu re t h e correct t h i c k n ess.

ceeds, it i s i m po rtant to reposit i o n the contra l atera l h a n d

O l d e r women (wh e re m u c h of the breast i s fatty-re­

accord i n g ly.

p l aced) and h e a v i e r patie nts often h ave a t h i c k e r f l a p

It is i m pe rative that t h e assista nt h o l d i n g t h e s k i n hooks

of s u bcuta n e o u s f a t sepa rat i n g t h e s k i n f r o m t h e u n ­

m a i nta i n retract i o n stra i g ht u p (FIG 6) . Ofte n , a res i d e n t

d e r l y i n g breast pa renchym a . I n contrast, yo u n g e r a n d

w i l l ret ract towa rd t h e m se lves so t h ey h ave a better

t h i n patients m a y h a v e breast tissue c l o s e l y a b utti n g t h e d e r m is, a l l o w i n g f o r a very n a rrow m a r g i n o f e r r o r while raising the flap. •

F l a ps can be e l evated u s i n g cautery, scisso rs, or a sca l pe l . Ca utery w i l l h e l p prov i d e h e m ostasis d u r i n g t h e p roce­ d u re . If s h a r p d i ssect i o n is used, press u re o n the b reast with a l a p a rotomy s p o n g e w i l l h e l p m a i nta i n h e m ostasis.

•

The s u pe r i o r f l a p i s co m p l ete w h e n you reach the level of the c l a v i c l e . At t h i s poi nt, the pecto ra l i s m uscle should be i d e ntified and the pectora l i s fasc i a d iv i d e d (scored) a l o n g the l e n g t h of the f l a p (FIG 8) .

•

A t t h i s poi nt, i f a n S L N b i o psy is to be pe rfo rmed, t h i s c a n u su a l ly be p e rformed t h ro u g h t h i s i n c i s i o n . Pe rfor m ­ i n g the S L N at t h i s t i m e p o i nt a l l ows a d e q u ate t i m e for i ntraoperative a n a lysis i f convers i o n to a n MRM is b e i n g considered. The l atera l edge of the pectora l is m uscle is i d e ntified a n d the clavi pecto ra l fascia is i d e ntified and d iv i d e d . T h i s a l l ows access to the f i brofatty tissue of the axi l l a . The senti n e l nodes ca n n ow be i d e ntified by u s i n g the g a m m a p robe or by fo l l ow i n g any b l u e-sta i n e d l y m p hatics.

•

The m ed i a l m a rg i n s h o u l d exten d to the l atera l edge of the ste rn u m . G o i n g too fa r m ed i a l ly can l e a d to excess ive

It is i m po rtant that the assista nt retract stra i g ht up wh i l e the flap is raised; oth e rwise, exposu re of the dermis or i nj u ry of the flap i s m o re l i kely.

FIG 6

•

d og-ea r i n g , w h i c h w i l l need exc i s i o n and thus l e n g t h e n the i n c i s i o n . I n the c a s e of b i l atera l m a stecto m i es, g o i n g too fa r m ed i a l ly c a n a c c i d e n t l y c o n n ect the t w o i n ci s i o ns,

C h a p t e r 1 0 S I M PL E MASTECTOMY

• At the superior extent (clavicle o r 2 n d r i b), the pectora l i s fascia i s d ivided along its l e n gth .

FIG 8

•

•

• V i s u a l izati o n of the edge of the latissi m u s d o rsi m uscle assu res the co m p l eten ess of the latera l f l a p .

FIG 9

potent i a l ly conta m i n a t i n g the prophylactic s i d e a n d

latiss i m u s d o rs i m uscle but i d e ntify i n g the edge of these

co m p l i ca t i n g reco nstruct i o n .

f i b e rs can e n h a nce the co m p l eteness of the l atera l f l a p

The i nfe r i o r f l a p is t h e n e l evated in an i d e n t i c a l m a n n e r

(FIG 9) . Avo i d i n g a n u n n ecessa ry m o b i l ization of the

t o the level of the I M F. It is i m p o rtant t o m a r k t h i s, a s

latiss i m u s d o rsi m uscle i n tota l m a stecto my patie nts

it ca n easily be lost wh i l e e l evati n g the f l a p . The assis­

u n d e r g o i n g i m m e d i ate reconstruct i o n is especi a l ly i m ­

tant c a n prov i d e feed back to the su rgeon as the I M F i s

porta nt, as creat i n g extra d i ssect i o n f l a ps i n t h i s latera l

a p p roached . E l evat i n g past the I M F is n o t o n l y u n n eces­

tissue c a n comprom ise the p l astic s u rgery aesthetics. It is

sa ry but can a l so com p l i cate reco nstruct i o n , n ecessitat i n g

i m po rta nt that the latera l extent of the b reast tissue i s

the p l astic s u rgeon to recreate it t o assu re sym m etry.

rem oved . T h i s i n c l udes the axi l l a ry ta i l of S p e nce, w h i c h

F i n a l ly, the l atera l m a r g i n is deve l o p e d . As t h i s is not

exte n d s a r o u n d the s u pe r i o r aspect of the pectora l i s

an M R M , it is not n ecess a ry to t h o ro u g h l y m o b i l ize the

m uscle to the clavi pecto r a l fasc i a .

resect i o n a n d f u rt h e r l oca l t h e r a py i n t h e f o r m of post­

REMOVAL OF THE BREAST TISSUE •

m a stecto my r a d i a t i o n i s u n n ecessa ry. Patie nts with p a l ­

O nce t h e f l a ps have been co m p l eted c i r c u m ferenti a l ly to

p a b l e b reast t u m o rs a b utti n g t h e c h est wa l l s u rface

t h e a p p ro p r i ate l a n d m a rks, it is t i m e to exc ise the b reast

s h o u l d h ave a wedge of u n d e r l y i n g pecto r a l i s m u scle at

tissue a n d t h e pecto ra l i s fascia off t h e pectora l i s m a j o r

the site of the t u m o r resected e n b l oc with the m a stec­

m u scle. It is i m p o rta nt to rem ove t h e fasc i a with t h e spec i m e n to assu re n e g ative m a r g i n s . F a i l u re to excise

tomy spec i m e n . •

t h e fascia with t h e spec i m e n m a y l e a d to a positive d e e p

d o n e with the contra l atera l h a n d but g rasp i n g the fas­

m a rg i n , i n c rease ch est wa l l rec u rrence, a n d p r o m pt the

cia with a r i g ht-a n g l e c l a m p can fac i l itate t h is. The fas­

use of postmastecto my r a d i a t i o n . 5 It ca n be usef u l to

cia is e l evated off the m u scle u s i n g cautery, m o v i n g the

resect a tiny sa m p l e of pectora l i s m uscle fi b e rs ( l a b e l e d

ca utery back a n d forth in the d i rect i o n of the fi b e rs of

a s sa m p l e of a d d i t i o n a l poste r i o r m a r g i n ) to se rve a s

the m uscle (FIG 1 0) . T h i s tech n i q u e m i n i m izes the d a m ­

pat h o l o g i c d o c u m e ntat i o n that t h e m a stectomy s p e c i m e n i n c l u d e d t h e pectora l i s fasc i a . S o m e patie nts c a n h ave d iffuse D C I S exte n d i n g t h ro u g h o ut t h e b reast to its poste r i o r s u rface, but by d efi n it i o n , the n o n i nvasive natu re of this d i sease i s such that d o c u m enti n g resect i o n of t h e pecto ra l i s f a s c i a is cons istent with a n a d e q u ate

T h e b reast tissue is retracted i nfe r i o rly. T h i s is typica l ly

a g e t o the pecto ra l i s m uscle. •

S m a l l perforators exte n d i n g from the pectora l i s to the b reast should be g rasped with a h e m ostat o r for­ ceps a n d cauterized . There a re s l i g htly l a rg e r perfora­ tors m e d i a l ly. It is best to p reserve th ese if possi b l e . If n ot, th ese should be g rasped and cauterized o r suture

1437

1438

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

• Retract i n g t h e b reast i nfe r i o r l y, the breast tissue and pectora l i s fascia a re taken off the pectora l i s major. The ca utery is m oved back and fo rth i n the d i rect i o n of the fi bers of the m uscle.

FIG 1 0

FIG 12 • As o p posed to the pectora l i s fascia, w h i c h is taken with the breast tiss u e, the fasci a over the serratus anterior i s l eft i ntact.

l i g ated (FIG 1 1 ) . If th ese a re accide nta l ly d ivided, they ofte n retract i nto the m uscle and can be d i ff i c u l t to

routi n e l y i d e ntified t h ro u g h visua l exposu re u n less the

contro l . Some patie nts (espec i a l ly older a n d/o r l ess fit

patient is undergoing a n ALN D .

patie nts) w i l l have a weakened, atte n u ated, a n d fattyrepl aced pectora l i s m usculature. Caution s h o u l d be exer­

•

•

I nte rcosta l n e rve b l ock: M a ny mastecto my patie nts w i l l benefit from i ntrao perative i nject i o n o f a p p roxi m ately

cised d u r i n g the latera l retract i o n of the b reast in these

5 ml of 0 . 5 % ro p i vaca i n e i nto 2 o r 3 i nte rcosta l spaces

cases, a s overly a g g ressive t u g g i n g o n the breast can

a l o n g the s u rg ica l f i e l d l atera l to the pecto ra l i s m u scl e .

res u l t i n the m uscle b e i n g i n a dvertently avu lsed from its

The s u rg e o n s h o u l d n otify the a n esthesia staff who w i l l

costoch o n d r a l a n d ste r n a l atta c h m e nts.

t h e n g ive the patient a few extra d e e p b reaths. A t maxi­

D i ssect i o n of t h e b reast off the pectora l i s m uscle con­

m a l e n d exp i ration, the patient is taken off t h e vent i l ator

t i n ues i nferiorly toward the I M F a n d t h e n out latera l ly.

wh i l e the s u rgeon i nj ects the l o n g -a ct i n g a n esthetic j ust

Resect i n g the pectora l i s fascia has o n c o l o g i c s i g n ificance;

at the i nfe r i o r edge of the selected r i b to b l o c k the asso­

h owever, fasc i a ove r l y i n g the serratus a nte r i o r m uscle

c iated i nte rcosta l n e rves. Ve n t i l ator-assisted res p i rations

can be l eft i ntact (FIG 1 2) . D i ssect i n g deep to t h i s fasci a

t h e n res u m e . If i nte rcosta l n e rve b l ocks as we l l a s i n ci ­

a n d expos i n g the serratus m uscle bed resu lts i n u n n eces­

s i o n a l l o n g-act i n g a n esthetic i nject i o n is p l a n ned, t h e n

sa ry bleed i n g and ca n p l ace the l o n g thoracic n e rve at

the maxi m u m vo l u m e of s a f e a n esthetic d e l ivery (based

risk for i n j u ry, because this i m porta nt m otor n e rve is n ot

o n body weight of the patie nt) s h o u l d be ca l c u l ated .

• M e d i a l p e rforators a re g rasped and cauterize d .

FIG 1 1

C h a p t e r 1 0 S I M PL E MASTECTOMY

m i n dfu l of the location of the latiss i m u s d o rsi m uscle. I n ­

DRAIN PLACEMENT •

advertent i n se rt i o n o f the d ra i n t h r o u g h t h i s m uscle c a n

A c l osed suct i o n d r a i n is p l a ced over the pectora l i s major

resu lt i n excessive b l e e d i n g from the tract. I n cases w h e re

m uscle through a sepa rate sta b incision a n d sutu red in

the d r a i n tract does b l eed excessively, the best remedy is

p l ace with a m o n ofi l a m e n t sutu re (FIG 1 3) . W h e n in­

to s i m p ly rem ove the d r a i n , apply p ressu re, and replace

sert i n g the drain t h ro u g h the s k i n f l a p, it i s u sefu l to be

the d ra i n t h ro u g h a d i fferent tract.

FIG 13 • A flat c h a n n e l d r a i n is p l a ced over the pectora l i s m a j o r m uscle t h ro u g h a sepa rate sta b i n c i s i o n p r i o r t o closi n g .

CLOSURE •

•

Alth o u g h excess t e n s i o n on t h e i n c i s i o n c a n l e a d to

a n e l l i pse. There a re t i m es, p a rt i c u l a rly i n o l d e r, heavier

wo u n d com p l icat i o n s, excess s k i n w i l l l e a d to red u n ­

women, w h e re exc i s i n g the l atera l dog e a r s i m p l y m oves

d a nt f l a ps, w h i c h c a n be u n co mforta b l e f o r t h e patie nt;

the dog ear m o re poste r i o rly. In th ese cases, a fish-ta i l

t h ey can be d iffi c u lt to m o n itor for recu rrence a n d c a n i nterfere with wea r i n g a prost h e s i s . I n c a s e s w h e re post m a stecto my ra d i a t i o n a n d d e l ayed reco n st r u ct i o n i s p l a n n e d , it m a y be h e l pf u l to l e a ve t h e s k i n f l a ps a l itt l e looser, b u t a f l o p py a n t e r i o r s k i n f l a p w i l l be u n ­ s i g htly a n d se rves a s a site f o r recurrent s e r o m a accu­ m u l a t i o n . Excess skin c a n be excised, so that t h e i n c i s i o n a p p roxi m ates flat o n t h e c h est wa l l . R e m e m b e r that t h e p a t i e n t i s l y i n g f l a t b a c k, b u t o n c e awake w i l l s l o u c h f o rwa rd s l i g htly, so a s m a l l a m o u nt of te n s i o n w i l l be rel eased .

Com m o n ly, the m e d i a l a n d l atera l aspects of the i n c i ­ s i o n w i l l " d o g e a r. " Ofte n, th ese c a n be easily excised as

p l a sty (FIG 1 4A-C) can be usefu l 6 •

The d e r m a l layer s h o u l d be cl osed with i nte r r u pted deep dermal a bsorba b l e sutu res. Because the Jackson-Pratt (J P) d ra i n w i l l evacu ate the postope rative seroma forma­ t i o n , the m a stecto my s k i n flap c l o s u re should be s u bject to m i n i m a l tens i o n . A reaso n a b l e c l o s u re a ltern ative ca n t h e refore rely on a few i nterru pted sutu res to l i n e up the a p p ro p r i ate s k i n closu re, fo l l owed by a r u n n i n g , cont i n u ­ o u s a bsorba b l e deep d e r m a l suture. The s k i n can be a p ­ p roxi m ated with a n a bsorba b l e 4 - 0 m o n ofi l a m ent sutu re in a r u n n i n g su bcutic u l a r c l o s u re o r a s u r g i c a l a d h esive.

1439

1440

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

A

B

d

c

FIG 14 • F o r patie nts with excessive l atera l tissue that ca n n ot be excised a s a s i m p l e e l l i pse, a f i s h -ta i l p l asty can be usefu l . A. The skin is rea p p roxi m ated so the m ed i a l aspect c l oses a p propriately. B. T h e l atera l corner is b ro u g ht m ed i a l l y, creat i n g two s m a l l e r e l l i pses s u p e r i o r l y a n d i nfe r i o r ly. These two e l l i pses a r e t h e n excised sepa rate ly and the wound is c l osed (C) so that t h e re is a Y exte n s i o n latera l ly.

PEARLS AND PITFALLS Patient expectati o n s

• • • •

Pat i ents w h o a re ca n d i d ates for b reast conse rvat i o n t h e r a py (B CT) s h o u l d u n d e rsta n d t h e re is n o i m p rove m e nt i n s u rviva l w i t h a mastecto my. A l l patie nts u n de rg o i n g m a stecto my s h o u l d be offe red consu ltati o n with a p l astic s u rgeon to d iscuss reco nstruct i o n options. Patients may have concerns reg a rd i n g cosmesis a n d sexu a l i d e ntity after m a stectomy that s h o u l d be a d d ressed p reoperative ly. Pat i ents s h o u l d a l so u n d e rsta n d the pote n t i a l for red u n d a ncy o r dog e a rs after m a stectomy a n d h ow th ese can be a d d resse d .

C h a p t e r 1 0 S I M PL E MASTECTOMY

P l a n n i n g the i n c i s i o n

• • •

R a i s i n g the f l a ps

• • • •

Remov i n g the breast

• • • •

C l o s u re

• •

I n c l u d e t h e exc i s i o n a l b i o psy sca r i n the e l l i pse. F o r p a l p a b l e t u m o rs, i n c l u d e a n adeq u ate a m o u nt of s k i n over the t u m o r. P l a n the e l l i pse so that it w i l l l i e fl at, without excess l axity, yet not too t i g ht. M e a s u re the s u p e r i o r and i nfe r i o r i nc i s i o n s to confirm they a re ro u g h ly the s a m e l e ngth . M a ke s u re to sta rt in t h e r i g h t p l a n e with the i n it i a l i nc i s i o n a n d n ot go too fa r i nto the s u bcuta n e o u s fat. The assista nt s h o u l d h o l d the s k i n hooks stra i g h t up. B e n d i n g the skin backward can i n adver­ tently lead to exposi n g d e r m i s o r " b utto n h o l i n g . " Cou nterte n s i o n with t h e o p posite h a n d is t h e key t o b e i n g i n t h e r i g h t p l a n e . A s y o u p rog ress, repositi o n the h a n d accord i n g ly. Be ca refu l n ot to pass the I M F w h i l e ra i s i n g the i nfe r i o r f l a p . Retract the b reast i nfe r i o r l y a n d m ove the ca utery med i a l to latera l, p a ra l l e l to the pectora l i s m a j o r m uscle fi bers. Rem ove the fascia of the pecto ra l i s with t h e speci m e n . G rasp perforators w i t h a forceps o r c l a m p a n d coa g u l ate rat h e r t h a n try to d i rectly cauterize. D o not retract the b reast latera l l y with excess fo rce, this w i l l avu lse the m u scle from the ste rn u m . Excise excess s k i n so that the f l a ps c l ose f l at a g a i nst the c h est wa l l . M e d i a l a n d l atera l d o g e a rs s h o u l d b e excised, b u t d o n ot keep reposit i o n i n g a l atera l d o g e a r m o re poste r i o rly. A p l a sty ca n erad i cate a d o g e a r but c a n m a ke reco nstruct i o n m o re d iffi c u lt. A dog e a r c a n a lways be corrected at a later date u n d e r loca l a n esthetic.

POSTOPERATIVE CARE •

•

•

A nonadherent dressing can be placed over the incision. Patients can be placed in a breast binder with Kerlix fluffs in order to apply even compression. This will help prevent hematoma but should not be excessively tight. Patients do not need to be admitted to the hospital over­ night, they may be safely discharged to home. Arranging for a visiting nurse can be helpful for drain management and wound checks. The drain can be removed when the output is less than 30 mL/24 hours for 2 days in a row.

OUTCOMES •

•

1441

Overall, local (chest wall) recurrence after mastectomy is low, ranging from 0 . 6 % to 9 . 5 % , increasing with increasing stage, the presence of nodal metastases, and positive margins after mastectomy. However, local recurrence rates also ap­ pear to be decreasing as systemic therapies improve.7 Local recurrence is also related to the histologic subtype, with lu­ minal subtype tumors (ER/PR positive) less likely to recur than HER2/neu overexpressing or triple negative tumors after mastectomy. 8 Because local recurrence rates remain higher among patients with node-positive disease or positive margins, postmas­ tectomy radiation therapy (PMRT) should be considered in these situations. PMRT is strongly indicated for patients with positive margins or more than four positive lymph nodes. It should also be considered for patients with one to three positive lymph nodes, particularly, if they have other risk factors for chest wall recurrence.

COMPLICATIONS • • • • • •

Seroma Wound infection Hematoma Wound dehiscence Flap necrosis Positive margins

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer ( COMIC£) trial: a randomized controlled trial. Lancet. 201 0;376(9714) :563-5 7 1 . Peters NH, van Esser S, van den Bosch MA, e t a l . Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET-randomised controlled trial. Eur J Cancer. 2 0 1 1 ;47:8 79-8 86. Solin LJ, Ore! SG, Hwang WT, et al. Relationship of breast magnetic resonance imaging to outcome after breast-conservation treatment with radiation for women with early-stage invasive breast carcinoma or ductal carcinoma in situ. J Clin Oneal. 2008;2 6 : 3 8 6-3 9 1 . Tejirian T, DiFronzo LA, Haigh PI. Antibiotic prophylaxis for pre­ venting wound infection after breast surgery: a systematic review and metaanalysis. J Am Colt Surg. 2006:203 ( 5 ) : 729-734. Dalberg K, Krawiec K, Sandelin K. Eleven-year follow-up of a ran­ domized study of pectoral fascia preservation after mastectomy for early breast cancer. World J Surg. 201 0;34( 1 1 ) :2539-2544. Hussien M, Daltrey IR, Dutra S, et al. Fish-tail plasry: a safe technique to improve cosmesis at the lateral end of mastectomy scars. Breast. 2004; 1 3 ( 3 ) : 206-209. Yi M, Kronowitz SJ, Meric-Bernstam F, et al. Local, regional, and sys­ temic recurrence rates in patients undergoing skin-sparing mastectomy compared with conventional mastectomy. Cancer. 20 1 1 ; 1 1 7: 9 1 6-924. Lowery AJ, Kell MR, Glynn RW, et al. Locoregional recurrence after breast cancer surgery: a systematic review by receptor phenotype. Breast Cancer Res Treat. 2 0 1 2; 1 3 3 : 8 3 1-84 1 .

-

Chapter

11

Skin-Sparing and N ipple/ Areolar-Sparing Mastectomy

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

t

Elen i To usimis

DEFINITION •

•

Skin-sparing mastectomy is defined as removal of the breast tissue while preserving the natural skin envelope for imme­ diate breast reconstruction. This is an effective treatment option for patients with operable breast cancer without skin involvement. By preserving the patient's skin envelope with a smaller incision, it markedly improves the aesthetics of the breast reconstruction. To further enhance cosmesis, the nipple and areola can be preserved at the time of mastectomy in select patients . This is called nipple-sparing mastectomy.

•

•

•

•

•

ANATOMY As with all types of mastectomy, a thorough understanding of the anatomy of the breast, chest wall, and axilla is neces­ sary. The goal of mastectomy is to remove the breast tissue while maintaining the viability of the skin envelope. The breast tissue is encapsulated by the superficial fascia that adheres to the subcutaneous tissue in a lobulated fashion ( FIG 1 ) . This makes it difficult to remove all of the breast tissue during mastectomy and maintain skin viability.

The boundaries of the breast ( FIG 2 ) are defined by the clav­ icle superiorly, the sternum medially, the 6th rib inferiorly, and the latissimus dorsi muscle laterally. The axillary tail of the breast extends toward the low axilla and is called the axillary tail of Spence. Posteriorly, the breast adheres to the pectoralis major muscle and is separated by the deep fascia of the breast (see FIG 1 ) . A skin-sparing mastectomy involves preserving the skin envelope while removing the nipple-areolar complex and underlying breast via a small incision ( FIG 3 ) . Nipple-sparing mastectomy is a total skin-sparing mastectomy with preser­ vation of the nipple-areolar complex. When performing a skin-sparing mastectomy, it is important to remove as much breast tissue as possible while maintain­ ing the viability of the skin. This is a balancing act from the oncologic standpoint to remove the majority of the breast tissue but not make the skin flaps so thin, resulting in skin necrosis and flap loss. The anatomic plane that divides the

Superficial fascia Deep layer Superficial layer Deep -' �-'-"--1. fascia ------lh Pectoralis major muscle Pectoralis minor muscle ------1;-----\-

Anterior mammary fascia

Retromammary fascia

FIG 1 • Cross-sect i o n of the breast d e m o nstrat i n g the su p e rfi c i a l fascia, i n c l u d i n g both the s u perfic i a l a n d deep layers.

1442

+

Rache Sim m ons

FIG 2

•

Anato m i c b o u n d a ries of the b reast.

C h a pt e r 1 1

.... -

... ' I I I \ ' ....

...

_ _

....

' \ I I I ' ...

.,

' I ' '

•

- - ..... ....

.... ... ....

_ .... ...

....

.... -

... ' I I I \ ' ...

'

.... '

\ '

....

_f"""

...

' \ I I I ' ...

C. Periareolar with inferior extension

B. Small eliptical periareolar

FIG 3

•

... ....

I I I

A. Round periareolar

•

1443

S K I N -SPA R I N G A N D N I PPLE/AREOLAR-SPA R I N G MASTECTOMY

/

1 I \

.... ...

' ...

- ... ...

_ _

...

\.. .... -

'

I I I

D. Periareolar with lateral extension

A-D. S u r g i c a l i n ci s i o n s used for a ski n-spa r i n g m a stectomy.

subcutaneous tissue and the underlying breast parenchyma is formed by the superficial fascia of the breast. This is an ill­ defined thin layer visualized by a faint white fascial line (see FIG 1 ) . The dissection is carefully performed in this plane. The remaining tissue on the skin envelope usually ranges between 2 and 5 mm in thickness depending on the patient's anatomy. It is crucial to flap viability to preserve both the subcutaneous venous plexus under the skin as well as the branches of the 2nd intercostal perforator in the upper medial flap as it exits the ribs. This is the largest blood supply to the skin flap ( FIG 4A.B) . Once the flaps are created t o the clavicle superiorly including the axillary tail of Spence, medially to the sternum, laterally to the latissimus dorsi muscle, and inferiorly to the 6th rib, the breast is then removed posteriorly from the pectoralis major muscle including the underlying deep fascia overlying the muscle. It is important when creating the flap medially not to extend to the contralateral breast.

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

Patients with operable breast cancer are candidates for either breast conservation therapy (BCT) or skin-sparing mastectomy with or without reconstruction. It is important for patients to understand that the survival between BCT and mastectomy is equal. However, mastectomy does carry a slightly lower locoregional recurrence rate of about 2 % versus 5 % i n 1 0 years after BCT. 1 Another important difference between the two surgical treat­ ment options is that mastectomy usually does not require postoperative radiation therapy. Postmastectomy radiation is recommended for patients with tumors greater than 5 em in size, patients with positive margins after mastectomy, or select patients with axillary lymph node involvement for locoregional control and to improve survival.2

:�:;.!!;til2-cm gap in

t h e I M F o r b e l ow if d e s i red . B e s u re t o u n f o l d a l l edges

muscle coverage, and/or wants large reconstruction

of t h e expa n d e r. I f perform i n g b i l atera l reconstruct i o n ,

(>350 m l ) .

sym m et ry i n expa n d e r p l a c e m e n t s h o u l d be c o n f i r m e d by p a l pati n g t h e expa n d e r p o rts o n each s i d e a n d e n s u r­

A l g o r i t h m to dete r m i n e when to use ADA. I M F, i nfra m a m m a ry fo l d .

FIG 13

•

i n g sym m etric h o rizonta l a n d vertica l positio n i n g . If a n expa n d e r req u i res a d j u st m e n t i n posit i o n i n g , it i s criti­ ca l to g ra s p t h e rigid backing of t h e i m p l a nt and then

Third Step-Preparation o f Tissue Expander •

a d j u st t h e posit i o n . I f only t h e p o rts o r a nt e r i o r s h e l l a re a d j u sted, t h i s u s u a l l y h a s n o effect o n t h e position

Tissue expa n d e rs come with a i r i n t h e m to p reve nt the inner shell from sti c k i n g to itse lf. There a re usua l ly m a rk­

of t h e backing, which d ete r m i n es i m p l a nt position o n c e

ings for o r i e ntatio n , but it is h e l pf u l to d raw a vertical

fu l ly i nflated.

line o n the expa n d e r with a marking p e n to assist with

•

2 3 g a u ge) is i nserted i nto t h e port a n d a l l a i r i s removed .

rior m uscle with r u n n i n g a bsorb a b l e 2-0 b r a i d e d sutu re,

The most com m o n ly used tissue expa n d e rs a re a n ato m i c

closi n g the pocket. A sm a l l open i n g is l eft superol atera l ly

(creat i n g lower p o l e exp a n s i o n ) a n d t h u s they a re tex­

to a l l ow eg ress of fl u i d . Altern ative ly, if an ADA is used,

t u red (to p revent rotati o n ) . There is typ i ca l ly m o re s h e l l

the pectora l i s major m u scle is sewn to the ADA with i n ­

i nfe r i o r l y, a n d w h i l e deflat i n g the exp a n d e r, it is i m p o r­

terru pted f i g u re-of-e i g h t b r a i d e d a bsorba b l e 2 - 0 suture

(FIG 1 S) .

tant to fo l d excess s h e l l i nward as o p p osed to fo l d i n g it u pwa rd a n d on to itse lf, where it m i g ht cover the p o rt •

The i nfero l atera l edge of the pectora l i s major muscle is sutu red to the a nteromed i a l edge of t h e serratus a nte­

positi o n i n g the exp a n d e r i n the pocket. A need l e (us u a l l y

•

The a u t h o r's p refe rence is t o i nfl ate the tissue expa n d e r

a n d get p u n ct u red (FIG 1 4) .

w i t h ste r i l e sa l i n e as m u c h as the soft t i s s u e (muscle/

The autho r's p refe rence is to p l ace 60 to 1 80 m l of ste r i l e

s k i n ) w i l l a l low without u n d u e tensi o n . T h i s is typ ica l ly

sa l i n e i n the tissue expa n d e r p r i o r to p l a ce m e nt, w h i c h

1 80 to 240 m l . It is i m p o rtant to do t h i s p r i o r to s k i n

a l l ows the a nterior s h e l l to m o v e a w a y f r o m the r i g i d

closu re, as p l a c i n g the need l e t h r o u g h the m uscle w i l l

back i n g . It is i m po rtant to control positi o n i n g of t h i s

occas i o n a l ly cause b l eed i n g, w h i c h can be contro l l e d

backi n g as it is what dete r m i nes fi n a l expa n d e r posit i o n .

d i rectly. Otherwise, a h e m atoma co u l d expa n d i n t h e su bcuta neous space without n otice u n t i l the patient i s

FIG 1 4 • The tissue expa n d e r is m a rked w i t h a vertical l i n e for o r i e ntat i o n . A l l a i r is removed w i t h the excess i nfe r i o r i m p l a nt fo l d e d i nward as shown to avoid p u n ctu r i n g the i nfer i o r i m p l a nt w h i l e placing n eed l es for expa n s i o n i n c l i n i c postoperative ly. A m i n i m u m o f 6 0 m l o f sa l i n e is i nsti l l ed, dyed with m ethy l e n e b l u e . This a l l ows for q u ick i d e ntification of i n a dvertent i m p l a nt r u pture d u r i n g w o u n d c l o s u re a n d a l so a l l ows t h e c l i n i c staff t o confirm p l acement o f t h e fi l l i n g need l e d u ri n g subsequent expa n s i o n s .

• T h e i nferol atera l edge of the pecto ra l i s major is sewn to the superomed i a l edge of the serratus anterior with a r u n n i n g 2-0 a bsorba b l e polyfi l a m e n t suture to cover the i m p l a nt. I f a n ADA is used, the pectora l i s major is sewn to the edge of the ADA with i nte r r u pted f i g u re-of-e i g h t 2 - 0 a bsorba b l e polyfi l a m e n t sutu re, as s h o w n .

FIG 15

1481

1482

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

out of s u rg e ry. I n cases w h e re there is s i g n ificant concern reg a rd i n g the cuta neous c i rc u l at i o n , t h e n o n ly 0 to 60 m l o f i nflation i s advisa b l e . •

Two c l osed s u ct i o n d ra i n s a re p l a c e d i n t h e s u bcuta­ neous s p a c e . One i s o r i e nted s u p e r i o r l y and t h e other i n f e r i o r l y. T h e skin i s c l osed w i t h i nt e r r u pted 3-0 ab­ s o r b a b l e m o n ofi l a m e n t s u t u r e f o r t h e d e r m i s and a r u n n i n g 4-0 a bs o r b a b l e m o n ofi l a m e n t s u t u r e f o r s u b ­ c u t i c u l a r c l os u re (FIG 1 6) . T h e a u t h o r's preference i s to use s k i n g l u e a l o n e a s a d ress i n g , w i t h o u t p l a ce m e nt of a s u r g i c a l b ra , w h i c h a p p l i e s p ressure to t h e t e n u ­ o u s m a stect o m y f l a ps a n d i s a n i m p e d i m e nt to p h y s i c a l exa m i n a t i o n .

•

Anti b i otics a re cont i n ued

pa rentera l l y for at

l east

24 h o u rs posto peratively and tra nsitioned to oral a n t i b i ­

• The patient i s shown fo l l owi n g p l acement of tissue exp a n d ers and c l o s u re over two c l osed suct i o n d r a i n s . I nter n a l a bsorb a b l e sutu res a re used, w i t h s k i n g l u e a s t h e o n ly d ress i n g . N o b ra is a p p l ied, w h i c h m i g ht a p p ly p ressu re to te n u o u s m a stecto my f l a ps .

FIG 16

otics for a wee k, as with h o l d i n g postoperative a n t i b i otics has been shown to be associated with an u n a ccepta b l e

60 to 1 20 m l) . O n ce exp a n s i o n i s co m p l ete accord i n g

rate of i m p l a nt i nfect i o n . 6 D r a i n s a re removed w h e n

t o patient p refe rence a n d s u rg e o n 's satisfact i o n , t h e

o u t p u t is l ess t h a n 30 m l p e r 24 h o u rs a n d exp a n s i o n

a ut h o r's p refe rence is t o pe rfo rm o n e a d d i t i o n a l over­

is beg u n typica l ly 2 weeks posto perative ly. Expa n s i o n

expa n s i o n , w h i c h can prov i d e some a d d i ti o n a l tissue to

can cont i n u e o n a wee kly basis, a d d i n g as m u c h f l u i d

create m i n i m a l ptos is at the exc h a n g e p roce d u re at least

a s the patient w i l l t o l e rate without d i scomfort (usu a l ly

1 m o nth l ater (as described in the following text) .

IMPLANT EXCHANGE First Step-Removal of Tissue Expander •

As n oted e a r l i e r, the patient is m a rked i n the sta n d i n g posit i o n . Asy m m etries a re n oted a n d the i d e a l conto u r f o r the fi n a l i m p l a nts is m a rked .

•

The m a stecto my scars h ave often w i d e n e d d u r i n g expa n ­ s i o n a n d th ese can be excised . A sta i r-step a p p roach t o the i m p l a nt pocket i s usu a l ly p e rformed, so a n y w o u n d breakdown i n o n e l a y e r d o e s n o t expose the suture l i n e of the other layer. If the sca r is o r i e nted o b l i q ue l y

(FIG 1 7), 2 to 4 em of su peromed i a l s k i n e l evati o n w i l l expose t h e pectora l i s major, w h i c h c a n b e i n cised p a r a l ­ l e l to t h e m uscle fi bers (FIGS 1 8 a n d 1 9) . I f a transve rse a p p roach was used, t h e n su perol atera l a n d i nferomed i a l s k i n e l evat i o n is req u i red t o expose the pecto ra l i s major and a l low for a n i n ci s i o n p a ra l l e l to the m uscle fi bers. •

The i m p l a nt pocket is entered a n d the capsu le is b l u ntly sepa rated from the expa nder, wh ich is removed . If the ex­ pander is too l a rge, it ca n be ruptu red with a needle or

FIG 18 • If the o b l i q u e i nc i s i o n is used for mastecto my, it is easy at the exc h a n g e p roced u re to e l evate a su peromed i a l f l a p expos i n g t h e pectora l i s major m uscle w h e re it tends t o b e t h i cker. T h i s w i l l a l low a " st a i r-step" a p p roach t o t h e i m p l a nt pocket. Any w o u n d h ea l i n g issue at o n e l evel w i l l not expose the suture l i n e at the other leve l .

sca l pel t o assist i n remova l . If there was any d o u bt a bout the f i n a l expa nder vo l u m e, it can be measured at this point.

Second Step-Creation of Implant Pocket •

Ideal ly, the expanders can be removed a n d the perm a n e nt i m p l a nts p laced without further i ntervention; h owever, this is a l m ost never the case. S u perior a n d superomed i a l capsu­

The patient is shown p r i o r to the exc h a n g e p roced u re, 1 month fo l l owi n g the l a st expa n s i o n i n c l i n ic. S h e h a s been expa nded to 6 0 0 m l a n d desi res 550 m l i m p l a nts.

FIG 17

•

lotomy is often req u i red to soften the tra nsition from the chest wa l l to the i m p l a nt (FIG 20) . The pocket may need to be medial ized, latera l i zed, el evated, o r displaced i nferiorly.

C h a p t e r 1 5 TWO-STA G E I M PLANT B R EAST RECONSTRUCT I O N

• A m uscu l a r i n c i s i o n is m a d e p a ra l l e l t o t h e pectora l i s m a j o r m uscle fi bers t o access the i m p l a nt pocket. The c a ps u l e is a lso i ncised with ca utery and the expa n d e r is b l u ntly sepa rated from the capsu l e .

FIG 19

FIG 2 1 • The patient is posit i o n e d u p r i g ht with both u p p e r extre m ities we l l p a d d e d a n d secu red to a r m b o a rd s a b d u cted l ess t h a n 90 deg rees.

These can a l l be acco m p l ished t h r o u g h capsulotomy. If t h e f i n a l i m p l a nt is rou g h l y the s a m e width as the expa nder, then a correspo n d i n g capsu lorrhaphy at the opposite side of the pocket is necessa ry using figu re-of-e ight i nterru pted 0 a bsorba b l e suture. If the i m p l ant is wider than the ex­ pander, this may not be necessa ry as the capsu lotomy w i l l increase pocket d i a m eter. •

If the expa n d e r was p l a ced below the I M F, or if t h e I M F needs t o b e e l evated, t h i s i s acco m p l ished with f i g u re­ of-e i g h t i nterrupted 0 a bsorba b l e suture. The patient i s s a t u p r i g ht (FIG 21 ) a n d the i nfe r i o r m astecto my f l a p i s l i fted a w a y f r o m the c h est wa l l . U s u a l ly, the o l d I M F c a n be visu a l i zed a n d m a rked (FIG 22); oth e rwise, the d e ­

FIG 22 • When the i nfe r i o r m a stecto my f l a p is e l evated g e ntly from the c h est wa l l , the patie nt's o r i g i n a l I M F is st i l l visi b l e a n d ca n b e m a rked for recreati o n o f t h e native I M F. A h i g h e r or l ower I M F can a lso be create d .

s i red I M F c a n be m a rked . The need l e i s passed t h r o u g h the capsu l e a n d the I M F m a r k i n g exte r n a l ly is visua l i zed. The need l e t i p should j u st catch the deep derm is, res u lt­ i n g in a sma l l i n d entati o n when t i e d . These i n d entati o n s w i l l resolve i n seve r a l weeks. After pass i n g the need l e t h r o u g h the capsu l e/d e r m is, t e n s i o n can be adjusted b y exa m i n i n g the fo l d exte r n a l ly (FIG 23) a n d e l evat i n g it

FIG 20 • A su peromed i a l and s u p e r i o r capsu l otomy is m a d e j u st a b ove the ch est wa l l u s i n g a l i g hted retractor. T h i s w i l l softe n t h e tra nsition from c h est wa l l t o i m p l a nt a n d a l l ow for m o re i m p l a nt m o b i l ity with i n t h e pocket.

FIG 23 • A s u t u re i s p l a c e d i n t h e c e n t e r of t h e I M F, t h r o u g h t h e ca p s u l e a n d j u st catc h i n g t h e d e e p d e r m i s . T h e s u t u re i s p u l l e d u pw a r d a n d t h e l e v e l of t h e I M F a d j u sted a s d e s i red to recreate a s h a r p and we l l -d ef i n e d I M F. O n c e h e l d i n a p p ro p r i ate p o s i t i o n , i nte r n a l i n s p e ct i o n w i l l reve a l w h e re a s u t u re s h o u l d be p l a c e d o n t h e c h est wa l l . To m i n i m i ze p a i n , s u t u r i n g to t h e r i b s s h o u l d be a v o i d e d i f poss i b l e . I f t h e l o w e r p o rt i o n of t h e expa n d e r was p l a c e d at t h e I M F a n d g o o d l o w e r p o l e expa n s i o n a n d a c r i s p I M F i n g o o d p o s it i o n h a s r e s u l t e d , t h e n t h i s m a n e u v e r i s u n n ecessa ry.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

FIG 24 • The I M F has been reesta b l ished with m u lt i p l e f i g u re­ of-e i g h t c a ps u l o r rh a p hy sutu res, sta rt i n g in the center of the IMF and p roceed i n g m ed i a l ly a n d latera l ly u n t i l a n adeq u ate I M F i s recreate d . A te m p o ra ry i m p l a nt sizer is h e l pf u l to assess the reco nstructed I M F d u r i n g t h i s p rocess.

• A h o rizonta l capsu l otomy a p p roxi m ately h a l f way up the inferior mastectomy f l a p is pe rfo rmed to f u rther expa n d t h e lower p o l e a n d create m i n i m a l ptosis. M u lt i p l e rad i a l capsu l otomies (perpen d i c u l a r t o the h o rizonta l ca psu l otomy and exte n d i n g from the I M F to the i ncision) w i l l f u rt h e r expa n d the l o w e r p o l e .

FIG 26

as desired. I nte r n a l i n spect i o n with the sutu re sti l l u n d e r

i nfe r i o r m a stectomy f l a p, at l e a st 4 em o f f t h e c h est

te n s i o n w i l l i n d i cate w h e re the correspo n d i n g sutu re

wa l l , w i l l expa n d the lower p o l e of the pocket (FIG 26) .

th row in the c h est wa l l m u st be m a d e . Sutu r i n g i nto the

Add iti o n a l rad i a l ca psu l ot o m i e s ca n be a d d e d f o r f u r­

r i b should be avoided, as t h i s resu lts i n pa i n . The fi rst

t h e r lower p o l e exp a n s i o n or e l sew h e re to create sym ­

sutu re is p l aced at the center of the I M F a n d t h e n o n e to t w o sutu res a re p l a ced m ed i a l ly a n d latera l ly u n t i l a n a d e q u ate fo l d i s created (FIGS 2 4 a n d 2S) . •

m e t r i c pockets. •

i m p l a nt vo l u me, w h i c h ca n be p l aced i nto the i m p l a nt

operation, potentia l ly w i t h a n ADA, w h i c h has the a d d e d

pocket to assess position, sha pe, a n d vo l u m e . T h i s is p a r­

benefit of permitt i n g a h i g h e r i n it i a l fi l l vo l u m e . A h i g h e r

ticu l a rly i m po rtant i n b i l atera l reco nstruct i o n s, where

i n it i a l fi l l vo l u m e h a s the potenti a l to better preserve

two s i zers a re req u i red to confirm pocket sym m etry.

l ower p o l e f u l l ness. N o t i m e is spent reco nstruct i n g t h e I M F at the exc h a n g e p roced u re . Alth o u g h t h i s may be a s i m p l e r a p p roach, it may res u l t i n a b l u nted I M F. The a ut h o r's p refe rence is to treat each case i n d iv i d u a l ly and

•

D u r i n g pocket creat i o n , it is h e l pf u l to have a te m p o ra ry sizer i n f l ated (with a i r or sa l i ne) to ro u g h ly the desi red

Some su rgeons p refer to esta b l is h t h e I M F at the i n it i a l

Third Step-Implant Selection and Closure •

When o r d e r i n g i m p l a nts for the exc h a n g e p roced u re,

s u r g i ca l l y create a crisp I M F at the exc h a n g e proce d u re

it is wise to order i m p l a nts that a re one size s m a l l e r

if n ecessa ry. F o r exa m p le, patie nts u nd e rg o i n g d e l ayed

a n d o n e s i z e l a rg e r t h a n the i m p l a nt s i z e determ i n e d

reco nstruct i o n w i l l benefit from s i g n ificant lower p o l e

by the patie nt's fi n a l expa n s i o n vo l u m e ( p r i o r to f i n a l

expa n s i o n a n d t h u s the expa n d e r is p l aced i nfer i o r to t h e

overexpa n s i o n ) . As mentioned e a r l i e r, te m p o ra ry s i zers

desi red I M F a n d the I M F is reco nstructed at the exc h a n g e

a re u s u a l ly used and c a n be adj usted to dete r m i n e an

p roced u re . A patient w i t h m i n i m a l excess s k i n a n d pto­

a cce pta b l e f i n a l i m p l a nt vo l u m e . I nflati n g the sizer

sis u n d e r g o i n g i m med iate reco nstruct i o n w i l l benefit

beyo n d the final expa n d e r vo l u m e u su a l ly resu lts in

from a n ADA to m a x i m ize the i n it i a l fi l l vo l u m e (p rese rve

excessive u p p e r p o l e f u l l n ess, a noticea b l e step-off

l ower p o l e fu l l n ess), esta b l i s h the I M F, a n d avo i d i nfe r i o r

between the c h est a n d i m p l a nt, a n d t i g h t closure. The

c a ps u l o rr h a p h y at the exc h a n g e p roced u re .

c h est should transition to the i m p l a nt smoot h l y a n d t h e

To f u rt h e r expa n d t h e lower p o l e a n d create m i n i m a l ptosis, ca psu l otomy o f t h e i nf e r i o r pocket is t h e n p e r­

b reast m o u n d s h o u l d h a v e s l i g ht ptosis. •

fo r m e d . A h o r i z o nta l ca psu l otomy h a l f way u p t h e

When p l a c i n g sa l i n e i m p l a nts, ch oose an i m p l a nt that has the desi red vo l u m e as the upper e n d of its vo l u m e ra n g e . F o r exa m p l e, if 3 8 0 m l i s the desi red i m p l a nt vo l u me, use an i m p l a nt with a vo l u m e r a n g e of 360 to 390 m l . T h i s avo i d s r i p p l i n g at the expense of m a k i n g the i m p l a nt s l i g htly f i r m e r. S o m e s u rgeons will i n fact overfi l l t h e i m p l a nt b y 1 0 % t o avo i d r i p p l i n g .

•

The pockets a re i rrigated, h e m ostasis is o bta i n ed, a n d the final i m p l a nts a re opened. Alth o u g h m a n y surgeons w i l l reprep t h e patient, p l ace n e w d ra pes, d i p retractors i n prep solution, a n d h a n d l e t h e i m p l a nts with fresh g l oves, t h e re is n o data to s u p p o rt these p ractices. The a uthor does n ot take a n y spec i a l p reca utions, as the p roced u re is a clean, ste r i l e p roce d u re. The i m p l a nts a re p l aced

Compa rison of the l eft side, where the I M F h a s been recreated, a n d the r i g h t s i d e, where it has n ot .

FIG 2 5

•

and the m uscu l a r c l osure is performed with a r u n n i n g 2 - 0 braided a bsorba b l e suture. T h e caps u l e is not i n c l uded

C h a p t e r 1 5 TWO-STA G E I M PLANT B R EAST RECONSTRUCT I O N

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Additional Procedure-Nipple Reconstruction and Revisions •

W h e n exa m i n ed with a critica l eye, a l m ost a l l patie nts have some deg ree of asym m etry fo l l ow i n g reconstruc­ tion (FIG 28) . A p p roxi mately 30% w i l l req u est a t h i rd proce d u re to a d d ress t h i s asym m etry. Correct i n g the u nfavora b l e res u l t i n i m p l a nt breast reco nstruct i o n i s a co m p l ex s u bject, i nvo l v i n g tech n i q ues to a lter i m p l a nt posit i o n , b reast sha pe, i m p l a nt type, a n d soft tissue c h a r­ a cte ristics. M a ny patients u lt i m ately o pt for NAC reco n ­

T h e i m p l a nts have been p l aced a n d t h e wounds c losed without drains. S k i n glue has been applied. The d i m p l i n g observed a t t h e I M Fs wi l l resolve i n severa l weeks.

F I G 27

•

struct i o n (FIG 29) (see P a rt 5, C h a pter 20). I n m a ny cases, m i n o r rev i s i o n s can be pe rfo rmed at the t i m e of NAC reco nstruct i o n ; h owever, the n i p p l e s h o u l d o n l y be cre­ ated once the b reast m o u n d is in its f i n a l position, a n d

in this closure if poss i b le, thus creat i n g a n a nterior cap­

t h u s i t is n o t advisa b l e to adjust t h e i m p l a nt pocket a n d

su l otomy (made u p o n i n it i a l a p p roach to the i m p l a nt

create t h e n i p p l e d u r i n g t h e s a m e operat i o n .

pocket) . No d r a i n s a re p l aced . The s k i n is c l osed with i nterru pted deep derma l 3-0 m o n ofi l a ment a bsorba b l e sutu re a n d a r u n n i n g 4-0 su bcuti c u l a r a bsorba b l e sutu re

(FIG 27) . A s k i n g l u e is a p p l ied, a n d a bra is o n l y used if s u p po rt i n g the i m p l a nt in a p a rticu l a r positi o n is desi red .

29 • Options f o r n i pp le-a reol a r com p l ex (NAC) reconstruction i n c l u d e tattoo on ly, n i p p l e reconstruction with a reola tattoo, and n i pp l e reconstruction with areola g raft. This patient opted for a "3-D" tattoo performed by a p rofessional tattoo a rtist that speci a l i zes i n NAC tattoo (Vi n n i e Myers in F i n ksbu rg, M D-http://www.vi n n iemyers.com). She is very h a p py with the aesthetic resu lt, although she has some chronic discomfort latera l to the right breast. It is very com m o n for patients to have some degree of chronic sensory dysfu nction following mastectomy. M uch of this resolves with time a n d can i m p rove with therapy a n d massage; however, every patient should be cou nseled of this risk. It is a lso very com mon for patients with i m p l a nts to be aware of their presence permanently. No patients th i n k the i m p l a nts fee l j u st l i ke their native b reasts. The i m p l a nts have d ropped slig htly, resulting in a more obvious step­ off from the chest wa l l to the i m p l a nts, and cou l d be corrected with elevation of the i m p l a nts (which would affect NAC position on the breast mound) o r fat g raft i n g . FIG

FIG 28 • Th ree m o nths fo l l owi n g the exc h a n g e p roced u re, the patient i s very h a ppy a n d i nte rested in n i p p l e reco nstruct i o n . The r i g ht I M F is 2 em l ower t h a n the l eft I M F, but the patient does not d e s i re correct i o n . It is i m p o rtant to esta b l ish the final i m p l a nt position prior to n i p p l e reco nstruct i o n ; otherwise, l ater i m p l a nt reposit i o n i n g w i l l affect h o w the n i pp l e is posit i o n e d o n the b reast m o u n d . T h e re is m i n i m a l ste p-off from the c h est wa l l to the i m p l a nts, w h i c h is the res u l t of mastectomy a n d co m m o n ly s e e n i n i m p l a nt reco nstruct i o n . T h i s can be corrected with fat g raft i n g-a n effective a n d pop u l a r but controvers i a l proced u re at t h i s t i m e . The patient d i d n ot d e s i re f a t g raft i n g .

PEARLS AND PITFALLS I n d icat i o n s

• •

I nc i s i o n p l acement

Expa n d e r selecti o n

Pati ents with a h i story of radiation a re poor c a n d i d ates for i m p l a nt reconstruct i o n . R i s k factors for i nfect i o n and wound h ea l i n g co m p l i cati ons i n c l u d e smoking, radiation, and obesity.

•

An o b l i q u e i n c i s i o n p a ra l l e l to t h e pectora l i s m u scle fi bers p rovides the best cosmesis a n d easiest a p p roach for the exc h a n g e p roced u re . Excess s k i n c a n be excised t h r o u g h a l i n e a r i n ci s i o n o n ly, as a d d it i o n a l i nc i s i o n s w i l l comprom ise c i rc u l at i o n and risk m a stecto my flap necrosis. Seco n d a ry p roced u res a re freq uently n ecessa ry in patie nts with excess s k i n .

•

Expa n d e rs a re selected based o n b reast w i d t h , not vo l u m e .

•

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

Expa n d e r p l acement

• • •

M a r k i n g the exp a n d e r assists in correct o r i e ntat i o n . Remove a l l a i r a n d p l a ce sa l i n e dyed w i t h methy l e n e b l u e to a l l ow d etect i o n o f i m p l a nt r u pt u re as we l l a s co n f i r m a t i o n o f p o rt access for staff perform i n g expa n s i o n s . Prov i d e at least 24 h o u rs of postoperative a n t i b iotics.

I m p l a nt sel ect i o n

•

I m p l a nts a re selected based on vo l u m e p r i m a r i ly, ta k i n g breast width i nto considerati o n . H i g h-prof i l e i m p l a nts a re typica l ly used, except i n patients w i t h wide ch ests who benefit f r o m moderate p rofi le, w i d e r i m p l a nts.

Patient expectati o n

•

Two-stage i m p l a nt breast reco nstruct i o n is typica l ly a yea r- l o n g p rocess. Sym m etry in the n u d e is a lways the g o a l but i s s e l d o m ach i eved . Sym m et ry i n c l oth i n g is the most reaso n a b l e expectati o n .

•

POSTOPERATIVE CARE •

•

Following the mastectomy and tissue expander place­ ment, the patient is maintained on antibiotics for at least 24 hours and more commonly for 1 week or until drains are removed. Drains remain in place at least 3 days and then are removed when output is less than 3 0 mL per day. Only one drain from each side should be removed at a time, as sometimes the output of the second drain will increase after the first drain is removed. The author's preference is to allow patients to shower with drains in place. The patient should be seen within 1 week to evaluate for postoperative infection and/or mastectomy flap necrosis and to remove drains if appropriate. Expansion is begun 2 weeks after sur­ gery and continued on a weekly basis thereafter until the patient and surgeon are happy with the final volume. One additional " overexpansion " is performed and the exchange procedure is scheduled at least 1 month later to allow the tissues to soften. Following the exchange procedure, patients may shower after 48 hours. Although the author feels very strongly about giving patients extended postoperative prophylactic antibiotics after mastectomy and expander placement, the exchange procedure is a clean procedure and the mastectomy flaps have been delayed and have robust perfusion. Thus, no postoperative antibiotics are usually given. Although there is little data to support practices such as repreping the patient, changing drapes, changing gloves, or dipping retractors in prep solution, this is commonly performed by surgeons placing implants.

OUTCOMES •

•

Patient satisfaction with implant breast reconstruction is high, provided the preoperative consultation appropriately identified the patient's priorities, goals, and preferences with respect to reconstructive options, and realistic expectations were discussed ( FIGS 30 to 32 ) . Although some studies have indicated that patients undergoing prosthetic reconstruction are less satisfied than those undergoing autologous tissue reconstruction/·8 other studies have shown significant im­ provements in psychosocial outcomes regardless of the type of reconstruction.9 It is common to tell patients undergoing implant recon­ struction that, on average, they will require some form of surgery every 10 years. These could be procedures for sym­ metry, infection, rupture, or capsular contracture. Although some surgeons exchange silicone implants every 10 years to avoid extracapsular ruptures, most only offer surgery if a problem is identified. One study evaluated long-term out­ comes of autologous versus implant reconstruction and noted stable survival of 90% of autologous reconstructions

A

FIG 30 • T h i s patient is 1 yea r out from the exc h a n g e proce d u re a n d 6 m o nths out from NAC reco nstruct i o n with loca l f l a ps to reconstruct the n i p p l e a n d a re o l a tattoo . S h e h a s a h i g h e r body m ass i n d ex ( B M I ) a n d m o re s u bcuta neous fat, a n d t h e m a stecto my d i d n o t exte n d very f a r s u perio rly. Thus, she h a s a sm ooth transition from the c h est wa l l to the i m p l a nts.

FIG 31

•

B A.B. T h i s patient is 6 months out from u n i latera l

reconstruct i o n . S h e d i d not d e s i re NAC reco nstruct i o n or a contra l atera l mastopexy for sym m etry. S h e has a very accepta b l e a p pe a r a n ce i n a b r a .

C h a p t e r 1 5 TWO-STA G E I M PLANT B R EAST RECONSTRUCT I O N

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REFERENCES 1.

2.

3.

4. • T h i s patient is 9 months out from h e r exc h a n g e p roced ure. S h e h a d p r i o r a u g m entation m a m m a p l asty a n d t h i n soft t i s s u e cove rage i nfe r i o rly; t h e refore, a n ADA w a s u s e d t o a u g m e n t soft tissue cove rage of the expa n d e rs .

FIG 32

•

versus a gradual decline to 70 % survival of implant recon­ structions . 1 0 In general, autologous reconstructions improve or remain stable with time, whereas implant reconstructions tend to worsen slightly over time. There is no increased risk of breast cancer recurrence in patients undergoing therapeutic mastectomy and implant reconstruction. Detection of recurrence and outcome when recurrence is detected are not affected by the presence of an implant reconstruction . 1 1

5.

6.

7.

8.

9.

COMPLICATIONS • • • • •

•

Bleeding Infection Inj ury to surrounding structures (e.g., cutaneous nerves) Mastectomy flap necrosis Long-term risks of implants: capsular contracture, rupture, rippling, infection, malposition, and exposure Asymmetry, imperfect cosmetic result

10.

11.

Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg. 2 0 1 2 ; 1 29 ( 5 ) : 1 043-1048. Abbott AM, Miller BT, Tuttle TM. Outcomes after tumescence tech­ nique versus electrocautery mastectomy. Ann Surg Oneal. 2 0 1 2; 1 9 ( 8 ) : 2607-2 6 1 1 . Seth AK, Hirsch EM, Fine NA, e t al. Additive risk o f tumescent technique in patients undergoing mastectomy with immediate recon­ struction. Ann Surg Oneal. 2 0 1 1 ; 1 8 ( 1 1 ) :3 04 1-3046. Chun YS, Verma K, Rosen H, et al. Use of tumescent mastec­ tomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction. Am J Surg. 20 1 1 ;2 0 1 ( 2 ) : 1 60-1 65. Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg. 2 0 1 2 ; 6 8 ( 4 ) : 346-3 5 6 . Clayton J L , Bazakas A, L e e CN, et a l . Once is n o t enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruc­ tion is associated with an increased risk of infection. Plast Reconstr Surg. 2 0 1 2; 1 3 0 ( 3 ) :495-502. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000; 1 06 : 769-776. Christensen BO, Overgaard J, Kettner LO, et al. Long-term evaluation of postmastectomy breast reconstruction. Acta Oneal. 2 0 1 1 ;5 0 ( 7 ) : 1 053-1 06 1 . Wilkins EG, Cederna PS, Lowery JC, e t al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postopera­ tive results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000; 1 06 (5 ) : 1 0 14-1025; discussion 1 026-1027. Rusby JE, Waters RA, Nightingale PG, et al. Immediate breast recon­ struction after mastectomy: what are the long-term prospects ? Ann R Coil Surg Engl. 2 0 1 0;92 ( 3 ) : 1 93-197. McCarthy CM, Pusic AL, Sclafani L, et al. Breast cancer recur­ rence following prosthetic, postmastectomy reconstruction: inci­ dence, detection, and treatment. Plast Reconstr Surg. 200 8 ; 1 2 1 ( 2 ) : 3 8 1-3 8 8 .

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Chapter

16

Pedicled Latissimus Dorsi Flap Breast Reconstruction after I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

Mastectomy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Fra n k Fa ng

DEFINITION •

•

ANATOMY •

A deyiza 0. Momoh

•

The latissimus dorsi myocutaneous flap was originally performed for chest wall reconstruction after radical mas­ tectomy by Iginio Tansini in 1 906 but fell out of favor when mastectomies were primarily closed or skin grafted . 1 Although the latissimus flap remained a dependable option for anterior chest wall reconstruction,2-4 it was not until 1 977 when it was first described to reconstruct a true breast mound in combination with a prosthetic implant.5 The latissimus dorsi myocutaneous flap currently remains a viable and frequently used option for breast reconstruction. Typically, patients who required chest wall irradiation and are either unwilling or unable (lack of donor site tissue volume) to undergo one of the other autologous flap options for breast re­ construction will proceed with this option. Furthermore, this flap has found use in the reconstruction of congenital defects such as Poland syndrome in the younger patient population.6 For the purpose of breast reconstruction, this technique usually requires flap transfer combined with an initial tissue expan­ sion process followed by a subsequent saline- or silicone-filled prosthetic implant placement. Breast reconstruction with a latis­ simus dorsi myocuataneous flap without an implant is also pos­ sible but less commonly used due to flap volume limitations?

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The latissimus dorsi is a large, flat, triangle-shaped muscle on the back measuring approximately 25 X 35 em; it mirrors the pectoralis major posteriorly.

The muscle origin is a broad aponeurosis that spans the lower six thoracic vertebrae ( superomedially) , supraspi­ nous ligament (central medial region) , thoracolumbar fascia (inferomedially), and posterior iliac crest (inferiorly) . The lateral border o f the muscle separates from the serratus anterior as a free potential space until one encounters the small slips of origin from the l Oth to 1 2th ribs, where the latissimus interdigitates with the slips of origin of the exter­ nal oblique and serratus anterior muscles. The superior border of the muscle has an area of adhesion to the region of the inferior angle of the scapula but otherwise contains free potential space with the underlying layer. The muscle converges in the axilla to insert on the crest of the lesser tuberosity of the humerus. The latissimus dorsi adducts, extends, and rotates the humerus medially ( "pull-up," rowing, or free-style swimming motions) . The latissimus dorsi flap is a Nahai-Mathes type V myocu­ taneous flap, meaning that it may survive based solely on either the thoracodorsal artery or the segmental perforators from the intercostal and lumbar arteries. The thoracodorsal artery ( arising from the subscapular branch off the axillary artery) enters the deep surface of the latissimus dorsi muscle in the posterior axilla approximately 10 em inferior to the muscle insertion into the humerus and 2 . 6 em medial to the lateral border of the muscle ( FIG 1 ) . The artery then divides into the medial (also known a s trans­ verse) and the lateral ( also known as vertical or descending) branches. The medial branch is located approximately 3 . 5 em below and parallel to the superior border. The lateral branch

Axi l lary artery and vein Subscapular artery and vein Circu mflex scapular artery and vein Teres major muscle

Latissimus dorsi muscle ---'--

Pectora l i s m ajor m u s c l e

"""'-11-',C-- Serratus anterior muscle

Branch to serratus anterior

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FIG 1 • Vascu l a r a n atomy of the thoracodorsa l a rtery and ve i n .

C h a p t e r 1 6 P E D I CL E D LAT I S S I M U S D O R S I FLAP B R EAST RECON STRUCT I O N AFTER MASTECTOMY

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is located approximately 2.6 em medial and parallel to the lateral border. The serratus branch (artery to the serratus anterior) , which j oins the thoracodorsal artery just before its entrance to the latissimus muscle, is a useful landmark as it guides one directly to the thoracodorsal pedicle. There is usu­ ally a single vena comitans of the thoracodorsal artery. 8•9 The thoracodorsal motor nerve enters the muscle with the vascular pedicle. Cutaneous sensory nerves arise from the intercostal nerves at the midaxillary line and also in the paraspinal region.

surgical procedures during which the thoracodorsal arterial pedicle may have been sacrificed (e.g., axillary lymph node dissection or modified radical mastectomy ) .

SURGICAL MANAGEMENT •

PATIENT HISTORY AND PHYSICAL FINDINGS •

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A thorough history and physical examination are critical in preparing for reconstruction. Pertinent aspects of the history include previous axillary operations (e.g., lymph node dissections or biopsies) and medical conditions that would preclude patients from an operation of moderate length under general anesthesia. Certain patients (e.g., paraplegic or wheelchair-dependent individuals who cannot afford even a minimal weakening of shoulder strength) probably should not undergo latissimus dorsi breast reconstruction. The average patient, however, will likely not notice a difference in shoulder function after a period of full recovery. A focused exam of the axilla and back for scars that may preclude use of the muscle flap or affect placement of the skin paddle is necessary. The presence of a viable and innervated muscle may be con­ firmed by having the patient activate the muscle by placing the hands on the hips and pushing firmly. However, a vigor­ ous muscle contraction does not necessarily indicate an intact thoracodorsal arterial pedicle, as the nerve is quite separated from the thoracodorsal artery proximal to the branch point from the subscapular artery and could be potentially pre­ served despite ligation of the thoracodorsal artery. A team-based approach involving surgeons, anesthesiolo­ gists, primary care physicians, and other specialists such as cardiologists when needed ensures that patients are evalu­ ated as a whole and all key concerns are addressed.

Preoperative computed tomography ( CT) angiography of the donor site ( FIG 2 ) is recommended in patients with previous

In consulting with patients, decisions about the timing of reconstruction ( immediately after mastectomy or delayed) and the type of reconstruction are made taking patient factors and tumor characteristics into consideration. Patient factors of significance include the following: Patient preference Smoking history History of previous axillary operations that compro­ mise the vascular pedicle of the donor site Medical comorbidities that would preclude patients from undergoing an operation of moderate length. Tumor characteristics as they relate to the following: The need for postmastectomy radiation therapy The need for close postmastectomy surveillance prior to reconstruction In general, patients known to require postmastectomy radiation therapy are reconstructed in a delayed fashion to avoid the detrimental effects of radiation on flaps. A history of radiation therapy also serves as a relative indication for use of an autologous form of reconstruc­ tion, as implant-only reconstructions in the setting of radiation are prone to higher rates of complications and failure.

Preoperative Planning • •

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IMAGING AND OTHER DIAGNOSTIC STUDIES •

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Basic labs (chemistry and blood counts ) All anticoagulant and antiplatelet medications should be stopped a week prior to the operation. Warfarin can be bridged with enoxaparin a week prior. Smokers are required to quit for a minimum of 4 weeks prior. Patients receive preoperative antibiotics with intraoperative redosing. Patients receive deep vein thrombosis (DVT) prophylaxis with use of a pneumatic compression device at the beginning of the case; preoperative subcutaneous heparin is not typi­ cally used in our practice. A Foley catheter will be needed, given the length of the case. A headlight may be helpful in the harvest of the latissimus dorsi muscle. A beanbag is needed for lateral decubitus positioning. A sterile Doppler probe is helpful to have available in case there is any concern for the location or integrity of the tho­ racodorsal pedicle during the case.

Thoracodorsal artery

Positioning Marking/positioning •

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FIG 2

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Preoperative CT a n g iography of the thoracodorsa l vesse ls.

The inframammary fold (IMF ) , medial limit, and lateral limit of the breast should be marked with the patient upright. With the patient in the sitting position, have the patient activate the latissimus muscle ( by placing hands on the hips and coughing) and mark anterolateral margin of the muscle.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

Other key landmarks for the limits of the latissimus muscle are the tip of scapula, vertebral column, and pos­ terior iliac crest. They should be marked for additional orientation. The pivot point for the flap is the approximate pedicle loca­ tion: It should be marked 2 to 3 em medial to lateral border and 9 em below the apex of the axilla. Eight to 1 0-cm-wide skin paddles can generally be closed primarily (verify adequate skin laxity by pinching) . The skin paddle must be placed over the muscular portion of the latis­ simus, as the vascularity of the skin over the thoracolumbar fascia is notoriously poor. In most patients, it is necessary to stay at least 8 em superior to the posterior iliac crest to avoid the thoracolumbar fascia ( FIG 3 ) . Verify that the skin paddle has been designed correctly for rotating to the planned anterior position by measuring from the estimated pedicle pivot point to the inferolateral tip of the skin paddle. This distance must equal the distance from the pivot point to the medial limit of your planned mastectomy incision. The orientation of the axis of the skin paddle can be varied ( FIG 4) . A horizontally oriented skin paddle allows the scar

Vertical

FIG 4

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Transverse

Poss i b l e o r i e ntat i o n s of the latiss i m us d o rsi f l a p s k i n

p a d d les.

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FIG 3

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F l a p m a r k i n gs.

RECIPIENT SITE PREPARATION

to be hidden by a bra strap but may limit the size of the paddle harvested. Measure the breast base width to guide your choice of tissue expander size. Patient positioning varies by surgeon. Harvesting a full latis­ simus dorsi flap requires a lateral decubitus position with a special arm support for the ipsilateral arm and an axil­ lary roll under the contralateral axilla to prevent brachial plexopathy. The lower extremities will also require adequate padding. Placing patients in the supine position during the earlier or latter parts of the case is based on surgeon preference and laterality of reconstruction (unilateral vs. bilateral) . Bilateral procedures absolutely require position changes. The description in the following text will include multiple position changes to make clear the sequence of events for the procedure. This sequence can then be modified.

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(IN EITHER SUPINE OR LATERAL POSITION) •

g e r b readths t u n n e l created to a l low for tra nsfer of the f l a p . T h i s tunnel should not v i o l ate the I M F.

Deve l o p the rec i p i ent site with the patient in s u p i n e posi­ tion: E l evate the skin and su bcuta neous f l a ps off t h e pec­

•

The l atera l d i ssect i o n is pe rfo rmed i n a s u p rafasci a l p l a n e

tora l i s major to recreate the mastectomy d efect i n cases

with i n the t u n n e l a n d exte n d s t o the latera l b o r d e r o f

of d e l ayed reco nstruct i o n ; for i m m ed iate reconstruct i o n ,

the latiss i m us .

the m a stecto my s k i n flaps a re a l ready deve l oped by the

•

patient is repositioned (FIG 5) .

N a t u r a l borders of the breast s h o u l d be p reserved, i n ­ c l u d i n g the I M F a n d s k i n a d h e rence to the ste r n u m a l o n g the m i d l i n e . A possi b l e except i o n wo u l d be i n d e l ayed

D i ssect 2 to 3 em past the border of the l atiss i m us, o n i t s deep su rfa ce, to fac i l itate f l a p e l evat i o n w h e n the

b reast surgeon. •

Li m it the latera l d issect i o n , w h e n poss i b le, to the a nte­ r i o r axi l l a ry l i n e with the except i o n of a th ree to fou r f i n ­

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E l evat i o n of the pecto ra l i s major m uscle is t h e n per­ formed, d is i nsert i n g the m uscle from its atta c h m e nts to

reconstruct i o n w h e re the i nfe r i o r d i ssect i o n can exte n d

ri bs at the I M F. T h i s d i s i nsert i o n is term i n ated at latera l

a p p roximately 0 . 5 to 1 . 0 em i nfe r i o r to the I M F to a l l ow

border of the stern u m .

the exp a n d e r to sit at the I M F after the latiss i m u s is i n set.

C h a p t e r 1 6 P E D I CL E D LAT I S S I M U S D O R S I FLAP B R EAST RECON STRUCT I O N AFTER MASTECTOMY

Latissimus dorsi

Serratus anterior

Pectoralis major

Caudal

FIG S • View of the ch est wa l l with exposu re of the pectora l i s major, serratus a nte r i o r, a n d latera l border of the latiss i m u s d o rsi m uscle.

•

The a nterior c h est s u r g i c a l s ite is t h e n packed with m o ist

t h i s border of the f l a p d u ri n g h a rvest i n the l atera l de­

l a pa roto my s p o n g es, t u c k i n g a s p o n g e latera l ly u n d e r the

c u b itus posit i o n . An l a b a n sheet is t h e n used to sea l the

l atera l border of the latiss i m u s . T h i s a lso h e l ps i d e ntify

m astectomy d efects.

FLAP HARVEST •

The patient is either p l aced in a latera l d e c u b itus position

(FIG 6) for a u n i l atera l flap h a rvest o r i n a prone posit i o n for b i l atera l f l a p h a rvests. •

A l l position c h a n ges req u i re repre p p i n g a n d red ra p i n g

•

The i n c i s i o n is m a d e on t h e l i n es of the d e s i g n e d s k i n

of the o p e rative f i e l d s . p a d d l e . As s o o n a s s u bcuta n e o u s f a t is v i s u a l ized, t h e p l a n e of d i ssect i o n s h o u l d be beve l e d outward i n a fash i o n to p rese rve as m a n y vasc u l a r p e rforators as poss i b l e . •

The s k i n a n d s u bcuta neous tissue a re e l evated off the latiss i m u s m u scle u n t i l the s u p e r i o r, med i a l , a n d i nfe r i o r l i m its of the m u scle a re visu a l ized.

FIG 7 • Exposure of s u p e rfi c i a l su rface of the m uscle d u ri n g f l a p h a rvest.

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Retract i o n can be a c h a l l e n g i n g aspect of t h i s step . A Deaver o r H a rri n gton retractor a n d B o v i e e l ectroca u ­ tery exte n s i o n a re h e l pf u l (FIG 7).

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D i ssect i o n u n d e r t h e latera l edge of the latiss i m u s is n ow i n iti ated, sta rti n g in the a rea i nfero l atera l ly. N ote that the a nterior edge of the m uscle often a p p roaches the m i d a xi l l a ry l i ne .

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I d entification of the latera l border of the m uscle is easy if e l evation is beg u n w h i l e the patient is s u p i ne, with p l acement of a l a p a rotomy sponge u n d e r the m uscle edge as o u t l i ned previously.

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D i ssect i o n deep to the latiss i m u s n e a r the p e d i c l e s h o u l d be d o n e cautiously w i t h e l ectroca utery to m i n i m ize t h e c h a nce for ped i c l e d a m a g e .

FIG 6 h a rvest.

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Patient positi o n i n g ( l atera l decu b itus) for flap

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Visu a l ization of the p e d i c l e is n ot n ecessa ry for m ost ped i c l e d f l a p s with the exce pti o n of f l a p s req u i ri n g

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

a d iv i s i o n of t h e m u scle i nsert i o n or f l a ps req u i ri n g d e n e rvat i o n . •

N ote that the serratus b r a n c h a rtery (FIG 1 ) c a n g u i d e you f r o m the serratus a nte r i o r m uscle to the s u p e r i o rly l ocated t h o racodorsa l vesse l s .

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Late r a l a n d m e d i a l row seg m enta l patte rn p e rfo rato rs to the s k i n w i l l be encou ntered in the paras p i n a l reg i o n a n d s h o u l d be meticu l o u s l y cauterized.

•

The latiss i m u s m uscle is d ivided m ed i a l ly a n d i nfe riorly at the p o i n t where the m uscle fi bers tra nsition i nto the thoraco l u m b a r fasc i a .

•

Deep to the latiss i m u s m u sc l e, the d i ssect i o n s h o u l d be l i m ited to m uscle o n ly, l e a v i n g beh i n d a d i pose tissue, as this conta i n s m a ny l y m p h atic c h a n n e ls; p reserv i n g this lym p h atic circulation is thought to reduce the risk for

FIG 8

sero m a . •

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E l evated latiss i m u s d o rs i myocuta neous f l a p .

The f u l ly e l evated f l a p (FIG 8) is t h e n rotated i nto t h e previously created l atera l c h est wa l l t u n n e l f o r passa ge

•

to the mastectomy d efect.

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The back d o n o r site is t h e n c l osed i n layers. Prior to closu re, f i b r i n sea l a nt such as Tisse e l or Evicel c a n be i nsti l l ed i nto the d o n o r s i t e . Alth o u g h n ot a bsol utely

P l a c i n g a l a rg e s i l k stitch o n the m ed i a l edge of the f l a p s k i n padd l e is h e l pf u l for l ocat i n g the f l a p with i n t h e

necessa ry, this m a n e uver is t h o u g h t to reduce the risk for

t u n n e l a n d su bseq uently for tracti o n t o s l i d e the f l a p

sero m a .

t h ro u g h the su bcuta neous tu n n e l . •

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A d r a i n t u b e is p l aced i n back d o n o r site.

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D ress i n g s i n t h e form of a s k i n g l u e prod u ct, Steri-Stri ps, o r an o i ntment a re t h e n a p p l ied to the suture l i n e .

INSETTING OF THE FLAP • •

The patient is repositioned to the s u p i n e posit i o n . The latissi m us m uscle is advanced i nto the rec i p ient site. Any restrict i n g bands of tissue near the ped i c l e p i vot poi nt c a n be ca refu l ly lysed to y i e l d better f l a p rotat i o n a n d a n i d e a l positi o n of the ped i c l e .

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Co m p l ete skeleto n i zation of the p e d i c l e is not necessa ry. D i s i n se rt i o n of the m uscle atta c h m e nts to the h u merus c a n be pe rfo rmed to gain a few a d d it i o n a l ce n t i m ete rs of rea c h .

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Ligation of the t h o racodorsa l n e rve e l i m i n ates contrac­ tion of the m uscle, which can be bot h e rso m e to some patie nts. M ost patie nts, h owever, d o n ot com p l a i n a bout persistent m uscle contract i o n s after transposition of this m uscle without sacrifi c i n g the m otor n e rve.

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The latiss i m u s m u scle is t h e n i nset to the I M F with i nter-

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A tissue expa n d e r selected based on the patie nt's c hest

• Tiss u e expa n d e r p l aced beh i n d the pectora l i s major (su pe r i o r) a n d l atissi m u s d o rsi (inferior) m uscle f l a p s with i n t h e mastecto my d efect.

FIG 9

ru pted a bsorba b l e sutu res. wa l l d i m e n s i o n s (pri m a r i ly b reast base width) i s t h e n p l aced i n the pocket f l a n ked s u p e r i o r l y by the pectora l i s m a j o r m uscle f l a p a n d i nferiorly b y the latissi m u s d o rs i myocuta neous f l a p (FIG 9) . •

Tissue expa n d ers with suture tabs can be used, as they a l low the expa n d e r to be secu red to the c h est wa l l te m ­ porari ly, p reve n t i n g m i g ration a n d o pti m i z i n g exp a n s i o n of d e s i red a reas of the b reast m o u n d .

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The pectora l i s major m uscle is t h e n a p p roxim ated to the l atissi m u s with i nterru pted or r u n n i n g a bsorba b l e sutu res.

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If t h e re a re concerns for te n s i o n on the f l a p, fi l l i n g of the tissue exp a n d e r (FIG 1 0) should be d e l ayed .

FIG 10

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I ntraoperative fi l l of the tissue expa n d e r.

C h a p t e r 1 6 P E D I CL E D LAT I S S I M U S D O R S I FLAP B R EAST RECON STRUCT I O N AFTER MASTECTOMY

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1493

The su bcuta neous t u n n e l o pe n i n g to the l atera l tissue expa n d e r pocket can be c l osed to p revent latera l m i g ra­ t i o n of the i m p l a nt .

•

A d r a i n tube is p l aced deep to the s k i n f l a ps but su perfi­ cial to the m u scle f l a ps at the i nfe r i o r p o l e of the b reast, exit i n g at the l atera l ch est wa l l .

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S k i n c l o s u re is performed i n layers with a bsorba b l e i nter­ ru pted deep d e r m a l sutu res a n d a ru n n i n g su bcuticu l a r suture (FIG 1 1 ) .

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D ress i n g s in the form of a s k i n g l u e product, Steri-Stri ps, o r an o i ntment a re then a p p l ied to the suture l i n e .

FIG 1 1

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I nset f l a p s k i n p a d d l e .

PEARLS AND PITFALLS Preope rative p l a n n i n g

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Preope rative C T a n g i og ra p h y is worthw h i l e w h e n axi l l a ry l y m p h n o d e d i ssect i o n h a s been performed prev i o u s ly. T h e t h o racodorsa l vesse l s a re occasi o n a l ly l i g ated d u r i n g axi l l a ry d issect i o n s .

Posit i o n i n g

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M i n i m i z i n g the posit i o n c h a n ges w i l l reduce s u r g i ca l d u rati o n . F o r i n stance, a latera l posi­ t i o n for both rec i p i e n t site preparation and donor site h a rvest fo l l owed by s u p i n e posi­ ti o n i n g for the i n set and expa n d e r p l acement ta kes advantage of a s i n g l e position c h a n g e .

Free i n g the latissi m u s d o rsi

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I d e ntifyi n g and beg i n n i n g the d i ssect i o n u n d erneath the l atera l border of the latiss i m u s wh i l e the patient i s s u p i n e a l l ows for a n e a s i e r f l a p e l evat i o n once the patient is i n a l atera l positi o n . D i s i nsert i n g t h e m uscle attac h m e nts t o t h e h u m erus i m p roves t h e reach of t h e m uscle.

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Avo i d ta k i n g out d o n o r site drains too early as seromas a re co m m o n with t h i s f l a p e l evat i o n .

Posto pe rative seroma

POSTOPERATIVE CARE •

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Patients can be transferred from the operating room (OR) to a postanesthesia care unit (PACU) or directly to a unit with nursing capabilities for flap monitoring. Flaps are monitored by physical exams (color, temperature, capillary refill) performed every hour for the first 4 hours and then checks can be spaced out to every 2 hours and 4 hours over subsequent hospital days. DVT prophylaxis is the only form of anticoagulation used routinely. Diet is advanced from clear liquids to regular on postopera­ tive day 1; there are no restrictions on caffeine. Patients are assisted to ambulate beginning on postoperative day 1 . Foley catheters and intravenous (IV) fluids are discontinued; IV medications/patient-controlled analgesias (PCAs) are con­ verted to orals on postoperative day 1 . Patients are typically ready for discharge home from post­ operative days 2 to 4. Surgical drains are discontinued once the output is less than 30 mL for 2 consecutive days. Activities are limited and weight-lifting restrictions are in place for 6 weeks postoperative. The first postoperative visit is at 1 week following discharge.

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Postoperative results for a left delayed breast reconstruction in an irradiated patient ( FIG 1 2 ) .

OUTCOMES •

Breast reconstruction outcomes may be assessed in several ways. Patient satisfaction, shoulder girdle function and re­ operation rates are all parameters that have been analyzed in recent literature. An evaluation of patient satisfaction showed that latissimus dorsi breast reconstruction patients are gener­ ally satisfied with their decision, with 8 0 % of surveyed pa­ tients indicating that they would both recommend the surgery to another person and undergo the surgery again if given the choice. Over 70% of surveyed patients found the size, shape, and scars associated with their reconstructions to be "good" or " excellent. " However, contrary to what is previously be­ lieved, over one-third of patients questioned reported moder­ ate to severe loss of shoulder force and function. By strict physiometric measurements, there is comparable shoulder range of motion and slight decrease in shoulder strength when compared to preoperative measurements at 1 year postopera­ tively. This amount of change does not substantially affect the ability to perform daily activities for most patients. 1 0 Also, reoperation rate was 5 0 % for prosthesis-related problems at a mean follow-up time of 14.9 yearsY

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

FIG 1 2 • A patient with l eft b reast i nvasive d ucta l carc i n o m a w h o u n d e rwent b i l atera l m a stect o m i es, adjuvant c h e m othera py, a n d l eft c h est wa l l r a d i ati o n . Above, 4-m onth postoperative res u l t after c o m p letion of tissue exp a n s i o n . Below, 9 months afte r exc h a n g e of the tissue exp a n d e rs for s i l icone i m p l a nts.

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Breast reconstruction patients are typically satisfied in the short term ( < 5 years) with their choice of reconstruction across implant-based to autologous forms of reconstruction.12 Over the long term ( > 8 years) , satisfaction with abdominal­ based flap reconstruction is maintained, whereas satisfaction with implant-based techniques tends to depreciate.12 Studies have also shown greater satisfaction with autologous reconstruction in patients requiring unilateral reconstruc­ tions. This is likely the result of better symmetry with the natural contralateral breast.12 Patient satisfaction in bilateral reconstructions has been found to be similar across all techniques provided that the same technique is used on both sides,12 highlighting again the importance of symmetry.

COMPLICATIONS Flap-Related Complications •

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Infections/implant extrusions-risks for these complications are elevated for implant-only reconstruction of irradiated sites. Autologous tissue transferred to the chest over a pros­ thesis offers greater resistance to infection or implant extru­ sion than do prostheses alone on irradiated sites.U·14 Delayed wound healing-this complication typically occurs at the interface between the mastectomy flap and latissimus flap skin paddle. It often is a result of marginal mastectomy flap necrosis from poor skin perfusion, which is more likely in smokers and in the previously radiated breast skin. Partial flap loss-an uncommon complication ( - 3 % or less) that is also related to poor perfusion.15•16 It can be the result of poor skin paddle design. An excision of the necrotic seg­ ment is usually required. Total flap loss-this is one of the most devastating com­ plications encountered and it occurs in less than 1% of reconstructions. 15•16

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Capsular contracture-recent studies based on the newest generation implants report approximately 1 6 % P

Donor Site Complications •

•

Seroma-approximately 9 % of latissimus dorsi flap donor sites encounter a seroma. 15•16 Some studies report as high as 3 4 % . 1 7 Delayed wound healing-wound healing problems are encountered often in morbidly obese patients, diabetics, and smokers. These wounds are managed by debridement and dressing changes with healing by secondary intention.

REFERENCES 1. 2. 3. 4. 5. 6. 7.

8. 9. 10.

11.

Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg. 1 9 8 0;65 ( 5 ) : 6 8 6-692. Davis HH, Tollman JP, Brush JH. Huge chondrosarcoma of rib. Surgery. 1 949;26:699. Campbell D . Reconstruction of the anterior thoracic wall. I Thorac Surg. 1950; 1 9 ( 3 ) :456. Olivari N. The latissimus flap. Br I Plast Surg. 1 9 76;29 ( 2 ) : 1 26-1 2 8 . Schneider WJ, Hill HL Jr, Brown R G . Latissimus dorsi myocutaneous flap for breast reconstruction. Br I Plastic Surg. 1 9 77;3 0(4) :277-2 8 1 . Hester T R Jr, Bostwick J III. Poland's syndrome: correction with latis­ simus muscle transposition. Plast Reconstr Surg. 1 9 82;69(2) :226-2 3 3 . Chang DW, Youssef A, C h a S, e t a l . Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg. 2002; 1 1 0 ( 3 ) : 75 1-75 9 . Zenn MR, Jones G E . Reconstructive Surgery: Anatomy, Technique, and Clinical Applications. St. Louis, MO: Quality Medical; 2 0 1 2 . Strauch B, Y u H - L . Atlas o f Microvascular Surgery: Anatomy and Operative Techniques. 2nd ed. New York, NY: Thieme; 2006. Glassey N, Perks GB, McCulley SJ. A prospective assessment of shoul­ der morbidity and recovery time scales following latissimus dorsi breast reconstruction. Plast Reconstr Surg. 2008;122( 5 ) : 1 3 34-1 340. Tarantino I, Banic A, Fischer T. Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation. Plast Reconstr Surg. 2006; 1 1 7( 5 ) : 1 3 8 7-1394.

C h a p t e r 1 6 P E D I CL E D LAT I S S I M U S D O R S I FLAP B R EAST RECON STRUCT I O N AFTER MASTECTOMY

1 2 . Hu ES, Pusic AL, Waljee JF, et a!. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124( 1 ) : 1-8. 13. Kroll SS, Schusterman MA, Reece GP, et a!. Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plast Reconstr Surg. 1 994;93 ( 3 ) :460-469. 14. Spear SL, Boehmler JH, Taylor NS, et a!. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Plast Reconstr Surg. 2007; 1 1 9 ( 1 ) : 1-9.

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15. De Mey A, Lejour M, Declety A, et a!. Late results and current indications of latissimus dorsi breast reconstructions. Br J Plast Surg. 1 9 9 1 ;44( 1 ) : 1-4. 16. Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results. Plast Reconstr Surg. 1992;89(4): 666-672. 17. Sternberg EG, Perdikis G, McLaughlin SA, et a!. Latissimus dorsi flap remains an excellent choice for breast reconstruction. Ann Plast Surg. 2006;56( 1 ) : 3 1-35.

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Chapter

17

Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction �

I

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·

I

Da le Collins Vida l

DEFINITION •

•

•

All patients undergoing mastectomy, or those who have un­ dergone a prior mastectomy, are potential candidates for breast reconstruction. The choice to have breast reconstruc­ tion is personal, and the options available for breast recon­ struction are affected by an individual's anatomy, weight, prior surgical procedures and radiation, and personal pref­ erences. Each patient is unique and consideration must be made of their current breast size, goal breast size, and ana­ tomic limitations. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap was first described by Hartrampf in the 1 9 80s and remains the autologous "workhorse" of breast recon­ struction. Diabetic patients, smokers, and patients with an elevated BMI or a pendulous panniculus have higher risk for flap failure.

PATIENT HISTORY AND PHYSICAL FINDINGS • •

•

•

•

Current breast size, the patient's goal for breast size, and the amount of abdominal tissue will also guide surgical planning and the need for a contralateral symmetry surgery. Risks, benefits, and alternate therapies must also be reviewed with the patient including other autologous options ( free and pedicled) and implant-based reconstruction options.

Anatomy •

•

A complete medical and surgical history is essentiaL Prior comorbidities should be identified and the decision for preoperative anesthesia evaluation should be made. Current related history must include cancer stage; B R CA status; and prior treatments including lumpectomy, biopsy, neoadjuvant chemotherapy, and radiation. Accurate documentation of any prior abdominal, pelvic, cardiac, and groin surgery is necessary in order to evaluate the candidacy for a TRAM flap.

Emily B. Ridgway

•

•

As with any surgical technique, a thorough working knowl­ edge of the anatomy of the chest and abdominal wall and any variants is essentiaL The primary blood supply of the breast originates from internal mammary perforating branches. Secondary blood supply is received via perforat­ ing arteries from the lateral thoracic, pectoral, thoracic, and lateral intercostal arteries . Many of these vessels are injured during mastectomy and much of the mastectomy flap blood supply is compromised and relies on dermal and subcutane­ ous vessels running j ust deep to the dermis. The abdominal wall is made of skin, varying thickness of subcutaneous adipose tissue, and an anterior rectus fascia overlying the paired rectus abdominis muscles ( FIG 1 ) . Deep t o the muscles i s the posterior rectus fascia made up of the transversus fascia and internal oblique muscle fascia above the arcuate line and the transversus fascia below the arcuate line. The paired rectus muscles originate from the pubic bone and extend to the cartilage of the 6th, 7th and 8th ribs. The blood supply comes from the dominant deep inferior epigastric artery and the superior epigastric artery ( FIG 2 ) .

Aponeurosis of t h e external o b l i q u e -----1Rr---'lr--

Transversus abd o m i n i s '-----'-- Transversus fascia

Arcuate l i n e

'-'---- I n g u i n a l l i g ament (formed by the i nferior border of the external o b l i q u e aponeurosis)

1496

FIG 1

• Abd o m i n a l wa l l m u scu l at u r e .

C h a p t e r 1 7 PEDICLED TRANSVERSE RECTUS ABDOM I N I S MYOCUTANEOUS FLAP BREAST RECONSTRUCTION

1497

I n the case o f the pedicled TRAM flap, the flap i s based on the superior epigastric vessels.

SURGICAL MANAGEMENT -,-----• ...-Su perior e p i g astric artery

Preoperative Planning •

•

"------- Deep i nferior e p i g astric artery

FIG 2

•

Abdom i n a l wa l l b l o o d s u p p ly. •

•

•

Additional blood supply comes from the posterior perforat­ ing vessels accompanying the 8th through 1 2th intercostal neurovascular bundles. Within the muscle, the superior and inferior epigastric arter­ ies may not have direct anastomoses under normal condi­ tions. These connections are made or increased with surgical delay of the deep inferior epigastric artery. Musculocutaneous perforators pass through the muscle and anterior rectus fascia ( FIG 3 ) . They are often gathered in the periumbilical area and in mirrored medial and lateral rows of perforators. The medial and lateral row of perforators on a given side is separated by approximately 1 .5 to 2 em.

•

For high-risk patients, ligation of the inferior epigastric artery (surgical delay) should be considered. Surgical delay of the inferior epigastric artery is performed 10 to 14 days prior to the mastectomy. This is often performed at the time of sentinel lymph node biopsy in order to limit events requir­ ing anesthesia. On the day of reconstruction, the patient is marked first in the standing position. At the breast, the inframammary fold (IMF ) , midline and a line 1 em off the midline on either side, the lateral breast extension, and proposed or prior mastectomy skin incision approach are marked. The width of the proposed breast reconstruction is measured as this will guide the ideal width of the abdominal flap, which is particularly important in delayed breast recon­ struction where there is often a paucity of breast skin ( FIG 4 ) . On the abdomen, the midline is marked and an ellipse of skin including the umbilicus is marked. In our experience, all patients offer at least 13 em in width of the ellipse and this can be assessed with a pinch test ( FIG 4) . The patient i s then seated and any further extensions o f the incisions are laterally marked to remove any " dog ear. "

M uscu locutaneous perforators

FIG 3 • S u r g i c a l d e l a y is pe rfo rmed to l i gate the deep i nfe r i o r e p i g astr i c a rtery a n d ve i n .

FIG 4 • Preope rative m a r k i n g of ch est a n d a b d o m e n i n the sta n d i n g posit i o n . N ote the latera l d i m e n s i o n of the p l a n ned b reast should correl ate to the h e i g ht of the p l a n ned TRAM f l a p . The TRAM f l a p i s centered a r o u n d t h e s i t e of l a rg est pe rforators at the p e ri u m b i l ica l reg i o n .

1498

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

•

Perio perative antibiotics a re p rovi ded a n d a Foley catheter

•

The f l a p c a n be ra ised w h i l e the m astecto my is b e i n g

and seq uenti a l com p ression d evice (SCD) boots a re p laced . perfo r m e d . N o t u m esce nce is used . The s u p e r i o r i nc i s i o n is m a d e fi rst, a n d the u p p e r a b d o m i n a l wa l l is raised t o the l evel of t h e costoc h o n d r a l ca rt i l a ges. O n the s i d e of the p l a n ned reconstruct i o n , a t u n n e l is m a d e t h ro u g h the I M F i nto the m a stecto my pocket that fits a fist a n d the p l a n ned f l a p . •

The patient is t h e n fl exed a n d the s u p e r i o r a b d o m i n a l f l a p brou g ht down t o verify its p e n d i n g c l o s u re a n d the poss i b l e h e i g ht of the f l a p to be create d . The i nfe r i o r i nc i s i o n is t h e n m a d e . B eg i n n i n g l atera l l y o n each s i d e , the f l a p i s t h e n e l evated with e l ectroca utery a bove the level of the fascia until the latera l border of the rectus

• If a b i l atera l reco nstruct i o n i s p l a n ned, the m i d l i n e i n c i s i o n m a y a l so be m a d e t o h e l p i n exposu re f o r d i ssect i o n .

FIG 6

a b d o m i n i s is see n . At t h i s p o i nt, either b i po l a r o r very l ow ca utery is reco m m e n ded for conti n u i ng to co m p l ete the i d e ntification of both the m ed i a l a n d l atera l rows of pe rfo rators (FIG S) . If a b i l atera l reconstruct i o n is p l a n ned, the m i d l i n e i n c i s i o n may a l so be m a d e to h e l p i n expos u re f o r d i ssect i o n (FIG 6) . N o p e rforators s h o u l d be sacrificed at t h i s t i m e . •

O n ce a l l p e rfo rato rs have been i d e ntified, the f l a p vascu­ l a rity is assessed . I n u n i l atera l reconstruct i o n cases, if o n e f l a p h a s a h e a rt i e r b l ood s u p p ly, t h i s f l a p is chose n .

•

Methylene b l u e is t h e n used to m a rk t h e p l a n ned fas­ cia i n cisions i n c l u d i n g each row of perforators and o n ly the i nterve n i n g fasc i a . A n o . l O b l a d e is used to i n cise the fasc i a and sharp d i ssect i o n around the outs i d e of each med i a l and l atera l p e rforator under I o u p e m a g n ification

(FIGS 7 and 8) . The width of t h i s fascia (a p p roximately 2 em) is a lso i n c l uded i n the flap superiorly to the level of the costoc h o n d ra l cart i l a g e (FIG 8) . The u n d e r l y i n g rectus m uscle is t h e n secured to the a nterior rectus fas­ cia and ove r l y i n g Scarpa's fascia with severa l 3-0 Vicryl sutu res o n either s i d e to p revent the f l a p from b e i n g avu lsed f r o m the m uscle.

FIG S • Late r a l flap e l evati o n : B eg i n n i n g l atera l ly o n each s i d e, the flap i s e l evated with Bovie ca utery a bove the l evel of the fasci a u n t i l the l atera l border of the rectus a b d o m i n is is see n . At t h i s poi nt, either b i p o l a r or very l ow ca utery is reco m m e n d e d for conti n u i n g to co m p l ete the i d entificat i o n of b o t h the med i a l a n d l atera l rows of perforators.

FIG 7 • M ethy l e n e b l u e is t h e n u s e d to m a r k the p l a n ned fascia i n cisions i n c l u d i n g each row of p e rforators a n d o n ly the i nterve n i n g fasc i a .

F I G 8 • Perforator d i ssect i o n . A n o . 1 0 b l a d e i s u s e d to i n cise the fascia a n d s h a r p d i ssect i o n a r o u n d the outs i d e of each medial and l atera l perfo rato r under l o u pes m a g n ificat i o n .

C h a p t e r 1 7 PEDICLED TRANSVERSE RECTUS ABDOM I N I S MYOCUTANEOUS FLAP BREAST RECONSTRUCTION

FIG 9 • Flap e l evat i o n : The width of the fasc i a with i n the TRAM (a p p roximately 2 em) i s a l so i n c l uded i n the flap s u p e r i o r l y to t h e level of the costoch o n d r a l cart i l a g e .

•

C i rc u m fe rent i a l m u s c l e d i ssect i o n is t h e n co m p l eted, t h e d e e p i nf e r i o r e p i g astric a rtery i d e ntified a n d c l i pped, and t h e inferior p o rt i o n of t h e m u scle d iv i d e d . T h e f l a p i s t h e n r a i s e d a n d a n y poste r i o r p e rforators a n d i nter­

FIG 1 1 • F l a p p l acement: The f l a p is t h e n rotated i nto the i p s i l atera l or contra l atera l m astectomy d efect via the prepared t u n n e l .

costa l n e rves c l i p p e d s u c h that t h e re is no tet h e r i n g of t h e f l a p (FIG 9. At t h e s u p e r i o r b o r d e r of t h e fasc i a l d i ssect i o n , a b a c k c u t i s m a d e t o a l low t h e f l a p to ro­

•

tate s u p e r i o r l y without t e n s i o n o r k i n k i n g of the b l ood

I n u n i latera l cases, a p l icati o n may be pe rfo rmed o n t h e

s u p p ly. T h e f l a p i s then p l aced with i n t h e m a stectomy

contra latera l s i d e t o restore the u m b i l icus t o the m i d l i n e .

pocket.

T h i s p l i cation a n d c l o s u re s h o u l d exte n d f r o m the costo­

The d o n o r site is t h e n verified for h e m ostasis p a rt i c u l a rly

c h o n d r a l m a rg i n to the p u b i c bone to create a sm ooth

at the s ite of the deep i nfe r i o r e p i g astric a rtery l i gation

d e s i ra b l e a b d o m i n a l conto u r. The bed i s then fl exed a n d

a n d the n a rrow g a p i n the a nterior rectus fasc i a c l osed

two d ra i ns a re p l aced exit i n g t h r o u g h i nfero l atera l sta b i nc i s i o n s . The Sca rpa's fascia is t h e n a p p roxi m ated with

with 0-Vicryl and 0-polyd i oxa n o n e (PDS) sutu res (FIG 1 0) .

0-Vicryl sutu res and the d e r m i s c l osed with b u ried deep dermal 3-0 Vicryl fo l l owed by a su bcuticu l a r 4-0 M o n ocryl and d e r m a l g l u e . •

By t h i s t i m e, t h e m a stecto my f l a p c a n be e i t h e r c l i n i ­ ca l ly assessed or stu d i es used to assess t h e v i a b i l ity of t h e m a stecto m y fl a ps . T h e latera l b o r d e r of t h e b re a st c a n be recreated u s i n g d e r m a l to fasc i a 3-0 V i c ry l s u ­ t u res. P u c ke r i n g at t h i s t i m e i s expected a n d w i l l r e ­ s o l v e . I n c a s e s of q u est i o n a b l e f l a p v i a b i l ity, t h ese a re a s m a y b e e x c i s e d o r t h e f l a p i n set d e l ayed to a l l o w f u r­ t h e r d e b r i d e m e n t of t h e f l a ps 3 to 5 d ays l at e r. I n cases w h e re t h e m a stecto my fl a p i s v i a b l e, t h e TRAM f l a p i s d e - e p i t h e l i a l i z e d i n n o n-n i p p l e-spa r i n g cases except f o r the site of the n i p p l e-a reo l a r c o m p l ex ( N AC) o r e n ­ t i re l y i n cases of n i p p le-spa r i n g m a stecto m i es (FIG 1 1 ) . T h e fl a p i s t h e n s e c u r e d m ed i a l l y a n d s u p e r i o r l y w i t h V i c ry l sutu res to t h e pecto ra l i s fasc i a . A d ra i n i s p l aced r u n n i n g a l o n g t h e I M F and exit i n g t h r o u g h a latera l sta b i n c i s i o n (two d ra i n s a re p l a c e d if axi l l a ry l y m p h

F I G 1 0 • Fascia c l o s u re : The a nterior rectus fascia is c l osed with i nterrupted 0-Vicryl and a ru n n i n g 0-PDS suture. The poster i o r sheath has not been v i o lated . H e m osta sis is c r u c i a l p r i o r to c l o s u re of the fasc i a .

n o d e d i ssect i o n h a s b e e n perfo r m e d ) a n d t h e wo u n d i s c l osed w i t h d e e p d e r m a l 3 - 0 V i c ry l sutu res a n d a 4-0 M o n ocryl s u b c u t i c u l a r s u t u r e fo l l owed by d e r m a l g l u e

(FIG 1 2) .

1499

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOGIC SURGERY

FIG 1 2 • I m med iate tra m reco nstruct i o n for l eft s k i n spa r i n g mastecto my.

PEARLS AND PITFALLS Preoperative p l a n n i n g

A t h o r o u g h h i sto ry a n d physica l w i l l i d e ntify h i g h-risk facto rs. S m o k i n g cessation s h o u l d be stro n g ly e n c o u r a g e d . H i g h -risk patie nts s h o u l d be considered for s u r g i c a l d e l ay. A t h o r o u g h d i scuss i o n with the patient reg a rd i n g g o a l s a n d reaso n a b l e expectati o n s is essenti a l .

• • • •

Patient m a r k i n g I ntraoperative tech n i q u e

•

Ca refu l m a r k i n g of the patient i n the sta n d i n g a n d seat i n g posit i o n s is esse n t i a l to a su ccessf u l TRAM flap.

•

U s e either b i p o l a r o r very l o w ca utery t o avoid i n j u ry t o the m e d i a l a n d l atera l rows o f perforators. Ca refu l ly assess the m a stecto my flap v i a b i l ity. Excise any q u est i o n a b l e a reas o r consider d e l a y i n g the f l a p i n set.

•

POSTOPERATIVE CARE •

•

•

• •

• •

Awaiting extubation and during transfer of the patient, the bed is kept in the flexed position. Routine postoperative care includes removal of the Foley catheter on the night of surgery, SCD boots, and subcuta­ neous deep vein thrombosis (DVT) prophylaxis beginning 6 hours after the procedure is completed and per the Caprini scale. Patients are moved to the chair and ambulated the afternoon of surgery or next morning. Incentive spirometry is encouraged hourly. No bra is initially placed to prevent compression of the ped­ icle, and a binder is placed when patient is ambulating but not while in the chair or sitting up in bed again to avoid compression of the pedicle. The binder is recommended for 6 to 8 weeks followed by use of compression undergarments for comfort. A surgical bra without underwire is placed in clinic on the first visit once the mastectomy flap has matured. No postoperative antibiotics are given after inset of the flap. Patients are discharged between 1 and 3 days after the pro­ cedure or on the day of inset if inset has been delayed.

•

•

•

OUTCOMES •

•

•

•

COMPLICATIONS •

The most common complications related to breast recon­ struction is mastectomy flap necrosis. Careful inspection and experience with your breast surgeon is critical.

Partial flap loss or fat necrosis are also possible but have been limited by our requirements of smoking cessation and experience with surgical delay prior to TRAM. Complete flap loss is very unusual. Abdominal bulge, hernia, and back pain are also reported complications of TRAM patients. DVT and pulmonary embolus are life-threatening com­ plications.

•

In immediate breast reconstruction cases, common revisions include lateral abdominal dog ear scar revision. If the case was not nipple sparing, this can be performed under local anesthesia at the time of nipple reconstruction. Asymmetry can be improved also based on the patient's breast size goal and preoperative size, with contralateral breast reduction or mastopexy. Secondary revisions are more common in cases of delayed reconstruction. These can be performed to improve symme­ try at the time of nipple reconstruction. In all cases, the superior pole may have a paucity of tissue and can be improved with autologous fat grafting. A common secondary procedure includes NAC reconstruction, dog ear revisions, and fat grafting to the superior pole. With these revisions, we have found patients to be very satis­ fied with their outcomes, with a few number of interventions ( FIG 1 3 ) .

C h a p t e r 1 7 PEDICLED TRANSVERSE RECTUS ABDOM I N I S MYOCUTANEOUS FLAP BREAST RECONSTRUCTION

A

B

SUGGESTED READINGS 1.

Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2) : 216-225. 2. Kanchwala SK, Bucky LP. O ptimizing pedicled transverse rectus abdominis muscle flap breast reconstruction. Cancer]. 2008;14(4) : 236-240. 2. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free. j Surg Oneal. 2006;94(6) : 532-537. 3. Shestak KC. Breast reconstruction with a pedicled TRAM flap. Clin Plast Surg. 1998;25(2) : 167-182.

150 1

FIG 1 3 • A,B. Pre- a n d postoperative i mages of d e l ayed TRAM flap breast reconstruction.

4 . Mizgala CL, Hartrampf CRJr, Bennett G K . Assessment o f the abdom­ inal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg. 1994;93(5) : 988-1002. 5. Atisha OM, Comizio RC, Telischak K M, et al. Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement. Ann Plast Surg. 2010;65(6) : 524-527. 6. Nair N, Atisha OM, Streu R, et al. An innovative approach to the primary surgical delay procedure for pedicle TRAM flap breast recon­ struction. Plast Reconstr Surg. 2010;125(4) : 173e-174e. 7. Kerrigan CL, Collins ED. Are perforator flaps truly more cost-effective than TRAM flaps? How good is the evidence. Plast Reconstr Surg. 2001;107(3) : 881-883.

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Chapter

18

Free Transverse Rectus Abdominis Musculocutaneous Flap Reconstruction after Mastectomy

I

- -----------------------------------

�

-----------------------------------------------------

I

Ma urice Y. Na habedia n

DEFINITION • •

•

•

•

•

•

Breast reconstruction using free tissue transfer techniques have become routine procedures following mastectomy. The most common free flaps for breast reconstruction in­ clude the free transverse rectus abdominis musculocutaneous (TRAM) flap and the deep inferior epigastric perforator (DIEP) flap. Indications for these flaps are primarily based on the availability of sufficient skin and fat at the abdominal donor site. There are several decision points to be considered when determining candidacy for a free TRAM or DIEP flap. Many patients are now choosing to have bilateral mastectomy and reconstruction in the setting of unilateral breast cancer or for prevention of breast cancer. Once the decision to proceed with an abdominal free flap for breast reconstruction has been made, decisions relating to the type of abdominal flaps are considered and based on patient anatomy and surgical experience. Non-muscle-sparing free TRAM flaps are technically easier but are associated with increased donor site morbidity that includes contour abnormalities and weakness. These mor­ bidities are increased when the continuity of the rectus abdominis muscle has been disrupted, such as with the tradi­ tional pedicle TRAM and the MS-0 (full width) free TRAM. For these reasons, the full-width free TRAM flap is rarely performed and will not be included in this review. Muscle-sparing free TRAM flaps and DIEP flaps are tech­ nically more challenging and require a better understand­ ing and appreciation of perforator anatomy and dissection techniques. This chapter will focus on the free TRAM flap, whereas the DIEP flap is covered in Part 5, Chapter 19. Muscle-sparing TRAM flap classification 1 ( FIG 1 [top]) MS-0: no muscle preservation (traditional TRAM flap) MS- 1: medial or lateral muscle preservation MS-2: medial and lateral muscle preservation (central muscle sacrificed) MS-3: total muscle preservation (DIEP flap)

•

•

•

Many women with moderate to excessive volume are in­ terested in these options because of the abdominoplasty appearance of the abdomen that is usually obtained. In women that lack a suitable quantity of abdominal soft tissue, alternative donor site options such as the gluteal or medial thigh region are considered. Sufficient donor site volume must be assessed to deliver appropriate breast volume. In some cases of bilateral free flap reconstruction, a hemiabdominal flap may not provide

1502

adequate volume and adjuncts such as combining flaps with implants or autologous fat grafting may warrant consideration. Prior abdominal surgery or body habitus may necessitate the use of computerized tomographic angiography (CTA) or magnetic resonance angiography (MRA) to assess the patency and location of the perforators and deep inferior epigastric artery and vein.

SURGICAL MANAGEMENT Preoperative Planning •

•

• •

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

·

Ke ta n M. Pa tel

A thorough history should focus on comorbidities, smoking history, previous surgeries, and medications that can alter surgical management and affect microvascular reconstruc­ tion. (Examples include coagulopathies, previous cardiac bypass surgery, previous abdominal surgery, and antiplatelet medications.) Physical exam will uncover hernias and previous abdominal scars. In addition, an assessment of the anterior abdomen for thickness and dimensions will aid in estimating a recon­ structed breast volume. General complications include bleeding, hematoma, seroma, infection, delayed healing, and injury to surrounding structures. Specific complications include a 1 % to 3 % total flap failure rate, 2 early revisional surgery for microsurgical anastomotic thrombosis, late revisional surgery for contour irregulari­ ties, breast asymmetry, poor cosmetic result, and donor site complications that include an abdominal bulge/hernia (3 % to 5 %) / complex scarring, lateral "dog ears," and prolonged pain. Average length of surgery can range from 4 to 8 hours for a unilateral reconstruction and 6 to 12 hours for a bilateral reconstruction. Appropriate deep vein thrombosis (DVT) prophylaxis and perioperative antibiotics are routinely used due to the length and extent of surgery. The decision to proceed with a free TRAM or DIEP flap is sometimes made preoperatively and other times intra­ operatively. Patients with a high body mass index (BMI) ( > 3 5) who have an overriding pannus are usually sched­ uled preoperatively for a muscle-sparing free TRAM flap. In other patients, who are found to lack a dominant perfora­ tor intraoperatively, the decision to convert from a DIEP to a free TRAM is made. If one or two dominant perforators are found, a DIEP flap is performed.

Anatomy •

The lower abdominal skin is supplied by perforating vessels from the primary source vessels that include the superior and deep inferior epigastric system.

C h a p t e r 1 8 FREE TRAM FLAP R E C O N STRUCT I O N AFTER MASTECTOMY

1503

...:.IO!tW ..:.. III • l lU III·----;--- MS-1 TRAM

MS-2 TRAM (medial and lateral muscle preserved; central muscle harvested)

-----,----

(medial or lateral muscle segment harvested)

/

/ \ \

'

/

'

,.

'

, -'

....

..... ....

MS-0 TRAM -------' (entire muscle harvest)

MS-3 TRAM or D I E P (no muscle sacrificed)

-------:-- Rectus abdominis muscle

Lateral and medial branches

:s; ��-tf-"""TI , ' �'V �-------:,...

----�- --

Pedicle Deep inferior epigastric vessels -----'----------_.._,..----4gj,.,_

-�---------'--- External iliac

vessels

FIG 1 • The va riations of m uscle preservati o n d u r i n g abdom i n a l flap ha rvest a re shown . A traditional M S-0 represents the entire h o rizonta l seg ment of rectus h a rvest. An MS-1 ha rvest can either spare the med i a l or l atera l seg m e nts of rectus abdom i n is m uscle as shown. S pari n g of the latera l seg ment of m uscle may resu lt i n a n i m p roved functio n a l benefit as motor i n n e rvation to t h i s seg ment i s s p a r e d . M S-2 f l a p ha rvest spa res the m e d i a l and l atera l m uscle seg ments w i t h ha rvest o f a centra l portion of the m uscle. An M S-3 or D I E P f l a p spares t h e entire m uscle a n d req u i res i ntra m uscu l a r perforator d i ssect i o n .

1504

•

•

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

Source vessels travel vertically along the fibers of the rectus abdominis muscle on each side of the abdomen and send vertical perforating vessels to the overlying skin and subcu­ taneous tissue. The inferior epigastric system originates from the medial as­ pect of the external iliac system just superior to the inguinal

•

•

ABDOMINAL FLAP HARVEST •

•

•

ligament. The pedicle enters the rectus abdominis muscle on the undersurface from the inferolateral aspect of the muscle at the junction of the lateral and central third of the muscle. Two main intramuscular branches are identified: a lateral and medial branch. These branches then send perforating vessels to the overlying skin ( FIG 1 [bottom]).

The patient is ma rked i n the up right position (FIG 2). The a nterior superior i l iac sp i n e (AS I S) is pa lpated a n d m a rked b i l atera l ly. T h e upper extent o f the a b d o m i n a l flap is d e l i neated, con n ecti n g t h e two AS I S m a rks a cross the abdomen and stayi n g app rox i m ately 1 em a bove the u m b i l icus. The lower abdom i n a l l i n e is an estimation that extends from the two AS I S markings i n a c u rvi l i near fashi o n . The i nferior l i m it of this l i n e is the p u b i c symp hysis. The fi n a l i nferior l i ne is determ ined in the operat i n g room afte r the upper ski n flap is red raped. The markings for a free TRAM flap a n d a DIEP flap a re i d e ntica l (FIG 3) . The i n iti al incision is the upper abdom i n a l e l l ipse. The i ncision exte nds to the a nterior rectus sheath using elec­ troca utery (FIG 4). The upper abdom i n a l a d ipocuta neous flap is typ i ca l ly u ndermined to the m i dp o i nt between the u m b i l icus and the xip h o i d p rocess. The patient is fl exed 1 0 to 30 deg rees a n d the lower a b d o m i n a l e l l ipse is defi n itively d e l i n eated and i ncised. The u m b i l icus is i ncised a n d p reserved on its sta l k.

•

•

•

F l ap e l evation beg i n s from a l atera l to m e d i a l d i rec­ tion at the l evel of the a nterior rectus sheat h . The "safe zone" exte nds to the l atera l edge of the l i nea sem i l u na­ ris. M e d i a l to the l i nea sem i l u na ris, extre me p reca utions a re taken to p reserve and avoid i nj u ry to perforat i n g vessels from the deep i nferior ep ig a stric system (FIG 5) . A d e c i s i o n at t h i s stage m u st be made t o determ i n e if a m u sc le-sp a r i n g free TRAM flap or DIEP flap will be performed . I n either case, the latera l i n n e rvation to the rectus a b d o m i n i s m uscle is p reserve d . If b i l atera l free D I E P flaps are to be performed, m e d i a l to latera l a n d latera l to med i a l perforator d i ssection is performed (FIG 6) . This i s fac i l itated u s i n g b ip o l a r cau­ tery or m o n op o l a r ca utery at very low cu rrent. Mosqu ito c l a mps are used to e l evate and d ivide stra nds of m uscle fi bers without i n j u ry to the perforators or u nderlying vasc u l ature. With the m uscle-sp a r i n g free TRAM tech n i q ue, a n island of perforato rs i s defi ned a n d the a nterior rectus sheath surro u n d i n g the i s l a n d of perforators is i n cised (FIG 7).

Common ell1pt1cal exc1s1on pattern for mastectomy

Medial and lateral branches

TRAM and D I E P flap markings

Deep inferior epigastric artery and vein

FIG 2 • An o b l i q u e or horizonta l e l l ipse is tra d itionally performed d u ri n g a non-n ipp le-sparing mastectomy. Other config u rations that can be used in c l u d e a periareol a r c i rcu l a r pattern or a vertica lly oriented pattern. Knowledge of the rib a n atomy a n d i ntercosta l spaces wi l l a i d in selecting a recip ient site for m icrosu rg ical a nastomosis. A l a rge i nterspace, usually the 3 rd or 4th i ntercosta l space, is usually selected . The i ntern a l m a m m a ry vessels a re located close to the sternocosta l j u nctio n .

C h a p t e r 1 8 FREE TRAM FLAP R E C O N STRUCT I O N AFTER MASTECTOMY

FIG 3 • The abdomen i n sup i n e position is shown. The upper incision is usua l ly l ocated j ust a bove the u m b i l icus. The l ower incision is p laced i n the lower abdom i n a l crease or i n a position to a l low for donor site closu re.

•

•

The m e d i a l a n d latera l sheath is e levated off the m uscle a n d the retrorectus space is defi n e d . The surro u n d i n g m uscle is d ivided u s i n g monop o l a r o r bipo l a r cautery. The superior portion of the rectus m uscle is cauterized and the d ista l extent of the vasc u l a r pedicle is c l ipped. Palpation beneath the m uscle w i l l h e lp i d entify the p u lse and l ocati o n of the pedicle to ensure that the pedicle is with i n the m uscle seg ment (FIG 8) . O n ce t h i s is performed, the flap is s o l e l y based o n t h e deep i nferior ep i gastric system a n d elevated f r o m d ista l

FIG 4 • The upper incision is performed fi rst. If b i l atera l reconstruction is being performed, the abdom i n a l flap can be d ivided down the m i d l i n e .

F I G 5 • F l ap elevation beg i n s f r o m the l atera l e d g e . As t h e rectus sheath is encou ntered, latera l row perforators can b e fou n d p ierci n g the fascia t o perfuse the overlying s k in a n d fat.

•

•

to p roxi m a l . Ca utery d i ssection p roceeds at low cu rrent (FIG 9) . T h e p roxi m a l portion o f the p e d i c l e can be visua l ized trave l l i n g towa rd the latera l edge of the rectus m uscle a n d i s d issected using s h a rp i nstru m e nts. A l l side branches are cl ipped or l igated . Ca re m u st be taken to avo i d i n j u ry to the vesse ls a n d i ntercosta l n e rves at this stage as d i a ­ t h e r m i c i n j u ry may resu lt i n vessel t h ro m bosis or n e u r a l i n j u ry (FIG 1 0) . Ped icle d i ssection is cont i n u e d p roxi m a l ly as deemed necessary for adeq u ate pedicle length. S l i g htly in c reased ca l i be r of the deep i nferio r ep i gastric a rtery (DIEA)/deep i nferior ep i gastric vein ( D I EV) is seen with more p roxi m a l d i ssect i o n . App roximately 1 0 t o 1 2 em may be obta in e d if d issection i s conti nued to the exter n a l i l iac vessels.

FIG 6 • D i ssection from the med i a l aspect of the flap is performed u n t i l medial row perforato rs a re encou ntered a n d/ or u n t i l safely over the rectus m uscle.

1505

1506

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 7 • When h a rvest i n g a m u scl e-sp a r i n g TRAM flap, a fasc i a l i s l a n d is created around the perforators. The rem a i n i n g fascia is elevated off o f t h e surro u n d i n g m uscle f o r better visu a l ization and d i ssect i o n .

F I G 9 • Once t h e m uscle cuff i s ha rvested, p roxi m a l d i ssection will reve a l the pedicle vesse ls.

FIG 8 • Ca refu l d i ssection of the superior extent of the flap w i l l a l low for l i gation of the d i sta l pedicle to a l low for d i sta l to p roxi m a l flap h a rvest.

FIG 1 0 • Care is taken to avoid i n j u ry to the pedicle d u r i n g retro g rade p e d i c l e d i ssectio n .

RECIPIENT VESSEL DISSECTION

•

•

The two sets of recipient vessel s for free flap breast recon­ struction i n c l u d e the i ntern a l m a m m a ry a n d thoracodor­ sal a rtery a n d vei n . The m ost com monly used recip ient vesse ls are the i ntern a l m a m m a ry system .

The i ntern a l m a m m a ry vesse ls r u n paramed i a n to the stern u m d i rectly beneath the costa l carti l a g e on the left a n d the right side. The thoracodorsa l vessels are poste­ rior in the axi l l a ry space and traverse a l o n g the anterior su rface of the latissi m u s dorsi m uscle.

C h a p t e r 1 8 FREE TRAM FLAP R E C O N STRUCT I O N AFTER MASTECTOMY

Internal mammary vessels (underneath rib and muscle)

r-,..

---------:

FIG 1 1 • Selecti o n of the i nterspace is usua l ly performed i ntraoperative ly with p a lpation of the i nterve n i n g r i b seg me nts. Selecti o n of a r i b too low can resu lt i n a s m a l l e r ca l i ber vei n and a n a rrow i nterspace.

•

•

•

•

The exposure tech n i q u e described is for the i ntern a l m a m ­ m a ry system . An appropriate i ntercosta l space is chosen that wi l l a l low for adequate access for perform i n g m i crosurgery. This is usually the 3 rd or 4th i nterspace (FIG 1 1 ). The pectora l i s major m uscle overlyi n g the desired r i b i s d ivided a l o n g the d i rection of the fi bers u s i n g e lectrocautery. An adequate window is made, a l lowi ng for f u rther r i b a n d vesse l d i ssection (FIG 1 2) . The peric h o n d ri u m is then removed overlying the costa l portion of the r i b a n d d i ssection p roceeds in a s u bperichondrial fash i o n (FIG 1 3) . Doyen surgical i n struments a re used to release the pos­ terior perichondri u m . Caution is taken in this d i ssection, as i n advertent passage thro u g h the posterior perichon­ drium can resu lt i n i ntern a l m a m m a ry a rtery a n d i ntern a l

FIG 1 2 • D i v i s i o n a l o n g the pectora l i s m a j o r fi bers w i l l reve a l the desired carti l a g i nous rib f o r resect i o n .

•

•

•

m a m m a ry vei n (IMA/I MV) vessel i nj u ry or entry i nto t h e p l e u r a l space. A rib cutter is t h e n used t o isolate a n d re­ move a l atera l seg ment of costa l cartilage (FIG 14). R i b remova l with a bone rongeur then p roceeds from l atera l to medial, again avo i d i n g i n j u ry to the posterior pericho n d r i u m (FIG 1 5) . F o l l o w i n g comp lete remova l of the costa l cart i l a g e seg­ ment, the posterior perich o n d r i u m is d ivided, e l evated, and ca refu l ly excised using bip o l a r ca utery and m icrodis­ section (FIG 1 6) . T h e i nter n a l m a m m a ry a rtery a n d vei n a re visualized. The vei n is usua l ly the med i a l structure. Occa s i o n a l ly, a vena comitans is p resent. The recip ient vessel s are f u r­ ther d i ssected to clear the perivascu l a r tissue u s i n g I o upe m a g n ification (FIG 1 7) .

FIG 1 3 • The pericho n d r i u m i s i n cised a n d a n e l evator is used to c i rcu mferentia l ly d issect around the rib seg ment.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 14 • A rib cutter is used to rem ove the carti l a g i nous seg ment of rib.

FIG 16 • Ca refu l d i ssection is performed to sepa rate the posterior peric h o n d ri u m from the u nderlyi n g vesse ls.

FIG 1S • A ron g e u r is used to finish the remova l of the carti l a g i n o u s portion of rib. Ca re is taken to avo i d i n j u ry to the posterior pericho n d r i u m as the i ntern a l m a m m a ry vesse ls l i e deep to this struct u re.

FIG 1 7 • Perivasc u l a r d i ssection is performed i n order to p repare the vessels for m i croa nastomosis.

MICROSURGICAL ANASTOMOSIS • •

•

•

I ntravenous hep a r i n is u s u a l l y a d m i n i stered prior to d ivi­ s i on of the i nferior ep i gastric vesse ls. The h a rvested flap is positioned over the chest wa l l such that the i nferior ep i g a stric a rtery a n d vei n are a l ig n ed with the i ntern a l m a m m a ry a rtery a n d vei n . The med i a l a nastomosis is usua l ly performed fi rst, which is typ i c a l l y the venous a nastomosis. This is fo l l owed by the latera l or a rterial a nastomosis. The decision to use the vasc u l a r coup l e r (FIG 1 8) or to perform a h a n d -sewn a nastomosis is based on s u rgeon p reference. If a coup l e r i s chosen, 2 .0- to 3.0-mm ring is

•

•

usu a l ly reco m m e n d e d . If a h a n d-sewn venous a nastomo­ sis i s chosen, 8-0 o r 9-0 sutu res a re used i n a n i nterrupted o r conti n uous fash i o n . Avoi d a nce of back-wa l l sutu res is critica l (FIG 1 9) . Usua l ly 8 to 1 0 sutu res a re needed to comp l ete the a rtery (FIG 20). Fol l ow i n g comp letion of the a rterial a n d venous a n a sto­ m oses, the vascu l a r pedicle m ust be app ropriately posi­ tioned on the chest wa l l to p revent twist i n g and k i n k i n g i n o r d e r t o m i n i m ize pedicle-re l ated comp l ications such as throm bosis. Position i n g of the flap on the chest wa l l is a n i mportant step to recreate the breast conto u r and shape. Fortunately

C h a p t e r 1 8 FREE TRAM FLAP R E C O N STRUCT I O N AFTER MASTECTOMY

1509

Internal mammary vein Internal mammary artery Venous coupling device

Inferior epigastric vein Inferior epigastric artery

Forceps used to tamp vessel onto coupler spikes

Venous coupling device

FIG 18 • When the venous cou p l e r is chosen to perform the venous a n a stomosis, proper o r i e ntat i o n of the co u p l e r d evice wi l l e n s u re a n efficient a n asto mosis. Perfo r m i n g the donor ve i n fi rst wi l l a l l ow for reorientat i o n of the d evice prior to perform i n g the rec i p i e nt side. The ta m p i n g forceps h ave a s m a l l centra l hole that a l l ows correct position i n g of the ve i n on the cou p l e r s p i kes.

FIG 19 • The med i a l ly located ve i n i s usually a n a stomosed fi rst with i nterru pted m icrosutu res.

FIG 20 • Arter i a l a nastomosis is then performed u s i n g the same m icroanastomosis tech n i q ues.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

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with free fla ps, there a re no poi nts that tether the flap and mobi l ity of the flaps is m a i nta ined for opti m a l shaping. The a b d o m i n a l donor site closu re is a n i m porta nt phase of the breast reconstruct i o n . With the D I E P f l a p, there is no m uscle rem oved a n d usu a l ly no fascia; therefore, the closu re consisted of a p r i m a ry closure u s i n g a non­ a bsorba b l e monofi l a m ent. Rei nforce m e nt with a syn­ thetic mesh is rarely necessa ry. With the m u scle-spa r i n g free TRAM, m uscle a n d fasci a are re moved; therefore, i t is sometimes necessary to rep l ace the fascia w i t h a syn­ thetic or b i o l o g i c mesh. This is more com m o n with b i lat­ era l reconstructions compared to u n i latera l (FIG 21 ) . Two d r a i n s a re usua l ly p laced i n the donor site a n d one d ra i n i n the reconstructed b reast.

FIG 2 1 • The donor defect is shown. When l a rger seg ments of a nterior rectus sheath a re ha rvested (such as in MS-0 a n d M S - 1 TRAMs), m e s h is used t o either rei nforce the anterior abdom i n a l wa l l or to rep l ace the a nterior fasc i a .

PEARLS AND PITFALLS F l a p d i ssection

• •

•

M i croa nastomosis tech n i q ues

•

Flap i n setti n g

• •

F i n g e r p a l pation of the pedicle p u lse i s cruci a l during m u scle-sparing ha rvest tec h n i q ues. A longer pedicle will a l low for a l a rg e r vessel i nterna l d i a m eter that more closely matches the i nter n a l m a m m a ry vessel d i a m eter. Seco n d a ry venous d r a i n a g e may be h e l pf u l for l a rg e r f l a ps. Radiated i ntern a l m a m m a ry vesse ls a re l ess p l i a b l e and may tea r m o re easily when using a venous cou p l e r device. Excisi n g rad i ated mastectomy f l a p s k i n may prevent tig htness of the f l a p i nset a n d l ater conto u r i rreg u l a rities. Suture tacks i n the s u perior portion of the flap w i l l m a i nta i n conto u r of the s u perior pole of the b reast.

POSTOPERATIVE CARE •

•

• •

Close flap monitoring occurs in the first 72 hours to ensure flap viability. A strict nursing flap check protocol includes frequent Doppler examination, color, and capillary refill as­ sessments. Tissue oximetry is used on almost all flaps. Patients are maintained on postoperative antibiotic therapy for approximately 5 days and aspirin for 1 to 2 weeks to prevent anastomotic thrombosis. Ambulation is encouraged on postoperative day 1 or 2. Patients usually stay in the hospital for 3 to 4 days following surgery and are discharged home. They are encouraged to shower on postoperative day 3.

•

•

•

• •

OUTCOMES •

The free TRAM reconstruction has been demonstrated to re­ sult in high levels of patient satisfaction and quality of life.4 In long-term evaluation, autologous tissue reconstruction maintains a more natural-appearing breast as compared to implant-based reconstruction.5

Abdominal donor site morbidity is relatively low.6•7 Bulge/ hernia formation may occur in approximately 3 % to 5 % of patients. In the event that surgical repair is necessary, this is usually achieved with fascial plication and reinforcement with a synthetic mesh. The free TRAM and DIEP flaps for breast reconstruction are valuable options for breast reconstruction following mastectomy. Free tissue transfer techniques are useful in complex situa­ tions such as prior radiation therapy, prosthetic failure, and in overweight and obese patients. Microsurgical expertise is necessary to obtain predictable outcomes and a low failure rate. Donor site morbidity rates are acceptable. Most women will achieve an "abdominoplasty" appearance of the abdomen following free TRAM and DIEP flap reconstruction.

COMPLICATIONS •

The most relevant complications following microvascu­ lar breast reconstruction include anastomotic thrombosis,

C h a p t e r 1 8 FREE TRAM FLAP R E C O N STRUCT I O N AFTER MASTECTOMY

•

hematoma, and flap failure. Postoperative flap monitor­ ing is necessary to ensure prompt operative exploration in cases of vascular thrombosis. This is usually accomplished using tissue oximetry or Doppler analysis. Return to the operating room is necessary when there is a disruption in flow. Revision maneuvers include mechanical throm­ bectomy, tissue plasminogen activator (TPA), and redo anastomosis. Donor site morbidities are slightly more common and include contour abnormalities (hernia/bulge), incisional dehiscence, delayed healing, hematoma, and seroma. These complications can be managed conservatively but sometimes require opera­ tive intervention.

REFERENCES 1. Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg. 2005;115:436.

151 1

2. Nahabedian MY, Momen B, Manson PN. Factors associated with anastomotic failure after microvascular reconstruction of the breast. Plast Reconstr Surg. 2004;114:74-82. 3. Nahabedian MY. Secondary operations of the anterior abdominal wall following microvascular breast reconstruction with the TRAM and D!EP flaps. Plast Reconstr Surg. 2007;120:365-372. 4. Yueh JH, Slavin SA, Adesiyun T, et al. P atient satisfaction in post­ mastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125:1585-1595. 5. Hu ES, P usic AL, Waljee JF, et al. P atient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124:1-8. 6. Seiber JC, Nelson J, Fosnot J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part I. unilateral reconstruction. Plast Reconstr Surg. 2010;126:1142-1153. 7. Seiber ]C, Fosnot ], Nelson J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part II. Bilateral reconstruction. Plast Reconstr Surg. 2010;126:1438-1453.

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Chapter

19

Deep Inferior Epigastric Perforator Flap Breast Reconstruction after Mastectomy I

�

- ----------------------------------------------------------------------------------------I

t

Adeyiza 0. Momoh

•

DEFINITION •

Autologous reconstruction techniques after mastectomy are well-established options for breast reconstruction. Although over the years multiple flap options for reconstruction have been described, abdominal-based flaps continue to be the workhorse for autologous breast reconstruction. Abdominal flaps provide distinct advantages over implant-based recon­ struction including a natural contour, superior symmetry and appearance of the reconstructed breast mound, and higher patient satisfaction.1•2 A secondary benefit of these flaps is the improvement they provide to the abdominal contour. Hartrampf et aJ.3 first described the pedicled transverse rec­ tus abdominis myocutaneous (TRAM) flap in 1982, with its benefits of providing a soft, ptotic, aesthetically pleasing reconstruction that closely approximates the natural breast. Technical advancements and the continued quest to improve on flap perfusion and minimize donor site morbidity led to the introduction of the deep inferior epigastric perforator (DIEP) flap by Koshima and Soeda4 in 1989 with later popularization by Allen and Treece5 in 1994. The DIEP flap has gained in popularity over the years, and the potential benefits it offers include less abdominal wall weakness, bulging, and hernias.6-8

ANATOMY •

•

1512

• •

• •

•

• •

•

The DIEP flap is an adipocutaneous flap based on intramus­ cular perforators from the deep inferior epigastric artery (DIEA) and deep inferior epigastric vein (DIEV). The DIEA and DIEV originate from the external iliac vessels in the groin and course superomedially toward the lateral border of the rectus abdominis muscle.

Type I

Type I I

·

Type I l l

•

•

Deep to the rectus abdominis muscle, the DIEA and DIEV most commonly bifurcate (type II branching pattern) in the vicinity of the arcuate line and join up with the superior epi­ gastric vessels above the umbilicus. Other encountered branching patterns are the type I with no branching and type III with trifurcating vessels ( FIG 1 ) . Perforators to the lower abdominal skin and adipose tis­ sue come off the pedicle at multiple levels and are referred to as medial or lateral rows of perforators, indicating their relative position within the rectus/entry point into the flap. Most perforators are found within a 10-cm radius from the umbilicus. Zones of perfusion based on fluorescent perfusion studies9 are illustrated in FIG 2-illustration with zones transposed onto rectus/pedicle. In general, perfusion of the hemiabdominal flap ipsilateral to the perforators (zones I and II) is stronger than it is to the contralateral abdominal flap across the midline (zones III and IV). Medial row perforators have a greater likelihood of perfus­ ing tissue across the midline than do lateral row perforators. In contrast, lateral row perforators have a greater likelihood of perfusing the most lateral extent of the ipsilateral hemiab­ dominal flap than do medial row perforators. Medial and lateral rows of perforators communicate via a subdermal plexus. There is also communication between DIEA and DIEV sys­ tem and the superficial inferior epigastric artery (SIEA) and superficial inferior epigastric vein (SIEV) system. The SIEV is the dominant outflow vessel for the lower abdo­ men in many patients.

FIG 1 • Type I, type I I , a n d type I l l vasc u l a r b ra n c h i n g patterns.

C h a p t e r 1 9 DEEP I N FERIOR EPIGASTRIC PERFORATOR FLAP BREAST RECONSTRUCTION AFTER MASTECTOMY

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FIG 2 • Zones of perfus io n of the lower abdomen based o n fluorescent perfusion stud ies.

PATIENT HISTORY AND PHYSICAL FINDINGS

IMAGING AND OTHER DIAGNOSTIC STUDIES

•

•

•

•

•

A

A thorough history and physical examination are critical in preparing for reconstruction. Pertinent aspects of the history include previous abdominal or chest wall operations and medical conditions that would preclude patients from a lengthy operation under general anesthesia." A focused abdominal examination evaluating the amount of lower abdominal adipose tissue and the location of surgical scars if present A team-based approach involving surgeons, anesthesiolo­ gists, primary care physicians, and other specialists such as cardiologists, as needed, ensures that patients are evaluated as a whole and all key concerns are addressed.

B

•

•

Preoperative computed tomography (CT) angiography of the donor site has been advocated in recent years. The preoperative scans provide a road map for flap perfora­ tors, with information on perforator location, size, and distribution ( FIG 3 ) . I n patients with long low transverse abdominal incisions, the scans also allow for the assessment of continuity of the flap pedicle beyond the incision. Information gathered from scans has been shown to decrease operative times.10 CT scans, however, are not an absolute requirement for preoperative planning.

c

FIG 3 • A.B. Preoperative CT a n g i og raphy of the l ower a b d o m e n . C. A 3-D ren d e r in g of the abdom i n a l soft tissue. Perforator locations based o n axia l cuts are tra nsposed to the ski n su rface to e n h a nce preoperative p l a n n i n g .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

SURGICAL MANAGEMENT •

In consulting with patients, decisions about the timing of re­ construction (immediately after mastectomy or delayed) and the type of reconstruction are made, taking patient factors and tumor characteristics into consideration. • Patient factors of significance include the following: Patient preference Body habitus or the availability of abdominal donor tissue Body mass index Smoking history History of previous abdominal operations that compro­ mise the vascular pedicle or donor site Medical comorbidities that would preclude patients from undergoing a lengthy operation • Tumor characteristics as they relate to the following: The need for postmastectomy radiation therapy or The need for close postmastectomy surveillance prior to reconstruction In general, patients known to require postmastectomy radiation therapy are reconstructed in a delayed fashion to avoid the detrimental effects of radiation on flaps. A history of radiation therapy also serves as a relative in­ dication for use of an autologous form of reconstruction, as implant reconstructions in the setting of radiation are prone to higher rates of complications and failure.

Preoperative Planning •

•

• • •

Positioning

Marking/positioning • •

•

•

In addition to basic labs, patients should be type and screened, particularly in cases of bilateral reconstructions.

A FIG 4

•

All anticoagulant and antiplatelet medications should be stopped a week prior to the operation. Warfarin can be bridged with enoxaparin also a week prior. Smokers are required to quit for a minimum of 4 weeks prior. Patients receive preoperative antibiotics with intraoperative redosing. Patients receive deep vein thrombosis (DVT) prophylaxis with use of a pneumatic compression device and subcutane­ ous heparin at the beginning of the case.

Preoperative markings of the breast and abdomen are per­ formed with the patient in the upright position. Key landmarks for the breast marked are the chest midline, inframammary fold, and a periareolar marking in the case of a skin-sparing mastectomy. The breast base width is also measured ( FIG 4A). The upper marking for the abdominal flap is made at or just above the umbilicus with the location of perforators on preoperative imaging, providing some guidance. The breast base width is used to mark the potential vertical height/ distance from the upper marking to the lower marking. The lower marking is then made to complete the elliptical pattern ( FIG 4B) . Patient positioning in the operating room (OR) is supine and the table is turned 180 degrees from the anesthesiologist, providing better access for two surgical teams ( FIG S ) .

B A . B reast preoperative m a r k i n g . B. Abdom i n a l preoperative ma rki n g .

C h a p t e r 1 9 DEEP I N FERIOR EPIGASTRIC PERFORATOR FLAP BREAST RECONSTRUCTION AFTER MASTECTOMY

Anesthesiologist

Surgical team 2 (reconstruction)

Surgical team 1 (surgical oncology)

Position of base of microscope later in case FIG 5

•

Patient pos it i o n i n g i n the O R .

FLAP HARVEST • • •

•

•

•

•

S k i n preparation with c l i p p i n g is performed as needed. The breasts a n d abdomen a re prepped a n d d ra ped i n a ste r i l e fas h i o n . The upper abdom i n a l i ncision is made with a sca l pel, a n d d issection through t h e a d i pose tissue down t o a nterior abdom i n a l wa l l fascia is perfo rmed with electroca utery. An a d i pocuta neous f l a p is e levated cep h a l a d with the electroca utery, e n d i n g at the xiphoid centra l ly a n d at the costa l m a rg i ns l atera l ly. Less e l evation may be needed in patients with ample s k i n laxity. The OR ta b l e is refl exed a n d the ra ised upper a b d o m i ­ n a l f l a p i s tra nsposed downward to assess the a b i l ity o f t h is s k i n edge to meet the l ower abdom i n a l m a rk i n gs for c l os u re. The lower abdom i n a l m a r k i n gs are at th is time adj usted as needed a n d the table retu rned to its orig i n a l positi o n . The l ower abdom i n a l i ncis i o n is m a d e su perficia l l y with a sca l pe l a n d ca refu l d issection t h ro u g h the a d i pose tiss u e i s performed, a nticipat i n g the presence of the S I EA a n d S I EV, typica l ly a bove Scarpa's fascia (FIG 6). O n ce the s u perfi c i a l vessels are vis u a l ized, a Weit l a n e r retractor i s i ntrod uced t o provi de f u rther expos u re a n d

FIG 6 • D issection of the SIEV with i n the l ower abdom i n a l i ncis i o n .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 7 • The latera l row of perforators vis u a l ized with s u p rafascia l flap e l evat i o n .

• •

•

•

•

•

the vessels a re d issected out toward the fem o ra l vessels with use of tenotomy scissors a n d b i p o l a r e l ectroca utery. In patients who a re not good ca n d i d ates for the S I EA f l a p (SI EA) based on the a bsence of adequate-sized vessels, the ve i n is d issected to a length g reater than or e q u a l to 5 em prior to l igating it with hemoc l i ps a n d d i vi d i n g it. D issection down to the anterior abdom i n a l wa l l fascia is then com p l eted with e lectroca utery. F l a p elevation is performed i n the s u p rafascial p l a n e f r o m l atera l to m e d i a l w i t h e lectroca utery u n t i l the lateral row of perforators a re encou ntered j ust m e d i a l to the edge of the rectus fascia (FIG 7) . An i n c ision is made around the u m b i l icus a n d a l o n g t h e m i d l i n e of the f l a p i n b i l atera l reconstruction cases o r i n cases with h e m i a bdom i n a l f l a ps l a rge e n o u g h for a u n i l atera l reconstruct i o n . The u m b i l ica l sta l k is d issected out with b l u nt-ti pped scissors and d ivis i o n of the flap down the m i d l i n e is com p l eted with electroca utery. I n u n i latera l reconstructions that req u i re use of portions of the f l a p that cross the m i d l i ne, the u m b i l icus is d is­ sected out without s p l itt i n g the f l a p . S u p rafascial e l evation of the f l a p f r o m its med i a l edge i s performed with e l ectroca utery u n t i l the med i a l row of perforators are encou ntere d .

FIG 9

•

•

•

•

•

•

•

•

•

FIG 8 • Perfus i o n m a p with laser-ass isted i n d ocya n i n e g reen fluorescent dye with d a rk a reas i n d icati ng poor perfus i o n .

•

Su bfasc i a l expos u re of f l a p perforators.

D issection around the perforators is performed with a low-energy electroca utery, and at t h is t i m e, a l l per­ forators a re assessed for their size and location with i n the flap. Sma l l perforators (< 1 . 5 m m i n d i a m eter) a re l i g ated with hemoc l i ps and one o r more perforators with i n either the medial o r l atera l row are selected for use. Laser-ass isted i n d ocya n i n e g reen fl u o rescent dye can be e m p l oyed at t h is p o i nt to assist with p e rforator se­ l e ct i o n. A p p r o p r i ate-sized Ac l a n d c l a m ps a re p l aced o n a l l perforators exc l u d i n g t h e few s e l ected and the dye is a d m i n istered by t h e a n esth es i o l o g ist i ntrave­ n o us l y. With i n a few m i n utes of t h e dye a d m i n istra­ tion, a rea l -t i m e perfus i o n map of t h e flap is vis u a l ized (FIG 8) . Alternative ly, ca p i l la ry refi l l c a n be assessed with the Acl a n d c l a m ps i n p l ace for a few m i n utes to determ i n e a d e q uacy of f l a p perfus i o n based on the few selected perforators . The a nterior rectus fascia adjacent t o the selected row o f perforators i s i ncised w i t h el ectroca utery i n a cra n ioca u­ d a l orientation (FIG 9) . A m i l l i meter cuff of fascia i s c u t w i t h a tenotomy a r o u n d the perforator, freei n g it f r o m the s u r ro u n d i n g a nterior rectus fascia. Two to 3 m l of hepa r i n ized sa l i n e is then i nj ected i nto the rectus m uscle adjacent to the i n d i v i d u a l perforators with an o l ive-ti pped ca n n u l a . The hepari n ized sa l i n e used i n t h is fas h i o n hydrod issects t h e surro u n d i n g soft tissue away from the perforator a n d a i ds with visua l iza­ tion of the perforator cou rse. T h is tech n i q u e is repeated as needed throughout the co u rse of the i ntra m uscu l a r d issection (FIG 1 0) . T h e perforators a r e d issected t h ro u g h the rectus m uscle with the a i d of a b i p o l a r electroca utery d own to the l a rg e r deep i nferior epigastric a rterial a n d venous system that r u ns beneath the m uscle. The conti n u ation of the D I EA and D I EV system to the s u perior e p i g astric vessels is encou ntered a bove the m ost cephalad perforator a n d these vessels are l i g ated with

C h a p t e r 1 9 DEEP I N FERIOR EPIGASTRIC PERFORATOR FLAP BREAST RECONSTRUCTION AFTER MASTECTOMY

A

FIG 1 0 • Hydrod issection tech n i q u e for i ntra m uscu l a r per­ forator d issection i l l ustrated. Hepari n ized sa l i n e is i njected adjacent to the perforator a n d creates a d issection p l a n e between the perforators a n d m uscle. T h e arrows i l l ustrate the course of the hepari n ized sa l i ne, which tracks a l o n g the perforator with each i njection .

•

•

a p p ropriate-sized hemocl i ps 1 t o 2 em cep h a l a d to the perforator. The s u b m uscu l a r d issection proceeds toward the external i l iac vessels in the pelvis a n d is performed with the electroca utery, leavi ng a cuff of a d i pose tissue around the vessels. The D I EA a n d vei n are d issected to a point where their l ength a n d size a re a ppropriate for the recipient vessels i n the chest (FIG 1 1 ) .

A FIG 1 2

•

B FIG 1 1 • A. I ntra m uscu l a r a n d s u b m uscu l a r d issection of perforators a n d vasc u l a r ped icle. B. D I E P f l a p pedicle prior to l igatio n .

• •

•

Once ready for tra nsfer to the chest, the a rtery is first l i g ated d ista l l y with hemoc l i ps fo l l owed by the ve i n (s). A tenotomy scissors is used to d ivide the vessels proxi m a l t o t h e c l i ps. The ha rvested f l a p (FIG 1 2) is prepared o n a back table by fl ush i n g the flap from its a rterial end with hepa r i n ized sa l i n e until the venous outflow clears u p and is less b loody.

B A.B. F l a p ha rvested a n d prepped on a back ta b l e .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

RECIPIENT VESSEL EXPOSURE {INTERNAL MAMMARY} •

•

•

•

•

A com mon choice a n d the a uthor's preference for rec i p i ­ e n t vessels are the i nterna l m a m m a ry a rtery a n d vei n . A l ­ ternatively, the thoracodorsa l a rtery a n d vei n can be used. O n ce the m astectomy is com p l ete, the defect is i rrigated and h e m ostasis with electrocautery is performed as n eeded . The med i a l carti l a g i n o us aspect of the 3rd r i b is p a l pated t h ro u g h the pectora l is major m uscle. The m uscle fibers over th is med i a l aspect of the r i b a re s p l it (idea l ly a long the fibers) with e lectroca utery a n d a Weit l a n e r retractor is i ntrod uced between the m uscle fibers to provide expo­ s u re. The m uscle s p l it is performed from the lateral edge of the stern u m to a point a p p roxi m ately 6 em l atera l . The anterior costal perich o n d r i u m is scored a l o n g its length with the e lectroca utery a n d a lso perpe n d i c u l a r to the lengthwise i ncis i o n at the med i a l a n d l atera l extents of the exposed cart i l a g e . A freer or na rrow periostea l elevator is then used to e l evate the pericho n d r i u m off the u nderlyi n g carti lage circumferenti a l l y (FIG 1 3) .

•

•

•

•

•

The ca rti lage is then excised with a ron g e u r from latera l to m e d i a l , expos i n g the posterior perich o n d ri u m . The i n ­ tern a l m a m m a ry a rtery a n d vei n a r e somet i m es vis i b l e t h r o u g h the poste rior perich o n d r i u m a t t h is poi nt. A second Weit l a n e r is i ntrod uced perpend i c u l a r to the fi rst us i n g the latera l cut end of the rib as a n anchor for one end of the retractor w h i l e the opposite end retracts the m e d i a l mastectomy f l a p out of the f i e l d . An i ncis i o n i s made latera l ly t h ro u g h the posterior peri­ chond r i u m with a sca l pel a n d a freer is then i ntrod uced u nderneath the perich o n d ri u m and used to push a l l soft tissue a n d vessel d ownwa rd. The posterior perichon d r i u m is then s p l it from latera l to m e d i a l , expos i n g the u n derlying i ntern a l m a m m a ry a rtery (IMA) a n d i ntern a l m a m m a ry vei n (IMV) . The posterior perich o n d r i u m is b l u ntly d issected off the u nderlying vessels with a freer a n d excised com p l etely to p rovide opti m a l expos u re of the reci pient vessels. The IMA and IMV are d issected c i rcu mferent i a l l y and a backg rou n d mat with attached suction is p laced beneath both vessels (FIG 1 4).

Rib cartilage

Perichondrium Pectoralis major muscle

FIG 1 3

•

E l evati o n of the r i b perich o n d ri u m .

FIG 1 4 • Exposed IMA a n d IMV with p l acement of a back­ ground mat with suct i o n .

MICROVASCULAR ANASTOMOSIS • •

• •

The ha rvested D I E P f l a p is tra nsferred to the chest a n d secured t o t h e chest wa l l with sutu res. With m a g n i fication from a m i croscope, the f l a p vessel e n ds a re prepa red, sharply cutti ng i rreg u l a r vessel ends a n d l oose adventit i a . S i m i l a r preparation of the IMA a n d IMV a re performe d . Anastomosis of the a rteries a n d vei ns can be performed i n whichever order based on the s u rgeon's p reference.

•

•

The a uthor preferent i a l l y cou p l es the vei ns prior to the a rte r i a l a n astom osis. An a ppropriate-sized s i n g l e Acl a n d clamp is p laced proxi­ m a l ly on the IMV and a h e m ocl i p is a p p l ied d ista l ly prior to cutt i n g the IMV with tenotomy scissors . The cut vessel end is then fl ushed with hepa r i n ized s a l i n e . A vessel sizer i s used t o determ i n e the a p p roxi mate vei n d i a m eter for both t h e f l a p ve i n a n d t h e IMV a n d the s m a l l e r of the two vessels determ i n es the cou p l e r s ize to be used.

C h a p t e r 1 9 DEEP I N FERIOR EPIGASTRIC PERFORATOR FLAP BREAST RECONSTRUCTION AFTER MASTECTOMY

•

•

•

The flap ve i n is fi rst p l aced in one e n d of the cou p l e r fo l l owed by the IMV a n d the cou p ler is c l osed without p l a c i n g tens i o n on either vess e l . The previously p laced c l a m p is then taken off the IMV. O n e e n d of an a p p ropriate-sized, d o u b l e oppos i n g Acl a n d c l a m p is p l a ced proxi m a l ly on the IMA a n d hemoc l i ps a re a p p l ied d ista l ly p r i o r t o cutt i n g t h e IMA. The f l a p a rtery is then i ntrod uced i nto the opposite e n d of the d o u b l e-oppos i n g Acl a n d c l a m p . An en d-to-end a n astomos is of the a rterial e n ds is per­ formed with 8-0 or 9-0 nylon sutu res i n an i nterru pted or ru n n i n g fas h i o n (FIG 1 S) .

• • • • •

Once the anastomosis is com plete, the flap end of the clamp is taken off first prior to ta king off the end on the IMA. With flow reesta b l ished, papaverine is i nfi ltrated i nto the adventitia of the a rteries to p reve nt spas m . T h e f l a p a n d a n astomosed vessels a re warmed with warm sa l i n e and a l l owed to reperfuse for a few m i n utes. Doppler s i g n a ls are id e ntified on the f l a p s k i n a n d ma rked with sutu res. Fat g rafts obta i ned from either the abdom i n a l donor site or f l a p edge are p laced around the a n astom osis to h e l p secure the desi red position of the vessels a n d reduce kinking.

F I G 1 5 • M i crovascu l a r a n astomosis u n d e r a n operat i n g m ic roscope. A d o u b l e oppos i n g Acl a n d c l a m p h o l ds t h e a rte r i a l e n d s i n p l ace a n d a n end-to-end a n astomos is is being performed with i nterru pted 8-0 nylon sutures. The D I EV has been coupled to the IMV i n the backgro u n d .

FLAP INSET/DONOR SITE CLOSURE • •

•

•

•

•

•

•

Peri pheral zones of the f l a p that may be l ess opti m a l ly perfused are excised. The f l a p is then p l aced with i n the m astectomy defect a n d i nterrupted a bsorba b l e sutu res a re used to secure the flap to the m e d i a l aspect of the chest wa l l . The pattern of the skin paddle is marked and a l l skin (epider­ m is and derm is) outside of the paddle is excised with electro­ cautery (FIG 1 6). De-epithelial ization here is a lso an option. A d r a i n is p l aced a l o n g the i nferior aspect of the mas­ tectomy defect and exits the skin a l o n g the a nterior axi l l a ry l i n e. S k i n clos u re for the flap i nset is performed in l ayers with a bsorba b l e i nterru pted deep dermal sutu res and a ru n ­ n i n g s u bcutic u l a r suture. The OR table is reflexed; two d r a i ns a re p laced i n the abdom i n a l donor site; a n d clos u re of the defect is per­ formed with a pprox i m ation of Scarpa's fascia, the deep derm is, a n d s u bcutic u l a r layer. The u m b i l icus is del ivered throug h the s k i n f l a p a bove the horizonta l abdom i n a l clos u re a l o n g the m i d l i n e by creati ng an app ropriate-s ized defect with a f u l l-th ickness excisi o n . The u m b i l icus is then i nset with a layered closure. M i n i m a l d ressi ngs i n the form of a skin glue prod uct, Steri­ Stri ps, or a n o i ntment a re then a p p l ied to all suture l i n es.

FIG 16 • Flap with all s k i n outs i d e of the s k i n p a d d l e excised; p reserved S I EV ca n be s e e n o n t h e m e d i a l aspect o f the f l a p .

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PEARLS AND PITFALLS Preoperative eva l uation

• •

Preoperative CT a n g i og raphy is a usef u l tool to assist with perforator selection-It provides i nformation o n perforator location a n d size b u t does not g ive i nformation on flow/perfus i o n . Flap perfusion based on a few perforators i s better assessed b y laser-assisted i ndocya n i n e g reen fluorescents dye or by physical exa m ination with occ l usion of a l l perforators with the exception of the few selected perforators.

Patient positio n i n g

•

With t h e patient i n s u p i n e position, t h e ta ble c a n b e tu rned 1 80 deg rees from t h e anesthesiolog ist, provid i n g better access f o r two surgical teams.

D issection of the vessels

•

Preserve as long a length of the S I EV (2:5 em) as poss i b l e for use as a n a d d it io n a l outflow vessel i n f l a ps with venous congesti o n after elevation o r tra nsfer to the chest. The hydrodissection technique used for the i ntra m uscu lar perforator d issection simpl ifies this portion of the opera­ tion, creating d issection pla nes and a l lowing for better visua l ization of the perforators and small vascu lar branches.

•

POSTOPERATIVE CARE •

•

•

• •

Patients can be transferred from the OR to a postanesthesia care unit (PACU) or directly to a unit with nursing capabili­ ties for flap monitoring. Flaps are monitored by physical examinations (color, tem­ perature, capillary refill, and handheld Doppler signals) per­ formed every hour for the first 24 hours and then checks can be spaced out to every 2 hours and 4 hours over subsequent hospital days. Additional flap monitoring with continuous near-infrared spectroscopy (NIRS) tissue oximetry is employed for 72 hours postoperatively. DVT prophylaxis is the only form of anticoagulation used routinely. The patient's bed is kept in semi-Fowler's position at all times.

• • •

• • • • •

Diet is advanced from clear liquids to regular on postopera­ tive day (POD) 1 with restrictions to caffeine intake. Patients are assisted out of bed to a chair on POD 1 and they ambulate beginning on POD 2 . Foley catheters and intravenous (IV) fluids are discontinued and IV medications/patient-controlled analgesias (PCAs) are converted to orals on POD 2. Patients are typically ready for discharge home from POD 3 to POD 5. Surgical drains are discontinued once the output is less than 30 mL for two consecutive days. Activities are limited and weight-lifting restrictions are in place for 6 weeks postoperatively. The first postoperative visit is at 1 week following discharge. Preoperative photographs of a patient with a left breast invasive cancer who opted for DIEP flap reconstructions are presented in FIG 1 7A,B.

A

c

FIG 1 7 • A,B. Preoperative p h otog ra phs of a patient with a left breast i nvasive ca ncer. C, D. Postoperative photog ra phs of the breasts and a b d o m i n a l donor site after i m med iate b i l atera l D I E P flap reconstruction with s u bseq uent revisions i n c l u d i n g b i l atera l n i p p l e reconstructions. T h e patient w i l l u ndergo n i p p l e tatto o i n g a s a fi n a l proce d u re.

C h a p t e r 1 9 DEEP I N FERIOR EPIGASTRIC PERFORATOR FLAP BREAST RECONSTRUCTION AFTER MASTECTOMY

•

reconstructions. The ultimate cause of flap loss is a throm­ bosis of the vascular pedicle, which could be brought about by a variety factors ranging from technical problems to hypercoagulable conditions. Early detection of thrombosis with a return to the OR and correction of the inciting prob­ lem leads to flap salvage in most cases.

The same patient's postoperative results after immediate bi­ lateral DIEP flap breast reconstruction and subsequent revi­ sions are presented in FIG 1 7C,D .

OUTCOMES •

• •

•

•

•

The goals of breast reconstruction are to create breast mounds that are aesthetically pleasing, symmetric, and simi­ lar to the natural breast in appearance and feel. Patient satisfaction is of great importance in assessing out­ comes of reconstruction. Breast reconstruction patients are typically satisfied in the short term ( < 5 years) with their choice of reconstruction across implant-based to autologous forms of reconstruction _ I I Over the long term (>8 years), satisfaction with abdominal­ based flap reconstruction is maintained, whereas satisfaction with implant-based techniques tends to depreciate. 1 1 Studies have also shown greater satisfaction with autologous reconstruction in patients requiring unilateral reconstruc­ tions.12 This is likely the result of better symmetry with the natural contralateral breast. Patient satisfaction in bilateral reconstructions has been found to be similar across all techniques provided that the same technique is used on both sides,12 highlighting again the importance of symmetry.

COMPLICATIONS Flap-Related Complications •

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•

•

Infections-Surgical site infections are rare as these are clean cases and the autologous tissue transferred to the chest offer greater resistance to infection than do prostheses. Delayed wound healing-This complication typically occurs at the interface between the mastectomy flap and DIEP flap skin paddle. It often is a result of marginal mastectomy flap necrosis from poor skin perfusion, which is more likely in smokers and in the previously radiated breast skin. Fat necrosis-Varying degrees of fat necrosis are encountered in 10 % to 1 5 % of reconstructions; it occurs in small segments of flap adipose tissue with poor perfusion. This complication is apparent within a few weeks of the operation and presents as a firm palpable nodule, which occasionally causes some discomfort. These areas of necrosis can be directly excised or managed with liposuction (ultrasound assisted or suction assisted) during revision procedures. Partial flap loss-an uncommon complication that is also re­ lated to poor perfusion. Here, a segment of the flap is lost. It can be the result of poor perforator selection or thrombosis of one or more of the selected perforators. An excision of the necrotic segment is usually required. Total flap loss-This is one of the most devastating com­ plications encountered and it occurs in less than 2% of

152 1

Donor Site Complications •

•

Hernias/bulges-the result of abdominal wall weakness; this complication is seen with much less frequency when com­ pared to the TRAM flap, which by definition takes muscle and fascia as part of the flap harvest. The incidence of this complication has been shown to decrease with use of mesh reinforcement in TRAM flap harvests. Delayed wound healing-Wound healing problems are encountered often in morbidly obese patients, diabetics, and smokers. Perfusion to the infraumbilical portion of the abdominal donor site is marginal in some patients; fat necrosis occurs in this area and ultimately results in a wound dehiscence. These wounds are managed by debridement and dressing changes with healing by secondary intention.

REFERENCES 1. Kroll S, Baldwin BA. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg. 1992;90:455-462. 2. Alderman AK, Wilkins EG, Lowery J, et al. Determinants of patient satisfaction in post-mastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769-776. 3. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a trans verse abdominal island flap. Plast Reconstr Surg. 1982;69:216-225. 4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without recuts abdominis muscle. Br J Plast Surg. 1989;4 2: 645-648. 5. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994 ;32:32-38. 6. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. T he donor site morbidity of free DIEP flaps and free TRAM flaps for breast recon­ struction. Br J Plast Surg. 1997;50:322-330. 7. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg. 2002;109:91-101. 8. Momoh AO , Colakoglu S, Westvik T S, et al. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg. 2012;69(1) : 19-23. 9. Holm C, Mayr M, Hofter E, et al. P erfusion zones of the DIEP flap revisited: a clinical s tudy. Plast Reconstr Surg. 2006;117:37-43. 10. Smit JM, Dimopoulou A, Liss AG, et al. P reoperative CT angiography reduces surgery time in perforator flap reconstruction. ] Plast Reconstr Aesthet Surg. 2009;62:1112-1117. 11. Hu ES, P usic AL, WaljeeJF, et al. P atient-reported aesthetic s atisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124 : 1-8. 12. Craft RO, Colakoglu S, Curtis MS, et al. P atient s atisfaction in uni­ lateral and bilateral breast reconstruction. Plast Reconstr Surg. 2011; 127:1417-1424.

I

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Chapter

20

Nipp le-Areolar Reconstruction I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

-+

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

An ita R. Kulka rn i

DEFINITION •

Nipple-areolar reconstruction (NAR) is typically performed as the final stage of breast reconstruction after mastectomy. The nipple is reconstructed to give three-dimensional projec­ tion, and the areola is reconstructed separately to mimic a natural nipple-areolar complex (NAC).

PATIENT IDSTORY AND PHYSICAL FINDINGS •

•

•

NAR is an elective stage of breast reconstruction that can be performed after any type of primary breast mound reconstruction. Published studies indicate that approxi­ mately 50% of breast reconstruction patients elect to un­ dergo NAR.1•2 NAR is performed at least 3 months after breast reconstruc­ tion is complete. This allows the final breast shape and posi­ tion to be obtained prior to placement of the NAC. NAR can also be performed in a delayed fashion at any time a patient decides, including months or years after breast mound reconstruction.

•

•

•

•

• •

•

There are many described techniques for nipple reconstruc­ tion, including nipple sharing, local flaps, cartilage grafts, dermal grafts, and prostheses.3 Local flaps are the most pop­ ular option and are described in detail in this chapter. Reconstructed nipples lack the rigid ductal and smooth muscle elements of a natural nipple; therefore, the long-term maintenance of nipple projection continues to be the most challenging aspect of NAR. 4 Multiple autologous and prosthetic materials (auricular cartilage, rib cartilage, toe pulp, acellular dermal matrix, calcium hydroxylapatite, polytetrafluoroethylene implants, etc.) have been attempted to give permanent rigidity to the nipple; however, no single technique has demonstrated de­ finitive superiority.3 Areolar reconstruction is primarily done by skin grafting, tattoo, or both. The first described technique in this chapter is a skate flap for nipple reconstruction with a full-thickness skin graft for areolar reconstruction. This procedure is typically done in the operating room under sedation or general anesthesia. The second described technique is a C-V flap for nipple re­ construction, which can be used in combination with a tat­ too for areolar reconstruction. This procedure can be done in the office under local anesthesia.

·

An drea L. Pusic

Anatomically, the NAC is located at the anterior-most pro­ jecting part of the breast mound at the level of the inframam­ mary fold, centered on the reconstructed breast mound. The nipple has an average projection of 5 mm and the areola has an average diameter of 35 to 45 mm.

POSITIONING •

•

In the operating room, patients are positioned supine with arms at 90 degrees secured to arm boards. Both breasts are prepped into the field to allow for evaluation of symmetry. Patients are secured to the operating table to allow upright evaluation intraoperatively. In the clinic, patients are positioned supine with arms at sides.

Skate Flap (Nipple) and Full-Thickness Skin Graft (Areola) • •

SURGICAL MANAGEMENT •

Amy K. Alderm a n

•

•

• • •

The patient is placed in supine position with arms abducted at 90 degrees. Arms are secured on arm boards. The NAC position is selected at the anterior-most projecting part of the reconstructed breast with the patient in an up­ right position. In unilateral nipple reconstruction, the NAC is placed symmetrically to the opposite side ( FIG 1 ). A donor site is chosen for the full-thickness skin graft, which will be used to reconstruct the areola. Commonly used sites include the lateral edge of the mastectomy scar, the lower abdomen, and the groin crease. Additionally, the areolar graft can be taken adjacent to any of the patient's existing scars . A 3 8 - or 42-mm nipple sizer is used to mark the areolar skin graft. An ellipse is drawn tangent to the areolar graft to allow linear closure of the donor site. The areolar skin graft is scored with a knife prior to harvest. The ellipse is then excised as a full-thickness skin graft ( FIG 2 ) . The areolar graft i s aggressively defatted with a small sharp scissor, leaving only full-thickness skin behind ( FIG 3 ) . The skate flap is designed at the previously marked site ( FIG 4) . A 1- t o 1 . 5-cm circle i s drawn a t the planned location of the nipple.

Preoperative Planning •

In unilateral NAR, the position, size, and shape of the op­ posite nipple are taken into consideration to design the re­ construction in addition to anatomic landmarks. In bilateral NAR, anatomic landmarks and standard measurements are used to position and design the NAC.

1522

FIG 1 • N i pp l e position is selected sym metrica l ly to the native n i pp l e .

C h a p t e r 20 N I P PLE-AREO LAR RECONSTRUCT I O N

1523

F I G 2 • Areo l a r s k i n g raft i s ma rked with a 3 8 - m m n i p p l e sizer. An e l l i pse is d rawn ta ngenti a l l y to fac i l itate l i near c l os u re. FIG 4

• • •

•

• • • •

•

A 3 8 - or 42-mm nipple sizer is used to mark the areola centered around the nipple. A horizontal line is drawn across the circle at the superior edge of the marked nipple. The upper portion of the circle is crosshatched to mark the area that will be de-epithelialized. The lower portion of the circle will be raised as the "skate flap" to create the new nipple. The epidermis is scored along all incisions. The crosshatched semicircle is de-epithelialized ( FIG 5 ) . The flap is then raised from the edges a t the level o f the mid­ dermis. The deepest layer of dermis is left down in order to provide a vascularized bed for the areolar skin graft ( FIG 6 ) . The flap remains attached to the deep dermis a t the marked nipple. The flap is raised in a slightly deeper plane at the center in order to include some fat with the flap to provide bulk ( FIG 7 ) . The corners o f the flap are centralized and sutured to the underlying dermis using 5-0 Vicryl Rapide ( FIG 8) . The edges o f the flap are sutured together using interrupted 5-0 Rapide ( FIG 9) . The cap is sutured down to close off the nipple ( FIG 1 0) . The full-thickness skin areolar skin graft is sutured to the bed using 4-0 chromic half-buried horizontal mattress su­ tures. The buried portion of suture is placed along the native breast skin to avoid scarring on the breast ( FIG 1 1 ) . A 1-cm hole i s cut in the center of the areolar graft to expose the nipple ( FIG 1 2 ) .

FIG 3

•

Areo l a r s k i n g raft i s a g g ress ively defatted .

FIG 5

•

•

Skate f l a p des i g n .

Crosshatched a rea i s de-epithe l i a l ized.

FIG 6 • Skate f l a p is ra ised i n the m id d e r m a l p l a ne, leav i n g centra l ped icle attached .

FIG 7

•

S kate f l a p is s h own raised .

1524

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 1 0

•

Open e n d of n i pp l e is sutu red down as a cap.

FIG 8 • Edges of skate f l a p a re brought togethe r centra l ly to recreate n i p p l e .

FIG 11 • • •

•

•

Areo l a r s k i n g raft is sutu red to s k i n edges.

The graft i s secured t o the nipple using interrupted 5-0 chro­ mic sutures. 4-0 chromic tacking sutures and piecrust incisions are placed in the areolar graft ( FIG 1 3 ) . A protective dressing i s applied using Mastisol o n the na­ tive breast, crisscrossed Steri-Strips, 2 X 2 fluffed gauze, and foam tape ( FIG 1 4A-D) . The goal of the dressing is to protect the NAR without putting any pressure on the skate flap. The dressing is kept in place for 5 to 7 days after surgery, at which time it is removed in clinic.

C-V Flap • •

This procedure can be performed under local anesthesia with the patient awake. With the patient in a seated upright position, the NAC posi­ tion is marked at the anterior-most projecting part of the breast ( FIG 1 S ) .

FIG 9

•

Edges a r e sutu red together i n m i d l i ne.

FIG 12 • Centra l h o l e is cut i n a reolar s k i n g raft to a l low n i p p l e t o protrude.

FIG 1 3 • Tacking sutu res a n d piecrust i n c is i o ns are p l a ced in a reolar s k i n g raft.

C h a p t e r 20 N I P PLE-AREO LAR RECONSTRUCT I O N

A

1525

B

c

F I G 1 4 • Bo lster d ress i n g . A . Mastisol is a p p l ied to s u rrou n d i n g breast skin, fol l owed by tig htly ad herent Steri-Strips p l a ced i n crosswise fas h i o n t o a p p ly press u re t o g raft. B. F o a m ta pe d ress i n g with a centra l h o l e f o r n i p p l e i s p laced over crosswise Steri-Strips. C. 2 x 2 fluffed g a uze is p l aced over the n i p p l e . D. Add it i o n a l foa m tape is tented over the fluffed g a uze without putt i n g any p ress ure on n i pp l e reco nstruct i o n .

D •

•

•

•

C-V flap is drawn as shown. The length of the flap is approximately 5 em (A to F), and the width is approximately 1.5 em. The width of the flap (BD to CE) determines the projection of the nipple ( FIG 1 6) . The subcutaneous tissue is infiltrated with 1 % lidocaine with 1: 100,000 epinephrine ( FIG 1 7) . Incisions are made along all edges except points B to D at the base of the nipple. This area is left attached and serves as the blood supply to the flap ( FIG 1 8) . The flap i s raised from both sides i n the midsubcutaneous fat plane ( FIG 1 9A,B) .

• •

The incision is closed from point B to C and D to E ( FIG 20 ) . One flap edge (point A ) i s brought to the center and sutured in place with 5-0 Vicryl Rapide ( FIG 21 ) The opposite flap edge (point F) is brought to the center and sutured to the first flap edge ( FIG 22 ) . The cap i s sutured down t o close the top o f the nipple and the remainder of the incision is closed with 4-0 Vicryl deep and 4-0 Monocryl running subcuticular ( FIG 23 ) . Nipple projection i s shown with both reconstructions com­ plete ( FIG 24) . .

• •

•

FIG 1 5 • B i latera l n i pp l e position ma rked a t t h e a nterior-most p roject i n g part of b reast m o u n ds adjacent to m astectomy scars . F I G 1 7 • 1 % l idoca i n e with 1 : 1 00,000 e p i n e p h r i n e i s i njected su bcuta neous ly.

F I G 1 6 • Markings f o r C-V f l a p . Length f r o m A to F is a p p roximately 5 em, width from BD to CE is a p p roxi m ately 1 . 5 e m .

FIG 18 • C-V f l a p is i ncised through to m i dfat level a l o n g a l l i ncis i o ns except 8 t o D .

1526

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 21 • O n e f l a p edge (point A) is centra l ized a n d sutu red to the deep s u rface.

A

FIG 22 • Opposite flap edge (po i nt F) is centra l ized and sutured to poi nt A.

B FIG 1 9 • A. C-V f l a p is ra ised i n the m idfat p l a n e . B. C-V f l a p is shown ra ised .

FIG 23 • Cap is sutu red d own to close off n i pp l e, and a l l i n c is i o ns are closed with i nterru pted sutu res.

FIG 20

•

I ncis i o n is closed (po i nt B to C a n d D to E).

FIG 24

•

F i n a l res u lt showi n g p rojection of b i l atera l C-V f l a ps.

C h a p t e r 20 N I P PLE-AREO LAR RECONSTRUCT I O N

1527

PEARLS AND PITFALLS I n d i cations

•

N i pp l e-areo l a r reconstruction s h o u l d be deferred u nt i l the fi n a l breast m o u n d s h a p e is o bta i n e d .

Placement of i ncision

•

Fl a ps should be based adjacent to the mastectomy sca r whenever possible to avoid additional scarring.

Projection

•

N i pple projection w i l l decrease by 50% i n the first year; therefore, projection should be overesti m ated at the time of reconstruction. Projection ca n be i ncreased l ater with dermal fi l l ers such as co l lagen or hya l uronic acid.

•

Areol a

• •

Areol a r tattoo i s often used a s a n a d d ition t o s k i n g raft i n g or a s a p r i m a ry m o d a l ity f o r areo l a r reconstruct i o n . Tattoos often n e e d more t h a n one a p p l ication spaced o v e r severa l months i n o r d e r to achieve the final desi red color.

POSTOPERATIVE CARE •

• •

After nipple reconstruction, a protective dressing should be applied and maintained in place for 1 week postoperatively. Brassieres should be avoided for the first 6 weeks to prevent pressure on the nipple flap. If no skin graft is used, patients may shower after the dress­ ing is removed 1 week postoperatively. If a skin graft is used for areolar reconstruction, the bolster is removed 1 week postoperatively in the clinic, and daily Xero­ form dressing changes are performed for 1 week. After 2 weeks, patients may shower and apply moisturizer to the graft.

OUTCOMES •

•

All modes of nipple reconstruction result in some degree of loss of projection over time, up to 50 %.5 Most loss of projection occurs within the first 3 months, and final nipple shape and size is typically achieved by 1 year.6 C-V flaps tend to lose more projection than skate flaps over time. Dermal fillers such as collagen and hyaluronic acid can be injected into the nipple to increase projection.

COMPLICATIONS • • • •

Loss of nipple projection Partial or complete flap necrosis Partial or complete loss of areolar skin graft Infection

REFERENCES 1.

2.

3.

4.

5.

6.

Andrade WN, Baxter N, Semple JL. Clinical determinants of patient satisfaction with breast reconstruction. Plast Reconstr Surg. 2001; 107(1) : 46-54. Schover LR, Yetman RJ, Tuason LJ, et al. P artial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality. Cancer. 1995;75(1) : 54-64. Boccola MA, Savage J, Rozen WM, et al. Surgical correction and reconstruction of the nipple-areola complex: current review of tech­ niques. J Reconstr Microsurg. 2010;26(9) : 589-600. Farhadi J, Maksvyryte GK, Schaefer DJ, et al. Reconstruction of the nipple-areola complex: an update. ] Plast Reconstr Aesthet Surg. 2006;59(1) : 40-53. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110(3) : 780-786. Few JW, Marcus JR, Casas LA, et al. Long-term predictable nipple proj ection following reconstruction. Plast Reconstr Surg. 1999;104(5) : 1321-1324.

-

Chapter

21

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I

�

Reduction Mammoplasty - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

·

I

Sebastia n Win ocour

DEFINITION •

Reduction mammoplasty is defined by the removal of ex­ pendable breast skin and parenchyma, and repositioning the nipple-areolar complex (NAC) in patients who suffer from breast hypertrophy. The goal is to achieve an overall reduction in breast volume in an aesthetic manner without sacrificing breast sensation or function. Other terms for re­ duction mammoplasty include breast reduction and reduc­ tion mammoplasty.

DIFFERENTIAL DIAGNOSIS •

The differential diagnoses of breast hypertrophy include breast carcinoma, phyllodes tumors, benign breast masses (including fibroadenomas, neurofibromas, lymphangiomas, and breast cysts), hematomas, ectopic tumors producing sex steroids, pregnancy, lactation, and virginal hypertrophy. It is of paramount importance to distinguish benign breast hyper­ trophy from breast carcinoma, which is much less common, tends to be unilateral, is usually eccentric with respect to the NAC and typically presents as a defined lesion firm to touch.

•

•

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

A thorough history should be performed prior to treatment, identifying physical, functional, and psychological symp­ toms. It is also important to obtain a detailed past medi­ cal and surgical history, reproductive history, family history, social history, and current medications and allergies from the patient. 1 Physical and functional problems associated with macro­ mastia include pain (neck, back, and shoulder), mastodynia, shoulder grooving, intertriginous rashes and/or infections, physical activity restriction, and difficulty fitting into clothing. Patients often suffer from psychological symptoms related to breast size, including feelings of physical unattractiveness and embarrassment in both private and social settings.2•3 Past medical history should screen for any diseases that would impact the patient's ability to recover from the reduc­ tion mammoplasty, such as heart or lung disease, or impact the viability of the NAC postoperatively, such as collagen vascular diseases.1 A history of previous benign or malignant breast masses should also be elicited. Obtaining a thorough past surgical history should identify any previous breast or chest wall incisions that may influence planning of either the skin pattern incision or the pedicle to the NAC.1 Because childbearing can affect the size and shape of a woman's breasts, the reproductive history of the patient is important to understand and anticipate the effect reduc­ tion mammoplasty will have on the future breast.1 Inquir­ ing about plans for future pregnancies and breastfeeding is important to inform patients of the risks of the procedure. Finally, in patients who have recently given birth and who

1528

•

Va lerie Lemain e

may be currently breastfeeding, it is important to discuss timing of surgery because it is ideal to delay surgery for at least 1 year after completing either. Obtaining a thorough family history is important to identify patients at increased risk for breast carcinoma. Younger pa­ tients with a family history of breast cancer, in addition to any patient older than the age of 40 years, should undergo a preoperative mammogram in order to identify any sus­ picious lesions prior to surgery.2 Some surgeons routinely obtain a bilateral mammogram in all patients considering reduction mammoplasty. Smokers are at increased risk of compromise of the blood sup­ ply to the NAC and for poor wound healing.1 Therefore, elicit­ ing a smoking history may alter the timing of surgery. Current recommendations indicate that a period of at least 4 weeks of smoking cessation prior to surgery is ideal for best outcomes. Macromastia can present at different periods in a woman's life and therefore surgical timing is important. When present during adolescence, the timing of reduction mammoplasty needs to be balanced with the effects of macromastia on self­ esteem and physical activity restriction with ongoing puber­ tal breast development and potential future childbearing.4 In older patients who have encountered recent significant changes in overall weight, it is prudent to delay surgery for at least 1 year until their weight has stabilized, as this can translate into disproportionate changes in breast volume. A bilateral breast examination should be performed in every patient, including examination of the axillary and supra­ clavicular lymph node basins. The patient's height, weight, body mass index, and body surface area, as well as appropri­ ate breast measurements should be taken, including breast width, sternal notch/clavicle to nipple distance, midline in­ framammary fold to nipple distance, and the dimensions of each areola. 2 In addition, breast characteristics should be noted including symmetry, upper pole contour and fullness, presence of breast ptosis, skin quality including presence of striae, and breast tissue density ( FIG 1 ). 1

FIG 1

•

A typical patient suffering from m acromast i a .

C h a p t e r 2 1 R E D U C T I O N M A M M OPLASTY

•

1529

A discussion of patient's desires and expectations following surgery is essential to avoid dissatisfaction and misunder­ standings. In addition, the patient should be informed about possible complications associated with reduction mammo­ plasty, including changes in nipple sensation, asymmetry, un­ appealing breast size or shape, scarring, fat necrosis, NAC loss, inability to breastfeed, hematoma, and infection.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

The American Cancer Society recommends screening mam­ mograms starting at age 40 years in patients with aver­ age risk of developing breast cancer.5 These patients, and younger patients at increased risk of breast cancer, should therefore undergo a preoperative mammogram prior to re­ duction mammoplasty. Many plastic surgeons routinely per­ form a preoperative screening mammogram in all patients undergoing this procedure.

A

SURGICAL MANAGEMENT •

•

There are multiple surgical approaches to reduction mam­ moplasty; however, all must deal with the following four considerations: ( 1) reduction in the parenchymal volume of the breast, (2) creation of the NAC pedicle, (3) reduction of expendable skin followed by redraping, and (4) reposition­ ing of the NAC.3 This chapter will describe the most com­ monly practiced Wise pattern (inverted T) technique, which reduces the medial, lateral, and superior breast parenchy­ mal volume and maintains blood supply to the NAC by an inferior pedicle. Other techniques include the superior me­ dial breast reduction,3 short scar periareolar inferior pedicle reduction (SPAIR),l and the liposuction breast reduction,6 among others. Advantages to the Wise pattern technique include its repro­ ducibility, popularity, and applicability to a wide range of breast shapes and sizes, whereas disadvantages include lon­ ger scars and a tendency toward developing breast ptosis over the long term.

I I I

•

Preoperative markings with a permanent marker should be performed in the upright position in the preoperative hold­ ing area on the day of surgery. The chest midline, breast meridian, and inframammary creases are initially marked. The inframammary crease should then be transposed onto the anterior breast to mark the desired new nipple position.7 The distance from the ster­ nal notch/clavicle to this point is measured and transposed symmetrically to the other breast. Eight-centimeter obliquely vertical limbs are then drawn medially and laterally from this point. They should be separated by a distance of 8 to 10 em between their inferiormost points, depending on the desired breast width reduction. The bases of the verti­ cal limbs are subsequently connected medially and laterally with a curvilinear line that joins the inframammary crease. Minor adjustments are made to account for breast asymme­ try and minimize the appearance of standing cones ( FIG 2 ) .

' '

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B FIG 2 • A.B. Preoperative marki ngs a re made with the patient i n the sta n d i n g position prior to s u rgery.

•

Preoperative Planning •

I I

I

I

I

Although there is limited data to support the use of preop­ erative antibiotics for reduction mammoplasty, the general consensus among plastic surgeons is that prophylactic an­ tibiotics covering skin flora should be administered at least 30 minutes prior to skin incision.8 Data can be also be ex­ trapolated from several general surgery mastectomy studies demonstrating that antibiotic prophylaxis reduces the inci­ dence of postoperative wound infections.9

Positioning • •

•

Reduction mammoplasty is performed under general endo­ tracheal anesthesia. Because the procedure requires intraoperative assessment of breast symmetry, shape, and contour in the semi-upright position, the patient should be placed in the supine position with the bed break at the hips. The patient's arms should be securely padded on adjustable arm boards, ready for repositioning. Sequential compression devices are applied to the lower ex­ tremities and a Foley catheter is inserted.

1530

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

i nfra m a m m a ry l i ne, l e a v i n g t h e NAC i ntact. The d e r m i s between t h e vert i c a l l i m bs i s preserved to m a i nta i n t h e d e r m a l a n d s u b d e r m a l p l ex u s b l ood s u p p l y to t h e N A C . I n c i s i o n s a re m a d e a r o u n d t h e n eo-NAC a n d a l o n g t h e vert i c a l l i m bs down to t h e su bcuta n e o u s tissue is o l at­ i n g the i nfe r i o r ped i c l e from the s u rrou n d i n g b reast p a r e n c h y m a (FIG S) .

PREINCISION INFILTRATION AND MARKINGS •

The breast bases a n d p l a n ned i ncisions may i n itia l ly be i nfi ltrated with 1 % Xyloca i n e with 1 : 1 00,000 e p i n e p h ­ r i n e . T h e n , a n 8- to 1 0-cm-wide i nferiorly based dermal ped icle is m a rked on the ski n of each breast, exte n d i n g i n a c i rcu l a r fas h i o n a bove the N A C a l l the w a y down to the chest wa l l . Using a cookie cutte r centered on the n i p p le, a 40- to 44- m m c i rcu l a r marking is made with the breast s k i n under m i n i m a l to n o tension to red uce the d i a m eter of the NAC (FIG 3) . Tou r n i q u ets may then be p l aced around each b reast base to assist with hemostasis (FIG 4) . After the s k i n i ncisions a n d de-epith e l i a l ization of the dermal ped i cles a re com p l eted, the tou r n i q uets are removed.

Initial Incisions •

The m a rk i n g s of t h e NAC a n d d e r m a l ped i c l e a re i n it i a l l y scored with t h e sca l p e l . The s k i n of t h e i n ­ fe r i o r ped i c l e i s t h e n de-epith e l i a l ized down t o t h e

A

F I G 3 • A 40- t o 44-mm cookie cutter i s centered on the n i p p l e with the breast skin under m i n i m a l to n o tension to mark the neo-NAC.

c

FIG 4 • Tou r n i q u ets are pl aced around each breast base to m i n i m ize blood loss and are removed after s k i n incisions a n d de-epith e l i a l ization of the d e r m a l ped icles.

F I G S • A-C- T h e s k i n markings a r e scored with t h e sca l p e l after which the i nferior ped icle i s de-epith e l i a l ized d o w n t o the i nfra m a m m a ry l i ne, leavi ng the neo-NAC i ntact.

C h a p t e r 2 1 R E D U C T I O N M A M M OPLASTY

153 1

B

A

FIG 6 • A.B. S k i n f l a ps are ra ised med i a l ly, latera l ly, a n d s u periorly a r o u n d the pedicle.

Creation of Skin Flaps •

Med i a l ly, latera l ly, and s u periorly based skin flaps are then ra ised to sepa rate the skin from the breast parenchym a . T h e flaps a re designed t o g rad u a l ly i ncrease i n th ickness as one approaches the chest wa l l to ensure a smooth breast conto u r when the skin is eventua l ly red raped over the breast. They should measure 1 to 2 em i n thickness (FIG 6) . 1

Creation o f the Nipple-Areolar Complex Pedicle and Parenchymal Excision •

•

The i nferior ped icle is then created without u n d e r m i n ­ i n g the b l o o d s u p p ly to the N A C . The excess breast

parenchyma is systematica l ly excised med i a l ly, latera l l y, a n d s u periorly. S u periorly, breast tiss u e is removed down to the chest wa l l exte n d i n g u p to the level of the clavicle, whereas m e d i a l ly, it is removed down to the pectoral fas­ cia but sto p p i n g short of m i d l i n e . F i n a l ly, a l ayer of b reast tissue is left on the chest wa l l latera l ly in an attem pt to p rese rve the i n n e rvation to the NAC (FIG 7) . Wou n d i r­ rigation a n d meticu l o us hemostasis is achieved prior to p roceed i n g . A l l breast parenchyma removed from t h e breast i s i n i ­ tia l ly wei g h e d a n d s u bseq uently sent to pathology for eva l uation (FIG 8) .

lll..rJ/1.�--- Tissue area to be removed B

A

FIG 7 • A.B. The i nferior ped icle i s created without com prom is i n g the b l ood s u p p ly to the NAC by excis i n g b reast parenchyma i n the m e d i a l , latera l, a n d s u perior q u a d ra nts.

1532

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 9 • The b reast s k i n flaps a re red raped over the ped icle a n d secu red with sta p l es .

FIG 8 • The excised spec i m e n i n c l u d es s k i n a n d parenchyma a n d s h o u l d be weighed prior to havi n g it sent to patho logy.

•

The s a m e p roced u re is repeated on the o pposite breast with the goal of ach ievi ng b reast sym m etry in shape a n d size.

Skin Reduction and Redraping •

•

The s k i n f l a ps are red raped over t h e b reast a n d tem po­ ra r i l y a p p roxi m ated us i n g sta p l es (FIG 9) . The patient is t h e n p l aced i n t h e sitt i n g position and m i n o r adj ust­ m ents can be m a d e to s k i n a p p roximation to ach ieve sym m etry a n d i m p rove a esthetics. The fi n a l m a r k i n gs for the m e d i a l a n d l atera l i nfra m a m m a ry m a rg i ns can t h e n be m a d e; after w h i c h , t h e s k i n is excised as needed. O n ce sym metry is a c h i eved, a n d with the patient sti l l i n a sitt i n g position, t h e f i n a l NAC position i s determ i n ed with a 38- to 42- m m cookie cutter a n d m a rked on the breast (FIG 1 0) . The s k i n is then excised a n d the NAC is exteriorized (FIG 1 1 ) .

F I G 1 0 • The f i n a l N A C position i s chosen a n d ma rked w i t h a 38- to 42- m m cookie cutter.

Repositioning o f the Nipple-Areolar Complex •

•

O n ce the NAC is exteriorized, the position a n d orienta­ tion of the i nferior ped icle is verified to ens u re that it is not d istorted. A G i l l ies suture us i n g a bsorba b l e m o n ofi la­ ment may be p laced at the i n verted T j u n ction, which is the point of maxi m a l tens i o n . The NAC is then secu red in its correct orientation with bu ried dermal a bsorba b l e monofi lament sutu res i n fou r q u a d ra nts . A l l i ncis i o ns a re then closed i n l ayers with deep d e r m a l i nterrupted ab­ sorba b l e m o n ofi lament sutu res, fo l l owed by a n a bsorb­ able r u n n i n g su bcuticu l a r m o n ofi lament suture (FIG 1 2) . A d ry d ress i n g i s a p p l ied to a l l wounds . B u l b suction d ra i ns may be l eft prior to c l os u re.

FIG 1 1 • The NAC is exte riorized by i ncis i n g the c i rcu l a r m a r k in g a n d removing the c i rcu l a r p a d d l e of s k i n a n d soft tiss u e . Care is taken n ot to i nj u re the underlying NAC.

C h a p t e r 2 1 R E D U C T I O N M A M M OPLASTY

FIG 1 2

•

1533

T h e f i n a l res u lt after a l l s k i n i ncisions a r e c l osed.

PEARLS AND PITFALLS Pre i ncision i nfi ltration

•

A s p i n a l need le is h e l pf u l for thoro u g h infi ltration of the breast bases with a n esthetic a n d e p i n e p h r i n e solution.

I n iti al i ncis i o ns

•

O n l y the dermis of the vertica l l i m bs s h o u l d i n it i a l l y be i ncised to a l l ow for better traction d u r i n g de-epith e l i a l izat i o n . De-epithe l i a l ization can be more efficiently performed w i t h Kaye scissors a s compared to a sca l pel b l a d e .

•

Creation of s k i n f l a ps

•

Appropriate f l a p t h i ckness is critica l for g o o d blood s u p p ly to the s k i n a n d to m a i nta i n sm ooth breast conto u r. The s k i n f l a ps s h o u l d g rad u a l ly i ncrease in th ickness as one a p p roaches the chest wa l l .

Creation of the NAC pedicle a n d parenchyma l excision

•

Avoid d issection below t h e i nfra m a m m a ry fo l d m e d i a l a n d latera l t o t h e NAC ped icle t o p reve nt i nferior m i g ration of tiss u e and breast ptosis postoperative ly.

S k i n red uction and red ra p i n g

•

Sta p l es ca n be an effective a lternative to s k i n a p proxi mation c l a m ps when red ra p i n g the s k i n f l a ps over the b reast. Cross h atched orientation ma rks can be p laced after the s k i n is red raped to ens u re s k i n seg ments a re accu rate ly a p p roxim ated when sta p l es a re removed.

•

Reposition i n g o f the NAC

•

Verify that the ped icle is not d istorted prior to s k i n c l os u re to avo i d ischem i a to the NAC d u e to u n us u a l positio n i n g .

of common preoperative symptoms including neck pain (91 %), back pain (96 %), shoulder grooving ( 100%), as well as a subjective improvement in perception of self-image (92 %). 10

POSTOPERATIVE CARE •

After reduction mammoplasty, the patient should b e placed in either a breast binder/wrap or supportive brassiere that should be worn regularly for 2 to 4 weeks after surgery. This maintains pressure on the breasts, minimizing hematoma and seroma formation, and also relieves tension on the skin incisions, preventing wound dehiscence and unfavorable scarring ( FIG 1 3 ) .

OUTCOMES •

Outcomes following reduction mammoplasty are excellent with high overall patient satisfaction rates.8 The complica­ tions most frequently reported are ( 1) symptomatic scar­ ring ( 6 %), (2) wound dehiscence ( 5 %), and ( 3 ) infection ( 1.2 %). 10 Patients also report high reduction or resolution

COMPLICATIONS • • • • • • • • • •

Undesirable scarring Wound dehiscence Infection (cellulitis or abscess) Decreased NAC sensation Breast asymmetry Unappealing size and/or shape Fat necrosis NAC loss Difficulty or impossibility to breastfeed Hematoma

1534

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

A FIG 1 3

•

B Postoperative res u lt at (A) 1 month a n d (B) 1 yea r after s u rgery, respectively.

REFERENCES 1. 2. 3. 4.

5.

Hammond DC. Atlas of Aesthetic Breast Surgery. P hiladelphia, PA: Saunders/Elsevier; 2009. Jones G, ed. Bostwick's Plastic and Reconstructive Surgery. 3rd ed. St. Louis, MO : Quality Medical P ublishing, Inc; 2010. Hall-Findlay E, Evans GRD, eds. Aesthetic and Reconstructive Sur­ gery of the Breast. P hiladelphia, PA: Saunders/Elsevier; 2010. Hoppe IC, P atel PP, Singer-Granick CJ, et al. Virginal mammary hy­ pertrophy: a meta-analysis and treatment algorithm. Plastic Reconstr Surg. 2011;127(6) : 2224-2231. Smith RA, Cokkinides V, Brooks D, et al. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer I Clin. 2010;60(2) : 99-119.

6. 7. 8. 9.

10.

Adam WP. Reduction mammaplasty and mastopexy. Select Read Plast Surg. 2002;9(29) : 1-36. Guyuron B, Eriksson E, P ersing JA, et al, eds. Plastic Surgery Indica­ tions and Practice. P hiladelphia, PA: Saunders/Elsevier; 2009. Kalliainen LK. ASP S clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. 2012;130(4) : 785-789. Bunn F, Jones DJ, Bell-Syer S. P rophylactic antibiotics to prevent surgi­ cal site infection after breast cancer surgery. Cochrane Database Syst Rev. 2012;(1) : CD005360. DeFazio MV, Fan KL, Avashia YJ, et al. Inferior pedicle breast re­ duction: a retrospective review of technical modifications influencing patient safety, operative efficiency, and postoperative outcomes. Am I Surg. 2012;204(5) : e7-e14.

I

Chapter

22

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

Wide Excision of Primary Cutaneous Melanoma 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Russell 5. Berman

DEFINITION •

•

•

W ide excision (WE) of a primary cutaneous melanoma is the term used to describe the definitive surgical management of the primary melanoma site. It is defined as the surgical removal of the primary tumor and/or the biopsy site that includes a defined radial margin of normal-appearing skin and underlying subcutaneous tissue. The appropriate mar­ gin of resection is determined by the Breslow thickness as discussed in this chapter. Depending on primary tumor characteristics and clinical nodal status, WE may be performed concomitantly with either intraoperative lymphatic mapping and sentinel lymph node biopsy (SNB) (for patients with clinically negative nodes and a primary tumor suggesting sufficient risk of occult re­ gional node metastasis) or regional lymphadenectomy (for pa­ tients with clinically involved regional lymph nodes without distant metastasis)1 (refer to Part 5, Chapters 3 1, 32, and 34). The main function of the WE is to remove the primary tumor along with any nearby microscopic melanoma cells. In addition to following oncologic principles, the surgeon should also aim to simultaneously minimize dysfunction or disfigurement. This procedure is also known as a wide local excision.

•

•

DIFFERENTIAL DIAGNOSIS •

A WE should not be performed unless a definitive pathologic diagnosis of melanoma has been obtained.

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

•

A patient with newly diagnosed melanoma should undergo a comprehensive history that includes assessment of age, gen­ der, personal or family history of melanoma or other malig­ nancy as well as history of any nevus syndromes. The patient should also be assessed for any other significant medical and surgical history or issues, medications used, and allergies. History of sun exposure and use of tanning beds, if any, should also be obtained. A thorough history may also pro­ vide clinical clues as to the extent of disease present at diag­ nosis. Symptoms such as worsening headaches or abdominal cramps may suggest distant metastatic disease and warrant additional workup. A physical examination is extremely important in the newly diagnosed patient with melanoma. If a biopsy has been performed, the anatomic site and orientation of the biopsy should be documented along with the presence or absence of any residual pigmented lesion. Skin and soft tissue between the primary site and draining regional nodal basin(s) should be examined for any signs of satellite metastases or in-transit disease. Melanoma most commonly metastasizes via regional lymphatics to re­ gional lymph nodes. Nonetheless, because melanoma may

•

•

�

Jeffrey E. Gersh e n wa ld

metastasize to both regional and distant nodes, all palpable lymph nodes should be carefully examined in the new mela­ noma patient, including cervical, supraclavicular, axillary, epitrochlear, inguinal, and popliteal nodes. For patients with a melanoma in a region of ambiguous drainage (typically considered to be the head and neck and trunk regions), mul­ tiple nodal basin drainage is possible. Given the importance of the lymphatics in melanoma, meticulous attention to the lymphatic exam is essentiaL Evidence of lymphedema in the melanoma-bearing extremity may also suggest regional nodal disease. It is imperative to confirm the specific site(s) of any primary melanoma to be treated. Although this may seem obvious, many patients have had concomitant and/or prior skin biopsies, and further clarification with source information, including pre-biopsy photographs and/or direct consultation with the referring clinician, may be necessary. Because biopsy sites may heal prior to treatment, photographic images are often obtained to document location(s) of all biopsy sites for which treatment is/may be planned. The clinician should document the presence of any lymph­ adenopathy along with details such as firm, fixed, or matted nodes. Clinically suspicious lymph nodes should be evalu­ ated by fine needle aspiration biopsy (often performed with ultrasound guidance) and cytologic analysis. Biopsy-proven regional metastasis renders a sentinel node biopsy (SNB) procedure unnecessary to diagnose stage III disease in the involved basin. Importantly, palpable "reactive" lymphadenopathy may sometimes develop following biopsy of the primary mela­ noma, thus highlighting the importance of pathologic confir­ mation of metastatic melanoma before definitive treatment of the basin-for example, lymphadenectomy-is considered. Newly diagnosed melanoma patients should also undergo a head-to-toe skin examination to identify the presence of other suspicious skin lesions. Although it is beyond the scope of this section to review biopsy techniques in detail, an appropriate biopsy should include the epidermis, dermis, and at least a cuff of subdermal fat. This allows the derma­ topathologist to accurately report the essential components of primary melanoma tumor histopathologic microstaging, including, at a minimum, Breslow thickness (in millime­ ters), presence or absence of ulceration, mitotic rate, Clark level, status of peripheral and deep margins, and presence or absence of satellite lesions. W hen signs and/or symptoms are suggestive of additional disease, a well-performed physical examination may raise suspicion for distant metastasis. Particular attention should be paid to the neurologic examination, assessing for any localizing symptoms or mental status changes. The find­ ing of hepatomegaly, abdominal mass, or a rectal exam significant for mass or occult blood should prompt further workup. Finally, distant dermal or subcutaneous nodules or distant adenopathy also warrant investigation.

1535

1536

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

IMAGING AND OTHER DIAGNOSTIC STUDIES • •

•

•

•

Treatment planning for patients with primary melanoma is based largely on primary tumor histologic microstaging. In the absence of symptoms, the use of imaging studies as part of a staging workup has not been shown to significantly impact survival or the treatment algorithm of the newly diagnosed, clinically node-negative melanoma patient. For asymptomatic preoperative stages I and II melanoma pa­ tients, preoperative cross-sectional imaging has a very low yield.2 In one study, only 1 of 344 (0. 3 %) studies correlated with confirmed melanoma metastasis; no significant impact on proposed surgical management or staging was noted. 3 Even among asymptomatic microscopic stage III patients (i.e., sentinel-node positive), cross-sectional imaging stud­ ies infrequently identify distant metastatic melanoma.4 Although positron emission tomography (PET)/computed tomography (CT) generally includes images of the extremi­ ties, regions not typically imaged during standard CT or magnetic resonance imaging (MRI), a benefit for routine use of PET/CT has yet to be demonstrated in this patient population. In the otherwise asymptomatic patient with clinically palpa­ ble adenopathy, the detection rate of asymptomatic distant metastasis is higher and baseline imaging for staging (CT, PET/CT, MRI) is recommended.5 There is no specific tumor marker or biochemical parameter that has been validated and employed for melanoma screen­ ing or recurrence. Elevated serum lactate dehydrogenase (LDH) level is an adverse prognostic factor in patients with distant metastatic melanoma and is included in the Ameri­ can Joint Committee on Cancer (AJCC) staging system for stage IV disease. Patients with elevated serum LDH levels LDH levels are classified as Mlc regardless of distant ana­ tomic site(s) involved.6

Correct

Incorrect

Proposed

� excision

� Excisional --+----tH biopsy

FIG 1 • I m porta nce of orientation of excis i o n a l b i o psy. An exci­ sional b i o psy of the extrem ity is typica l l y oriented p a ra l le l to the l o n g axis of the extre m ity (right panel). I n t h is exa m p le, i ncorrect orientation (left panel), wou l d l i kely res u lt in the n eed for s k i n g raft closu re, w h i l e p r i m a ry c l os u re cou l d be l i kely be achieved if the b io psy had been correctly orie ntated (right panel). Note the in the right panel exa m p l e, the overa l l excision h as been exte nded to accommodate p r i m a ry closure. It is a l ways i m porta nt to consider next steps when perfo r m i n g a b io psy.

SURGICAL MANAGEMENT Preoperative Planning

Biopsy •

•

•

•

Most cutaneous lesions suspicious for melanoma have been biopsied by a dermatologist or other health care provider prior to treatment referral. If the biopsy of a lesion suspicious for melanoma has not yet been performed, the surgeon should plan and perform a biopsy: to establish a definitive histologic diagnosis, to obtain appropriate microstaging of the lesion (if melanoma is confirmed), and to maximize the potential for primary closure of the subsequent W E. An excisional biopsy should include a narrow margin of normal-appearing skin around the suspicious lesion along with a cuff of underlying subcutaneous fat to provide the dermatopathologist with sufficient material to fully diagnose and, if melanoma, to histologically microstage the primary tumor. An excisional biopsy of the extremities is typically oriented parallel to the long axis of the extremity ( FIG 1 ) . On the trunk and head and neck, the orientation of the biopsy should ideally follow the lymphatic drainage of the involved

•

•

•

skin while also being mindful of the lines of tension for opti­ mal closure. lncisional biopsies are sometimes necessary for large lesions, especially in cosmetically sensitive areas. Such a biopsy approach does not always reflect the full primary tumor microstaging of the lesion, including margin assessment, and such limitations need to be considered during definitive treatment. Shave biopsies are not generally recommended when a cuta­ neous lesion is suspicious for melanoma, because the full ex­ tent of the lesion (especially Breslow thickness) may not be included in the biopsy and the approach may limit accurate microstaging of the primary tumor. Confirmation of the melanoma biopsy site(s) must be per­ formed prior to any planned definitive treatment.

Histopathologic microstaging of primary melanoma •

In order to determine the appropriate extent of surgery for a patient with a primary melanoma-including WE margin and whether to offer/perform intraoperative lymphatic map­ ping and SNB-assessment of several of the primary tumor's histopathologic features is essential.

C h a p t e r 22 W I D E EXC I S I O N OF PRI MARY CUTA N E O U S M E LA N O M A

•

Breslow thickness (in millimeters), mitotic rate (expressed in mitoses/mm2), presence or absence of primary tumor ul­ ceration, and the biopsy margin status (peripheral and deep margins) are all essential to define T stage and to guide ap­ propriate surgical therapy; they should be assessed by a dermatopathologist. Additional primary tumor information that may be useful to the operative surgeon includes the presence or absence of lymphovascular invasion, neurovas­ cular invasion, regression, extent of tumor-infiltrating lym­ phocytes, histologic subtype, and Clark level.

Pressure points need to be padded and axillary and chest rolls need to be appropriately positioned. Some surgeons are comfortable performing both WE and inguinal SNB in the lateral position; a potential advantage is that repositioning is not required. Alternately, SNB can be performed in the supine position, and the patient repositioned for the W E.

Distal extremity •

Margins of excision • •

WE includes a radial margin of skin and underlying subcuta­ neous tissue, with margins appropriate for tumor thickness. The radial margin chosen for the WE is based on the primary tumor (Breslow) thickness. At least five prospective random­ ized trials conducted over the past three decades informed an evidence-based approach. Although detailed discussion is beyond the scope of this section, the recommendations from the National Comprehensive Cancer Network (NCCN) for the radial margin are as follows:5 • Melanoma in situ: 0.5-cm margin (Note: For large diam­ eter melanoma in situ, for example, lentigo maligna type, margins >0.5 em may sometimes be considered to ade­ quately treat occult early invasive disease). • Less than or equal to 1.0 mm: 1.0 em • 1.0 1 to 2.0 mm: 1.0 to 2.0 em • 2.0 1 to 4.0 mm: 2.0 em • Greater than 4.0: 2.0 em

•

•

Depending on primary tumor characteristics and other con­ siderations, lymphatic mapping and SNB are most often performed in the same operative setting as a W E. For this reason, proper patient positioning should account for both the location of the primary melanoma and the location(s) of draining regional nodal basins. This may become challenging when the primary melanoma drains to multiple nodal basins and/or to interval, ectopic, and/or in-transit sites. Skin graft donor sites or other reconstructive issues must also be con­ sidered when positioning the patient.

•

•

•

Proximal extremity •

•

For proximal upper extremity lesions, a supine position is generally appropriate for WE and SNB. For more posterior lesions near the shoulder, a modified supine position using a shoulder roll or a lateral decubitus position provides easy access for WE and closure. The arm, prepped circumferen­ tially, should be supported to prevent injury to the brachial plexus and/or shoulder. For proximal lower extremity lesions, the supine position provides excellent exposure of anterior or lateral sites, al­ lowing both WE and SNB. When the melanoma is on the posterior proximal leg or the buttock, the WE may be per­ formed with the patient in the lateral or prone position.

In general, a supine position is appropriate for most distal extremity lesions. If SNB is also to be performed, access to the axillary, epitrochlear, and inguinal nodal basins is readily achieved. If a patient's melanoma drains to the popliteal nodal basin, then an alternative position other than the supine ap­ proach should be used. The prone position is sometimes used so as to allow the sentinel node to be removed through an inci­ sion that could be incorporated into a full popliteal node dis­ section incision if evidence of metastasis were to be identified. Heel melanomas not only have the potential to drain to the popliteal basin but may also require specialized reconstruc­ tive approaches (e.g., wound vac device, rotational flaps, and/or vascularized free flaps). In this situation, use of a beanbag on the operating room table allows for reposition­ ing as indicated.

Truncal sites

Positioning

General positioning strategies

1537

W hen an SNB is performed with WE of a truncal mela­ noma, the possibility of multiple nodal basin drainage pat­ terns must be considered when devising an operating room positioning strategy. A preoperative lymphoscintigraphy will demonstrate afferent lymphatic drainage patterns to major and unusually situated (e.g., ectopic, interval) nodal basins. For most anterior truncal melanomas (e.g., chest and abdo­ men), the supine position allows for access to the primary and draining regional nodal basins. For lateral truncal mela­ nomas, ideal positioning for the WE may include placing the patient in a partial or formal lateral position (with appropri­ ate padding and brachial plexus protection). W hen performing a WE only (e.g., for a thin melanoma without adverse risk features), back melanomas may be performed in the prone (e.g., for medial lesions) or lateral (e.g., for most back lesions) position at the discretion of the surgeon. Appropriate padding and brachial nerve protec­ tion must be employed and airway protection is essential. If SNB is being performed in the same operative setting, pa­ tient positioning must foster access to draining nodal basins including multiple and/or unusually situated nodal basins. It may be necessary to reposition the patient after the SNB and before the WE ( FIGS 2 and 3) .

Head and neck sites •

Head and neck melanoma patients must also be carefully positioned with consideration of the W E, reconstructive requirements, and in continuity access to draining regional nodal basins if SNB is to be performed. Whether in a supine, prone, or lateral position, the head and neck must be ap­ propriately supported and padded. Additionally, the airway, eyes, and ears must be protected.

1538

P a r t 5 OPERATIVE TECH NIQUES I N BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

A .......

Left groin

B

c

·. .

FIG 2 • Lym p h oscintigra p h i c i mages of a patient with a p r i m a ry cuta neous m e l a n o m a of the m i d l i ne m i d back demonstrates rad i otracer u ptake activity in the b i l atera l g r o i n s a n d the left axi l l a .

A

FIG 3 • Exa m p l e of an operative positioning strategy for patient with the m i d l i n e melanoma of the mid back u ndergoing wide excision and lym phatic mapping and sentinel node biopsy i n the same operative proced u re. (Note lym phosc i n itigra p h i c drainage to the bi latera l groin reg ions and left axi l l a as shown i n figure 2). Due to rad i otracer "shine throug h " from the primary i njection site i n the m i d l i n e back, the patient was placed i n the l atera l decu b itus position to address both the l eft axi l l a ry drainage a n d primary t u m o r site (m i d l i n e back) ( A and B) . (continued) B

C h a p t e r 22 W I D E EXC I S I O N OF PRI MARY CUTA N E O U S M E LA N O M A

1539

FIG 3 • (continued) The patient was then repositioned to s u p i n e to perform b i l atera l i n g u i n a l senti nel node b io psies (C) . Note that if rad i otracer s h i n e th roug h was not a problem, then the patient cou l d have been i n it i a l l y positioned i n the supine position (after i njection of both isosu lfa n blue dye and rad i oco l loid) to a d d ress the b i l atera l i n g u i n a l n o d a l bas i ns as wel l as left axi l l a ry n o d a l bas i n a n d then repositioned i nto the l atera l decubitus position to perform the wide excision of the back m e l a n o m a . Reg a r d l ess of a p p roach, it is i m po rtant to sca n i nterve n i n g reg i o ns with the g a m m a probe.

c

to be resected. If the primary melanoma is entirely or par­ tially i ntact, the margin s h o u l d be measu red from the pe­ riphery of the vis i b l e lesion. When the entire pigmented lesion has been excised by the previous biopsy, the m a rg i n should be measured from t h e peri phery o f t h e biopsy sca r.

WIDE EXCISION MARGIN •

The p l a n ned m a rg i n of excision of the primary melanoma is based on the B reslow tumor thickness as described a bove a n d refers to the rad i a l m a rg i n of normal-appearing skin

PLACEMENT AND ORIENTATION OF INCISION •

•

Proper p l a n n i n g of the i ncision is critica l . The s u rgeon m ust consider the req u i red rad i a l m a rg i n (i.e., margin of excision), the specific a nato m i c p r i m a ry site i nvolved, as we l l as the q u a l ity a n d q u a ntity of loca l soft tissue. Beca use the res u lt i n g f i n a l i ncis i o n may be s i g n ificantly longer than what the patient m i g ht h ave otherwise a ntici pated, based on the usu a l ly "sm a l l " b i o psy s ite,

•

we stro n g ly reco m m e n d that t h is theme be i nteg rated i nto the surgical cons u ltation and preoperative visits: a "sca l e " d rawi n g p resented to the patient at the t i m e of i n it i a l a n d/or preoperative visit is often very i nstructive. The reco m m e n ded m a r g i n of excis i o n is based o n pri­ m a ry t u m o r th ickness (described above) a n d is m easured from either the edge of the i ntact m e l a n o m a or b io psy scar, genera l ly res u lt i n g in the proposed circu l a r or ova l defect ma rked on the s k i n (FIG 4A,B) . When a p r i m a ry c l os u re is p l a n ned, the c i rcle or ova l can be mod ified i nto

A B FIG 4 • A.B. In t h is exa m p l e, the patient has a l ready been i njected with both Tc-99 sulfur co l loid a n d isosu lfan b l u e i ntraderma l ly around the bi opsy site for a lym phatic m a p p i n g a n d sent i n e l biopsy proce d u re at the time of wide excisi o n in the same operative sett i n g . The recommended m a rg i n of excisi o n is based on p r i m a ry tumor thickness a n d is measu red from either the edge of the i ntact m e l a n o m a o r b i o psy sca r, genera l ly resulting i n the proposed c i rcu l a r or ova l defect ma rked on the ski n .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

•

FIG S • When a p r i m a ry closure as p l a n ned, the circle or ova l is genera l ly fas h ioned i nto an e l l i pse prior to wide excis i o n to i m p rove cos m etic outcome a n d fac i l itate p r i m a ry closure.

•

•

•

•

a n e l l i pse prior to WE to i m p rove cos m etic o utcome a n d fac i l itate p r i m a ry clos u re (FIG S) . Excis i o n of a n e l l i pse of tissue resu lts in a m o re g ra d u a l tra nsition in wou n d conto u r a n d m i n i m izes " d o g ears " a t t h e poles o f the i n c is i o n . Creati o n of a n e l l i pse t h ree to f o u r t i m es as l o n g as it is w i d e has often been reco m m e n d e d i n textbooks; cos­ m etica l ly accepta b l e c l os u re can s o m et i m es be a c h i eved with a s m a l l e r rat i o and s h o u l d be i n d i vi d u a l iz e d . Alternatively, tissue that may contribute to dog ears can be resected after the oncologic portion of the W E . Depen d i n g o n the l i n es of tension of the skin, a mod ified e l l i pse such as lazy 5 or " h u rrica n e " -type (FIG 6) i ncision may fac i l itate c l os u re, genera l ly as tria n g u l a r-sh a ped seg ments of skin and underlying s u bcuta neous tissue. When feasi ble, the i ncis i o n s h o u l d be oriented to fac i l i ­ tate p r i m a ry c l os u re. O n the extre m ities, f o r exa m p l e, the WE i ncis i o n is usu a l ly oriented p a ra l l el to the long axis of the limb. Th is fac i l itates p r i m a ry c l os u re, res u lts i n g reater excis ion o f lym p h atics that a r e a t risk f o r mela­ noma t u m o r ce l l e m b o l i , a n d may decrease s u bseq uent lymphedema. B reast-Pri m a ry cuta neous m e l a n o m a of the s k i n of the breast should be managed with s i m i l a r p r i n c i ples as cu­ ta neous m e l a n o m a elsewhere. A mastectomy is not re­ q u i red to a c h i eve oncologic contro l .

SKIN INCISION •

•

The s k i n i n cisi o n is typica l l y made with a n o . 1 0 or 1 5 blade sca lpel, i n itia l ly to the l evel of the deep derm is. The rem a i n d e r of the dermis can be d ivided either using the e lectroca utery on cutt i n g mode o r by usi n g a sca l pe l . Ca re i s req u i red t o avo i d ca utery t o t h e s k i n edges, a s t h is may res u lt i n wou n d hea l i n g issues. The excis ion contin ues by deepe n i n g the i n it i a l i ncision i nto the s u bcuta neous tissue to the level of the m uscu l a r

H a nd, foot, a n d d i g its-G enera l m a r g i n g u i d e l i nes for cuta neous m e l a n o m a s h o u l d be fol l owed and cons i der­ ation for preservation of fu nction s h o u l d be maxi m ized. As a general p r i n c i p l e, it is not usu a l l y necessary to re­ move bone to obta i n oncolog ic control of the p r i m a ry m e l a n o m a . H owever, a m p utati o n is us u a l ly necessary if sta n d a rd WE for s u b u n g u a l or d ista l d i g it i nvasive cuta neous m e l a n o m a leaves i nsufficient soft tissue to m a i nta i n a f u n ct i o n a l d i g it without part i a l p h a l a nx bony resect i o n . P h a l a nx-preserv i n g a p p roaches can somet i m es be e m p l oyed for d ista l d i g it/s u b u n g u a l m e l a n o m a i n situ. Peri a n a l s k i n m e l a nomas s h o u l d be treated as cuta neous m e l a n o m as .

F I G 6 • Depen d i n g on the l i n es of tension of the skin, a mod ified e l l i pse such as lazy 5 or h u rrica ne-type i ncision may fac i l itate c l os u re .

fascia; ca re m ust be taken t o m a i nta i n a n a n g l e of attack through the s u bcuta neous tissue that is perpe n d i c u l a r to the s k i n s u rface. The act u a l d epth of excisi o n w i l l vary a ccord i n g to the a nato m i c location of the p r i m a ry m e l a ­ n o m a . It is r a r e l y necessary to i n c l u d e fascia w i t h WE5; an exce ption is when prior surgery at the site i n c l uded o r a butted the fascia such that clear margin ca n n ot be achieved or in the case of obvious t u m o r i nvolvement at the fascia.

C h a p t e r 22 W I D E EXC I S I O N OF PRI MARY CUTA N E O U S M E LA N O M A

EXCISION OF SPECIMEN •

•

O n ce the depth of the resection has reached the u n d e rly­ ing m uscu l a r fascia, the WE is com p l eted by d issect i n g s k i n a n d soft tissue f r o m the u n d e r l y i n g fascia usi ng t h e electroca utery (FIG 7) . WE speci mens are a l m ost a lways s u b m itted for per­ ma nent section a n a lysis; i ntraoperative frozen section a n a l ys is is the except i o n . When reconstruction may be

•

s i g n ificantly i m pa cted by a n i nvolved m a r g i n , " rush " perm a n e nt pathology (turnaround a bout 2 4 t o 4 8 h o u rs) may be coord i n ated with the pathology team (see a lso " De l ayed Wou n d C l os u re " l ater in t h is cha pter) . It is i m porta nt to properly orient the speci men i n the eve nt that final m a r g i ns a re i nvolved a n d a n additional resection (us u a l ly as a sepa rate operative procedu re) is req u i red (FIG 8) .

FIG 7 • The depth o f wide excis i o n d o w n to t h e m uscu l a r fascia is demonstrated. O n ce t h is depth is reached, the skin and soft tissue is d issected off the u nderlyi n g fascia, com p leti ng the wide excis i o n .

FIG 8 • The resected speci men i s ca ref u l ly oriented t o ens u re accu rate m a r g i n assess m e nt by the pathologist. It is a lso i m porta nt to orient in such a fas h i o n that re-excisi o n of i nvolved m a rg i ns can be accu rate ly ma pped b a c k to the patient.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

CLOSURE •

•

The majority of 1 -cm m a rg i n defects a n d many 2-cm m a rg i n defects can be closed p r i m a r i ly. Recru itment of a djacent tissue by fash i o n i n g local f l a ps often fac i l itates p r i m a ry clos u re a n d is dependent on the p r i m a ry t u m o r l ocation, m a r g i n , a n d the laxity of adjacent s k i n . S u r g i ­ cal defects may often be closed b y mobi l iz i n g tiss u e f l a ps that h ave been created by u n d e rm i n i n g in a s u p rafasc i a l p l a n e a n d i n c l u d e fu l l -thickness s k i n a n d underlying sub­ cuta neous fat (FIG 9A,B). Com p l ex c l os u re of a WE defect i nvo lves p lacement of one or two l ayers of deep a bsorba b l e sutu res (FIG 1 0), fo l l owed by p lacement of an i ntraderm a l layer of a b u ried a bsorba b l e suture. S k i n c l os u re ca n be carried out usi n g a n u m ber of tech n i q u es, depe n d i n g on the tissue tension, a nato m i c location, m o b i l ity, a n d s u rgeon p reference. A su bcuticu l a r skin clos u re may be performed us i n g an

F I G 1 0 • Photo d e m o nstrat i n g p l acement of d e e p a bsorba b l e sutu res to fac i l itate com p l ex p r i m a ry c l os u re of a W E . Typica l ly one or two l ayers of deep a bsorba b l e sutu res a re used. a bsorba b l e monofi l a m ent suture o r a n o n a bsorba b l e p u l l -t h ro u g h suture t h a t req u i res remova l . I nterru pted or ru n n i n g n o n a bsorba b l e sutu res and s k i n sta p l es may a lso be used as per s u rgeon p reference (FIG 1 1 ). Dermal a d h es ives o r a d h esive bands may be used to di­ rectly cove r the skin. A

B FIG 9 • Photo (A} a n d i l l ustrati o n (B) demonstrat i n g the m obi l ization of tiss u e f l a ps by u n d e rm i n i n g the fu l l thickness of s k i n a n d su bcuta neous fat at a level j ust s u perfic i a l to the m uscu l a r fasci a .

FIG 11 • After rea pproxi mation of deep layer(s), the skin may be closed using a n u m ber of d ifferent techniques and sutu res depen d i n g on location, tension, and surgeon preference. In this photog ra ph, i nterru pted vertical mattress sutures were used.

C h a p t e r 22 W I D E EXC I S I O N OF PRI MARY CUTA N E O U S M E LA N O M A

•

At the d iscretion of the s u rgeon, closed suction d ra i n ­ a g e m a y be used w h e n extensive u n d e rm i n i n g or l a rge f l a ps are necessary or when considera b l e dead space pers ists after layered c l os u re. If a drain is used, the exit site s h o u l d be p laced i n l i n e with the i ncis i o n so that any

potenti a l recu rrence can be reexcised without jeopard iz­ ing s u bseq uent wound clos u re. Alternatively, suture p l i ­ cation o f the m o re su perfic i a l tissue t o the u nderlyi n g fascia m a y somet i m es be used a n d obviate the n e e d for d ra i nage, even when l a rger f l a ps a re used.

RECONSTRUCTION •

•

•

When p r i m a ry c l os u re is not feas i b le, consid eration should be g iven to s k i n g rafts or local tissue f l a ps . The advantage of a s k i n g raft is that it is a relatively stra i g ht­ fo rwa rd proce d u re that m i n i m izes adjacent tissue m a ­ n i p u lation, a l l ows f o r easy l o n g -term m o n itori ng of t h e p r i m a ry m e l a n o m a site, a n d does n o t d isrupt lymphatic d r a i n a g e pathways . S k i n g rafts, h owever, a re i nsensate, provide l ittle protection to u nderlyi n g tissue, and may res u it in a m o re pronou nced conto u r defect. F u rthermore, compared to local tissue f l a ps, s k i n g rafts may res u lt i n more d isfi g u rement a n d prolonged hea l i n g . S k i n g rafts a re d iscussed i n deta i l i n Part 5, C h a pter 24. Typical ly, s p l it-th ickness s k i n g rafts a re ha rvested from the posterior or proxi m a l latera l t h i g h . Of note, when a l ower extrem ity m e l a n o m a req u i res a s k i n g raft closu re, the g raft s h o u l d be ha rvested from the contra latera l extremity. F u l l -thickness s k i n g rafts can be h a rvested from m u lti­ p l e locations, a l lowing for better s k i n color a n d textu re

•

DELAYED WOUND CLOSURE •

•

The majority of WE defects a re c l osed or reconstructed d u r i n g the same operation as the W E . There a re circum­ sta nces, however, when delayed reconstruction is the most a ppropriate co u rse of act i o n . These situations may i n c l u d e delaying reconstruction i n the sett i ng of l a rge d i ­ a m eter o r poorly defi ned m e l a nomas where m a r g i ns a re c l i n ica l ly equ ivoca l at t i m e of W E . U n l i ke its common use for assessment of m a rg i ns for n o n m e l a n o m a s k i n cancer, i ntraoperative frozen section m a r g i n assessment is i nfre­ q uently e m p l oyed for i ntraoperative m a r g i n assessment of melanoma WE. Del ayed reconstruction may a lso be benefi c i a l when t i m e i s n e e d e d f o r a g r a n u lation b e d to f o r m i n o r d e r to fac i l i ­ tate g rafting, s u c h a s after excis i o n o f a h e e l m e l a n o m a

•

•

matc h i n g to s k i n adjacent to the m e l a n o m a excis i o n . F u l l-th ickness s k i n g rafts m a y be ha rvested f r o m the i n ­ g u i n a l g r o i n crease, the l ower n e c k reg i o n overlyi n g t h e c lavicle, o r beh i n d the ear. After a n a p p ropriately sized e l l i pse of skin is excised down i nto the su bcuta neous fat, the donor site is p r i m a r i ly closed, res u lt i n g in l ess morbid­ ity t h a n the typica l s p l it-th ickness s k i n g raft donor site. The f u l l-thickness h a rvested skin is de-fatted and pre­ pa red as a skin g raft. The decis i o n to proceed with a l o c a l tiss u e o r rotati o n a l f l a p s h o u l d be m a d e after caref u l cons i d e ration of t h e featu res of the loca l t u m o r, i n c l u d i n g r i s k of sate l l ite or i n -transit m etastases, the pote n t i a l benefit to the patient from the fu ncti o n a l a n d cos m etic pers pective, the co m o r b i d ities of the patient, and the loca l tiss u e options ava i l a b l e . The adva ntages of loca l f l a ps i n c l u d e d u ra b l e, sensate, s i m i l a r th ickness, a n d textu red ski n . D isadvantages i n c l u d e rearra n g e m ent o f reg i o n a l soft tiss u e at risk for i n -trans it/sate l l ite m etastatic d isease. Adva ncement and rotat i o n a l f l a ps a re d iscussed i n de­ ta i l i n P a rt 5, C h a pter 23.

where s k i n g raft i n g o nto a g ra n u lating bed is often per­ formed in such a fas h i o n (FIG 1 2) . When wou n d clos u re i s d e layed, options f o r wou n d cov­ erage i n c l u d e te m porary wou n d d ress i n gs with rout i n e d ress i n g changes or a vacu u m-assisted sponge d ress i n g device (e. g . , vac u u m-assisted c l os u re [VAC] device). VAC devices are somet i m es not ava i la b l e u n t i l negative m a r­ g i ns a re confi rmed. I n some situations, a req uest for rush perm a n e nt patho l ­ o g y of the WE speci men may be coord i n ated i n advance with the pathology team, t h us fac i l itat i n g advance s u r g i ­ cal p l a n n i n g (often at 48 h o u rs postoperative) both i n terms o f o perat i n g r o o m s p a c e a n d co l l a boration with the reconstructive tea m . In such cases, a temporary occl usive d ress i n g is often used to protect the WE site until f i n a l m a rg i ns a re ava i l a b l e .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

A

B

D c FIG 1 2 • Photog ra phs d e m o nstrati n g use of d e l ayed reconstruction for a l a rge heel m e l a n o m a (A) . U pon comp letion of the WE (B), a vacu u m - ass isted sponge d ress i n g device is p laced i ntraoperatively (C). The recipient g ra n u lation bed, shown here after use of a vacu u m-assisted device for a p p roxi mately 3 weeks, is now opti m ized for s k i n g raft i n g (D).

PEARLS AND PITFALLS Preoperative strateg i es

• • •

Operative positi o n i n g

• • •

Placement o f i ncision

• • • •

I ntraoperative considerations

• • • •

Clos u re

• •

Orientation of b i o psy is i m porta nt whenever performed. H ea l i n g of b i o psy-Photo document b i o psy site for l ater site co nfirmation whenever it may be poss i b l e that site will be healed prior to defi n itive WE. Com p l ete h istory a n d physica l essentia l to ide ntify a d d it i o n a l suspicious p r i m a ry lesions as wel l as potenti a l s ites o f i n -transit metastasis, sate l l ites, a n d c l i n ica l n o d a l d isease. Pad a l l press u re poi nts . I nc l u d e potenti a l i nterva l a n d/or i n-tra nsit d r a i n a g e s ites with i n operative field if S N B is to be performe d . Do n ot ha rvest s k i n g rafts f r o m i n -transit reg i o n (i.e., between p r i m a ry t u m o r a n d d ra i n i n g n o d a l bas i n); a s a practical a p p roach, it is genera l ly n ot prudent to ha rvest s k i n g rafts from i ps i l atera l extrem ity. Extrem ities-Incision is genera l ly oriented para l lel to the l o n g axis of extremity. Always consider reconstructive options when p l a c i n g a n d p l a n n i n g i ncis i o n for W E . U s e rad i a l m a r g i ns a p p ropriate f o r t u m o r thickness. Be aware of su perficial (su bcuta neous) motor nerves (e.g., s u perficial peroneal a n d portion of s p i n a l accessory) Excis i o n s h o u l d be performed to, but not i n c l ude, l evel of the underlying m uscu l a r fascia, u n l ess the fascia itself is i nvolved with tumor or the prior b io psy p roced u re. Ma i nta i n perpe n d i c u l a r orientation t h ro u g h su bcuta neous tiss u e . Froze n section m a r g i n a n a l ysis is r a r e l y e m p loyed . Proper orientation of WE speci m e n is essent i a l to fac i l itate reexcisi o n of i nvolved m a rg i ns when necessa ry. Consider overa l l risks of locoreg ional a n d other metastases with a ny extensive reconstruction option e m ployed. Cons i d e r clos i n g dead space where a p p ropriate to red u ce l i ke l i h ood of seroma format i o n .

C h a p t e r 22 W I D E EXC I S I O N OF PRI MARY CUTA N E O U S M E LA N O M A

POSTOPERATIVE CARE

COMPLICATIONS

•

•

• • •

•

Specific postoperative care is dependent on the type of clo­ sure, the use of absorbable or permanent suture material, the extent of tension on the wound, and the presence or absence of a drain. In general, the patient can shower in 24 to 48 hours unless skin grafts are used. Drains (if used) usually stay in place until collected volumes remain 30 mL or less for 2 consecutive days. Specific restrictions may apply depending on anatomic loca­ tion (e.g., restrictions on weight bearing for melanomas on the plantar surface of foot) and type of closure (e.g., skin graft). Progressive increase in activity, weight bearing, or lifting over a 4- to 6-week period

• • • • • • •

Infection (cellulitis or abscess) Seroma Hematoma/ bleeding Wound dehiscence or separation Failure of take of skin graft or flap Poor functional or cosmetic outcome Numbness and/or hyperesthesia and/or pain Edema/lymphedema

REFERENCES 1. 2. 3.

OUTCOMES •

•

After an appropriate WE based on tumor thickness, true local melanoma recurrences are uncommon and likely repre­ sent lymphatic tumor emboli. Some "local recurrences" are a result of an incompletely or inadequately excised primary melanoma. Functional outcome is critical and early use of physical ther­ apy is encouraged when appropriate.

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4.

5. 6.

Gershenwald JE, Ross MI. Sentinel-l ymph-node biopsy for cutaneous melanoma. N Eng/] Med. 2011;364:1738-1745. Sabel MS, Wong SL. Review of evidence- based su pport for pretreatment imaging in melanoma. } Nat/ Compr Cane Netw. 2009;7(3) : 281-289. Buzaid AC, Sandler AB, Mani S, et al. Role of computed tomography in the staging of primary melanoma. J Clin Oncol. 1993;11:638-643. Aloia TA, Gershenwald JE, Andtbacka RH, et al. Utility of computed tomography and magnetic resonance imaging staging before comple­ tion lymphadenectomy in patients with s entinel lymph node-positive melanoma. J Clin Oncol. 2006;24:2858-2865. NCCN clinical practice guidelines: melanoma. http://www. nccn.o rg /professionals/physician_gls/pdf/melanoma/pdf Accessioned 08/08/2014 Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classificatio n. ] Clin Oncol. 2009;27(36) : 6199-6206.

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Chapter

23

Advancement and Rotational Flaps

I · - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - �- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

t

Jeffrey H. Kozlo w

DEFINITION •

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•

•

•

•

Advancement and rotational flaps are tissue transfer tech­ niques used in reconstructive surgery for the closure of acquired defects. A flap is an area of tissue designed for movement to another area while remaining vascularized. This is in contrast to a graft, which is transferred in a nonvascularized fashion and becomes revascularized only with local incorporation and vascular neogenesis. Advancement and rotation flaps are both considered local flaps because they borrow from the tissue adjacent to the defect. Distant flaps use tissue from areas away from the defect, and free flaps involve the transfer of tissue from a distant site by means of a microsurgical anastomosis. Local flaps can be defined by their vascularity. Random flaps are based on blood flow through the subdermal plexus to provide vascularity to the distal end of the flap ( FIG 1 ). Axial flaps are based on a longitudinal blood vessel incorporated into the flap design that can extend the effective length of a flap ( FIG 2 ) . Perforator flaps are based on underlying septa­ cutaneous or musculocutaneous perforators into the central area of the flap ( FIG 3 ) . Local flaps can also b e defined b y the geometry o f the inci­ sions used with example of common designs shown in the following text. Flap design includes evaluation of tissue laxity, optimization of scar position, and management of standing cutaneous deformities.

PATIENT HISTORY AND PHYSICAL FINDINGS •

The choice and design of local flaps is dependent on mul­ tiple factors including the region on the body for reconstruc­ tion, local and regional soft tissue laxity, relationships with

Perforatory blood vessels to subdermal plexus

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• • •

•

•

•

underlying critical anatomy, relaxed lines of skin tension for scarring, and underlying flap vascularity. Poor quality of tissue adjacent to the defect may preclude the use of local flaps. Local radiation damage will often limit the pliability of tis­ sues for transfer and inhibit the healing potential of tissue. Each patient is different and flap choice must be tailored to the individual, the size of the defect, and the location of the defect. There are often multiple different flaps that will adequately reconstruct a defect; there is no "one right answer" for any given case. Flap design should also consider potential oncologic impli­ cations including the need for recurrence monitoring, sec­ ondary reconstruction techniques, and margin management when reconstruction is done immediately after resection and margin status cannot be confirmed. For patients with lower extremity defects, an evaluation of arterial status and venous insufficiency should be considered.

IMAGING AND OTHER DIAGNOSTIC STUDIES • •

In general, local flaps do not require preoperative imaging or diagnostic studies. Doppler can be used to identify either axial or perforating blood vessels if clinically indicated.

SURGICAL MANAGEMENT Preoperative Planning •

A reconstructive plan can only be made after the resection is designed. In cases that may require a plastic and recon­ structive surgeon for advanced reconstructive techniques, it is always best to plan accordingly ahead of time and not consult intraoperatively.

FIG 1 • Demonstration of a " ra n d o m " pattern f l a p based on the subdermal p l exus-The d ista l aspect o f the f l a p rem a i ns vascu l a rized t h ro u g h the s m a l l vessels ru n n i n g u n d erneath the d e r m is o n ly. As the length of the f l a p in c reases, the bl ood flow thro u g h the s u bderma I p l exus decreases.

C h a p t e r 23 A DVAN C E M E N T A N D ROTAT I O N A L FLAPS

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Muscle

Subdermal plexus

•

FIG 2 • Demonstrati o n of a n axi a l pattern f l a p­ The f l a p des i g n i n corporates a named a rterial s u pply a l o n g the l ength of the f l a p, which in c reases perfus i o n to the d ista l aspect of the f l a p compared to a ra n d o m pattern f l a p .

Axial blood vessel

Preoperative markings may include important regional ana­ tomic landmarks (such as facial rhytids) that may be ob­ scured with the injection of local anesthetic intraoperatively.

Positioning •

Patients should be positioned to optimize not only sur­ gical access for tumor resection but also for access to

Epidermis Dermis Subcutaneous tissue

•

any local areas potentially usable for the subsequent reconstruction. All areas should be prepped widely to allow for access to all local and regional flap option. All extremities should be prepped and draped circumferentially. For areas where symmetry is important (such as the face or breasts), it is important to have the contralateral side in the operative field as well.

�

Muscle

Subdermal plexus

•

•

There are m u lt i p l e loca l f l a ps that are ava i l a b l e for use in reconstruct i o n . Not a l l of them can be h i g h l i g hted i n th is text; however, t h e m ost common f l a ps for general reconstruction a re described i n the fo l l ow i n g text. I n some cases, m u lt i p l e local flaps are req u i red a n d tech n i q u es can be combined to achieve clos u re of the defect. In most flaps, the a rea is often infi ltrated with loca l a n esthesia including 1 : 1 00,000 to 1 :200,000 pa rts epinephrine to h elp with hemostasis a n d m i n i m ize electrocautery injury

•

• •

FIG 3 • Demonstration of a perforator-based f l a p­ The f l a p is centered around a s i n g l e blood vessel, which perfo rates through the fasci a l layer from the u n derlying m uscle o r m uscu l a r septa to then s u p p ly the s u b d e r m a l p l exus.

to dermal edges. However, overinjection of local anesthe­ sia can res u lt i n tissue edema that decreases flap mobil ity. S k i n hooks are used on the m a r g i ns of a f l a p for h a n ­ d l i ng; the u s e of forceps is d isco u raged d u e to i nj u ry to the f l a p edges from overzea l o us p ress u re. D ra i ns a re typica l l y not used u n l ess f l a ps are l a rge. F l a ps desig ned around j o i nts s h o u l d be i nset u n d e r the g reatest tension of the j o i nt to avoid postoperative d e h iscence.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

SIMPLE ADVANCEMENT FLAPS Flap Design •

Based on either the s u bderm a l p l exus as a vasc u l a r sup­ ply from the base of the f l a p to the d ista l end o r can i nc l u d e a n axial vessel for a d d it i o n a l length a n d deg rees of freedom I ncisions a re d es i g n ed i n a para l l e l fas h i o n e q u a l to the d i mensions of the defect (FIGS 4A a n d SA); choice of d i rection is based on loca l tissue laxity. Cl assic teac h i n g is that a maxi m u m 3 : 1 ratio of length to width can be used when the f l a p is based on the subder­ m a l p l exus.

•

•

Defect Closure •

•

•

Flap Elevation •

I ncisions a re made exte n d i n g from the defect i n a p a ra l l el fas h i o n toward base of f l a p . D issection is carried down to the depth of defect or deeper i n order to match vol u m etric d i mensions of reconstruction.

•

�

The centra l portion of the f l a p is u n dermi ned either i n t h e d e e p su bcuta neous level or below t h e fascia, de­ pend i n g on f l a p des i g n and re l i a nce o n subdermal o n ly versus axial-based b l ood s u p p l y (FIGS 48 a n d 58) .

•

Ca ref u l hemostasis is ass u red after f l a p elevation; hema­ tomas u n d e r the f l a p can compromise vasc u l a rity a n d overa l l o utcome. O n ce f l a p has adequate adva ncement to fi l l defect, clos u re often occ u rs from the base of the f l a p to h e l p " push " the f l a p i nto the defect, w h i c h can h e l p a l l eviate tens i o n over the d ista l clos u re (FIG 4C) . Sta n d i n g cuta neous deformities can occ u r as the base is adva nced. These a reas can be resected with a sca r per­ pend i c u l a r to the d i rection of the f l a p . Dermal closure is performed using a n a bsorba b l e suture fo l l owed by either a su bcutic u l a r or s i m p l e exte r n a l su t u r e (FIG SC) .

Blood '""'' .

A

A

B

•

=

Undermined area

----t---- Defect

c

B

B

FIG 4 • The des i g n of an advancement f l a p is based on s u b d e r m a l blood s u p p ly f r o m the base of the f l a p . The i n it i a l para l le l i ncisions a re d rawn from the wound edges (A) . The advancement f l a p is u n de r m i ned towa rd the base, leavi ng o n ly the subdermal blood s u p p ly to vascu la rize the d ista l t i p (B) . The f l a p is then advanced forwa rd and pushed i nto the defect. The previous base corner of the f l a p (po i nt A) has been pushed forward and is a p p roxi mated to p o int A 1 (C) .

C h a p t e r 23 A DVAN C E M E N T A N D ROTAT I O N A L FLAPS

B c FIG 5 • A. I n t h is case, an axial-based adva ncement f l a p for n asa l reconstruction is desig ned to i n corporate the a n g u l a r a rtery for a d d it i o n a l length. This u n d e rm i n i n g is seen i n B as the f l a p is fold back toward its base prior to advancement. The final advancement a n d c l os u re of the advancement flap is demonstrated i n C.

A

ROTATIONAUTRANSPOSITION FLAPS

Flap Elevation

Flap Design

•

•

• •

Desig ned as a sem i c i rcle exte n d i n g from one corner of the defect (FIGS 6A a n d 7A) D i rection a n d orientation of f l a p is based on loca l a reas of laxity. Based on a pivot point at " base " of f l a p that determ i n es a m o u nt of rotation ava i la b l e

D

Defect

1111

I

X1 - Pivot

Blood supply

A c1

B

-- -

c D

/

�

A1

B 81

c

•

1

1

B

Defect

\

•

I ncis i o n is made t h ro u g h s k i n a n d s u bcuta neo us tissues to depth of defect or g reater. F l a p is u nderm i n ed i n same or deeper p l a n u p to the base (FIG 68) . Ca ref u l h e m ostas is is ass u red i n u n d e r m i ned a rea to avo i d a hematom a that may compromise f l a p .

D1

•

=

Undermined area

FIG 6 • The semicircu l a r m a rki ngs for a rotation flap are demonstrated . T h e s u bsequent advancement o f the flap i s demonstrated b y t h e movement of poi nts A, B, C, a n d D to A ' , 81, C1, a n d 0 7 , respectively (A). The rotation flap is u ndermi ned back toward the base leavi ng the d ista l portion of the tissue perfused throug h the subdermal p l exus. Additi o n a l back-cuts across the base s h o u l d be done j u d icious to not com p rom ise vascu la rity of the f la p (B). The rotation f l a p is rotated i nto the defect for closure. The movement of the flap relative to the adjacent skin is noted by the changed a l i g n ment of the C a n d D ma rks to the C' a n d 0 7 marks, respective ly. C. A s m a l l sta n d i n g cuta neous deform ity at the base of the flap may req u i re excis i o n .

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

A

FIG 7 • A. In th is c l i n ica l case, oppos i n g adva ncement f l a ps h ave b e e n des i g ned for reconstruction of a p l a nta r foot wou n d . B. I n t h is case, t h e oppos i n g f l a ps have both been adva nced to reconstruct the defect.

B

Defect Closure

Additional Designs

•

•

•

•

F l a p is advanced a n d rotated i nto defect with clos u re often sta rt i n g at base of defect to h e l p push a n d rotate f l a p i nto defect (FIG 6C) . Derm a l clos u re is performed using an a bsorba b l e suture fo l l owed by either a s u bcuticu l a r or s i m p l e exte r n a l su­ t u re (FIG 7B) . Excision of standing cutaneous deformities should be away from the base of the flap to avoid decreasing flap vascularity.

M u lt i p l e va riations i n f l a p des i g n a re co m m o n ly u s e d b u t based on the same p r i n c i p l e a s earlier. For exa m p l e • A bi lobed flap uses two adjacent rotation/transposition flaps. The flap d irectly adjacent to the defect is used to close the primary defect and the other flap is then used to close the donor site for the first flap (FIG SA-c). • A rhomboid f l a p is designed a l o n g the longer edge of a defect a n d tra nsposes s k i n from a n a rea of lax­ ity to the defect, a l lowi ng for p r i m a ry c l os u re of the donor site (FIG 9A-C) .

8

\\\

Defect

8

Blood supply

A

x

x1

--

Defect

Ciosed primarily B

8

{

c

A

FIG 8 • The b i l obed f l a p uses two rotation-transposition f l a ps for clos u re of a defect. A. Flap A is used to c l ose the p r i m a ry defect a n d flap 8 is used to c l ose the donor site from flap A . B. The f l a p is e l evated i n the su bcuta neous tiss u es leav i n g blood s u p p ly from the s u bderm a l p l exus at the base of the both " lobes " of the f l a p . C. The f l a ps a re then transposed with p r i m a ry c l os u re of the donor site for flap 8 by rea pprox i m ation of x to x 1 •

C h a p t e r 23 A DVAN C E M E N T A N D ROTAT I O N A L FLAPS

B A

X

........­ c

c

B

Blood supply

A

X

c

c

x1

D

=

Initial defect

V-Y ADVANCEMENT FLAP

•

Flap Design

•

• • •

•

The vascu l a rity of the V-Y adva ncement f l a p is based o n t h e centra l perforat i n g vessels. Orientation is designed on a reas of local laxity and mobil ity. I ncis i o ns a re designed from wide p a rt of defect a n d then gently ta pered i nto a tri a n g l e perpe n d i c u l a r to wou n d e d g e (FIG 1 0A a n d F I G 1 1 A) . Ca re is taken to des i g n l a rge e n o u g h f l a p to a l l ow for some u n d e rm i n i n g at base of flap for a d d i t i o na l a d ­ va ncement w h i l e sti l l leavi ng e n o u g h centra l contact with deeper tissues for vasc u l a r ity.

Flap Elevation •

I ncisions a re made throug h skin a n d s u bcuta neous tissues. D issection thro u g h the su bcuta neous tissues should be beveled away from the flap i n order to i ncrease the a rea for captu re of u nderlying perforators i nto the centra l flap.

FIG 9 • The rhomboid f l a p is a n other va riation o n the rotation-transposition flap and works we l l with e l l i ptica l - or rhomboid-s h a ped defects. The flap is designed off the " o b l i q u e " a n g l e of the defect d i rectly perpe n d i c u l a r to the defect. An a d d it i o n a l i ncis i o n designed para l lel to the side of the defect is used to create a m i rror i m a g e of the defect t h ro u g h the s h a red border of the f l a p and the defect (A) . The f l a p is then el evated i n the su bcuta neous tissues leavi ng b l ood supply from the subdermal p l exus (B) . The f l a p is then rotated a n d tra nsposed to fi l l the defect with the f l a p donor s i t e closed p r i m a r i l y w i t h a pproximation o f 1 x to x (C) .

The fascia can a lso be d ivided to a l low for additional flap m o b i l ity. Can u n d e r m i n e the d ista l a n d prox i m a l o n e-fou rth of f l a p to a l low for a d d i t i o n a l advancement but m ust not u nderm i n e centra l l y beca use t h is a rea is key to vascu­ l a rity (FIG 1 08) . Th is is often d o n e by sprea d i n g with a scissors vertica l ly to preserve any potent i a l b l ood vessels ente r i n g the f l a p .

Defect Closure •

•

•

Ca ref u l hemostasis is ass u red after f l a p e l evation; hema­ to mas u n d e r the f l a p can com p rom ise vascu la rity and overa l l o utco m e . C l os u re sta rts at the " point" of the tria n g l e where the donor s ite is c l osed p r i m a r i l y to form the vertica l l i m b of the "Y. " This a lso h e l ps push the f l a p forward i nto the defect (FIG 1 OC) . The f l a p is then pushed forwa rd i nto the defect by clo­ s u re of the s i d es of the tri a n g l e (FIG 1 1 8) .

155 1

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

A

•

c

A

=

=

Blood supply B

Blood supply

•

=

Blood supply

FIG 1 0 • The V-Y f l a p is desig ned as a tria n g l e w i t h the base a l o n g the width of the defect a n d then gently tapered back. The b l ood s u p p ly for t h is f l a p is thro u g h the centra l connections with the underlying fascia/m uscle (A) . The V-Y f l a p is elevated with gently ta pering away from the centra l portion of the flap to in c rease the underlying perfus i o n . Some u n d e rm i n i n g can be performed at the base of the tria n g l e o r at the t i p of the tri a n g l e if needed, but n o u n d e rm i n i n g can be performed centra l ly. As the f l a p is adva n ced i nto the defect, the donor s ite w i l l be closed p r i m a r i l y (B). The V-Y flap is advance i nto the defect after the donor s ite is closed p r i m a r i ly. The c l os u re of the defect leads to the vertical l i m b o f t h e Y a n d acts l i ke a z i p p e r t o push t h e f l a p forwa rd in to the defect (C) .

B FIG 1 1 • A. I n t h is c l i n ical case, two potenti a l o ptions for a V-Y f l a p h ave been des i g ned with the decis i o n to use the f l a p designed back toward the heel selected d u e to the relative l axity of that donor site compared to the flap ru n n i n g tra nsversely across the p l a ntar foot. B. In t h is case, the f l a p has been n icely advanced i nto the defect with the res u ltant Y closure demonstrate d .

C h a p t e r 23 A DVAN C E M E N T A N D ROTAT I O N A L FLAPS

rem a i n t h is width a long the entire length to each of the l atera l borders (FIGS 128 and 1 3A) .

KEYSTONE FLAP Flap Design • •

•

•

Flap Elevation

Flap design is based on centra l perforators and use of "V-Y" closu res to gain local tissue for advancement into the defect. A h a n d h e l d D op p l e r ca n be used to identify specific l a rge centra l perforators for preservation if a d d it i o n a l m o b i l i ­ zation i s expected. The f l a p is m ost often des i g ned from the longer border of a defect by first marking out the l atera l borders of the f l a p at a 90-deg ree angle to the defect (FIG 1 2A) . T h e f l a p width i s t h e n determ i ne d t o be at l east t h e width of the defect if n o t l a rg e . T h e f l a p i s designed to

•

• •

B

A

I ncis i o ns are made through s k i n a n d s u bcuta neous tis­ s u es. T h is d issection is carried perpe n d i c u l a r to the s k i n w i t h m i n i m a l beve l i n g . The u n derlyi n g fascia may a lso be d ivided for a d d i t i o n a l m o b i l ity a n d ca n be es peci a l ly h e l pf u l i n l a rg e r f l a ps . A sma l l a m o u nt of s u bcuta neous or s u bfasci a l u n derm i n ­ i n g can be performed, but th is m ust be done j u d iciously u n l ess l a rge perforators have been knowi n g ly i n c l uded i n the f l a p des i g n .

•

=

Blood supply

D •

c

E

3

= Blood supply

FIG 1 2 • The first step in designing a keystone flap is to plan i ncisions from the corners of the defect perpendicular to the defect (A). Next, the flap is desig ned to be at least the width of the defect with the central blood supply from the underlying tissue providing the vascu larity to the flap (B). The flap is elevated by i ncising through the skin, su bcutaneous tissues, and fascia. The flap is then advanced i nto the defect and closure occurs first in this a rea of maximal tension (C). After the flap has been advanced i nto the defect, the corners of the donor site a re closed i n a V-Y fashion, which a lso help push t h e flap i nto the defect and transitions the flap i nto a rounder shape (D). The incision along the flap border opposite the i n itial defect is then closed by advancing the adjacent skin flap, which is often u ndermined (E).

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

Defect Closure •

•

The lead i n g edge of f l a p is adva n ced i nto the defect with deep dermal sutu res. In situations where this may be i n i ­ tia l ly u nder s i g n ificant tension, one c a n sta rt away from this a rea and work from peri p he ra l to centra l, h e l p i n g push the f l a p toward the defect (FIG 1 2C) . The defect tissue m a r g i n opposite the f l a p ca n a lso be u n ­ d e r m i n e d t o provide s o m e adva ncement. Alternative ly,

•

•

a n opposing keysto ne f l a p may a lso be designed a l o n g t h i s border t o provide a d d it i o n a l tissue laxity. The latera l ends of flap donor site a re then closed in a V-Y fashion to help recruit additional tissue centra l ly as the flap tra nsitions from a hemi-arc shape to a n e l l i pse (FIG 1 2 D). F i n a l ly, the tra i l i n g edge of the f l a p opposite the defect is sutu red back the edge of the donor site. This may req u i re u nderm i n i n g of adjacent s k i n f l a ps to ease the overa l l tension on t h e closure (FIGS 1 2 E a n d 1 3B)

A B FIG 1 3 • I n t h i s case, a 6-cm wide f l a p has been designed to m atch the 6-cm width of the defect (A) . I n t h i s case, the f l a p has been adva n ced a n d reconstructed the defect. The corners of the f l a p donor site have been c losed i n a V-Y fas h i o n a n d the flap shape has changed from a " keyston e " o r semi-arc shape to a more rou n d shape (B) .

PEARLS AND PITFALLS F l a p selection

•

Flaps that are not u n d e r m i ned (e.g., keystone fla ps) should be considered when margin status i s u n known.

F l a p design

•

F l a ps should be l a rge enough for readva ncement if necessa ry.

F l a p e l evation

•

Ca re m u st be taken with perforator-based f l a ps to avoid centra l u nderm i n i n g because the subdermal p l exus is tra nsected c i rcu mferentia l ly around the flap.

•

Ca re m u st be taken to avo i d h e m atomas or i n fections, which can compromise a f l a p . Postoperative i m m o b i l ization s h o u l d be considered f o r flaps around mova b l e a reas. Excision of res i d u a l sta n d i n g cuta neous deform ities s h o u l d be done j u d iciously to avoid com p rom ise of f l a p vasc u l a rity a n d can be done at a l ater operative d a t e if n ecessa ry.

Defect closure

• •

POSTOPERATIVE CARE • •

Flaps near joints should be immobilized with splinting to prevent mechanical dehiscence. Elevation for flaps on the extremities is critical for postop­ erative edema control.

COMPLICATIONS • • • • • •

Marginal flap ischemia Delayed wound healing Infection (cellulitis or abscess) Hematoma Poor cosmetic outcome Flap failure/loss

OUTCOMES •

Outcome data for cutaneous reconstruction are quite het­ erogeneous due to the multiple body areas, flap techniques, and individual surgeon preferences.

•

•

In general, the average incidence of a major complication is low but increases with the size of the defect and reconstruc­ tion. Minor complications include delayed wound healing, nonoperative infections, and need for secondary revision surgery. 1-3 The incidence of total flap failure is low when appropriate reconstructive principles are followed.

REFERENCES 1.

Griffin GR, Weber S, Baker SR. Outcomes following V-Y advancement flap reconstruction of large upper lip defects. Arch Facial Plast Surg. 2012;14(3) : 193-197. 2. Coombs C], Ng S, Stewart DA. T he use of V-Y advancement flaps for closure of pretibial skin defects after excision of cutaneous lesions. Ann Plast Surg. 2013;71(4) : 402-405. 3. Khouri JS, Egeland BM, Daily SD, et al. T he keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruc­ tion. Plast Reconstr Surg. 2011;127(3) : 1212-1221.

I

Chapter

24 1

S kin Grafts

I - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -t - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

·

I

Da vid L. Bro wn

•

DEFINITION •

•

A graft, unlike a flap, does not bring an independent blood supply with its tissue to the recipient site. Skin grafts can be defined based on their origin: autograft (same individual), allograft/homograft (another individual of the same species), or xenograft (from another species). Skin grafts represent a rung on the proverbial reconstruc­ tive ladder above those of primary closure and healing by secondary intention and below local flaps ( FIG 1 ) .

SURGICAL MANAGEMENT Preoperative Planning •

PATIENT lllSTORY AND PHYSICAL FINDINGS •

•

•

Skin grafting should only be considered once a viable re­ cipient bed is obtained. This includes debridement of non­ viable tissues, elimination of active infection, assurance of good vascularization to the wound bed, lack of significant fluid efflux from the wound (i.e., edema or bleeding), and coverage of vital structures (exposed bone, vessels, tendons, nerves, etc.). Indications include inability to perform primary closure or insufficient tissues for local skin flap coverage, uncertainty of tumor clearance, and comorbid conditions. Contraindications include active infection (i.e., bacterial counts > 105 CFU/g via quantitative culture), poor vascular­ ity of recipient bed (i.e., history of radiation to the area), and anticipation of further underlying reconstruction (i.e., nerve or tendon grafting). The Reconstructive Ladder

FIG 1 • The reconstructive ladder. S k i n g rafts occu py a n i ntermed i ate position i n t h e h e i ra rchy o f compl exity o f closu re tech n i q ue.

Relative contraindications: comorbidities that can affect the healing of skin grafts such as diabetes, smoking, and venous insufficiency.

•

Patients should be counseled regarding postoperative expec­ tations, wound management, and restrictions so that they can make preparations prior to the operation. Care of the donor site Split-thickness grafts-Xeroform versus OpSite versus other coverings. May shower; more pain with Xero­ form; watch for leaks and infection with OpSite Full-thickness grafts-Steri-Strips. May shower; some bruising; minimal pain Care of the graft site-bolster dressing. May shower if bolster is exposed, but do not let water run through the bolster continuous as this will wash out mineral oil (if used on cotton inside) and allow bolster to dry out over graft. Bolsters are usually taken down in 4 to 6 days, unless infection is suspected, then earlier. Choice of graft thickness Split-thickness skin grafts (STSGs) 12/1,000 inch is standard, with 6-16/ 1,000 inch being used for special situations. Thinner grafts: more assured healing at the recipient site; the more dermis is left behind for subsequent har­ vest as necessary and the less primary contraction and greater secondary contraction. Thicker grafts: more durable, as they carry more dermis with them. "Sheet " (unmeshed) grafts have the advantage of better cosmesis but are encumbered by seroma or hematoma formation underneath, which can lead to local failure of the graft. These grafts should be inspected early at approximately 24 to 48 hours and any underlying fluid removed via aspiration. "Pie crusting " is unaesthetic and is not associated with higher graft survival. Meshing of grafts can be performed with two advan­ tages. One is coverage of greater recipient surface area with less donor graft. The ratios 1:2 or 1: 1.5 are more commonly used, whereas 1:4 is typically reserved for extreme cases only. The larger the graft expansion, the more tenuous the coverage, and the more secondary contraction will occur. The second advantage is wound bed drainage and prevention of seroma or hematoma formation resulting in graft failure. A common method is meshing 1: 1 . 5 but applying the graft to the recipient site in an unmeshed fashion. Full-thickness skin grafts (FTSGs) Primary contraction is greater (about 40%), but sec­ ondary contraction is less (about 15 %), making them a good choice for joints, neck, eyelids, and so forth.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

Donor sites from FTSGs (usually straight-line layered closures) have the benefits of little postoperative pain and minimal scarring compared to STSGs. Choice of meshing versus sheet grafts Meshing: allows for egress of wound fluids and lessens the risk of seroma and hematoma. As interstices must heal via secondary contraction and re-epithelialization,

meshed grafts will contract more over time and b e less durable. More wound area is able to be covered with less donor site. Sheet grafts: prone to hematoma and seroma but are aes­ thetically more pleasing and exhibit less secondary con­ traction. Useful on hands and feet, across joints, and on the face and neck.

SPLIT-THICKNESS SKIN GRAFTS Patient Positioning and Setup •

•

•

•

The patient is positioned either prone or s u p i ne, so that the latera l or a nterolatera l thigh i s access i b l e for g raft h a rvest i n g . The a p p roxi mate donor site is ma rked out from several i nches below the trocha nter to severa l i nches a bove the knee (sm a l l e r if less is needed). The donor site is i njected with local a n esthetic i n the subdermal space, using a 22-g a u g e spinal need le. A m ix­ tu re of 0 . 5 % l idoca i n e with 1 :200,000 concentrati o n of e p i n e p h r i n e and 0 . 2 5 % b u p ivaca i n e works n icely for pro­ v i d i n g both hemostasis a n d postoperative p a i n re l ief. M i neral o i l is spread over the a rea to a l low for smooth g l i d i n g of the dermatome over the skin (FIG 2) .

Preparing the Dermatome •

•

•

The dermatome is asse m b l ed, a n d the a ppropriate width g u a rd is attached (FIG 3A). A 3-in g u a rd is a p p ropriate for most a p p l ications a n d fits the conto u r of the t h i g h we l l i n most a d u lt patients. Proper seat i n g of the b l a d e i n the m a c h i n e a n d u nder­ neath the g u a rd is assu red; u n even seat i ng can cause a n excessively t h i n g raft at one e d g e a n d ove rly t h i c k at t h e oth e r. The desired thickness of s k i n h a rvest is selected via the dial o n the side ( 1 2/1 ,000 inch is shown here) (FIG 3B).

A B FIG 3 • A. U nderside of dermatome, with b l a d e a n d 3 - i n g u a rd attached. B lade a n d g u a rd a re flush a g a i nst m a c h i ne, as asse m b l e d . B. Dermatome set to 1 2/1 ,000 i n ch thickness. •

To co m p l ete t h e h a rvest a n d sepa rate t h e e n d of t h e g raft from t h e p a t i e nt, t h e s u rg e o n l owers t h e h a n d l e o f t h e d e r m at o m e toward t h e patient (decre a s i n g t h e a n g l e of atta ck) a n d s l owly l i fts o f f t h e s k i n s u rface (FIG 4D) .

Harvesting the graft •

•

Either the s u rgeon (usi ng h i s n o n d o m i n a nt h a n d ) or a n assistant h o l d m a n u a l cou ntertension on the s k in (FIG 4A). The dermatome is p ressed a g a i nst the s k i n at a 45-degree a n g l e a n d, with moderate down force, is slowly adva n ced the l ength of g raft ha rvest (FIG 4B,C) . A

FIG 2 • P r o n e patient, w i t h the l atera l t h i g h showi n g from buttock crease (left) to knee (rig ht) . Note b l a n c h i n g of s k in f rom e p i n e p h r i n e i njection a n d g l ossi n ess of m i nera l o il a p p l icatio n .

B FIG 4 • Assista nt h o l d i n g cou ntertraction on s k in with the use of lapa rotomy sponge. B. Dermatome is p laced on skin, ru n n i n g at a 45-deg ree a n g l e . (continued)

C h a p t e r 24 S K I N G RAFTS

D

c

FIG 4 • (continued) C. F i rm, consistent pressu re is a p p l ied as the dermatome is moved along the donor site. D. At the end of the ha rvest strip, the s u rgeon should eva l uate the transection of the g raft from the donor site. N ote the persistent attachment. E. If the g raft rema i n s attached, the surgeon should release the power to the dermatome a n d hold the dermatome a couple of centimeters from the ski n . An assistant can then detach the g raft with scissors to prevent destruction of the g raft by the dermatome blade.

E

• •

A

Power is released on the dermatome when it rises 1 em a bove the skin, i n case the g raft rem a i n s attached . If the g raft is n ot i m m e d i ately sepa rated from t h e d o n o r s i t e at the e n d of the r u n with the d e r m atome, the s u rgeon s h o u l d release power to the dermatome a n d hold it a co u p l e of ce nti m eters over the s k i n u n t i l a n assistant ca n cut it free w i t h a M etze n b a u m scissor. Otherw i se, the g raft is p u l led back out t h r o u g h t h e b l a d e e n t r a n c e a n d c a n res u lt i n m a n g l i n g of t h e g raft (FIG 4E) .

B

Meshing the Skin Graft •

•

For meshed g rafts, the mesher is asse m b l ed, a n d an ap­ propriate cutt i n g wheel is chose n . 1 : 1 . 5 (sh own h e re, FIG SA) is a sta n d a rd ratio but can be varied up to 1 :4 depe n d i n g on the a m o u nt of donor sites ava i la b l e compa red t o the a rea need i n g cove rage as we l l as t h e specific a p p l icatio n . T h e g raft is p l aced superfic i a l s id e down on t h e ca rrier a n d r u n through the mesher (FIG 5B,C) .

FIG 5 • A. V i e w of a n opened mesher with space to place the chosen cutt i n g wheel ( i n this case 1 : 1 . 5 ratio). B. G raft p l aced dermal side u p o n the carrier, which is positioned with i n the mesher entrance. (continued)

1557

1558

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

p rovide p ressure on a n d m o isture to the g raft (FIG 6C) . Tru n k wounds can be covered with A l l evyn (Sm ith a n d N e p h ew) foa m, whereas tie-over's w i t h i nterru pted s i l k a re suita b l e for the face a n d h a n d, or wra p p i n g w i t h g a u z e a n d a n e lastic b a n d a g e f o r the extrem ities (FIG 6D) . Other Considerations •

c FIG 5

•

(continued) C. G raft, postmes h i n g .

Insertion o f the Graft into the Wound Site •

•

•

The g raft is p laced i n the wound bed, trimmed a p propri­ ately, a n d secured to the wou n d edges with surgical c l i ps or sutu res (4-0 chro m i c work well) (FIG 6A,B) . A n onstick d ress i n g is a p p l i e d . A bolster co nsist i n g of m i n e ra l oil- a n d sa l i n e-soaked cotton ba l ls or batti ng w i l l

Excess ( " l eft over") s k in g raft can be preserved i n tissue culture media at 4°( for a p p l ication to the wou n d s h o u l d ori g i n a l g raft l oss occ u r. G raft s u rviva l d i m i n ishes with storage time and is genera l ly considered to be poor after 1 0 to 14 days. Some c l i n ical situations ca l l for d e l ayed g raft p lacement (24 to 48 h o u rs postoperative ly) d u e to wound fl u i d seepage. I n cases s u c h as cove rage o f m uscle a n d omen­ ta l fla ps, or rece ntly debrided wounds over edematous tissues, g raft a p p l ication ca n be performed at the bed­ side. This saves a return trip to the operat i n g room (OR) for the patient.

A

B

c

D FIG 6 • A. Patient with right s u perior ch est wou n d . Meshed g raft p laced with i n wound, dermal s id e down , a n d m i n i m a l ly exp a nd e d . B. The g raft is trimmed a p p ropriately a n d secu red w it h sta i n less steel c l i ps. C. M i neral o i l- a n d sa l i n e-soaked cotton batting, wrapped i n Xeroform, is sha ped to the size of the wou n d . D. A foa m bolster is used t o secu re t h e d ress i n g over t h e g raft.

C h a p t e r 24 S K I N G RAFTS

1559

PEARLS AND PITFALLS H a rvest i n g the g raft

• •

•

Placing the g raft i n t h e wou n d bed

• •

• • •

Donor site

•

Proper seat i ng of the b l a d e in the m a c h i n e u n derneath the g u a rd s h o u l d be assu red; u n even seati ng can cause a n excessively th i n g raft at one edge and a n overly thick one at the other. If the g raft is not i m med iately separated from the donor site at the e n d of the r u n with the dermatome, the s u rgeon s h o u l d release power to the dermatome a n d h o l d it over the s k i n for an assista nt to cut it free with a M etze n b a u m scissor. Otherwise, the g raft can be p u l led back out through the b l a d e entra n ce, m a n g l i n g the g raft. R i n s i n g the g raft washes away vita l p rocoa g u l a nt factors and s h o u l d be avo id ed, if poss i b l e . To assure consistent a p p l ication of the g raft to the wound bed derm is-s id e d own and to tra nsfer it without b u n c h i ng, it s h o u l d be p l a ced on the carrier dermis side u p . If t h e g raft is n o t i m med iately needed f o r w o u n d cove rage, it can be stored on t h e b a c k table (a ppropriately ma rked to avo i d d i sposa l), wrapped i n m o istened g a u ze, o r left o n the carrier a n d covered with the same. Ca re should be taken to avo i d "tenti n g " a g raft over a n u n even wou n d bed . Extra g raft should be p laced to a l low for com p l ete conto u r touchdown. Placement of a meshed g raft d oes not need to i nvolve fu l l expa nsion of the g raft; l eavi ng it relatively u n expanded w i l l a l low for eg ress of wou n d f l u ids w h i l e speed i n g hea l i n g . " Pie-crust i n g " o f sheet ( u n m eshed) g rafts is thought t o be su perfl uous, as it w i l l l i kely n ot p reve nt a hematoma or seroma from form i n g between sl its a n d is aesthetica l ly u nappea l i n g . Some s u rgeons a p p ly e p i n e p h r i ne-soaked sponges to the fresh d o n o r site to l i m it bleed i n g . This is obviated with the use of local a nesthetic.

POSTOPERATIVE CARE

Rewrapping with gauze is performed for the patient to get dressed. The attached petrolatum gauze will form an artificial "scab" on the wound, and re-epithelialization will cause the gauze to become nonadherent at its edges over the next 10 days or so . Trimming of the gauze so that it does not catch and get pulled off is recom­ mended. Other dressings are used for donor site care, each for a specific quality. Silver-impregnated dressings help to pre­ vent infection. Occlusive dressings are significantly less painful but are plagued by infection.

Patient Expectations • • •

Patients should be told that the donor site is likely to cause more pain than the wound site postoperatively. Healing stages of the graft and donor site are discussed to educate the patient. Over large areas of grafting and/or uneven surfaces, some graft loss is to be expected.

Wound Management •

•

Dressings Bolsters should be left in place, barring complications such as fever and so forth, for 5 to 8 days. Patients may shower and get the bolsters wet with inci­ dental water contact. Soaking or significant water rinsing of the bolster is discouraged, as this washes out the min­ eral oil and allows the bolster to dry out. Following bolster removal, the graft is protected with once­ daily dressing changes with petrolatum gauze until it is more fully healed (usually another 7 to 10 days). After this point, the patient should moisturize the graft (and donor site) twice daily for a few months to prevent desiccation, as oil and sweat glands are not transferred with the graft. Donor site care Typically, split-thickness donor sites are covered with pet­ rolatum gauze, which is loosely attached to the skin with surgical clips around the perimeter. An ABD pad and a gauze wrap are applied in the OR. On postoperative day 1, the wrap and ABD are removed, and the attached gauze is left open to the air. It can get wet in the shower, but afterward, and several times per day, is dried with the use of a hair dryer set on cool air only.

Restrictions •

Judgment is exercised to determine the degree of immobi­ lization prescribed, depending on graft location. It is not necessary to splint the foot for grafts on the lower leg, but patients should keep the extremity elevated to prevent swell­ ing and edema and thus graft loss.

COMPLICATIONS •

•

•

•

Seroma and hematoma are the most common complications. If left untreated, they will lead to graft loss due to lack of contact with the wound surface. Infection can destroy a graft, particularly in the early post­ operative period, prior to revascularization. In the case of unexplained postoperative fevers, the dressings should be removed early and the wound inspected for infection, which can be potentially treated, with graft salvage. Secondary contraction of skin grafts is increased with thin­ ner grafts and with greater expansion of meshed grafts. This can affect underlying joint mobility and aesthetics . Incompletely debrided or poorly vascularized wound beds can lead to nonadherence and ultimate loss of the graft.

-

25

Chapter

Digit Amputations

I I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

-+

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

·

Ste ven C. Haase

Clinically node-negative patients with melanoma greater than or equal to 1 mm in thickness, or thin lesions with other worrisome histologic features, may be candidates for sentinel lymph node biopsy at the time of amputation. (see Part 5, Chapter 27). Patients with clinically involved nodes should undergo fine needle aspiration (FNA) biopsy and staging for distant metastases. These patients may require lymph node dissection at the time of amputation.

DEFINITION •

•

Digital amputation refers to the removal of a finger or thumb, most commonly at the level of the phalanges or in­ terphalangeal joints ( FIG 1 ) . More proximal amputations that include a significant portion of the metacarpal are re­ ferred to as ray amputations. The techniques found in this chapter have been described chiefly for the hand, although similar procedures can be used on the foot in many cases. Digital or ray amputation may be indicated for subungual melanoma, or for other large, invasive melanomas of the finger or thumb.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

PATIENT HISTORY AND PHYSICAL FINDINGS •

•

•

It is important to assess how long the lesion has been pres­ ent; how fast it has grown; and whether there has been any history of ulceration, bleeding, or pain. Lesions exhibiting rapid growth in addition to these other findings may require more aggressive treatment. A patient's age, handedness, occupation, and hobbies should be considered carefully in planning an operation that might significantly affect their function. In some cases, preop­ erative consultation with a physiatrist and/or occupational therapist may help a patient mentally prepare for what is a sometimes emotionally difficult operation. Physical examination should include both the epitrochlear and axillary lymph nodes. For lesions on the toes, examination should include the popliteal and inguinal basins. Proximal Metacarpophalangeal interphalangeal joint joint Collateral ligament Distal interphalangeal jo

r

SURGICAL MANAGEMENT Positioning •

For hand operations, patients are positioned supine, with the affected extremity extended on a hand table attached to the operating room table.

Lateral band of extensor tendon

�

r.

�

Middle Volar plate phalanx

Proximal phalanx

Flexor digitorum profundus tendon

M etacarpal bone •

Flexor digitorum superficial is tendon

A,B. Anatomy of the d i g it.

DIGITAL AMPUTATION

•

Skin Incision

1560

B

A

FIG 1

•

Central slip of extensor tendon

�

' 1 ·�..-1'--{

Distal phalanx

•

Suspicious lesions require biopsy to establish diagnosis. This should include a full-thickness sampling of the skin and/or nail matrix for accurate assessment of depth of the lesion. Increased depth of invasion is consistently associated with worse prognosis. 1 For large or fixed lesions, radiographs of the digit should be obtained to assess for the presence of bone involvement. If ra­ diographs demonstrate significant bone destruction, additional imaging with magnetic resonance imaging (MRI) may be re­ quired to assess the full extent of tumor spread in the hand.

The s k i n incision s h o u l d be designed as a "fish mouth," such that dorsa l a n d vo l a r flaps a re created that close in a more or less tra n sverse l i n e of closure that g ives a smooth, rounded conto u r to the a m p utation stu m p .

•

The s k in flaps s h o u l d be designed with e n o u g h laxity to cl ose over the u nderlyi n g skeleton to be p reserve d . Typica l ly, the l evel of d i sa rticulation or osteotomy s h o u l d be a few m i l l i meters proxi m a l to the level of the s k in in c is io n . I d e a l ly, the vo l a r f l a p can be designed a bit l o n g e r t h a n the d o rsa l flap (FIG 2A) to a l l ow resu rfacing of the entire

C h a p t e r 2 5 D I G I T AMPUTAT I O N S

Skin incision

Skin hook

F I G 2 • Dig ita l amputation tech n iq ue. A. The skin i ncision is designed just d ista l to the level of plan ned bone resection or disa rticu lation . The volar flap is designed longer than the dorsa l flap to a l low for coverage of the fingerti p with more d u rable, well-innervated volar skin. B. After remova l of the skeleta l elements and n a il complex, the neu rovascular bundle is identified on the volar flap, and the nerve is gently d issected proximal ly, u ltimately d ividi n g the nerve while on traction, and al lowing the stum p to retract proximal ly. C. The volar skin is advanced to cover the wound, and a smooth, rou nded closure is performed.

resection (disarticulation)

B

c

A

j o i nt, so this b u l ky, poorly vasc u l a rized tissue is d iscarded with the a m p utated part.

opposition su rface (contact su rface) of the f i ngert i p with the th icker, m o re densely i n n e rvated p a l m a r ski n . Soft Tissue Dissection •

The soft tissue s h o u l d be d ivided in a way that m i n i m i zes devasc u l a rization of the tissues o r ski n fla ps. S h a r p sca l ­ pel d issection d i rectly t o the b o n e ca n be performed both dorsa l l y and vo larly, d ivid i n g the n e u rovasc u l a r b u n d les, ten dons, and perioste u m .

Traction Neurectomy •

Bone Dissection and Osteotomy •

•

•

The periosteu m s h o u l d then be sharply el evated proxi­ m a l ly using a n elevator o r sca l pel, c i rcu mferenti a l ly around the d i g it. This w i l l a l l ow the bone cut to be posi­ tioned s l i g htly proxi m a l to the soft tissue d issect i o n . Bone d ivision is m ost efficiently acco m p l ished with a s m a l l osci l lati n g power saw. I n struments such as bone cutters o r rongeurs tend to crush a n d fract u re the proxi­ mal bone stock and are not reco m m e n d e d . If d i sa rticu lation is p l a n ned, the co l l atera l l i g a m ents s h o u l d be detached from the proxi m a l aspect of the

Closure •

Skin Incision

•

I ncisions are designed to avo i d a sca r i n the webspace . Conceptua l ly, the g o a l is to preserve one webspace and resect the other, rather than having a webspace at the operative site with a contracted scar i n its m i d l i n e (FIG 3A-E) . Usua l ly the d i ssection is performed m ostly t h ro u g h a d or­ sa l i n cision, which extends l o n g itu d i n a l ly from the base

Closure is usually performed with a s i n g l e layer of non­ a bsorba ble sutu res (FIG 2C}, which a re removed a bout 2 weeks later. Do not suture the exte nsor tendon to the flexor tendon over the end of the exposed bone; this w i l l functi o n a l ly shorten t h e flexor tendon t o that d i g it, resu lt­ i n g in wea kened g r i p strength due to the quadrigia effect.

of the f i n g e r. Pa l m a r i ncisions a re l i m ited to avo i d the poss i b i l ity of sensitive sca rri n g i n that l ocat i o n .

RAY AMPUTATION

•

The neu rovasc u l a r b u n d l e s h o u l d be i dentified with d e l i cate d i ssectio n . The a rtery may be cauterized; the nerve should be d issected away from the a rtery and fol­ l owed proxi m a l ly severa l m i l l i meters. The nerve s h o u l d be p laced on traction, d ivided proxima l ly, a n d a l lowed to retract (FIG 28} . This w i l l ensure that the n e u romas that i n evita bly form at the end of each d i g ital nerve will be l ocated p rox i m a l ly to the contact su rface of the fingerti p .

Dorsal Dissection •

•

Major sensory n e rves in the su bcuta neous tissue a re pre­ served when possi b l e . The exte nsor tendon is d ivided proxi m a l l y a n d the metaca rpal expose d . The peri oste u m of the metaca rpa l is i ncised l o n g it u d i ­ n a l ly a n d s u b periosteal d i ssection c a r r i e d out c i rcumfer­ enti a l ly a l o n g the shaft of the bone. The attach m e nts of

156 1

1562

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

Line of closure

. . I

: \/ / I

'.. ... ... ..

B

c

D E FIG 3 • S k i n i n ci s i o n for ray a m p utat i o n . A. D o rsa l i n ci s i o n c a n be d e s i g n e d p roxi m a l ly a s a stra i g ht l i n e, o r a s a z i g z a g , exte n d i n g d i sta l ly to e n c i rc l e t h e b a s e of t h e fi n g e r to be rem oved . N ote t h e preservati o n of a n i ntact webspace for c l o s u re, rat h e r than d i v i d i n g t h e w e b w i t h t h e i n c i s i o n . B. Vo l a r i n c i s i o n m u st be a z i g z a g o r chevron-sty l e i nc i s i o n t o avo i d l o n g itud i n a l scars cross i n g t h e flex i o n creases of t h e p a l m . C. C l o s u re i s shown, with preservati o n of t h e d e l i cate webspace s k i n . D. D o rsa l and (E) vo l a r skin m a r k i n g s for i n d ex fi n g e r ray a m p utat i o n .

t h e i ntrinsic m u scles a re d i s r u pted with t h i s d i ssection; most of these do not req u i re tra nsfer o r repa i r, with the exception of the origin of a d d u ctor p o l l icis (FIG 4) . When rem oved from the m i d d l e metaca rpa l d u r i n g ray a m p utation, t h i s m uscl e orig i n s h o u l d be reattached to the i n d ex metaca rpal with bone a n c h o rs or tra nsosseous sutu res. Bone Dissection •

For i n d ex, m i d d le, a n d s m a l l finger ray a m p utations, the osteotomy should be perfo rmed d i stal to the i n sertion of the wrist exte nsors: exte nsor carpi rad i a l i s l o n g us,

•

•

exte nsor carpi rad i a l i s b revis, a n d exte nsor carpi u l n a ris, respectively (refer to FIG 5). For the r i n g f i n g e r metaca rpal, which has no extrin­ sic tendon attac h m ents, the entire metaca rpa l can be d isarticu lated at the base and removed (if no tra nsposi­ tion is p l a n ned). For m i d d l e or r i n g finger ray a m p utations, some effort s h o u l d be made in e l i m i nating the tro u blesome g a p be­ tween d i g its that can result.2• 3 This ca n be acco m p l ished by two p r i n c i p l e methods: • Metic u l o u s soft tissue repa i r, i n c l u d i n g permanent sutu res i n the i ntermetacarpal l i g a ments a n d ca refu l postoperative s p l i nt i n g (FIG 6)

C h a p t e r 25 D I G I T AMPUTAT I O N S

Adductor pollicis muscle: Transverse head Oblique head

FIG 4

•

Anatomy of the a d d u ctor p o l l icis.

•

•

Tra nsposition of the adjacent border d i g it, req u i r i n g b o n y fixati o n of the m etaca rpa l, a n d often longer postoperative i m m o b i l ization (FIG 7) O n ce the bone has been tra nsected, d i ssection proceeds around the side(s) of the metaca rpa l head to divide the i ntermetaca rpa l l i g a ments.

Volar Dissection •

The vo l a r d issection is usua l ly d o n e last. The d i g ita l n e u ­ rovasc u l a r b u n d l es a re identified a n d tra nsected d i sta l ly, kee p i n g them rathe r long, i n contrast to the short-

F I G 5 • Dorsa l d i ssection com p l eted, with d ivision o f t h e metaca rpa l at the prox i m a l shaft, preserving the base with its tendon attachments.

•

e n i n g that is done for p h a l a ngea l-level a m p utations (FIG SA,B) . O n ce the r a y a m putation is com p l ete, the d i g ita l n e rves a re fo lded dorsa l ly i nto the perioste a l sl eeve l eft beh i n d after metaca rpa l remova l (FIG 9) . T h e n e rves a re se­ c u red in this deep, padded a rea, surrounded by hea lthy i nterosseous m uscle, where they are protected from tra u m a d u r i n g ro uti ne hand f u n ctio n .

F I G 6 • Ray resection without transposit i o n . Using perma n e nt sutu res to rea pproxi mate the i ntermetacarpal l i g a m ent, as wel l as m etic u l o u s s k in closu re, the finger " g a p " can be closed with soft tissue repa i r a l o n e .

1563

1564

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

FIG 7 • Ray resection with tra nspositi o n . Tra nsposition req u i res osteosynthesis o f the i nvolved metaca rpals w i t h wi res, p i n s, or p l ate a n d screws. O n e advantage is the potenti a l to m i n i m ize length d i screpancy of the sma l l finger by preserving added length at the base of the r i n g metaca rpa l, as i l l u strated here.

A

B

FIG 8 • A. Vo l a r d issection with id e ntification of the d i g ital nerves, which are preserved with some length, so they can be rel ocated i n the deeper d o rsa I tissues at the t i m e of closure . B. Ray resection com p l eted, with d i g ital n e rves tra nsected (black arro ws).

FIG 9 • D i g ital n e rves (white arrow) tra nsposed deep i nto the periostea l sl eeve between the i nterosseous m uscles.

C h a p t e r 25 D I G I T AMPUTAT I O N S

t i g htn ess o r l oosen ess of t h e d o rsa l s k i n c l o s u re, i n p a rt i c u l a r, ca n h e l p m a i nta i n p r o p e r o r i e ntat i o n o f t h e a d j a c e n t d i g its a n d h e l p avo i d m a l a l i g n m e n t o r "scissori n g . "

Closure •

1565

S k i n c l o s u re s h o u l d be meticu l o us, a d d ressi n g excess l a x ity a n d/o r sta n d i n g cuta n e o u s defo r m ities ( " d o g e a r s " ) if e n c o u ntered (FIG 1 0A B) . T h e re l ative ,

A

B

FIG 1 0 • A,B. F i n a l wou n d closure, which avo id s extensive i ncisions on the sensitive pa l m a r ski n .

PEARLS AND PITFALLS D i g ital a m p utations

•

When req u i red, retract the s k i n edges with s k i n hooks on ly. This avo id s tissue d a m a g e that can occ u r f r o m repeated g ra s p i n g of the tissues w i t h forceps.

Q u a d r i g i a effect

•

Because the flexor d i g itorum profu ndus tendons share a com m o n m uscu l a r origin, effectively shorte n i n g any one o f t h e tendons can l e a d to a n overa l l decrease i n g r i p strength. During force generation, t h e foreshortened tendon becomes t i g h t early, preventing transm ission o f force to the adjacent d i g its.

Neuroma detection

•

It can be d ifficult to d ifferentiate sym ptomatic n e u roma from o rd i n a ry hypersensitivity after finger a m p utatio n . A d i a g n ostic i njection of loca l a n esthetic i nto the specific a rea of the n e u roma, to a nesthetize the nerve i n isolation, can confi rm the d iag nosis of neuroma.

POSTOPERATIVE CARE •

•

For digital amputations, the postoperative dressing should be amply padded to allow for postoperative swelling. A hand-based splint for a short time (1 or 2 weeks) can be used if desired. Prolonged immobilization should be avoided so that the remaining finger joints (including the adjacent digits) do not become stiff. For ray amputations, the hand should be splinted for the first 2 weeks, taking care to maintain proper alignment of the digits in the splint, to avoid divergence or convergence of the fingers on either side of the amputation site. Sometimes,

•

temporary pinning of the fingers is warranted to maintain good alignment in this early postoperative period, as the soft tissues are healing. Splinting beyond 2 weeks may still be required for comfort and protection, but the orthosis use should not interfere with early mobilization of the interpha­ langeal and metacarpophalangeal joints, which may become permanently stiff if immobilized for too long. In all cases, consultation with a certified hand therapist may be of benefit to the patient, for help with orthosis fabrica­ tion, edema control, joint mobilization, scar massage, de­ sensitization, and molding of the finger stump for prosthesis wear, if desired.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

OUTCOMES •

Compared to the contralateral hand, patients with single-ray amputations have on average 13 % less key pinch strength, 2 6 % less oppositional strength, and 28 % less grip strength at long-term follow-up.4•5

COMPLICATIONS • •

Acute complications such as bleeding, infection, and delayed healing should be uncommon. Chronic complications include phantom pain and painful neuromas. Persistent sensation in an amputated part is common (over 80% in one prospective study) but is not always painful.6 Neuromas will form at the stump of divided nerves but are not usually symptomatic if the nerve endings are prop­ erly padded and located away from contact surfaces.

REFERENCES 1. Warso M, Gray T, Gonzalez M. Melanoma of the hand. J Hand Surg Am. 1997;22(2) : 354-360. 2. Colen L, Bunkis J, Gordon L, et al. Functional assessment of ray trans­ fer for central digital loss. J Hand Surg Am. 1985;10(2) : 232-237. 3. Steichen JB, Idler RS. Results of central ray resection without bony transposition. J Hand Surg Am. 1986;11(4) : 466-474. 4. P eimer CA, Wheeler DR, Barrett A, et al. Hand function following single ray amputation. J Hand Surg Am. 1999;24(6) : 1245-1248. 5. Melikyan EY, Beg MS, Woodbridge S, et al. T he functional results of ray amputation. Hand Surg. 2003;8(1) : 47-51. 6. Jensen TS, Krebs B, Nielsen J, et al. P hantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain. 1983;17(3) : 243-256.

I

Chapter

26

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

Resection of Head and Neck Melanoma 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

Sco tt A. McLean

DEFINITION •

•

•

Resection of head and neck cutaneous melanoma is per­ formed with wide surgical margins intended to achieve his­ tologically negative margins. Current guidelines for wide excision of the primary lesion, with an adequate margin of surrounding normal skin and deep soft tissue necessary to achieve clear surgical margins, are based on depth of invasion of the primary lesion (Table 1 ) . 1 However, given the com­ plex anatomic and functional nature of the head and neck, resection margins are sometimes modified to preserve normal function. Reconstruction of complex head and neck defects is often delayed until final histopathologic evaluation of mar­ gins is deemed negative. Reconstruction can be accomplished with primary closure, split- or full-thickness skin grafts, local or regional adjacent tissue transfer, or free tissue transfer. Patients with invasive melanoma and no clinical evidence or regional metastatic disease may warrant assessment of regional lymph nodes via sentinel lymph node (SLN) bi­ opsy. SLN biopsy has been shown to be both accurate and prognostic in head and neck melanoma. 2• 3 Current recom­ mendations on use of SLN biopsy are based on depth of invasion of the primary lesion as well as the presence of adverse histologic features such as ulceration and mitotic rate. Patients with melanoma measuring 1 mm or greater should be offered SLN biopsy. SLN biopsy should also be considered in patients with a thickness of between 0.76 and 0.99 mm if they have any of the following adverse features : greater than o r equal t o 1 mitotic figure p e r square millime­ ter, lymphovascular invasion, satellitosis, or young patient age. SLN biopsy may also be considered with thin mela­ noma when the deep margin was broadly transected. 1-s Patients who present with clinical evidence of regional meta­ static disease and patients who are found to have micromet­ astatic disease on sentinel lymph node biopsy ( SLNB) are offered completion lymph node dissection ( CLND ) . Based on the site of the primary lesion, the nodal basins included in the CLND may include the postauricular and suboccipi­ tal lymph nodes, the parotid gland and its associated lymph

Table 2: Nodal Basins Incl uded in Therapeutic Lymph Node D i ssection

Primary Tumor Thickness

Clinically Measured Surgical Margin

In situ :S 1 m m

0 . 5- 1 . 0 em 1 em

1 . 0 1 -2 . 0 m m 2 . 0 1 -4 m m

1 -2 e m 2 em

>4 m m

2

em

From National Comprehensive Cancer Network. Guidelines version 4.20 14. h ttp://www. nccn. org. Accessed August 2 0 7 4.

Nodal Basins Included in Therapeutic Lymph Node Dissection

Anterolateral sca l p, tem p le, late ra l

Parotid a n d cervical lymphatic

forehead, latera l cheek, a n d ear: all a r i si n g anterior to coro n a l plane through the exte r n a l a u d i tory c a n a l Chin and neck Sca l p a n d o c c i p u t poste rior t o

levels

1-V

Cervica l lymphatic levels 1-V Posta u r i c u l a r, s u boccipita l , a n d

coro n a l p l a n e throu g h the exte r n a l a u d itory c a n a l

cervical lymphatic levels

1 1-V

nodes, and the cervical lymph nodes levels I to V (Table 2) (see Part 5, Chapter 3 1).6

DIFFERENTIAL DIAGNOSIS •

Cutaneous melanoma of the head and neck usually pres­ ents as a pigmented lesion of varying size, shape, and color. Other benign and malignant cutaneous lesions can present in a similar fashion and include the following: Seborrheic keratosis Junctional nevi Compound nevi Dermal nevi Hemangioma Blue nevus Pyogenic granuloma Spitz nevus Pigmented actinic keratosis Pigmented or nonpigmented basal cell carcinoma Squamous cell carcinoma

PATIENT HISTORY AND PHYSICAL FINDINGS •

Table 1 : Surgical Marg i n Recommendations for Cutaneous Melanoma

Primary Cutaneous Lesion Location

•

•

A thorough history of the lesion of concern should include the duration of clinical symptoms; the presence of pruritus; bleeding; and any changes in the size, shape, or color of the lesion. Most cutaneous melanomas will present as either a new pigmented lesion or changes in an existing lesion that ex­ hibit the ABCDs of melanoma: A-Asymmetry, B-Border, C-Color, D-Difference (a change in the lesion) . A thorough past medical history should b e performed and include information regarding any previous malignancies, past surgical procedures, current medications and aller­ gies, family history of cancer, problems with anesthesia, and social history-including smoking history, occupation, sun exposure, and history of blistering sunburns.

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1568

•

• •

•

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

A focused review of systems should also be completed and include review of any constitutional, musculoskeletal, neurologic, respiratory, gastrointestinal, hepatic, skin, and lymphatic signs or symptoms. All newly diagnosed melanoma patients should undergo full body skin evaluation. A complete head and neck exam should be performed on every patient and include a thorough skin exam and palpa­ tion of the suboccipital, postauricular, parotid, and cervical nodal basins to rule out the presence of clinically palpable regional metastatic disease. A detailed cranial nerve exam should be performed to docu­ ment preoperative cranial nerve function.

•

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Newly diagnosed patients with localized cutaneous mela­ noma are not recommended to undergo distant metastatic workup. In the absence of clinical signs or symptoms of distant metastatic disease, no imaging modality has been shown to be useful in detecting occult metastatic disease and in fact more often lead to false-positive findings, requiring further unnecessary invasive procedures.1 Chest x-ray and serum lactate dehydrogenase are also both insensitive for the detection of occult metastatic disease. Many patients will require preoperative chest x-ray, complete blood count ( CBC), and electrocardiogram (EKG), depend­ ing on age, health status, and need for general anesthesia.

SURGICAL MANAGEMENT

•

Positioning •

Preoperative Planning •

•

Prior to proceeding to the operating room, the primary cuta­ neous lesion should be reexamined and confirmed with the patient. The surrounding skin should also be reexamined to

. .

make sure no new lesions have developed. In addition, the plan regarding surgical margins and primary closure versus delayed reconstruction should be confirmed with the pa­ tient. All cranial nerve functions in the operative field should also be retested prior to surgery. Patients who are scheduled for SLN biopsy in conj unction with excision of their primary cutaneous lesion will un­ dergo lymphoscintigraphy prior to their definitive excision. This procedure is done in the nuclear medicine department and is enhanced by the use of single-photon emission com­ puted tomography-computed tomography ( SPECT-CT) imaging.7 Prior to proceeding to the operating room, the SPECT-CT/lymphoscintigraphy should be reviewed to de­ termine the likely location of the SLN ( s ) ( FIGS 1 and 2 ) . These locations should then b e discussed with the patient and marked appropriately. If the location of a likely SLN is in close proximity to a cranial nerve, this should be discussed with the patient and the cranial nerve function should be well documented. Appropriate use of antibiotics and deep vein thrombosis (DVT) prophylaxis should also be discussed prior to pro­ ceeding to the operating room. In addition, it is crucial to have a thorough discussion with the anesthesia team regarding the use of long-acting paralyt­ ics. If cranial nerves are likely to be in the operative field, as is almost always the case in the resection of head and neck melanoma, the anesthesia team must be aware to avoid the use of long-acting paralytics.

Patients who are scheduled for wide local excision alone (melanoma in situ or Tla lesions) often can tolerate surgery under sedation with monitored anesthesia. In these cases, the head of the bed is often rotated 90 degrees away from the anesthesia cart to allow for easy access to the surgical field. Oxygen delivery methods can be designed to avoid

. •

FIG 1 • Lym phoscintigraphy with S P ECT-CT i m a g i n g after i njection of left posta u r i c u l a r p r i m a ry m e l a n o m a site. I m a g i n g reveals a left level II lymph node as wel l as seco n d a ry drainage to left leve ls Va a n d Vb.

C h a p t e r 26 R E S E C T I O N OF H EAD A N D N E C K M E LA N O M A

1569

FIG 2 • Lym phoscintigraphy with S P ECT-CT i m a g i n g after i njection of left posta u r i c u l a r p r i m a ry m e l a n o m a site. Ca refu l o bservati o n reve a l s the l e v e l I I lym ph node t o be located j u st i nferior to the ta i l o f the p a rotid a n d j u st a nterior to the sternoc l e i d o mastoi d m uscle. Like ly, this represents a n externa l j u g u l a r lym ph node.

•

crossing the surgical field and may include either nasal can­ nula or mask. In these cases with free-flowing oxygen, it is very important to discuss the risk of fire with the entire op­ erating room team. The entire face and neck can be prepped into the operative field. Wide draping can then be used with attention to avoid any tenting of drapes, which could lead to pooling of oxygen in the operative field ( FIG 3 ) . Patients who are scheduled t o undergo SLN biopsy i n con­ junction with the primary excision are almost always placed under general anesthesia. Again, the use of long-acting para­ lytics must be avoided. The head of the bed can be rotated 180 degrees away from the anesthesia cart to allow for easy surgical access to the operative field. Most primary lesions can be excised with the patient in the supine position. Rarely, the patient may need to be turned prone to allow access to the posterior scalp or suboccipital nodal basin. With the pa­ tient intubated, either half of the face and neck or the entire face and neck can be prepped and draped, depending on the need for surgical access.

PLACEMENT OF PLANNED INCISIONS

•

Primary Lesion Excision Site •

•

The primary lesion is ca refu l ly inspected a n d cleaned with a moist sponge. The lesion s h o u l d be ma rked out with careful attention to i n c l u d e a ny evidence of dermal exten­ sion. This may i n c l u d e any pale, erythematous, or l i g htly pigmented extension from the p r i m a ry lesion (FIG 4). With the primary lesion now ma rked, the a ppropriate m a r g i n is then m a rked c i rcu mferentia l ly around the vis­ ible lesion . The excision m a rg i n is most often 1 to 2 em, depe n d i n g on the depth of i nvasion of the p r i m a ry lesio n .

FIG 3 • Patient is u n d e r sedation with the entire face prepped to a l low for wide d r a p i n g and to avoid poo l i n g of oxygen with i n t h e s u rg i ca l f i e l d .

I n certa i n f u n ct i o n a l situations, the excision m a r g i n may be l eft a l ittl e short of sta n d a rd m a r g i n s . For exa m p le, if a lower eye l i d lesion req u i res 2-cm m a r g i ns, but at 1 em the excision wou l d cross the lid m a rg i n, it may be accept­ a b l e to use 1 em (FIG 5) . In this case, the s u rgeon m u st be wi l l i n g to reexcise t h i s m a r g i n s h o u l d it return positive on f i n a l h i stopath ologic review.

Injection o f Methylene Blue Dye •

To assist with SLN id e ntification, the dermis su rrou n d i n g t h e p r i m a ry lesion is i njected w i t h methylene b l u e dye. Usua l ly only 1 or 2 ml of dye is i nj ected (FIG 6) .

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FIG 6 • M ethylene b l u e dye i njected c i rc u mferenti a l ly i nto the d e r m i s s u r ro u n d i n g the lesi o n . A 30-g a u g e n e e d l e is used and effort i s m a d e to i nj ect d i rectly i nto the d e r m i s o n l y. FIG 4 • The m a i n lesion is p i n k a n d ra ised. N otice the p i g m e nted extension i nto the surro u n d i n g skin. The entire p i g m e nted a rea m ust be ma rked out prior to marking out c i rcu mferent i a l m a r g i n s .

Placement of Incisions for Sentinel Lymph Node Biopsy •

•

•

The i njection is made with a 30-g a u g e needle with the bevel of the need le fac i n g up. There should be s l i g ht pressu re as the dye is i njected a n d visua l ly the dermis s h o u l d beg i n to turn b l u e . If the dermis is n ot turning b l u e or the i njection i s pass i n g with no resista nce, the needle is l i kely too deep. This will cause the su bcutaneous tissue t o t u r n b l u e a n d ca n m a ke recog n ition o f tissue p l a nes m o re d i fficu lt. Several i njections s h o u l d be made i nto the dermis s u r­ rou n d i n g the p r i m a ry lesion u nt i l the lesion is surrounded by b l u e dye (FIG 7) .

•

•

FIG S • I n t h i s p l a n ned resection, the l ower eye l i d m a r g i n i s left a l ittle na rrow i n the h o p e s of avo i d i n g postoperative ectro p i o n . The m a r g i n s m ust be ca refu l ly exa m i ned by pathology and reexcised s h o u l d they return positive.

The preo perative lym p h osci n t i g r a p h y/S P E CT-CT i s a g a i n reviewed to h e l p determ i n e t h e a p p roxi m ate locat i o n of the S L N s in r e l a t i o n to v i s i b l e o r p a l p a b l e a n ato m i c str u ct u res. T h e i ntra o p e rative g a m m a probe c a n t h e n be used to confirm t h e site of t h e sent i n e l n o d e s . O n ce t h e locat i o n i s confi rmed, i n c i s i o n s a re m a rked to a l low a ccess to rem ove t h e sent i n e l n o d e s (FIG 8) . M a rk i n g the p l a n ned incisions s h o u l d take i nto accou nt pl acement a l o n g relaxed s k i n tension l i nes. In a d d ition, consideration should be g iven to any future potent i a l procedu res such as rotation f l a p reconstruction sites or the need for pa rotidectomy a n d cervical lymphadenec­ tomy (FIG 9) . At this poi nt, a l l p l a n ned incisions a re usua l l y i nj ected with local a n esthes i a . Typ i ca l ly 1 % l i d oca i n e with 1 : 1 00,000 e p i n e p h r i n e solution is used . A s m a l l vo l u m e s h o u l d be used t o h e l p avo i d i n advertent para lysis o f cra­ n i a l n e rves close to the operative sites.

FIG 7 • Methylene b l u e dye i njected i nto the dermis circumferent i a l l y around the lesi o n .

C h a p t e r 26 R E S E C T I O N OF H EAD A N D N E C K M E LA N O M A

FIG 8 • The i ntrao perative g a m m a p r o b e is u s e d to confirm the sites of the potent i a l S L N s .

FIG 9 • Sma l l incisions are p l a n ned a long rel axed s k i n tension l i nes.

EXCISION OF THE PRIMARY LESION Skin Incision •

The skin surro u n d i n g the p r i m a ry lesion is now s h a rply i ncised, being ca refu l to fol l ow the exact marking. The incision i s carried th ru the su bcuta neous tissue, now being ca ref u l to avo i d beve l i n g the cut towa rd the pri­ m a ry lesion.

Determining the Depth of the Excision •

• • • •

O nce the p e r i p h e r a l i n c i s i o n s a re m a d e a r o u n d the pri­ m a ry lesion, the d e pth of t h e excision m u st be deter­ m i n e d . I n general, the d e pth of the exc i s i o n is carried to the fasci a l plane deep to the s u bcuta neous tissue. •

FIG 1 0 • The fac i a l l e s i o n has b e e n excised to a depth j ust a bove the fac i a l m uscu lature.

The d e pth of the excision is h i g h ly dependent on the locat i o n of the p r i m a ry lesion, the size a n d d e pth of the lesion, a n d the a m o u nt of s u bcuta neous tissue deep to the l e s i o n . For fac i a l lesions, the excision is most often carried to a p l a n e j ust a bove the fac i a l m uscu l ature (FIG 1 0). Prea u r i c u l a r lesions a re excised to a depth of the pa rotid fascia (FIG 1 1 ) . Nasa l lesions a re excised a bove the level of the n a s a l carti l a ges. A u r i c u l a r l e s i o n s a re rem oved e i t h e r with o r without t h e u n d erlyi n g c a rt i l age, d e p e n d i n g o n t h e size of t h e p r i m a ry l e s i o n . I n m a ny cases, t h e u n d e r l y i n g c a rt i ­ l a g e s h o u l d be removed to e n s u re a d e q u ate n eg ative margins. Sca l p lesions a re usua l l y excised i n a s u b g a l e a l p l a n e with the underlying pericra n i u m left i ntact. In l a rge b u l ky le­ sions, the underlying pericra n i u m can a lso be removed to a l low for wider clear m a r g i n s (FIG 1 2) .

FIG 1 1 • Prea u ricu l a r lesions are excised to a depth j ust a bove the pa rotid fasc i a .

157 1

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

•

•

Neck s k i n can be excised either with or without the underlying p latysma m uscle, depe n d i n g on the size of the l es i o n . If there is any concern about deep i nvasion, it is easy to rem ove p l atys m a . With a l l excisions, atte ntion m u st be p a i d to avo i d i n g i n j u ry t o any underlying cra n i a l nerves.

Orientation •

O n ce t h e p r i m a ry l e s i o n is co m p letely excised, it m u st be ca refu l l y o r i e nted a n d m a rked for p e r m a n e n t pa­ t h o l ogy. M a r k i n g stitches s h o u l d be e a s i l y u n d e rstood and a l l ow for easy com m u n icat i o n between s u rg e o n a n d p a t h o l o g ist. Any a reas of spec i a l c o n c e r n s h o u l d a l so be n oted o n t h e pathol ogy req u est, s u c h a s w h e n m a rg i n s a re l e s s t h a n i d e a l d u e to f u n ct i o n a l c o n s i d e ra t i o n s .

FIG 12 • Sca l p lesions a re u s u a l l y excised i n a subgaleal p l a n e w i t h the u n derlying pericra n i u m l eft i ntact.

SENTINEL LYMPH NODE BIOPSY Intraoperative Gamma Probe •

The i ntraoperative g a m m a probe is now used to confirm the site of the SLN. I n some cases, the p r i m a ry excision site should be su rveyed to look for potenti a l SLNs, which may be deep to the p r i m a ry excision site. These nodes may not a ppear o n the S P ECT-CT d u e to the shadowing caused by the high i ntensity of the p r i m a ry lesion i njec­ tion site. Somet i m es, a b l u e lymphatic c h a n n e l can be seen at the edge of the excision site and can be fol l owed to an SLN (FIG 1 3) .

Incision and Node Dissection •

•

Before proceed i n g with lymph node d issection, it is i m ­ porta nt to confirm t h a t the patient has n o t b e e n g iven any para lytic agents. After confi r m i n g the previously ma rked SLN s ites with the g a m m a probe, the incision i s made and carried to

FIG 13 site.

•

The SLN i s i d e ntified deep to the p r i m a ry excision

•

•

•

•

•

the deep soft tissue. U s u a l l y a 2- to 3-cm incision is l o n g e n o u g h to a l low f o r e a s y d i ssection a n d visual izati o n . With the i n c i s i o n m a d e, s k in h ooks a re used t o retract the s k in edges. B l u nt d issection is then used to enter the deeper soft tissue. I n the neck, d i ssection will go deep to the p l atysma m uscle. I n the prea u ricu l a r reg ion, the d is­ section w i l l often p roceed deep to the parotid fascia i nto the pa rotid parenchym a . T h e i ntraoperative g a m m a probe is used frequently to h e l p determ i n e the d i rection of f u rther d issection. As the t i p of the probe gets closer to the sent i n e l node, the gamma cou nts will i ncrease. Oftentimes, a b l u e lymphatic c h a n n e l can be identified and can then be fol l owed to the SLN (FIGS 1 4 and 1 S). O n ce t h e n o d e i s i d e ntified, it i s ca ref u l l y rem oved with b l u nt d i ssect i o n and j u d i c i o u s use of b i p o l a r e l ec­ trocautery. The node is then exa m i ned away from the patient to document the g a m m a count and the p resence of b l u e dye. The node is l a beled with the a nato m i c

F I G 1 4 • Oftentimes, a b l u e lym phatic c h a n n e l ca n be identified.

C h a p t e r 26 R E S E C T I O N OF H EAD A N D N E C K M E LA N O M A

location, g a m m a cou nt, a n d presence of b l u e d y e a n d sent f o r h istopat h o logy. Confirmation and Closure •

•

FIG 15 • Lym p h at i c c h a n n e l s c a n then be fo l l owed to the SLN.

After remov in g the SLN, the g a m m a probe is then used to reexa m i n e the surgica l bed. The a rea where the node was removed s h o u l d now have a very l ow count com p a red to the count prior to node remova l . As a general r u l e, the count should drop to l ess t h a n 1 0 % of the count prior to node remova l . If the count rem a i n s el evated, further d is­ section i s warra nted to remove any other SLNs identified. O n ce a l l potentia l SLNs are removed, the surgical bed is i rrigated with s a l i n e . A Va lsa lva m a n e uver s h o u l d be performed to confirm there is no o n g o i n g b l eed i n g . The incision can be closed i n sta n d a rd fas h i o n and a s m a l l press u re d ress i n g a p p l ie d .

PRIMARY CLOSURE VERSUS DELAYED RECONSTRUCTION OF THE PRIMARY SITE Primary Closure •

• •

•

After the p r i m a ry lesion has been resected a n d the SLN b i o psy com p l eted, it is time to determ i n e the best method of closing the p r i m a ry site. If the p r i m a ry site can be closed without d i stort i n g the surgical m a r g i n s a n d without the u s e of rotati o n f l a p s or g rafts, t h i s ca n b e done i m medi ately. S h o u l d a m a r g i n return positive on perm a n e nt pat h o logy, it wou l d sti l l be easy to return for wider excision. This is usua l ly the case for sma l l lesions or for lesions o n the n e c k where excess s k i n can easily be adva nced. I n th ese cases, b i l atera l B u rrow's t r i a n g l e excisions can be performed a l o n g the d i rection of relaxed ski n te nsion l i nes. The s k i n is then u ndermi ned, advanced, a n d c losed with deep a bsorba b l e suture and superfic i a l suture at the skin edge. The wou n d is then d ressed with a s m a l l pressu re d ressi n g , which can be removed after 24 h o u rs.

FIG 16 • C i rcu mferent i a l pu rse-string suture is used to decrease the size of the wou n d .

Delayed Reconstruction •

•

•

•

I n m a ny cases, reconstruction of the p r i m a ry resection site will req u i re s i g n ificant tissue rearra ngement, s k i n g raft i n g , or even free tissue tra nsfer. I n these situations, it is prefera b l e to wait for f i n a l h istopathologic confir­ mation of negative surgical m a rg i ns prior to p roceed i n g with defi n itive reconstruction. I n these cases, the size of the wound can often be de­ creased with use of a c i rcu mferent i a l pu rse-string suture (FIG 1 6) . The wound can then be d ressed with a m o i st bolster d ress i n g u s i n g Vase l i n e o r Xeroform g a uze, bacitracin, cotton balls (FIG 1 7), o r a foa m-type d ress i n g (FIG 1 8) . T h e bolster d ress i n g can be secu red w i t h either s i l k s u ­ ture or surgica l sta ples. Wou n d i nfections a re very rare i n the head a n d neck a n d therefore postoperative antibiotics a r e n o t routi nely used even i n the sett i n g of a n open wou n d with a bolster

FIG 17 • A Xeroform ga uze d ress i n g is p l a ced over the resection site.

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FIG 1 8 • A Reston foam bolster is secu red to the sca l p to a p p l y p ressure after e i t h e r resection or ski n g raft reco nstruct i o n . FIG 20 a p p l i ed. I n s o m e cases, such as i m m u n e s u ppression or previous i nfection, antibiotics may be i n d i cated. Skin Graft and Rotation Flap Reconstruction •

•

•

O n ce the f i n a l s u rg ica l m a r g i n s have retu rned clear, de­ f i n itive reconstruction ca n be com p l eted . The method of reconstruction i s dependent on the site of the defect a n d t h e g o a l s o f t h e patient. Com p l ex faci a l defects s h o u l d be a d d ressed b y co l leagues w i t h experience i n fac i a l p las­ tic and reconstructive s u rgery. Facial s k i n a n d prea u r i c u l a r ski n defects a re most often closed with the use of cervicofacial rotation flaps a n d transposition fla ps. Incisions a r e p l a n ned a l o n g relaxed skin tension l i nes when poss i b l e and are carried to post­ a u r i c u l a r a n d posterior cervical ski n . These flaps create sta n d i n g cuta neous defo rm ities a l o n g the a rc of rota­ tion, which w i l l need to be excised. Very l a rge defects can be cl osed a n d a c h i eve exce l lent cosmetic outcomes (FIGS 1 9-21 ) . Eye l i d defects can be very d ifficult to repa i r without caus­ ing s i g n ificant ectro p i o n . Lid-tighte n i n g procedu res can

FIG 1 9 • Large fac i a l defect w i t h posterior cervica l i n c i s i o n made to a l low for cervicofa c i a l rotation flap reconstruct i o n .

•

•

•

Cervicofa c i a l rotation f l a p b ro u g ht i nto posit i o n .

be done i n conj u n ction w i t h s k in grafts, transposition fla ps, and rotation f l a ps. Oculop lastic s u rgeons should be i nvolved if there is concern a bout postoperative eye l i d fu nction (FIGS 22-24) . N a s a l defects can be closed w i t h s k in g rafts, com posite g rafts, tra nsposition fla ps, advancement fla ps, and the i nterpolated paramed i a n forehead f l a p . Each tech n i q u e can y i e l d exce l lent resu lts w h e n used i n the proper c l i n i­ cal sett i n g (FIGS 2S-27) . Auricu l a r defects a re m ost e a s i l y closed w i t h w e d g e exci­ s io n a n d advancement f l a p closure. Tra nsposition f l a ps can be used to reconstruct l a rge defects a n d achieve ac­ cepta b l e cosmetic resu lts (FIGS 28 and 29) .

FIG 2 1 • Exce l l ent cosmetic result severa l weeks after cervicofa c i a l reconstruction of l a rge fac i a l defect.

C h a p t e r 26 R E S E C T I O N OF H EAD A N D N E C K M E LA N O M A

FIG 25 • Postoperative result after f u l l-thickness s k i n g raft reconstruction of the nasal d o rs u m .

F I G 22 • Large rotation f l a p designed f o r reco nstruction of lower eye l i d defect.

•

•

Sca l p d efects are m ost e a s i l y closed with t h e use of fu l l -t h i c k n ess or s p l it-th i c k n ess s k i n g rafts. I n o l d e r patie nts, l a rg e a m o u nts of s u p ra c l av i c u l a r s k i n c a n be h a rvested a n d used to g raft l a rg e sca l p d efects. The s k i n i s t h i n n e d to the d e r m a l layer, m a k i n g s u re to rem ove a l l su bcuta n e o u s t is s u e . The s k i n g raft c a n be p l aced o v e r i ntact peri oste u m o r c a n be g rafted d i ­ rect ly to exposed b o n e . I n t h i s case, a b u rr c a n be u s e d to b u rr down t h e b o n e u nt i l p u n ctate vess e l s a re see n . T h e g raft i s t h e n secured with a b o l ster d ress i n g a n d l eft i n ta ct f o r 7 t o 1 0 d ays. N e c k s k i n d efects c a n a l m ost a l ways be c l osed with adjacent tissue tra n sfer reconstruct i o n as described e a r l i e r.

FIG 23 • The f l a p is ra i sed far e n o u g h to a l l ow for tension­ free closure .

F I G 24 • T h e rotati o n f l a p is sewn i nto p lace w i t h no tension i nferiorly, th u s avo i d i n g postoperative ectro p i o n .

FIG 26 • Postoperative result after para m e d i a n forehead f l a p reconstruction of right latera l nasal wa l l a n d alar r i m with use of ear carti lage g raft i n g to alar rim (latera l view).

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FIG 27 • Postoperative result after p a ra m e d i a n forehead f l a p reconstruction of right latera l nasal wa l l a n d alar r i m with use of ear carti lage g raft i ng to alar rim (fronta l view) .

FIG 28

•

Resection of left lower ear a n d h e l ica l r i m .

FIG 29 • Reconstruction of l eft ear with posta u r i c u l a r transposition f l a ps .

PEARLS AND PITFALLS I n d i cations a n d preoperative work u p

•

Excision of p r i m a ry lesion

•

• •

• •

A com p l ete h i story a n d physica l exa m should be performed i n c l u d i n g fu l l body s k in check. If SLN b i opsy is i n d i cated, lymphoscintigraphy with S P ECT-CT i m a g i n g should be reviewed prior to s u rgery. A deta i l ed cra n i a l n e rve exa m s h o u l d be com p l eted prior to procee d i n g with s u rg e ry. The p r i m a ry lesion s h o u l d be ma rked to i n c l u d e any p a l e, erythematous, or p i g m e nted adjacent s k i n . One t o 2-cm c i rcu mferentia l m a r g i n s a re m a rked depe n d i n g of depth o f i nvasion of the p r i m a ry les i o n . The depth of excision n e e d s to i n c l u d e e n o u g h n o r m a l t i s s u e to ensure com p l ete surgica l excision. M a rk the spec i m e n with clear orientation sutu res to a l low for defi n itive m a rg i n a n a lysis.

C h a p t e r 26 R E S E C T I O N OF H EAD A N D N E C K M E LA N O M A

SLNB

• • • • •

Closure vs. d e l ayed reco nstruction

• • •

Review p reoperative lymphoscintigraphy/SP ECT-CT to i d entify l i kely sites of S L N s . Ca refu l ly, i nject methylene b l u e d y e c i rcu mferentia l ly i nto the d e r m i s surro u n d i n g the p r i m a ry l e s i o n . E n s u re a n esthesia has n o t para lyzed the patient prior t o lymph node surgery. M a ke incisions a l o n g re laxed s k in tension l i nes a n d keep i n m i n d the poss i b l e need for rotation a d ­ va ncement f l a p reconstruction or future pa rotid/neck d issection i ncisions. Use the i ntraoperative g a m m a probe to loca l ize SLNs a n d m a ke s u re that all potenti a l SLNs a re removed . If wound ca n be closed by simple adva ncement f l a p without reorienting m a r g i ns, then wound can be c l osed p r i m a ri ly. If rotation/tra nsposition f l a p or s k i n g raft is needed, it may be wise to d e l ay reconstruction u nt i l f i n a l s u rg ica l m a r g i n s a re clear. Facial p l astic a n d ocu l o p lastic colleag ues s h o u l d be consu lted for closure of com p l ex wou n ds.

with negative SLN biopsy and decreases to an estimated 5 8 % in patients with a positive SLN.2

POSTOPERATIVE CARE •

Small pressure dressings are usually applied to small ad­ vancement flap reconstruction sites as well as SLN biopsy sites and are left intact for 24 hours. Larger cervicofacial advancement flap reconstruction sites are dressed with Jobst pressure dressings and are left intact for 2 to 3 days. When the dressings are removed, the incisions should be kept clean with half-strength peroxide and moist with Vase­ line. Topical antibiotic ointment may be used for 2 to 3 days but can cause skin irritation with longer use. When skin grafts are used, the bolster dressing is left intact for 7 to 1 0 days. After the bolster i s removed, the graft i s kept moist with Vaseline for 1 to 2 weeks or until the wound has com­ pletely healed.

OUTCOMES •

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In the hands of experienced head and neck surgeons, an SLN can be identified in nearly all patients. In patients with cuta­ neous melanoma of the head and neck with Breslow depth of 1 mm or greater or with Breslow depth between 0 . 75 mm and 0 . 9 9 mm with other adverse features, approximately 2 0 % are found to have a positive SLN. Upon completion lymphadenectomy, 2 5 % of patients with a positive SLN will have at least one more positive non-SLN. Approximately 4% of patients with negative SLNs will fail regionally within the sentinel node basin. 2 Positive SLN status is the factor most strongly associated with decreased recurrence-free survival (hazard ratio [HR] 4.23) and decreased overall survival (HR 3 . 3 3 ) .2 The esti­ mated 4-year overall survival approaches 84% in patients

COMPLICATIONS • • • • • •

Seroma or hematoma at the SLN biopsy site Infection at either the SLNB or primary resection site Wound dehiscence or epidermolysis of rotation flap reconstruction site Decrease in sensation at either surgical site Theoretical risk of cranial nerve injury Poor cosmetic outcome

REFERENCES 1. Bichaki ian CK, Halpern AC, Johnson T M, et al. Guidelines of care for the management of primary cutaneous melanoma. I Am Acad Dermatol. 2011;65:1032-1047. 2. Erman AM, Collar RM, Griffith KA, et al. Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma. Cancer. 2012; 118:1040-1047. 3. Gershenwald JE, Thompson W, Mansfield P F, et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sen­ tinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol. 1999;17(3) : 976-983. 4. Kupferman ME, Kubik MW, Bradford CR, et al. T he role of sentinel lymph node biopsy for thin cutaneous melanomas of the head and neck. Am } Otolaryngol. 2014;35:226-232. 5. Morton DL, T hompson JF, Cochran AJ, et al. Sentinel-node biopsy or nodal observation in melanoma. N Eng/ I Med. 2006;355(13) : 1307-1317. 6. Schmalbach CE, Johnson T M, Bradford CR. T he management of head and neck melanoma. Curr Probl Surg. 2006;43:781-835. 7. Zender C, Guo T, Weng C, et al. Utility of SPECT/CT for periparotid sentinel lymph node mapping in the surgical management of head and neck melanoma. Am] Otolaryngol. 2014;35:12-18.

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Chapter

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Sentinel Lymph Node Biopsy for Melanoma I

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Merrick I. Ross

DEFINITIONS •

The sentinel lymph node(s) are defined as the first nodes to receive direct lymphatic drainage from the cutaneous site of a primary melanoma and therefore the most likely lymph node(s) to harbor microscopic metastases. The technique of lymphatic mapping and sentinel lymph node (SLN) biopsy is used to determine the histologic status of the regional lymph node basin(s) in patients with early-stage (American Joint Committee on Cancer [AJCC] clinical stages I and II) mela­ noma without performing a formal lymph node dissection. The SLN concept as well as the minimally invasive technique,

Primary melanoma

+

Michael Kim

which initially used intradermal injections of vital blue dye1 ( FIG 1 ) and was later modified with the addition of radiola­ beled colloid injections2•3 at the site of the primary melanoma, was first studied and reported in detail by Morton and col­ leagues, demonstrating proof of concept in a large group of patients with primary melanoma and clinically negative re­ gional lymph nodes.1 This and several subsequent studies have confirmed that the lymphatic drainage patterns from specific regions of the skin can be accurately determined, the SLN is the most likely first site of regional lymph node metastasis, and if the SLN is histologically negative, the remaining lymph nodes in the mapped basin are unlikely to contain disease.

Afferent lymphatic channel

Sentinel lymph nodes

Sentinel lymph node

Sentinel lymph node

A

Injection site B Surgical exposure of

sentinel lymph node FIG 1 • Sent i n e l node loca l i zation u s i n g b l u e dye i njections. An a rtistic rendition of the sent i n e l node concept and afferent lym phatic d r a i n a g e patterns is depicted . After the i ntrad e r m a l i njection of b l u e dye around a p r i m a ry cuta neous melanoma (left abdom i n a l wa l l , Panel A), afferent lym p h atic d r a i n a g e t o a left i n g u i n a l senti n e l l y m p h n o d e a n d two left axi l l a ry sent i n e l lym p h nodes is shown. Panel B shows surgical exposu re, u s i n g a self-reta i n i n g retractor, of the fi rst of two senti n e l nodes i n the left axi l l a . N ote the two afferent lymphatic vessels entering the senti n e l node. Both nodes i n the axi l l a wou l d be defined as "senti n e l " because they each receive fi rst (pri m a ry) echelon d r a i n a g e from a specific afferent lymphatic vesse l . B oth nodes need to be rem oved from the axi l l a as we l l as the SLN i n t h e g r o i n to com p l ete t h e surgica l proced u re o f SLN b i opsy.

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The reported accuracy (sensitivity) of SLN biopsy is 9 5 % .1·3-5 The term " biopsy" is perhaps a misnomer (particularly to patients) because the biopsy procedure is excisional in nature in that the entire SLN is removed and subjected to rigorous histologic analysis. Alternatively, the term " sentinel lymphad­ enectomy" can be used to define the surgical procedure.

CLINICAL IMPORTANCE •

•

•

•

Improving outcomes: The sobering reality is that once patients with melanoma develop clinically apparent (palpable) nodal disease (advanced AJCC stage III), the risk of subsequent dis­ tant stage IV disease and recurrent lymph node basin disease, despite a complete therapeutic lymphadenectomy, is at least 5 0 % 6 and 1 5 % to 5 0 % / respectively. Therefore, the original motivation to study SLN biopsy was to establish an effec­ tive method of identifying and then treating lymph node dis­ ease early when microscopic, an approach termed " selective lymphadenectomy," not to be confused with the aforemen­ tioned " sentinel lymphadenectomy," which refers specifically to the SLN biopsy procedure. Such an approach would pre­ vent the development of clinically palpable nodal disease and in turn improve the outcomes for the node-positive patients in terms of both regional disease control and survival. The col­ lective experience with SLN biopsy demonstrates that these two goals have been accomplished.8•9 Staging and reducing morbidity: The stages I and II mela­ noma patient population represent at least 8 5 % of the newly diagnosed patients. The prognosis of this group is very het­ erogeneous and dependent on a variety of primary tumor fac­ tors, specifically tumor thickness, ulceration, and mitotic rate, and probably most importantly, the presence of occult lymph node involvement.1 0 The role of SLN biopsy as a staging tool has been well established, as several published multivariable analyses demonstrate that the histologic status of the SLN is the strongest independent predictor of survival for stages I and II melanoma and therefore offers another motivation for SLN biopsy.10•1 1 The procedure is also intended to identify patients with pathologically node-negative disease for whom additional surgery is not indicated and adjuvant systemic therapy may not be of benefit, sparing these patients the mor­ bidity of unnecessary surgery and treatment-related toxicities. SLN biopsy is now accepted as a standard of care12•13 in the surgical management of appropriately selected melanoma patients. Central to the success of this minimally invasive approach, and in turn achieving the earlier described staging and treatment goals, is the consistent and accurate identifi­ cation and complete removal of the SLN(s ) . Although i n simplest terms SLN biopsy i s a straightforward surgical procedure, in reality, the overall approach integrates several necessary components: identification of the appropri­ ate candidates, careful physical examination of the potential nodal basins at risk, preoperative assessment of the lymphatic drainage patterns, intraoperative localization and removal of all the SLN(s), and careful histologic assessment of the SLN(s).

IDENTIFYING THE APPROPRIATE CANDIDATES •

Primary invasive cutaneous melanoma: The selection criteria for identifying the appropriate candidates for SLN biopsy is

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based on the predicted risk for the presence of microscopic lymph node involvement for those patients with newly di­ agnosed primary melanoma and clinically negative nodes . This is best determined by the various primary tumor fac­ tors inclusive of tumor thickness, ulceration/4 and mitotic rate, which define the five AJCC stages I and II substages of primary melanoma. 1 0 The consensus recommendations are to offer SLN biopsy to any patient with a thickness of 1 mm or greater as long as they are safe operative candi­ dates . SLN biopsy should also be strongly considered in any patient with a thickness of 0.7 to 0 . 9 9 mm, particularly if they have at least one of the following adverse prognostic features: Clark level IV or V, one mitotic figure or more per square millimeter, and lymphovascular invasion or micro­ satellites. 12·15-17 For patients with a thickness of less than 0 . 76 mm, SLN can be considered if, based on other adverse risk factors, a risk of 8 % to 1 0 % of SLN involvement is anticipated. This, however, would be a minority of patients in this subset.14 Although these patients represent the vast maj ority who will be offered an SLN biopsy, a variety of other clinical scenarios are encountered with some fre­ quency where SLN may also be considered. These scenarios are described in the 6 bulleted points that follow directly. Primary melanoma in an ambiguous (unpredictable) lym­ phatic drainage site (i.e., head and neck or trunk location) and proven synchronous nodal involvement in at least one, but not all, of the potential regional lymph node basins at risk: These patients may be candidates for SLN biopsy to stage the other regional nodal basins proven to receive direct lymphatic drainage from the primary site but with­ out clinical nodal involvement. Generally speaking, these patients will undergo treatment of the primary melanoma and the involved nodal basin with a wide excision and for­ mal therapeutic lymphadenectomy in the same operative setting. In the event that preoperative lymphoscintigraphy ( FIG 2 ) demonstrates lymphatic drainage to an additional but clinically negative regional nodal basin, SLN biopsy

FIG 2 • Lym p h oscintigraphy showi n g lym phatic d r a i n a g e to m o re t h a n one n o d a l bas i n . An anterior-posterior view of a lymphoscintigraphy is shown, demonstrat i n g lymphatic d r a i n a g e f r o m a p r i m a ry m e l a n o m a site (blue circle) i n a n a m bi g u o u s ( u n p red icta b l e) d r a i n a g e l ocat i o n . Afferent d r a i n a g e is s e e n t o the right axi l l a a n d right n e c k (red arro ws) . This patient p resented with a newly d i a g n osed m e l a n o m a in the right mid back. Pa l pa b l e n o d e s were a p p reciated o n physica l exam i n the r i g h t a x i l l a ; a n u ltraso u n d -g u i ded f i n e need le aspiration confi rmed metastatic d i sease. The neck was c l i n ica l ly u n i nvolved by pa l pation a n d u ltraso u n d . T h e patient u n derwent s u rgery w i t h cu rative i ntent, which i n c l uded a rig ht axi l l a ry d issection, wide excis io n of the p r i m a ry site, a n d a n SLN b io psy i n the right neck. Final pathol ogy showed m icrometastatic d isease i n both SLNs removed.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

can also be performed at the same time in an attempt to be inclusive in the treatment of all nodal disease, both macro­ and microscopic. Mucosal melanoma: Patients with primary mucosal melano­ mas that are in locations with easy access for direct injection with the SLN localizing agents, conjunctival and anorectal in particular, can be candidates for SLN biopsy as part of their initial surgical management strategy. Although specific primary tumor criteria for these lesions are not well estab­ lished for predicting the presence of occult regional node involvement, these tumors are most often diagnosed late and likely to have a high enough inherent risk to consider SLN biopsy. True locally recurrent melanoma: Some patients develop recurrent melanoma at the edge of a previous wide exci­ sion site and may have one of the following three histologic features: in situ disease alone, in situ disease plus an invasive component, or invasive ( dermal) component only. All three of these events are likely the result of an inadequate wide excision and an undetected positive margin and therefore represent a "true " local recurrence and have a good chance for long-term survival with surgical treatment. Most of these patients have clinically negative nodes, and in the context of a recurrent invasive component with the appropriate tumor characteristics (see earlier discussion) , it is rational to offer these patients an SLN biopsy as a part of the definitive surgical therapy. Limited satellite/in-transit metastases: In contrast to the patients with "true " locally recurrent disease, these patients represent manifestations of the biologic disease continuum of regional cutaneous metastases (stage III ) . Not infre­ quently, these patients will present with clinically negative regional lymph nodes, stage Illb. If the extent of the region­ ally metastatic disease is limited ( one or two lesions) , a sur­ gical approach to the recurrence is rational. The presence of synchronous microscopic nodal disease not only impacts disease stage, advancing to Illc and therefore the progno­ sis, but also the treatment strategies. Therefore, SLN biopsy could also be used in this clinical scenario in conj unction with the resection of the recurrence( s ) . After a wide excision: I t is typical and preferable that the SLN biopsy be performed together in a single operative set­ ting in conjunction with the definitive wide excision of the primary melanoma following a diagnostic incisional or exci­ sional biopsy. Occasionally, a patient will have undergone a formal wide excision of the primary melanoma site and then be referred for consideration of an SLN biopsy. A theoretical concern is that the lymphatic drainage pattern of the skin brought together to close the surgical defect or surrounding a skin graft reconstruction has either been altered by the sur­ gery or is far enough away from the original primary lesion that it may not accurately reflect that of the removed skin that was directly adj acent to the primary melanoma, result­ ing in the identification and removal of the wrong SLN ( s ) . A few publications have p u t most of these concerns t o rest. The data shows that although more afferent lymphatic ves­ sels are likely to be accessed because of the broadened area injected, leading to more SLNs being removed and even the possibility of additional nodal basins explored in sites of ambiguous drainage (trunk and head and neck) , the correct SLNs will likely be among the specimens removed, providing

•

accurate nodal staging information. 1 8 As long as complex rotational flaps were not used for the reconstruction, SLN can be recommended to patients when this clinical setting is encountered. Prior surgery in a nodal basin: Occasionally, a primary mela­ noma will be diagnosed in a location with predicted or pos­ sible lymphatic drainage to a regional nodal basin in which surgical intervention has previously been performed, such as an SLN biopsy or lymph node dissection, as treatment for a previous melanoma or other malignancies. An SLN biopsy may still be possible, but a preoperative lymphoscintigra­ phy is mandated to determine how the lymphatic drainage has been affected or altered by the previous nodal surgery. Lymphatic drainage patterns may be demonstrated in one or more of the remaining nodes (if any exist) in the previously treated basin or diverted to another basin. This information is critical for appropriate surgical planning and operative positioning.

PATIENT HISTORY AND PHYSICAL FINDINGS •

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•

•

•

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•

Pertinent information such as a prior personal history of melanoma or other malignancies and current or recent symptoms referable to the presence of metastatic disease should be elicited from the patient during the history. Questions about allergic reactions to antibiotics, sulfa in particular, and intravenous (IV) contrast agents should be documented as this information may suggest an increased risk of an allergic reaction to the isosulfan blue dye and therefore may influence the decision to use a different blue dye such as methylene blue or not use any blue dye at all for the SLN procedure (see more details in the following text ) . A thorough head-to-toe skin examination should be per­ formed with the intent of identifying additional suspicious lesions that could represent another primary melanoma or other skin cancers. Diagnostic full-thickness punch or exci­ sional biopsies should be performed on selected lesions. Special attention should be paid to the region of the index melanoma. Visual inspection as well as palpation of the biopsy site and surrounding skin and soft tissues should be performed to determine the presence of any residual primary disease and/or satellite and in-transit metastases. Skin and soft tissues between the primary lesion and drain­ ing lymph node basins should be palpated and closely ex­ amined for in-transit disease. All suspicious cutaneous and subcutaneous lesions may undergo fine needle aspiration for pathologic diagnosis. All potential regional lymph node basins should be palpated for the presence of clinically apparent disease. This exami­ nation should include the epitrochlear and popliteal minor nodal basins when the primary melanoma is located distal to the elbow and knee, respectively. Palpable lymph nodes suspicious for metastatic disease should be assessed by either direct fine needle aspiration or further examined with ultrasound and biopsied with ultrasound guidance if confirmed to be radiographically sus­ picious. Such data may obviate the need for SLN biopsy in that basin and instead invoke a formal radiographic staging evaluation prior to carrying out a therapeutic lymph node dissection of the affected lymph node basin ( s ) .

C h a p t e r 27 S E N T I N E L LYM P H N O D E B I OPSY FOR M E LA N O M A

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HISTOLOGIC EVALUATION OF THE PRIMARY MELANOMA •

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An experienced dermatopathologist should review all pa­ thology slides related to the melanocytic lesion in question to both confirm the diagnosis of melanoma as well as to pro­ vide the microstaging (tumor thickness, ulceration status, and mitotic rate) information and other relevant adverse histologic features (see earlier discussion) . The decision t o proceed with a n SLN biopsy should b e based on the earlier described established criteria . In some situa­ tions, however, the primary lesion is essentially intact and the diagnostic biopsy represents only a small sampling of the entire lesion or very superficial in depth. This type of biopsy may accurately render a definitive diagnosis of melanoma but may lack the histologic features needed to recommend an SLN biopsy. In this situation, the entire lesion should be narrowly removed as an excisional biopsy for complete histologic evaluation.

FIG 3 • U ltraso u nd-g u ided f in e need le aspi ration of a suspicious n o n pa l pa b l e lymph node. A static u ltrasou n d i m a g e of biopsy need le (black arrow) with i n the node (red arrow) is shown.

PREOPERATIVE RADIOGRAPHIC STUDIES •

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•

•

Although symptom-directed preoperative radiographic im­ aging is a good practice in patients with newly diagnosed melanomas, generally speaking, most newly diagnosed early stage patients are asymptomatic; therefore, no special radiographic imaging is required or recommended prior to performing an SLN biopsy for most primary melanoma patients Y In the asymptomatic patient, extensive radio­ graphic staging is more likely to result in false-positive rather than true positive findings. One possible excep­ tion would be the patients with both very thick ( > 4 mm) and ulcerated primary lesions. Many surgeons would ob­ tain complete radiographic staging inclusive of computed tomography ( CT) of chest/abdomen/pelvis or positron emission tomography ( PET) scan and magnetic resonance imaging (MRI) of the brain routinely for this high-risk group . 19 In contrast, in patients with a locally metastatic lesion or a limited number of in-transit metastases for whom an SLN biopsy is being considered as part of the definitive surgical management, a thorough preoperative radiographic staging evaluation should be performedY As mentioned earlier, ultrasound examination should be performed in patients with suspicious palpable nodes. Furthermore, ultrasound evaluation of the regional nodal basins should also be used as an adj unct to physical ex­ amination particularly of the axilla, in obese patients, with thick and ulcerated melanomas to evaluate for the presence of macroscopically involved nodes. In these situations, the sensitivity of physical examination is low and the risk of harboring synchronous macroscopically involved nodes is relatively high. Ultrasound examination suspicious for nodal involvement can be confirmed with an ultrasound-guided fine needle aspiration ( FIG 3 ) . The success o f any SLN program i s dependent o n the pre­ operative determination of the lymphatic drainage pat­ terns from the primary melanoma site. Although the nodal basins at risk in extremity melanomas are relatively predictable, such is not the case for head and neck and trunk melanomas where lymphatic drainage patterns are

considered ambiguous or unpredictable. Preoperative identi­ fication of lymphatic drainage patterns is accomplished with lymphoscintigraphy. 20•21

PREOPERATIVE LYMPHOSCINTIGRAPHY •

•

•

Once the decision is made to perform an SLN biopsy, the most important preoperative decision is whether or not to perform a lymphoscintigraphy. The technique of cutaneous lymphoscintigraphy provides an objective description of the lymphatic drainage pattern from a primary cutaneous lesion to the nodal basin( s ) that receive direct afferent lymphatic drainage. Through the use of ex­ ternal gamma camera images, the migration of the radioac­ tive tracer that is injected intradermally (where the invasive melanoma cells are located) at the site of the primary tumor can be visualized to determine the following: ( 1 ) the major lymph node basin(s) receiving direct lymphatic drainage, (2) number and relative location of sentinel nodes within the basin, and ( 3 ) the existence and location of SLN(s ) located outside of a formal lymph node basin, referred to as either " interval" or " in-transit" SLNs that are located in the sub­ cutaneous tissues between the primary tumor and the formal nodal basin or ectopic in completely unpredicted anatomic locations.22 The lymphatic drainage patterns mimic how melanoma cells metastasize within the lymphatic compart­ ment. Approximately 5 % to 1 0 % of the time, an interval or in-transit SLN pattern will be identified during lympho­ scintigraphy on the trunk; these nodes are just as likely to be involved with metastatic disease as the SLNs in the for­ mal nodal basins.22 FIG 4 provides a simplified schematic of potential lymphatic drainage patterns. Two radiopharmaceutical agents are now available in the United States to be used for lymphoscintigraphy and for in­ traoperative SLN localization, both using a dose of 0 . 5 to 1 . 0 mCi of the radiotracer technetium-99m. Radiolabelled sulfur colloid has been the historical standard and is still used commonly, to date, but not specifically approved for

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRINE, AND ONCOLOG IC SURGERY

Efferent lymphatic vessels

A;'> 5 0 % decline), and an adenoma in a normal anatomic position unrecognized as a result of sur­ geon inexperience. Transient thyrotoxicosis may occur in one-third of pa­ tients following parathyroidectomy. It is thought to be the result of thyroid gland manipulation and it is self-limited. Beta-blocker therapy may be used for patients who are symptomatic. Recurrent HPT occurs in 1 % to 3% of patients and should raise concern for MEN I or MEN IIA.

REFERENCES 1 . Phitayakorn R, McHenry CR. Hyperparathyroid crisis: the use of bisphosphonates as a bridge to parathyroidectomy: a case series and review of the literature. I Amer Coli Surg. 2 0 0 8 ; 2 0 6 : 1 1 06-1 1 1 5 .

2. Nilsson IL, Yin L , Lundgren E , e t a l . Clinical presentation of primary hyperparathyroidism in Europe: nationwide cohort analysis on mor­ tality from nonmalignant causes. I Bone Miner Res. 2002;17(suppl 2 ) :N68-N74. 3. Bilezikian JP, Khan AA, Potts JT Jr. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. I Clin Endocrinol Metab. 2009;94(2):335-33 9 . 4. Phitayakorn R , McHenry C R . Incidence a n d location of ectopic ab­ normal parathyroid tissue. Am I Surg. 2006; 1 9 1 :41 8-423 . 5 . Pasieka JL, Parsons L L . Prospective surgical outcome study of relief o f symptoms following surgery i n patients with primary hyperparathy­ roidism. World I Surg. 1 9 9 8 ;22:513-5 1 9 . 6. Roman SA, Sosa JA, Mayes L , e t a l . Parathyroidectomy improves neurocognitive deficits in patients with primary hyperparathyroidism. Surgery. 2005; 1 3 8 : 1 121-1 1 2 8 ; discussion 1 1 28-1 129 . 7. Edwards ME, Rotramel A, Beyer T, et a l. Improvement in the health­ related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow up. Surgery. 2006;140:655-663. 8 . Rubin MR, Bilezikian JP, McMahon DJ, et al. The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years. I Clin Endocrinol Metab. 2008;93 ( 9 ) : 3462-3470.

I

Chapter

42

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Subtotal Parathyroidectomy or Total with Autologous Graft �

----------------------------------------------------

�

Bria n D. Sa un ders

DEFINITION •

Parathyroidectomy is a functional surgical procedure per­ formed to remove all or nearly all of a patient's hyperactive parathyroid tissue. Primary hyperparathyroidism is the most common pathologic entity requiring parathyroidectomy. Al­ though roughly 8 5 % to 9 0 % of primary hyperparathyroid­ ism involves a single overactive parathyroid gland, there are somatic, as well as inherited, conditions that result in mul­ tiglandular parathyroid pathology. 1 Further, secondary and occasionally tertiary hyperparathyroidism may require sur­ gical resection of more than one parathyroid gland. Subtotal parathyroidectomy is the removal of all but a small por­ tion of one parathyroid gland from the neck. This usually equates to removing three and a half parathyroid glands. The remnant portion of parathyroid tissue is left on its na­ tive blood supply and in its normal anatomic position. An alternative to a subtotal resection of parathyroid tissue is a total or complete removal of parathyroid tissue (e.g., all four glands) and the immediate transplantation of autolo­ gous parathyroid tissue into a heterotopic position.

•

•

DIFFERENTIAL DIAGNOSIS •

The necessity for a multiglandular resection of parathyroid tissue may be recognized preoperatively or intraoperatively. There are a number of etiologies for hyperparathyroid­ ism that are always multiglandular in nature and, as such, would warrant preoperative planning for either a subtotal parathyroidectomy or a total parathyroidectomy with para­ thyroid autotransplantation. These include multiple endo­ crine neoplasia (MEN) type I- and type Ila-related primary hyperparathyroidism and secondary hyperparathyroidism related to renal failure. Other pathophysiologic conditions leading to hyperparathyroidism may involve the overactiv­ ity of more than one gland. Intraoperative recognition of multiple enlarged glands, or recognition through intraopera­ tive parathormone monitoring data, may lead the surgeon to subtotally resect the parathyroids or perform a total para­ thyroidectomy with immediate transplant. These include sporadic primary hyperparathyroidism due to multiglan­ dular hyperplasia, lithium-related primary hyperparathy­ roidism, tertiary hyperparathyroidism, and CDC73 -related causes of hyperparathyroidism? This latter category is a fa­ milial hyperparathyroidism caused by germline mutations in the CDC73 gene (also known as HRPT2 or parafibromin) and includes familial, isolated hyperparathyroidism and hyperparathyroidism-jaw tumor syndrome.3

PATIENT lllSTORY AND PHYSICAL FINDINGS •

Hyperparathyroidism is a biochemical diagnosis. The eval­ uation of a patient for hyperparathyroidism may begin with an incidental note of an elevated calcium level on a

•

•

•

laboratory report or with interrogating a patient's calcium level based on the patient's presenting signs or symptoms. Patients with recurrent nephrolithiasis (especially calcium­ based kidney stone s ) or osteoporotic ( e .g., fragility or nontraumatic ) bone fractures should be evaluated for hy­ percalcemia and hyperparathyroidism. Other, less specific, symptoms that may warrant a biochemical investigation for hyperparathyroidism include fatigue; musculoskeletal aches and pains; neurocognitive decline; mood lability; abdominal pain; and recurrent, otherwise unexplained, pancreatitis. A detailed family history should be sought to evaluate the possibility of an inherited cause of hyperparathy­ roidism. The patient should be queried about family members with pituitary tumors, other cases of parathy­ roid disease, medullary thyroid cancer, pheochromocyto­ mas, enteropancreatic neuroendocrine tumors ( e specially gastrin-producing tumors), and ossifying fibromas of the mandible. Patients with suspected inherited causes of hyperparathy­ roidism should be counseled to seek genetic counseling and testing as this may impact operative planning, future disease surveillance, and the health of relatives. Renal-related secondary hyperparathyroidism is a con­ stant and expected biochemical finding in all patients with chronic kidney dysfunction. The degree of hyperparathor­ monemia is routinely followed by treating nephrologists, especially in patients who have progressed to some form of renal replacement therapy (peritoneal or hemodialysis ) . National management guidelines exist for the target para­ thyroid hormone ( PTH) level for each stage of chronic kidney disease.4 Physical examination findings for patients with hyper­ parathyroidism are uncommon. Certainly, the neck of each patient proposed for a parathyroidectomy should be thoroughly examined. The identification of a palpable mass would warrant further imaging investigation. It is dis­ tinctly unusual to palpate a parathyroid adenoma. A pal­ pable mass with severe hyperparathyroidism should raise the specter of the unusual entity of parathyroid carcinoma. Often, though, a palpable central neck mass in a patient with hyperparathyroidism is an incidentally discovered thy­ roid nodule. For patients planned to undergo a total parathyroidectomy with immediate autologous parathyroid transplantation, a detailed inspection of the forearms should be undertaken. It is important to note the handedness of the patient, as the parathyroid autograft is usually placed in the nondomi­ nant forearm. In patients with preexisting or impending renal failure, note should be made of arteriovenous fistula position. Great care should be taken to avoid inj uring a functional fistula or disturbing the bed of a soon-to-be con­ structed fistula.

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IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

•

Hyperparathyroidism (whether primary, secondary, or tertiary) is a biochemical diagnosis. This must be made to the satisfac­ tion of the surgeon prior to contemplating any procedure. The surgeon should consider imaging studies only after a diag­ nosis has been secured and the need for an operation has been established. Known multiglandular parathyroid disease processes that will require preoperative planning for a subtotal parathy­ roidectomy or a total parathyroidectomy with autologous graft do not require parathyroid imaging as both sides of the neck will need to be explored and all four of the parathyroid glands identified. High-resolution ultrasonography of the neck (whether per­ formed by the surgeon or a radiologist) is an excellent mo­ dality to attempt to localize enlarged parathyroid glands. Parathyroid adenomas appear as hypoechoic, ovoid masses that are separable from the thyroid gland. Upper parathyroid adenomas that lie in the tracheoesophageal groove will often be mobile with graded compression of the ultrasound probe ( FIG 1 A,B) . Parathyroid adenomas adj acent to the thyroid can usually be well seen, although ectopic parathyroid ad­ enomas (e.g., posterior to the clavicular heads) may be diffi­ cult to visualize due to limitations of the ultrasound waves in travelling through bone. Ultrasonography will also aid in the identification of concurrent thyroid pathology, which may then be dealt with at the time of the parathyroid operation. Nuclear medicine parathyroid scans using technetium sesta­ mibi as a tracer can accurately identify overactive parathy­ roid glands about 8 5 % of the time.5 When performed with

A

B •

N uc l e a r m e d i c i n e p a rathyro i d sca n . A. 2-h o u r d e l ayed p l a n a r view showi n g b i l ateral p a rathyro i d a d e n o mata. B. Fused sesta m i bi-SPECT/CT sca n show i n g b i l atera l sesta m i b i-avid p a rathyro i d lesions poste r i o r to each lobe of the thyro i d g l a n d .

FIG 2

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•

•

A

OELAYNECK

a concurrent single-photon emission computed tomography ( SPECT)/computed tomography ( CT) scan, this overlay of functional and structural imaging provides an excellent ana­ tomic map of disease localization invaluable to the operat­ ing surgeon (FIG 2A,B ) . One caveat is that small parathyroid adenomas in close association with the thyroid gland may be difficult to visualize with this imaging technique. Neck CT scan or magnetic resonance imaging (MRI) is oc­ casionally used to image parathyroid glands. Newer CT scan imaging protocols are becoming more widespread, such as 4D CT scans. This takes advantage of the timing of the in­ travenous (IV) contrast bolus, the vascularity of the para­ thyroid tumors, and the delayed washout of hyperactive parathyroid lesions. More invasive modalities of parathyroid localization include selective venous sampling for PTH measurement. This tech­ nique requires experienced interventional radiologists and is best reserved for the reoperative setting. Imaging prior to reoperative parathyroid surgery is essential to minimize exploration in a scarred operative field and to minimize iatrogenic morbidity. It is ideal to have two con­ cordant imaging studies prior to all reoperative parathyroid surgery (see Part 5, Chapter 45 ) .

SURGICAL MANAGEMENT Preoperative Planning •

•

B FIG 1 • H i g h-reso l u t i o n cervica l u ltraso u n d d e m o nstrati n g c l e a r pa rathyro i d a d e n omata. A. R i g h t t h y r o i d lobe w i t h a hypoechoic right u p p e r pa rathyro i d a d e n o m a i n the trach eoeso p h a g e a l g roove . B. Sag itt a l u ltraso u n d v i e w of t h e left thyro i d lobe with a hypoec h o i c l eft i nfe rior p a rathyro i d a d e n o m a .

•

•

Prior to any parathyroid operation, all diagnostic biochemi­ cal data should be reviewed to confirm to the surgeon's satisfaction that a diagnosis of surgically correctable hyper­ parathyroidism is present in the patient. If an autologous parathyroid transplant is planned, confir­ mation with the patient as to which upper extremity will be the recipient site should be sought. The wound classification for parathyroid surgery is clean. It is rare for parenteral antibiotics to be indicated prior to parathyroid surgery. Individual patient characteristics (e.g., cardiac valvular lesions, implanted prosthetic hardware) , however, should always be considered. Local or general anesthesia may be used.

C h a p t e r 42 S U BTOTAL PARATHYRO I D ECTOMY OR TOTAL WITH AUTOLOGOUS G RAFT

1713

Positioning •

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•

The patient is positioned supine on the operating room ( OR) table with the arms tucked either at the sides or lying on the abdomen. A sheet, fastened with towel clips, is used to secure the arms next to the patient and to allow for removal of the arm boards from the OR table ( FIG 3 ) . I f a parathyroid transplant i s planned t o the patient's fore­ arm, this arm can be extended from the patient and reprepped and draped at the time of that portion of the procedure (after the parathyroid tissue has been removed from the neck ) . A towel roll o r other small bump is placed behind the patient's shoulder to aid in extension of the neck. The bed is positioned with the head up, the feet down, and in some slight Trendelenburg. This is known as the semi­ Fowler's position or the beach chair position. Some surgeons will rotate the OR table 90 degrees to have the head of the patient away from the anesthesia providers and thus more accessible to the surgical team.

PLACEMENT OF I N C I S I O N •

A transve rse i n c i s i o n is m a d e i n t h e l i n e of a s k i n crease ro u g h ly 1 em ca u d a l to the cricoid carti l a g e o r two f i n ­ g e rbreadths ce p h a l a d to the s u p raste r n a l notc h . The incision may be betwee n 3 a n d 5 em i n l e n gt h and is cen­ tered o n the m i d l i n e of the neck (FIG 4). Some s u rgeons

FIG 3 • The patient i s posit i o n e d o n the O R ta b l e with the arms tucked, a ro l l behind the s h o u l d e rs, a n d the head e l evate d .

w i l l i nfi ltrate the reg i o n of the i n c i s i o n w i t h a local a n ­ esthetic co m b i ned w i t h e p i n e p h r i n e . Placement o f the i ncision with i n a natural s k i n l i n e o r crease of the neck is m o re i m p o rtant for posto pe rative cosmesis t h a n t h e l e n gth of the i n c i s i o n (FIG 5).

Hyoid bone

• S u rface a n atomy and relationsh ips for pa rathyro i d i n cision p l acement.

FIG 4

FIG 5 • D i a g ra m of p l a n ned p a rathyro i d ectomy i ncision, with clavicu l a r heads a n d ste r n a l n otch m a rked for refe rence.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRI NE, AND ONCOLOG IC SURGERY

CREATION OF FLAPS •

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Su perior flap raised

D i ssect i o n is deepened t h r o u g h the su bcuta neous tissues and t h r o u g h the p l atys m a m uscle with e l ectroca utery. S u b p l atys m a l flaps a re created superio rly, i nferio rly, a n d l atera l ly with a co m b i n at i o n o f e l ectroca utery a n d b l u nt d issect i o n (FIG 6). Care m ust be taken to avo i d i nj u ry to the p a i red a nte­ rior j u g u l a r ve i n s . S h o u l d a rent be made in one of these vei ns, it is best to l ig ate the vein rather t h a n atte m pt to cauterize the ve i n . The s u p e r i o r f l a p s h o u l d exte n d to the level of the thy­ roid ca rti l a g e and the i nfe rior flap down to the ste r n a l n otc h .

Anterior jugu lar

FIG 6 • Myocuta neous f l a ps a re raised superio rly, i nfe rior ly, a n d late ra l ly to fac i l itate s k i n retract i o n a n d to expose the various sites to be exp lored.

E NTRY I NTO T H E D E E P CE NTRAL NECK SPACE •

•

The avasc u l a r, m i d l i ne r a p h e betwee n the ste rnohyoid a n d ste r n othyroid m uscles o n each s i d e is entered with e l ectroca utery. T h i s m i d l i n e is best i d e ntified by d i g i ­ ta l pa l pation o f the m i d l i n e o f t h e u n d e rlyi n g trachea. These strap m uscles should be sepa rated to expose the u n d e rlying thyroid ist h m u s (FIG 7). The layers of the strap m uscles a re sepa rated i nto two by d ivid i n g the c o n n ective tissue in the layer betwee n t h e

•

ste rnohyoid a n d the ste rnothyro i d m uscles. The l atera l extent of t h i s d issect i o n is the late ra l borders of these m uscles and the ca rotid sheat h . This exposes the i nternal j u g u l a r ve i n , a site from w h i c h to d raw a base l i n e blood sa m p l e for i ntraoperative PTH m o n itori ng6 (FIG 8). An a lternate site for PTH sa m p l i n g is a p e r i p h e r a l ve n i ­ p u ncture (often i n the lower extremity) performed by the a n esthesiolog ist. If an a rte r i a l catheter is p resent for a n esthetic m o n ito r i n g , it is accepta b l e to use a n a rterial b l ood sa m p l e for PTH m o n ito r i n g .

Strap muscles

Thyroid isth mus

Sternocleidomastoid muscle

FIG 7 • The strap m uscles (ste rnohyoid a n d ste rnothyro id) a re sepa rated i n the m i d l i n e with e l ectroca utery to expose the u n d e r l y i n g thyro i d i st h m us.

C h a p t e r 42 S U BTOTAL PARATHYRO I D ECTOMY OR TOTAL WITH AUTOLOGOUS G RAFT

Internal jugular vein Thyroid gland ------

•

Su perior vena cava

The space betwee n the ste rnothyroid m u scle a n d the thyro i d lobe is d eve loped with a co m b i n at i o n of b l u nt d issect i o n a n d e l ectroca utery. The operation m ust n eces­ s a r i l y beg i n o n one s i d e of the neck, but an i d e ntica l pro­ ced u re w i l l be d o n e o n the contra late r a l s i d e of the neck to i d e ntify all fo u r pa rathyro i d g l a n d s . This space late r a l to the thyro i d lobe a n d med i a l to the carot i d a rtery i s deve l o ped back to the l evel of the preverte bral fasc i a . The cross i n g m i d d l e thyro i d ve i n may need to be d ivided.

•

FIG 8 • B l ood is d rawn from the i ntern a l j u g u l a r ve i n to test f o r PTH l eve l s .

This may be acco m p l ished with m eta l l i c c l i ps, sutu re, o r t h r o u g h any of t h e ava i l a b l e powered s u rg i ca l devi ces (FIG 9). Caution m u st be taken to avoid search i n g fo r pa rathyro i d tissue too soon, as it is poss i b l e for the t u m o r to be m o re poste r i o r t h a n o n e has o p e n e d , o r re m a i n i n g with either the thyro i d o r t h e ca rotid sheath. The recurrent l a ryngeal n e rve may be i d e ntified at this poi nt, coursing superiorly i n the tracheoeso p h a g e a l g roove (FIG 1 0).

Platysma muscle Left lobe of thyroid Anterior jugular vein Common carotid artery I nternal jugular vein

Sternocleidomastoid -.....____ muscle -.....____

FIG 9 • I n it i a l d i ssect i o n for a pa rathyro i d ecto my i n c l udes sepa rat i n g the str a p m u scles off the u n d e r l y i n g thyroid l o b e . The p l a n e j u st m e d i a l to t h e c a r o t i d sh eath i s fo l l owed poste r i o r l y to t h e l e v e l of t h e s p i n e . The o n l y transverse ly cross i n g struct u re i s t h e m i d d l e thyro i d ve i n , w h i c h ca n be l i g at e d . A l l soft tissue, a l o n g w i t h t h e thyro i d l o be, i s kept u n d e r t h e s u rg e o n 's f i n g e r.

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P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRI NE, AND ONCOLOG IC SURGERY

Left lobe of thyroid pul led anteriorly Strap muscles moved laterally Middle thyroid vein (ligated) Common carotid artery

I nferior thyroid vein

I D E NT I F I CATI O N O F SUPERIOR PARATHYRO I D G LANDS •

The superior p a rathyro i d g l a n d s l i e poste r i o r to the u p p e r pole of the thyro i d lobe. To explore t h i s space, the thyro i d lobe is r o l l e d a nteromed i a l l y u s i n g o n e's f i n g e r or a Kitt n e r d i ssector. The superior pa rathyro i d g l a n d s a re poste r i o r to the recurrent l a ry n g e a l n e rve as it passes u n d e rneath the t u bercle of Zuckerka n d l a n d j ust postero latera l t o t h e l i g a m ent o f B e r ry (FIG 1 1 ). T h e i r position is m o re constant than that of the i nfe r i o r pa rathyro i d g l a n d s . There is often sym m etry between s i d es of the neck, and if o n e ca n n ot l ocate a superior

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FIG 11 • R i g ht s u p e r i o r p a rathyroid a d e n o m a lyi n g poste r i o r to the r i g h t t h y r o i d l o b e (ro l led a nteriorly with Kittn e r d i ssecto r) . The right stra p m u scu lature i s s e e n retracted latera l ly.

• •

FIG 10 • The recu rrent l a ry n g e a l n e rve cou rses superiorly in the tracheoeso p h a g e a l g roove a n d can often be i d e ntified m ost easily at the l evel of the i nfe r i o r p o l e of the thyro i d g l a n d .

pa rathyro i d g l a n d on o n e side, it is ofte n advisa b l e to l ocate it on the contra l atera l s i d e . D u e to l i m ited s p a c e for e n l a rg e m e nt, superior p a r a ­ thyro i d a d e n o m a s often g row c a u d a d a n d u lt i m ately l i e i n a pseud oecto p i c p o s i t i o n i n the tracheoeso p h a g e a l g roove, low i n the n e c k . The b l ood s u p p ly, h owever, re­ m a i n s in the eutopic position near the u p p e r pole of the thyro i d l o b e . Caution m ust be taken e l evat i n g these l ow­ lying su perior p a rathyro i d a d e n o m a s out of the tracheo­ eso p h a g e a l g roove as they often lie with the recurrent l a ryngea l n e rve d raped ove r t h e m . Ecto p i c positions f o r the s u p e r i o r pa rathyro i d g l a n d s i nc l u d e low i n the tracheoeso p h a g e a l g roove, retro­ eso p h a g e a l , retrotracheal, with i n the ca rot i d sheath, a n d wit h i n the thyroid g l a n d . Exploration o f t h e ca rotid sheath beg ins with retraction of the sternothyroid m uscle l atera l ly to expose the carotid a r­ tery. Gentle b l u nt dissection a nterior to the ca rotid a rtery a l l ows separation of the ca rotid artery from the i nternal j u g u l a r vei n j ust latera l to it. Posterior i n the ca rotid sheath is the vagus nerve. Exposu re of the ca rotid sheath for a bout 5 to 6 em i n a cephaloca u d a l d i rection a l lows one to search for a soft, brown nod u l e consistent with a pa rathyro id ade­ noma (FIG 1 2). Care must be taken not to m ista ke nodu les posterior to the ca rotid sheath for pa rathyroid adenomas as these may i n fact be g a n g l i a of the sym pathetic cha i n . Once identified, t h e pa rathyroid t u m o r s h o u l d be dissected back to its s i n g l e vasc u l a r pedicle. G reat care should be taken to avoid entry i nto the pa rathyro id capsu l e a n d the potentia l for spilling a n d seed i n g pa rathyroid tumor ce lls i n the centra l neck space (known as pa rathyromatosis). Any u n ce rta i nty in the visual i d e ntification of pa rathy­ roid tissue s h o u l d prompt a b i o psy sent for frozen sect i o n a n a lysis. A sma l l fra g m e nt of t u m o r can be t a k e n with a p a i r of scissors. G e nt l e p ressure can control a n y s l i g ht ooze from the b i opsied g l a n d . O n ce the superior g l a n d h a s b e e n i d e ntified, it s h o u l d re­ m a i n in p l ace u n t i l the i nfe r i o r g l a n d has been identified. T h i s s a m e proced u re will be used to i d e ntify the superior pa rathyro i d g l a n d s o n each s i d e of the neck.

C h a p t e r 42 S U BTOTAL PARATHYRO I D ECTOMY OR TOTAL WITH AUTOLOGOUS G RAFT

Carotid sheath U pper parathyroid gland

Common carotid artery Esophagus

I nferior thyroid vein

I D E NT I F I CATI O N OF I N FERIOR

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PARATHYRO I D G LANDS •

The i nfe rior p a rathyro i d g l a n d s have a s l i g htly m o re va r i a b l e location t h a n the s u p e r i o r p a rathyroid g l a n d s rel ated to the g reater d ista nce o f m i g ration d u ri n g e m ­ b ryo l o g i c deve l o p ment. The typical l ocation f o r these g l a n ds is j ust ca u d a l and s l i g htly poste rior to the i nfe rior t i p of the l ower p o l e of the thyro i d l o b e . The i nfe rior pa rathyro i d glands often l i e i n a plane e q u a l to the tra­ c h e a . They a re u n iformly a nterior to t h e recu rrent l a ryn­ g e a l n e rve (FIG 1 3).

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FIG 1 3 • Left i nfe r i o r p a rathyroid a d e n o m a retracted away f r o m the i nfe rior p o l e of the thyro i d g l a n d .

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FIG 12 • Exp l o ration of the ca rotid sheath for a m issi n g o r ecto p i c superior pa rathyro i d g l a n d . The soft tissue cove r i n g the carot i d a rtery is o p e n e d , a n d t h i s s p a c e can be explored from the retro p h a ryngea l reg i o n i nto the poste r i o r s u p e r i o r m e d i asti n u m .

As the inferior pa rathyro i d g l a n d e n l a rg es, it may de­ sce n d with g ravity i nto the fatty tissue ca u d a l to the thy­ roid lobe a n d i nto the anterior superior m e d i asti n u m . Gentle d i ssect i o n i n t h i s reg i o n c a n a l low f o r i d e ntifica­ tion of a pa rathyro i d a d e n o m a without causing bleed i n g . T h e i nfe r i o r p a rathyro i d g l a n d s m a y l i e i n the co n n ec­ tive tissue l i g a m e nt that attaches the lower p o l e of the thyroid to the cervica l h o r n of the thym us (th e so-ca l l e d thyrothym ic l i g a m e nt). Ecto p i c positions fo r the i nfe r i o r pa rathyro i d g l a nds i n ­ c l u d e the thyrothym i c l i g a m e nt, the cervica l port i o n s of the thym us, the i ntrath o racic thym us, u n d escended with i n the neck, and with the thyro i d g l a n d itse lf. Each of th ese spa ces needs to be exa m i n ed for a m issi n g pa rathyro i d g l a n d . There is ofte n sym m etry o f l ocation of the i nfe r i o r p a rathyro i d g l a nds, a n d i n a b i l ity to find o n e i nfe r i o r p a rathyro i d g l a n d should p r o m pt atte m pts at i d e ntification of the contra latera l i nfer i o r pa rathyro i d g l a n d as a g u i d e . A tra nscervical thym ectomy may be d o n e to i d e ntify m i ss­ i n g o r ecto p i ca l ly located i nfe r i o r p a rathyroid g l a n d s . This p roced u re i s beg u n by d issect i n g the fatty t i s s u e i n t h e a nterior s u p e r i o r m e d i asti n u m j ust poste r i o r to t h e clavicu l a r head a n d j ust l a t e r a l to the trach e a . A search is u n d e rtaken fo r the ca n a ry ye l l ow color of t h e r e m n a n t thym us. Gentle tract i o n i n a c e p h a l a d d i rect i o n w i l l a l low o n e to extract t h e thymus from the m e d i asti n u m . An en­ cas i n g m e m b r a n e w i l l often need to be opened to fu l ly a l low the thym us to be removed . The cervica l thymic re m n a nt will thin out to a sma l l atta c h m e n t ofte n con­ ta i n i n g a blood vesse l that should be c l i pped o r suture l i gated (FIG 1 4). O n ce t h e i nfe r i o r p a rathyroid a d e n o m a is i d e ntified, it should be d i ssected back to its vasc u l a r pedicle. Any q u est ion as to its i d e ntity s h o u l d prompt a sma l l sa m p l e t o be t a k e n w i t h scissors f o r frozen sect i o n b i o psy. An i d e ntica l p roced u re w i l l be fo l l owed to i d e ntify the i nfe rior p a rathyro i d t u m o r o n the contra l atera l s i d e .

1717

1718

P a r t 5 OPERATIVE TECH NIQUES IN BREAST, EN DOCRI NE, AND ONCOLOG IC SURGERY

• A transcervical thym ecto my can be acco m p l ished to i d e ntify ecto p i c i nfe r i o r p a rathyro i d g l a n ds that l i e ca u d a l to the ste r n a l notc h . The thym i c tissue is g rasped and g e ntly p u l led u p from t h e m e d i asti n u m a n d i nto t h e cervi ca l i n c i s i o n .

FIG 1 4

FROZE N SECTI ON PATHOLOG I C ANALYS I S • •

It is often advisa b l e to confi rm the i d e ntity of the fo u r pa rathyro i d g l a n d s i d e ntified with frozen sect i o n . Frozen sect i o n is used to confirm i d entificat i o n as para­ thyro i d tissue m o re so than to q u a ntify ce l l u l a rity of the pa rathyro i d gland. It i s nearly i m possi b l e to re l i a b ly de­ term i n e p a rathyroid hyperp lasia from a pa rathyro i d ad­ e n o m a o n frozen sect i o n (FIG 1 5A,B).

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Low-power p h oto m i crog ra phs of (A) a a d e n o m a a n d (B) a hyperpl astic pa rathyro i d adenoma has a cha racte ristic comp ressed r i m pa rathyroid tissue, w i t h a d m ixed a d i pocytes a n d c h i ef c e l l s .

FIG 15

S U BTOTAL RESECTION OF PARATHYRO I D S

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If a s u btota l resect i o n of t h e pa rathyro i d g l a n d s is to be d o n e, one p l a n s to resect t h ree and a h a l f of t h e fo u r g l a n d s . T h i s i s best d o n e by d i v i d i n g o n e of t h e g l a n d s fi rst a n d conti n u a l ly c h e ck i n g o n i t s v i a b i l ity as t h e resect i o n of t h e seco n d t h ro u g h fo u rt h g l a n d s en­ s u e s to a vo i d a n i n a dvertent tota l pa rathyro i d ectomy. I n g e n e r a l , the remnant of pa rathyro i d g l a n d to re m a i n o n its native blood s u p p l y i n t h e neck s h o u l d be a por­ t i o n of the m ost n o r m a l-appearing g l a n d of the fo u r identified. If poss i b l e, a re m n a nt i nferior g l a n d s h o u l d be l eft, as this r e m n a n t w i l l sit m o re a nterior, and a nterior to the recu rrent l a ryngea l n e rve, m a k i n g it easier to reoperate upon if n ecessa ry.

p a rathyro i d g l a n d . The of n o r m a l p a rathyro i d

A suffi cient pa rathyro i d remnant is a bout 30 to 50 mg of tissue or the size of a n o r m a l p a rathyroid g l a n d . T h e pa rathyro i d r e m n a n t is created b y p l a c i n g a me­ ta l l i c clip o r c l i ps across the gland a n d sharply d ivid i n g t h e d i stal seg ment o f the g l a n d away from the r e m n a n t

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The r e m n a n t may a l so be tagged with a P ro l e n e suture to aid i n future i d e ntificat i o n if a reoperation becomes necessa ry. G reat care s h o u l d be taken w h e n p l a c i n g this m a r k i n g stitch to avo i d i n j u ry to the e n d a rte r i o l e feed­ ing the pa rathyro i d g l a n d . T h e seco n d t h r o u g h fo u rth g l a n d s a re rem oved b y d ivid­ i n g the vasc u l a r p e d i c l e of the g l a n d . The vasc u l a r pedi­ c l e can be c l i pped o r tied as per s u rg e o n p refe rence.

C h a p t e r 42 S U BTOTAL PARATHYRO I D ECTOMY OR TOTAL WITH AUTOLOGOUS G RAFT

Left thyroid lobe Common carotid artery

Inferior thyroid vein

FIG 16 • A re m n a n t of a l eft l ower pa rathyro id g l a n d is l eft o n its native blood s u p p ly. A meta l l i c surgical c l i p is p l aced to d ivide the g l a n d and to m a r k in the case that a futu re reope rative pa rathyro i d s u r g e ry becomes n ecessa ry. G reat care m ust be taken to e n s u re that the c l i p is not p l aced across the b l ood supply to the p a rathyro i d rem n a nt .

TOTAL PARATHYRO I DECTOMY • • •

A tota l p a rathyro i d ectomy i nvolves t h e rem ova l of a l l pa rathyro i d tissue (usu a l ly fo u r g l a n ds) from t h e neck. Each g l a n d is f u l l y d i ssected back to its vasc u l a r p e d i c l e, w h i c h is c l i pped or l ig ated a n d t h e n d iv i d e d . The p a rathyroid tissue to be tra n s p l a nted is i d entified a n d kept m o i st . G reat care should be taken to avo i d t h i s t i s s u e f r o m m i sta kenly b e i n g h a n ded off the ste r i l e f i e l d

(FIG 1 7).

FIG 17

I NTRAOPERATIVE PARATHYRO I D HORMON E MON ITO R I N G •

If i ntraoperative PTH mon itoring is being used, a postre­ section PTH va l u e should be d rawn and sent at 5, 1 0, or 1 5 m i n utes postresection of a l l pa rathyroid tissue. Ti m i n g is per the surgeon's protocol . Longer time poi nts ( 1 5 m i n utes) a re usua l ly used if the PTH speci men is being d rawn from a

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C a refu l atte ntion to h e m ostasis is of p a ra m o u nt i m por­ tance t h r o u g h o u t the e n t i re pa rathyro i d ectomy to ease in p a rathyro i d i d e ntificat i o n . Postope rative neck h e m atomas a re a rare but pote nti a l ly d isastro us com p l i cation fo l l owi n g p a rathyroid ectomy.

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Ex vivo right superior p a rathyro i d a d e n o m a .

centra l vei n (i ntern a l j u g u l a r) . Shorter time poi nts m a y b e used if t h e specimen is from a peripheral ven i pu n cture or a rad i a l a rterial l i ne.6 Reso l ution of hyperpa rathyro i d ism and l o n g-te rm e u ca l ­ c e m i a is we l l predicted b y postresect i o n PTH va l u es that a re at l east 5 0 % of the base l i n e va l u e and i nto the n o r­ m a l range ( 5.5 em), rapid growth ( > 0.5 em per year), the presence of chest pain or back pain unexplained by other causes, and compression of adjacent organs (esoph­ agus, trachea, or left main bronchus).2 More aggressive size criteria may be applied for patients with Marfan's syndrome (repair at 4.5 to 5 em) . However, stent graft outcomes appear less favorable in patients with

FIG 1 • Preope rative c omputed tom ography (CT) a n g iogram of an a o rtic a rch a n e u rysm .

C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S

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connective tissue disease, and therefore, alternative surgical techniques ( such as conventional aortic replacement sur­ gery) should be considered.2 The presence of significant concurrent cardiac disease may alter the surgical approach. Should significant coronary ar­ tery or valvular heart disease be identified in the preoperative period, consideration may be given to performing concomi­ tant coronary artery bypass grafting ( CABG) or valve re­ placement at the time of the aortic de branching procedure. During the second stage of the arch repair, stem graft deploy­ ment in the distal ascending aorta may require the placement of a guidewire across the aortic valve into the left ventricular cavity. The presence of a mechanical aortic prosthetic valve, through which a guidewire and the delivery system cannot safely be placed, may require a single-stage approach with deployment of the stent graft at the time of debranching (see endovascular second stage) . A bioprosthetic valve in the aortic position may allow for careful transvalvular introduction of devices, with preference to bovine pericardia! valves over porcine valves. Selection of the ideal treatment strategy for repair of an aor­ tic arch aneurysm remains controversial and is dictated by surgical experience and local area expertise. Aortic arch deb­ ranching and stent graft completion is an appealing repair option that avoids a thoracotomy incision and may avert the use of cardiopulmonary bypass and circulatory arrest. These types of hybrid procedures may be performed either as single- or two-stage repairs. However, conventional open re­ placement of the entire aortic arch/·4 or replacement of the ascending aorta and proximal arch with the creation of an elephant trunk followed by stent graft completion/·5 should be considered as clinically indicated. Debranching of the aortic arch off the ascending aorta may not be applicable for a patient with an aortic arch aneurysm who has previously undergone cardiac surgery and who is too high-risk for consideration of redo sternotomy. In this case, an alternative option would include extra-anatomic debranching of the aortic arch (carotid-carotid, carotid­ subclavian) followed by stent graft repair of the arch, with or without innominate artery chimney (snorkel) stenting.6 The preoperative CT scan requires careful review before undertaking an aortic arch debranching operation. Arch branch anatomy and appropriate landing zones need to be identified proximal and distal to the arch aneurysm, with criteria similar to those that apply for stent graft repair of a descending thoracic aortic aneurysm. Anatomic variations of the aortic arch anatomy may require modification of the debranching procedure. These include a bovine aortic arch (common trunk of the innominate and left common carotid),

AORTIC ARCH DE B RANCH I N G •

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Alth o u g h some a dvocate the use of a r i g ht tho racotomy i n c i s i o n o r u p p e r h e m i sternotomy, we p refer to expose the asce n d i n g a o rta through a convent i o n a l ste rnotomy i n c i s i o n . This provides opti m a l visu a l ization and contro l . T h e pericard i u m is i n c ised a n d retracted . T h e asce n d i n g a o rta is ca refu l l y m o b i l ized to fac i l itate l ater p l a ce m e n t of a proxi m a l l y posit i o n e d s i d e - b i t i n g

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1805

arch origin o f left vertebral artery, a n d a n aberrant right sub­ cia vi an artery. The ascending aorta is typically 6 to 7 em in length from the sinotubular j unction to the innominate artery. Placement of the proximal inflow anastomosis as low as possible on the ascending aorta (j ust distal to the sinotubular j unction) will result in an optimal 3- to 4-cm proximal landing zone for the stent graft repair. The largest currently available thoracic stent grafts are 42 to 46 mm in diameter. To provide a safe and durable proximal landing zone and avoid a proximal type I endoleak, we recommend replacement of an ascend­ ing aorta that is extremely short or if its diameter is 36 mm or larger. Open replacement of the ascending aorta would be performed at the time of the arch debranching procedure, with implantation of an aortic graft 34 mm or smaller. The size of the iliofemoral arteries is worth noting on the pre­ operative CT study. The external iliac arteries need to be larger than 7 mm in diameter to provide adequate vascular access to deliver the stent graft devices during the second stage. An iliac artery conduit may be needed if the iliofemoral arteries are extremely small or in the presence of severe calcification and occlusive disease. Alternatively, a single-stage antegrade introduction of the stent graft from the ascending aorta may be performed (see endovascular second stage) to avoid access problems from a retrograde iliofemoral approach. The diameters of the brachiocephalic arteries are measured on the preoperative CT scan to determine the interposition graft sizes for the debranching procedure. Most frequently, the size of the graft chosen for the innominate artery branch is 10 to 1 4 mm, with 6- to 8-mm grafts usually used for the left carotid and left subclavian arteries. Cerebral oximetry monitoring may be helpful for the aortic debranching procedure to monitor brain perfusion before and after clamping of the brachiocephalic arteries. For the second-stage endovascular procedure, cerebrospinal fluid ( CSF) drains are placed preoperatively to reduce the risk of spinal cord ischemia if a significant length of the descending thoracic aorta is to be covered.

Positioning •

For the arch debranching procedure, patients are positioned supine j ust as they are during standard cardiac surgical op­ erations. Prepping is performed from the neck to the knees, with draping higher than usual to strategically provide ac­ cess to the lower neck. The head may be turned slightly to the right to facilitate extension of the sternotomy incision proximally along the left sternocleidomastoid muscle.

c l a m p . The space b etwe e n the l eft s i d e of the a o rta and t h e p u l m o n a ry a rtery i s d i ssected, with s m a l l ves­ sels cauterized o r c l i p p e d and d i v i d e d . The a sce n d ­ i n g a o rta i s m o b i l ized p roxi m a l l y d o w n to t h e l evel of t h e a o rt i c root (si n otu b u l a r j u n ct i o n ) to e n a b l e i d e ntificat i o n (a n d avo i d i n j u ry) to t h e r i g h t c o ro n a ry a rte ry. The brach ioce p h a l i c a rteries a re c i rcu mferentia l ly ex­ pose d . The i n n o m i nate ve i n is m o b i l ized a n d retracted

1806

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

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8mm

with an u m b i l ica l tape to fac i l itate expos u re of the a rch vessels (FIG 2) . U n common ly, the i n no m i nate ve i n req u i res l i g ation and d ivision to aid i n a rch expo­ sure. The l eft s u bclavian a rtery i s often more poste rior than expected, and exposu re of this a rtery may be d if­ ficult. In th ese circumstances, the ste rnotomy i n c ision may be exte nded su periorly and l eftwa rd a long the ste rnoc l e i domastoi d m u sc l e . Alternatively, i n no m i nate and l eft caroti d d e b ra n c h i n g may be com b i ned with a l eft carotid-s u bclavian bypa ss/transposition p roce d u re, t h ro u g h a sta n d a rd s u p raclavicu l a r a p p roach, obviat i n g the n e e d t o expose the l eft s u b c l a v i a n a rtery t h ro u g h t h e ste rnotomy. Altho u g h a p reformed bifu rcated or m u lti l i m b g raft may be used, th ese occ u py a l a rge footprint and reduce the l e n gth ava i l a b l e for the asce n d i n g aortic l a n d i n g zone. I nstead, we p refer to construct a Y-g raft by sew i n g a bev­ eled s m a l l e r Dacron g raft e n d -to-s ide to l a rger Dacron g raft (FIG 3) . The g raft sizes a re sel ected based on the measu red d i a m eters from the p reoperative CT sca n . Typ i ­ cal ly, a 1 0- or 1 2- m m g raft is u s e d f o r the i n nom i n ate a r­ tery, a n d a 6- or 8-mm g raft is used for the l eft caroti d a rte ry. H e p a r i n is a d m i n i stered to a c h i eve a n a ctivated c l ot­ t i n g t i m e (ACT) of 200 secon d s . The b lood press u re is lowe red to 90 m m H g systo l i c, a n d a n aort i c s i d e ­ b i t i n g c l a m p i s p l aced o n t h e r i g ht a ntero l atera l s i d e (convexity) o f t h e asce n d i n g aorta, a s l o w as poss i b l e, with care not to com p ro m i se t h e r i g h t coro n a ry a rte ry.

FIG 3 • A Y-g raft i s constructed by sew i n g a beveled s m a l l e r Dacron graft (6 t o 8 m m ) e n d -to-s i d e t o l a rg e r Dacron g raft ( 1 0 to 1 2 m m ) .

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FIG 2 • After ste rnotomy, the pericard i u m is i n cised a n d retracte d . The asce n d i n g aorta is mob i l ized, a n d the brach ioce p h a l i c a rteries a re ci rcumferentia l ly exposed. The i n no m i nate ve i n is mobil ized a n d retracted with a n u m b i l i ca l tape to fac i l itate expos u re of the a rch vesse l s .

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A ret raction s u t u r e i n t h e r i g h t atr i a l a p p e n d a g e m a y be n e e d e d t o fa c i l itate p roxi m a l aort i c expos u re . C o n ­ s i d e ration m a y be g iven t o p e rfo rm i n g t h i s a n d s u b ­ seq u e nt ste ps i n t h e o p e r a t i o n with c a r d i op u l m o n a ry bypass to p rov i d e opti m a l h e modyn a m i c control d u r­ i n g c l a m p a p p l ication a n d remova l a n d to i m p rove b ra i n p rotect ion with syste m i c coo l i n g in the ra n g e of 32°C to 34°C. The p roxi m a l e n d of the l a rg e r (1 0 or 1 2 m m ) g raft is cut to the a p prop r i ate l e n gth so the Y-g raft easily reaches the a rc h vesse l s . The g raft is beve led and sewn e n d -to­ s i d e to the asce n d i n g aorta with a r u n n i n g 3-0 or 4-0 polypropy l e n e sutu re (FIG 4) . B ioG i u e may be a p p l ied to f u rt h e r s u p port the a n a stomos is. The aort i c clamp i s g e ntly released . A l a rg e c l i p may be p l aced a c ross the h e e l of the a n a stomosis. T h i s wi l l help visu a l ize the ori­ gin of t h e d e b r a n c h i n g g ra ft from the asce n d i n g aorta a n d precisely d efi n e the p roxi m a l l a n d i n g zone without the need for contrast d u r i n g the seco n d -sta g e e n d ovas­ c u l a r p roced u re . The i n nom i n ate a rte ry is tra nsected, a n d the p rox i m a l e n d is ove rsewn w i t h two l ayers o f 4-0 polypropy l e n e . The d i sta l l a rg e e n d o f the Y-g raft is then t u n neled u n ­ derneath the i n no m i n ate ve i n a n d sewn end-to-e n d to the i n nom i n ate a rtery with ru n n i n g 5-0 polypropylene (FIG 5) . N ext, t h e l eft com mon ca rot i d a rtery is transected, a n d the p rox i m a l e n d o f the ca rot i d a rtery is oversewn with 4-0 polypropy l e n e . The d i sta l s m a l l e r e n d of the Y-g raft is t u n n e l e d u n d e rneath the i n nom i n ate ve i n a n d sewn

C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S

FIG 4 • An aortic side-biti n g c l a m p is p l aced on the right a nterol ate ral s i d e (convexity) of the ascen d i n g aorta, as low as poss i b l e . The p roxi m a l end of the l a rg e r ( 1 0 or 1 2 mm) g raft is beve led a n d sewn e n d -to-si d e to the asce n d i n g aorta with a r u n n i n g 3-0 or 4-0 polypropylene suture.

FIG 6 • T h e l eft com mo n c a rot i d a rtery is tra n sected, and t h e p rox i m a l end of the c a rot i d a rtery i s ove rsewn with 4-0 polypropy l e n e . T h e d i st a l s m a l l e r end of the Y-g ra ft i s t u n n e l e d u n d e rn eath t h e i n nom i nate ve i n a n d sewn e n d -to- e n d t o t h e ca rot i d a rtery w i t h r u n n i n g 5-0 polypropy l e n e .

Innom inate vein Innominate artery •

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FIG 5 • The i n nom i nate a rte ry is tra nsected, a n d the p roxi m a l e n d i s ove rsewn 4-0 polypropylene. T h e d ista l l a rg e e n d o f the Y-g raft is then t u n neled u n d e rneath the i n no m i nate ve i n and sewn end-to-e n d to the i n no m i nate a rtery with r u n n i n g 5-0 polypropy l e n e .

e n d -to-e n d to t h e c a rot i d a rtery with r u n n i n g 5-0 poly­ p ropy l e n e (FIG 6) . A t t h i s poi nt, a decision needs t o be made reg a rd i n g t h e d e b ra n c h i n g strategy for t h e l eft subclavian a rte ry. I n d ications for l eft subclavian revasc u l a ri zation a re controve rsia l . Rout i n e versus sel ective strate g i es may be adopte d .' If the l eft subclavian a rte ry needs to be revasc u l a rized but can not safe ly be exposed, a ca rotid­ subclavian bypass can be performed as p reviously men­ tioned . If the subclavian a rtery can be exposed, the d i sta l a n a stomosis is created fi rst u s i n g a 6- or 8-m m Dacron g raft a n a stomosed either e n d -to-en d to the tra n sected a rtery or end-to-s ide (fu n ction a l end-to-e nd) fol lowed by l i g ation of the p roxi m a l a rtery in cont i n u ity. A side-biti n g c l a m p is t h e n p l a ced a long the carotid g raft, a n d the s u b­ clavian g raft is sutu red e n d -to-side to the carot i d g raft with 5-0 polypropy l e n e suture (FIG 7) . Prota m i n e is a d m i n istered t o reverse the h e p a r i n , a n d hemostasis is e n s u re d . The g rafts shou l d l i e tension free with i n the m e d i asti n u m . The perica rd i u m may be p a r­ tia l ly c losed ove r the g rafts, with care to avoid com p res­ sion of the g raft branches. Ch est tu bes a re positioned, and the ste r n u m is c losed rout i n e ly. After the stern u m is c losed, the blood p ressure shou l d be assessed i n each a r m a n d cerebra l oxi m etry mon itored t o confi rm a d e q u ate perfusion t h ro u g h the g raft branches a n d the a bsence of g raft com pression.

1807

1808

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

FIG 7 • If the subclavian a rtery can be exposed, the d i sta l a n a stomosis is created fi rst u s i n g a 6- or 8-mm Dacron g raft a n a stomosed e n d -to-end to the tra n sected a rte ry. The s u bclavian g raft is then sutu red e n d -to-s i d e to the caroti d g raft w i t h 5 - 0 polypropylene suture.

E N D OVASCULAR SECO N D STAG E •

•

•

The e n dovascu l a r second sta g e of the a rch repa i r is con d u cted i n a fairly s i m i l a r m a n n e r to that of stent g raft repa i r of a descen d i n g thoracic aortic a n e u rysm, as de­ scribed i n Part 6, C h a pter 13 (Thora cic E n dog rafti n g ) . The t i m i n g of the e n dovascu l a r repa i r as a s i n g l e versus sta ged a p p roach rem a i n s controversia l . We p refer to delay the second sta g e d e pe n d i n g on the c l i n ical seen a rio. It can range from a few d ays (sa me hosp ita l i za­ tion) to several weeks (sepa rate a d m ission) to a l low the patient to recover from the fi rst p roced u re . T h i s red uces the overa l l physiolog ic stress on the patient. Althou g h we favor d e l ivery of the stent g raft in a retro­ grade m a n n e r from the i l iofemoral a rteries, in cases of a mech a n ical aortic va lve or severe i l iofemora l occ l usive disease, s i n g le-stage a ntegrade deployment sho u l d be

•

•

•

considered . The tech nical variations for these l ess com mon situations a re beyond the scope of the present cha pter. The site of i n se rtion of the e n dovascu l a r g raft d e l ivery system is decided based on the size a n d q u a l ity of the ac­ cess vessels. In g e n e ra l , the g rafts a re d e l ivered t h ro u g h the com mon femora l a rte ry, whereas a n i l iac con d u it may be req u i red for very s m a l l or d iseased i l iofe mora l a rteries. The d e l ivery g u idewire is p l aced i n the l eft ventri cle d u r­ i n g the e n dovascu l a r p roced u re to p rovide suffi cient p rox i m a l ra i l s u p port for the e n dovascu l a r g raft. The p rox i m a l ste nt g raft is deployed in the asce n d i n g aorta j u st d ista l t o the orig i n o f the debranch i n g g raft. D u ri n g d e p loyme nt, it is usefu l to lower the blood p res­ s u re u s i n g one of a va riety of p h a rmacolog i c, ventri c u l a r paci n g or atri a l i n flow occ l u s ion tech n i q ues"

PEARLS AND PITFALLS I n d ications

•

The p reoperative CT a n g iog ram shou l d be reviewed in d eta i l to e n s u re the patient is a s u ita b l e ca n d i d ate for aortic a rch repa i r w i t h d e b ra n c h i n g a n d ste nt g raft i n g , i n c l u d i n g a p p ropriate l a n d i n g zones p roxi m a l ly a n d d i sta l l y a n d a d e q u ate vascu l a r access.

Proxi m a l type I endoleak

•

To optim ize the length of the p rox i m a l l a n d i n g zone and p revent a type I endoleak, the debra n c h i n g g raft sho u l d be p l a ced as low as poss i b l e on the asce n d i n g aorta . Preem ptive replacement o f t h e asce n d i n g aorta shou ld be performed if it is extremely short or i t s d i a m eter is > 34 m m .

Mech a n i ca l aortic p rosthesis

•

After aortic d e b ra n c h i ng, the e ndovasc u l a r g raft d e l ivery system may h a v e t o cross the aortic valve. Althou g h transva lvu l a r p l acement of a l a rge sheath is relatively safe for n ative and bioprosthetic va lves, it is contra i n d i cated for a m ec h a n ical aortic valve. Anteg rade ste nt g raft d e p loyment at the time of debranch i n g shou l d be con s i d e red i n the p resence of a mech a n i c a l p rosthesis.

I nj u ry to r i g ht coro n a ry a rte ry

•

Care shou l d be taken when a p p ly i n g the side-b iti n g clamp low on the asce n d i n g aorta to avoid occl usion or i nj u ry to the right coro n a ry a rte ry.

C h a p t e r 1 ARCH A N D G REAT V E S S E L R E C O N STRUCTI O N WITH D E B RA N C H I N G TEC H N I Q U E S

Asce n d i n g aortic d i ssection

•

The systo l i c blood p ress u re shou l d be lowe red to bosed Segment

FIG 5 • U l n a r a rtery reco nstruction i l l ustrat i o n . Exploration of the u l n a r a rtery co nfirms f i n d i ngs of a n g iogram d e m o nstrat i n g (A) u l n a r a rte ry throm bosis to the orig i n of the common d i g ita l a rteries. Reconstruction req u i res h a rvest i n g a Y branch of a saphenous ve i n g raft, whi c h is then reversed pri or to i nterposit i o n . B. E n d -to-side d ista l a n a stomosis, end­ to-e n d a n asto mosis of the ve i n branch to the co m m o n d i g ital a rte ry, a n d end-to-s ide a n a stomosis to c o m m o n d i g ital a rtery a re performed.

•

•

S N U FFBOX RADIAL ARTERY RECON STRUCTI O N Placement o f Incision •

At the level of wrist, the ra d i a l a rte ry turns d o rsa l l y u n ­ d e rneath t h e fi rst extensor c o m p a rtment (conta i n i n g t h e a b d ucto r p o l l icis l o n g u s a n d exte nsor p o l l icis b revis), then

Interposition Vein Graft

•

After i rrigation with h e p a r i n ized s a l i ne, i nterru pted sutu res a re p l a ced c i rcu mferenti a l ly u s i n g a t r i a n g u ­ lation tech n i q u e . The p rox i m a l a n asto mosis is pe rfo rmed fi rst, then flushed with hepa r i n and c l a m ped to a l l ow the ve i n g raft to exte n d t o l e n gth before prepa r i n g a n d co m p l et i n g the d i sta l a n a stom os(e)s.

runs betwee n the fi rst and t h i rd extensor co m p a rtments (extensor p o l l icis l o n g us) in the a rea known as the " a n a ­ tomic sn uffbox. " The d i seased seg ment a n d d i sta l targets shou l d be confi rmed by refe rence to the specific p reoper­ ative i m a g i n g stu d i es (FIG 6A, B) . A s k i n i ncision is m a d e o n the d o rs u m of the h a n d d i rectly o v e r the a n ato m i c snuffbox p a ra l l e l to the seco n d m etaca rpal (FIG 7A) . T h e su perfi c i a l ra d i a l n e rve is i d e ntified a n d preserved .

B 6 • S n uffbox ra d i a l a rtery reco nstruction a n g i o g rams: A.B. Angiograms d e m o nstrating cutoff of ra d i a l a rtery (arrow d e m o n strates fi l l i n g d efect correspo n d i n g to occ l u d e d segment) at the level of the a n atomic sn uffbox.

C h a pt e r 1 1

1 899

UPPER EXTREM ITY ARTE RIAL RECONSTRUCTION A N D REVASC U LARIZAT I O N

A B

c

Resection/Bypass of Diseased Segment •

•

•

This d i ssection is conti n u e d d i sta l ly betwee n the heads of the fi rst d o rsa l i nterosseous m uscle, a l lowi n g f u rther mo­ b i l ization of the d ista l ra d i a l a rtery a n d visua l ization of the o r i g i n of the deep p a l m a r a rc h . M icrovasc u l a r c l a m ps a re p l aced proxi m a l a n d d i sta l t o the throm bosed seg ment of the ra d i a l a rte ry. A l l branches from the t h ro m bosed seg m e nt s h o u l d be l ig ated a n d rem oved e n bloc (FIG 7B) .

FIG 7 • S n u ffbox rad i a l a rtery reco nstruct i o n : A. I n c i s i o n over the ra d i a l a rtery over the a n ato m i c sn uffbox w i t h m i cro backgro u n d p l aced u n d e r a rtery. B. Rad i a l a rtery is c l a m ped d i sta l ly. C. Vesse l is c l a m ped proxi m a l ly a n d isol ated w i t h vessel loops p r i o r to ve i n g raft i n g . Vein Graft Interposition •

The ve i n g raft s h o u l d be reversed a n d p l aced s u p e rfi c i a l to the exte nsor p o l l icis l o n g u s a n d exte nsor p o l l icis brevis ( m a k i n g the g raft i m med iately ben eath the skin) a n d t h e n sutu red e n d -to-e n d t o the ra d i a l a rtery proxi m a l l y a n d e n d -to-en d t o t h e d e e p a rch d ista l ly (FIG 7C) . See the " U l n a r Artery Reco n struct i o n " sect i o n for f u rther de­ script i o n o n vein ha rvest and m icrovasc u l a r a n a stomosis tech n i q u e .

HAN D FASCIOTOMY Placement of Incisions •

•

•

The 1 0 co m p a rtm ents of the h a n d i n c l u d e the t h e n a r, hy­ poth e n a r, a d d u ctor, a n d 4 d o rsa l and 3 vo l a r i nterosse i co m p a rtments. Four i n c i s i o n s a re req u i red to release a l l 1 0 compartments. The dorsa l a n d vo l a r i nterosseous com p a rtme nts a re de­ co m p ressed with two d o rsa l i n cisions over the i n d ex f i n g e r a n d r i n g f i n g e r m etaca rpal (FIG SA) . These i ncisions a re carried down to either side of the m etaca rpal to release the d o rsa l i nterosse i . D i ssection along the u l n a r and rad i a l aspects o f t h e i n dex metaca rpal m ust be suffi ciently deep (FIG SC) to release the fi rst d o rsal p a l m a r i nterosseous and the a d d u ctor com p a rtments. S i m i l a rly, to release the rema i n i n g p a l m a r i nterosse i, deep d i ssection is req u i red a l o n g the u l n a r and rad i a l aspects of the ring m etaca rpa l . M eti c u l o u s release a l o n g t h e length o f t h e metaca rpal i s essential t o e n s u re adequate deco m p ress i o n . The t h e n a r co m p a rtment is b o u n d by t h e n a r fasc i a a n d conta i n s the a b d u ctor pol l icis b revis, flexor p o l l icis b revis, and the opponens pol l icis. This co m p a rtment is decom­ p ressed with a l o n g itu d i n a l i n c i s i o n along the ra d i a l/ vo l a r (FIG SA) aspect of the t h u m b metaca r pa l .

""""' lnlefoeaei

a

FIG S • H a n d fasciotomy i l l u strat i o n : fasciotomy i n c i s i o n s of the h a n d . A. Dorsa l i n c i s i o n s over the i n dex (c) a n d r i n g (b) f i n g e r metaca r pa l . B. Vo l a r i n c i s i o n s over the hypoth e n a r (d) a n d t h e n a r (a) m u scles. C. Cross sect i o n at the level of the m etaca rpals of the hand d e m o n strat i n g that both d o rs a l and i nte rosseo u s co m p a rtments a n d the a d d ucto r com p a rtment to the thumb can be released t h ro u g h these four i n cisions with a p p ropri ate d i rection a n d d e pth as o ut l i ned (a-d) .

1 900

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

•

•

The hypot h e n a r c o m p a rtment is b o u n d by the hypothen a r fasc ia a n d conta i n s the a b d u ctor d i g iti m i n i m i , flexor d i g iti m i n i m i , and opponens d i g iti m i n i m i . This c o m p a rt­ m e nt is deco m p ressed with a l o n g itud i n a l i n cision a l o n g the u l n a r/vo l a r (FIG 88) aspect of the sm a l l m etaca rpa l . The finger ca n a lso have com p a rtment syn d rome if there is excessive swe l l i ng a n d depend i n g on c l i n ical assessment. H e re, the fasc i a l com p a rtments a re bound by C l e l a n d 's and G rayson 's l i g a m ents. The finger fasciotomy is performed by m a k i n g m idaxial i ncisions along the u l n a r aspect of the i n d ex, ring, and long fingers and o n the rad i a l aspects of the t h u m b a n d s m a l l finger. O nce i n cisions a re made, b l u nt d issection is cont i n ued through C l e l a nd 's l i ga m ent (fi rm fascia bands that r u n from side of the p h a l a n ges to the skin and a re d o rsa l to the neu rovascu l a r b u n d le), retract i n g the n e u rovasc u l a r b u n d l es i n a vo l a r d i rection a n d re m a i n i n g vo l a r to the flexor tendon sheath.

Carpal Tunnel Release •

If a n y compartment press u re is e l evated in the h a n d , then a l l c o m p a rtme nts s h o u l d be rel eased i n c l u d i n g t h e carpa l t u n n e l .

•

•

•

•

A l o n g itud i n a l pa l m a r i n c i s i o n is m a d e j ust d i sta l to the vo l a r wrist crease a n d exte n d i n g d i sta l ly for 3 to 4 em in the p rox i m a l p a l m a l o n g the cou rse of the rad i a l aspect of the r i n g f i n g e r. The p a l m a ris fasci a is d ivided l o n g itu d i n a l ly to expose the u n d e r l y i n g tra nsve rse carpal l i g a m e nt, whi c h is then i ncised u n d e r d i rect visu a l izatio n . The i n ci si on is exte nded at least 2 em i nto the forearm to e n s u re release of the deep a ntebrach i a l fasc i a . The carpa l t u n n e l release i n cision is cl osed p r i m a r i l y with i nterru pted nylon sutu res.

Wound Care •

•

•

•

Fasciotomy wounds a re left open for a m i n i m u m of 48 h o u rs o r u nt i l swe l l i n g has resolved . Seco n d a ry closure with wet-to-d ry d ress i n g s may occ u r over open i ncisions. Event u a l ly, these wo u n d s may need spl it-thickness s k i n g raft i n g . The h a n d s h o u l d be s p l i nted i n a safe position (70 to 90 deg rees of m etaca rpo p h a l a n g e a l [ M C P] flexion a n d p roxi m a l i nte rpha l a n g e a l [ P I P] j o i nts stra i g ht) .

PEARLS AND PITFALLS •

Alth o u g h a throm bosed u l n a r a rtery ca n be l i g ated, reco nstruction of the u l n a r a rtery can reconstitute n o r m a l flow a n d s h o u l d be atte m pted .

•

H a n d vasc u l a r repa i r a n d g raft i n g req u i res meticu l ous m icrovascu l a r tech n i q u e .

•

T h e d o rsal s i d es of t h e h a n d a n d foot have ve i n s of s i m i l a r s i z e t h a t a re i d e a l f o r ve i n g raft reco nstruct i o n .

•

Periarte r i a l sym path ecto my is p a rticu l a r l y effective i n scleroderma because the vessels a re encased i n adventit i a l sca rri n g .

•

E a r l y d i a g nosis a n d treatment f o r h a n d c o m p a rtment syn d ro m e i s critica l : W h e n i n d o u bt, release a l l compartme nts.

POSTOPERATIVE CARE •

•

•

•

Postoperative monitoring of the hand after vascular re­ construction is similar to finger replantations and can be performed with pencil Doppler monitoring or with pulse oximetry ( FIG 9) . Aspirin 8 1 m g i s given for 6 weeks postoperatively after vessel reconstruction. For periarterial sympathectomy, immediate digital range of motion is encouraged, and cold temperature and vasocon­ strictive drugs or substances (smoking, caffeine, etc . ) are avoided for at least 6 weeks. For compartment syndrome, aggressive strengthening and range of motion should be started once wounds have stabilized.

OUTCOMES •

Radial artery reconstruction patency in a study of 1 3 patients found that all vein grafts were patent after mean follow-up of 22 months, with a significant decrease in pain; however, no difference in numbness was seen. 3 In another study of 145 patients, an overall patency of vein grafts of 8 5 % over

FIG 9 • H a n d postope rative m o n itori n g : Revasc u l a rizat i o n of d i g its can be m o n itored with basic p u lse oxi m etry at the tip of the d i g its.

C h a pt e r 1 1

•

UPPER EXTREM ITY ARTE RIAL RECON STRUCTI O N A N D REVASCULARIZAT I O N

a n average follow-up period o f 34 months was found a s well as 1 0 0 % with arterial grafts.4 Long-term recovery after compartment syndrome release depends on the extent of inj ury and requires long-term hand therapy for recovery of hand function. Compartment release of the hand can result in normal function; however, contrac­ tures can develop, which may need eventual reoperation for contracture release.

COMPLICATIONS • • • • • •

Infection Dehiscence of incisions and other wound healing complications Failure of revascularization Distal emboli Thrombosis at anastomosis Long-term patency

• •

1 90 1

Stiffness of the fingers Continued ischemia, pain, and ulcerations

REFERENCES 1. Pomahac B, Hagan R, Blazar P, et al. Spontaneous thrombosis of the ra­ dial artery at the wrist level. Plast Reconstr Surg. 2004;1 14(4):943-946. 2. Leversedge FJ, Moore TJ, Peterson BC, et al. Compartment syndrome of the upper extremity. J Hand Surg Am. 20 1 1 ;3 6 ( 3 ) :544-559. 3 . Ruch DS, Aldridge M, Holden M, et al. Arterial reconstruction for radial artery occlusion. J Hand Surg Am. 2000;25 (2):2 82-290. 4. Masden DL, Seruya M, Higgins JP. A systematic review of the out­ comes of distal upper extremity bypass surgery with arterial and venous conduits. J Hand Surg Am. 2012;37( 1 1 ) :23 62-2367. 5 . Porter SB, Murray PM. Raynaud phenomenon. J Hand Surg Am. 2 0 1 3 ; 3 8 ( 2 ) : 3 75-3 77. doi: 1 0 . 1 0 1 6/j .jhsa.20 1 2 . 0 8 . 0 3 5 . 6. Hartzell T L , Makhni E C , Sampson C. Long-term results of periarterial sympathectomy. J Hand Surg Am. 2009;34 ( 8 ) : 1454-1460. 7. Bogoch ER, Gross DK. Surgery of the hand in patients with systemic scle­ rosis: outcomes and considerations. J Rheumatol. 2005;32(4):642-648 .

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Chapter

12

Exposure and Open Surgical Reconstruction in the Chest: ' '

------------------------------------

�

The Thoracoabdominal Aorta ----------------------------------------------------

Germ a n o Melissa n o

Efrem Civilini

·

Enrico Rina ldi

Roberto Chiesa

DEFINITION •

•

•

A thoracoabdominal aortic aneurysm (TAAA) involves the aorta at the diaphragmatic crura and extends variable dis­ tances proximally and/or distally from this point ( FIG 1 ) . 1 TAAAs can be classified in terms of their causes, the two most common being medial degeneration and dissection. Open treatment of TAAAs consists of graft replacement with reattachment of the main aortic branches: The inclusion tech­ nique was introduced by S. E. Crawford in the 70s and refined by subsequent surgeons in the following decades. TAAA re­ pair, especially in extensive aortic disease, is associated with greater operative risk than repair of other aortic segments. The main sources of morbidity are spinal cord (SC) ischemia and renal as well as respiratory and cardiac complications. Experienced surgical centers now report lower mortality and morbidity rates for TAAA repair,2 largely due to multimodal approaches to reduce surgical trauma and maximize organ protection. 3

•

•

IMAGING AND OTHER DIAGNOSTIC STUDIES •

To plan the best possible treatment strategy for each patient, our preferred modality is computed tomographic arteriogra­ phy ( CTA ) . The acquisition of computed tomography ( CT)

•

•

FIG 1 • An a n e u rysm is defi ned as thoracoabd o m i n a l when the h i g h l i g hted reg i o n i s i nvolved . Crawfo rd's cl assificati o n was deve loped to i m p rove stratification of perio perative p a ra p l e g i a r i s k . S u bcl assificat i o n s i n c l u d e the fo l l ow i n g : Exte nt I i n c l udes the t h o racic and a bdom i n a l a o rta, from the l eft subclavian a rtery to the level of the r e n a l a rteries; extent I I i n c l udes the enti re desce n d i n g a o rta from the level of the l eft subclavian a rtery to t h e a o rtic bifu rcation; extent I l l i n c l udes a o rta beg i n n i n g at the T6 level exte n d i n g to the bifurcat i o n o r l ower; extent IV i n c l udes t h e enti re abdom i n a l a o rta sta rt i n g at the level of the d i a p h ra g m (T 1 2) to the a o rtic bifu rcati o n o r lower.

1902

data in particular has benefited from spectacular progress, including multirow detectors, higher rotation and transla­ tion speeds with reduced scan times (single breath-hold), cardiac cycle synchronization, and better postprocessing capabilities. D igital Imaging and Communications in Medicine (DICOM) slices of adequate thickness (s::l mm) should be postprocessed on a digital workstation using a multi­ planar reformatting (MPR) tool to visualize a scan which angulation matches that of the aorta or the vessel under investigation. Postprocessing may be performed on a dedicated workstation (AquariusNet®, TeraRecon, Inc) or desktop computer with open source software ( O siriX and others ) in a user-friendly and time/resources-efficient way ( FIG 2 ) . Beyond analysis o f aortic diameter and the extent o f patho­ logic involvement, reformatted images are particularly useful for evaluating the presence, extension, and charac­ teristics of dissection and thrombus, particularly at pro­ posed sites of clamp placement and the infradiaphragmatic aorta when direct aneurysm cannulation is considered for distal aortic perfusion. The exact location and geometry of aortic branches is obtained to reveal possible anatomic variations or anomalies, which are particularly common at the level of the renal arteries and arch vessels. Vessel patency is also routinely evaluated; in particular, obstruc­ tion of the superior and inferior mesenteric artery and the hypogastric arteries and dominance of one vertebral artery are assessed. Three-dimensional rendering tools such as maximum inten­ sity projection (MIP ) , volume rendering, surface rendering, and so forth produce realistic imaging of the anatomic struc­ tures that may expand anatomic understanding, including, for instance, the most appropriate intercostal space to per­ form thoracotomy ( FIG 3 ) . Perioperative SC ischemia may precipitate paraparesis or paraplegia. Prior knowledge of the SC arterial supply in­ forms both procedural planning and risk stratification.

FIG 2 • M P R tools a l l ow the sag itta l reco nstruction to properly fo l l ow the major axis of the t h o racic a o rta. I n this refo rmatted i m a ge, the e n t i re t h o racic a o rta is i n c l uded despite s i g n ificant tortuosity.

C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T

FIG 3 • B e y o n d a o rtic i m a g i ng, the C T provides extensive a n ato m i c information to g u i d e exposu re and surgical decision making.

FIG 5 • O n ce t h e d u ra h a s b e e n p u nctured w i t h t h e i ntrod u c e r n e e d l e , a d r a i n a g e c a t h e t e r i s i n se rted 8 to 1 0 e m a l o n g t h e i nt ra d u ra l s p a c e . T h e catheter i s t h e n co n n ected to a press u re t r a n s d u c e r, a n d t h e fl u i d is d r a i n e d to keep t h e p ressure b e l ow 10 e m H 2 0. Autom ated syste m s a re a va i l a b l e for t h i s p u rpose.

Recent advances i n imaging techniques, especially nonin­ vasive techniques, increased the likelihood that patient­ specific risk criteria may soon be recognized and be widely available4 ( FIG 4).

Pulmonary function evaluation with arterial blood gases and spirometry is used to evaluate the respiratory reserve of all patients undergoing open surgery of the descend­ ing aorta. In patients with a forced expiratory volume in 1 second ( FEV ) of less than 1 L and a partial pressure 1 of carbon dioxide (PC0 ) greater than 45 mmHg, opera­ 2 tive risk may be improved by cessation of cigarette smok­ ing, treatment of chronic bronchitis (if present) , weight loss, and participation in a supervised exercise program for a period of up to 6 months prior to surgery. How­ ever, in patients with aneurysm-related symptoms, this type of respiratory rehabilitation may not be practical or possible.

SURGICAL MANAGEMENT Preoperative Workup and Patient Optimization •

•

Preoperative transthoracic echocardiography is a satisfac­ tory noninvasive screening method to evaluate both valvular and biventricular function. Stress testing identifies patients who require coronary catheterization and possible interven­ tion.5 Electrocardiographically (EKG) gated CT has recently emerged as a less invasive method of visualizing coronary anatomy. For severe, symptomatic coronary disease requir­ ing percutaneous transluminal angioplasty prior to aneu­ rysm repair, use of drug-eluting stems requiring prolonged double antiplatelet therapy should be avoided to reduce sub­ sequent perioperative bleeding. The use of estimated glomerular filtration rate (eGFR) , rather than serum creatinine levels alone, is recommended to assess renal function. 6 Based on the eGFR metric, chronic kidney disease has been shown to be a strong predictor of death following open or endovascular thoracic aneurysm re­ pair, even in patients without other clinical evidence of pre­ operative renal disease?

FIG 4

Positioning •

•

After inserting a cerebrospinal fluid drainage ( CSFD ) 8 cath­ eter into the subarachnoid space between L2 and L3 or L3 and L4 ( FIG 5), the patient is turned to a right lateral decu­ bitus position, with the shoulders at 60 degrees and the hips flexed back to 30 degrees. Preparation should allow for access to the entire left tho­ rax, abdomen, and both inguinal regions. Patient position is maintained with a moldable beanbag attached to a suc­ tion line for vacuum creation. A circulating water mattress is placed between the beanbag and the patient in order to modify body temperature as necessary ( FIG 6 ) .

• Pre p p i n g a n d d r a p i n g for TAAA. Poste rol atera l a spect of the l eft t h o rax, the a bd o m e n , a n d l eft g r o i n a re i n c l uded in the ste r i l e ope rato ry f i e l d . P l ease n ote the gentle cu rvatu re of the line i n d icat i n g the s k i n i n c i s i o n to avoid f l a p necrosis.

FIG 6 •

U s i n g a custo m ized c u rve p l a n , the w h o l e path of the a rteri a l feeder to the spi n a l cord (a rte ria ra d i c u l a ris m a g na) can be visu a l i zed from the a o rta to the a nterior spi n a l a rte ry.

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THORACO-PHRENO-LAPAROTOMY •

The thoracic i n c i s i o n varies i n l e n gt h a n d l eve l , d e p e n d ­ i n g o n exposure req u i re m e nts. U s u a l ly, t h e 5 t h , 6 t h , o r 7 t h i nte rcost a l space is e m p l oyed accord i n g to t h e a n e u ­ rysm a n atomy. The poste r i o r sect i o n of t h e r i b s i s gently s p read to reduce thoracic wa l l t r a u m a a n d fractu res; a nterol atera l ly, the i n c i s i o n c u rves gently as it crosses the cost a l m a r g i n to m i n i m i ze su bse q u e n t tissue n ecro­ sis. The p l e u r a l space i s e ntered after s i n g l e r i g ht l u n g venti l a t i o n i s i n itiate d . M o n o p u l m o n a ry vent i l at i o n i s m a i nta i n ed t h ro u g h o ut t h o r a c i c a o rta r e p l a c e m e n t

(FIG 7) . •

P a r a lysis of t h e l eft h e m i d i a p h ra g m cont r i b utes s i g n ifi­ cantly to posto pe rative res p i ratory fa i l u re; t h e refore, a l i m ited c i rc u mfere n t i a l rather t h a n rad i a l sect i o n of t h e d i a p h ra g m i s routi n e l y p e rformed, s p a r i n g t h e p h re n i c center. U n d e r favora b l e a n a to m i c co n d i ­ t i o n s, t h i s a p p ro a c h reduces res p i ratory wea n i n g t i m e 9

•

Speci a l ca re m ust be taken when iso l a t i n g the p roxi m a l a n e u rysm n e c k . The i nsertion o f a l a rg e ca l i be r eso p h ­ agea l p robe m a kes it easier to d i sti n g u is h the eso p h a ­ g u s at t h i s leve l . The va g u s n e rve a n d the o r i g i n of the recu rrent l a ry n g e a l n e rve m ust a l so be identified because they can a lso be damaged d u r i n g isolation and c l a m p i n g m a n euvers (FIG 9) . I d e ntification a n d c l i p p i n g o f some " h i g h " i ntercosta l a rteries can sometimes fac i l itate t h e prepa rati o n for the proxi m a l a n asto mosis, t h u s red u c i n g a o rtic bleed i n g . T h e u p pe r a b d o m i n a l a o rt i c seg m e n t is exposed v i a a t r a n s pe rito n e a l a p p ro a c h ; after e n te r i n g t h e p e r i to­ n e u m , m e d i a l vi scera l rotat i o n i s p e rformed to retract t h e l eft c o l o n , s p l e e n , a n d l eft k i d ney a nt e r i o r l y a n d to t h e right (FIG 1 0) . Use of a t r a n s p e r i to n e a l a p p r o a c h a l l ows d i rect assess m e n t of t h e a b d o m i n a l o r g a n s at t h e e n d of p roced u re . Extra c a r e m u st be t a k e n to avo i d d a m a g e to t h e s p l e e n , w h i c h i s p a rt i c u l a r l y p r o n e to b l e ed i n g aft e r c a p s u l a r i n j u r i e s reg a r d l ess of s i z e .

• The d i a p h r a g m is ci rcumferentia l ly d ivided (arrows) for seve ral ce ntimeters n e a r its p e r i p h e r a l atta c h m ent to the a nterior ch est wa l l sparing the p h r e n i c center (asterisk).

FIG 8

(FIG 8) .

•

FIG 7 • Thoraco-p h re n o - l a p a rotomy i n the 6 t h i ntercosta l space. A ci rcumferent i a l i ncision of the d i a p h ra g m is carried out (d otted l i ne).

FIG 9 • The va g u s n e rve (bla ck a rro w) a n d the ongm of the recu rrent l a ry n g e a l n e rve a re m o b i l ized a n d i d e ntified with vessel loops to p revent i nj u ry d u r i n g a o rt i c c l a m p i n g m a n euvers o r suture p l acement. When a n a o rtic cross­ c l a m p i n g between l eft carotid and subclavian a rtery is req u i red, these vesse l s a re a l so i d e ntified and contro l led with vesse l loops (white arrows).

FIG 10 • M ed i a l viscera l rotat i o n : The left colon, the s p l een, a n d t h e l eft kid ney a re retracted a nteriorly a n d to the r i g h t to v i s u a l ize the viscera l a n d i nfra renal a o rta. Tra nsperito n e a l a p proach a l l ows d i rect eva l u at i o n of the a b d o m i n a l o rg a n s t h rou g h out the p roced u re .

C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T

DISTAL AORTIC PERFUSION •

•

Cross-c l a m p i n g of the desce n d i n g thoracic a o rta pro­ d u ces i m med iate and s i g n ificant i n c reases in left ven­ tricu l a r afterload, myocard i a l oxygen co nsu m ption, a n d viscera l a n d r e n a l isch e m i a . Tec h n i q ues i n co rporat i n g d is­ ta l a o rtic perfus i o n with l eft h e a rt bypass (LH B P) have s i g ­ n ificantly i m p roved outcomes i n t h o r a c i c a o rt i c s u rg e ry. 1 0 I n preparation for L H B P a n d a o rtic cross-cl a m p i n g , l ow­ dose i ntrave n o u s h e p a r i n is a d m i n istered. If cessati o n of p u m p s u p port i s a ntici pated d u ri n g the case, a d d i t i o n a l h e p a r i n s h o u l d be a d m i n istered at that t i m e to p rovide fu l l a nticoa g u lati o n . The u p p e r l eft p u l m o n a ry ve i n is usua l ly ca n n u l ated for i nflow of oxyg e n ated b l ood, w h i c h i s routed t h r o u g h a centrifu g a l p u m p ( B i o - M e d icus®) i nto the l eft fe moral a rtery (FIG 1 1 ) . A " Y " c o n nector i n c l uded i n the c i rc u i t provides t w o occl usion/perfusion catheters (9 F r) for sel ective viscera l perfu s i o n when necessa ry.

FIG 11 • S c h e m a t i c view of d ista l a o rtic perfu s i o n . A 20-Fr ca n n u l a is i n serted i n l eft s u pe r i o r p u l m o n a ry ve i n fo r the a rte r i a l b l ood drainage (up) . N o n occlusive fem o r a l ca n n u l a (1 4 t o 1 8 F r) a l l ows synchronous p roxi m a l a n d d ista l perfus i o n f r o m the fe moral axis (down).

AORTIC REPAIR •

Once the neck of the TAAA is isolated and control led be­ tween clam ps, the descending thoracic aorta is tra nsected and sepa rated from the esophagus (FIG 1 2). The g raft is su­ tu red proxi m a l ly to the descending thoracic aorta using 2-0 polypropylene sutu re in a r u n n i n g fashion. The a nastomosis is rei nforced with Teflon felt (individual pledgets or single strip) (FIG 1 3). An additional aortic clamp is appl ied onto the abdom i n a l aorta above the celiac axis before the proxi­ mal aortic c l a m p is rem oved (seq uential cross-c l a m p i ng). I ntercostal a rtery re i m p l a ntation i nto the aortic g raft p l ays a critica l role in SC p rotect i o n . Patent i ntercosta l a rteries from T7 to L2 a re temporarily occluded to p reve nt back­ bleed i n g/max i m ize cord perfusion p ress u re 1 1 then sel ec­ tively reattached to the g raft by means of aortic patch or g raft i nterposition (FIG 14). When ready, the d i stal c l a m p

FIG 13 • The p roxi m a l a n astomosis routi n e l y rei nforced with a Tef l o n str i p .

FIG 1 2 • The p roxi m a l desce n d i n g t h o r a c i c a o rta is contro l led a n d co m p l etely tra n sected to avo i d accidenta l i n j u ry to the adjacent eso p h a g u s .

FIG 14 • Critica l i ntercosta l a rteries reatta c h m e nt . H e re visua l i zed a re two d iffe rent tec h n i q ues: On the left, an aortic i s l a n d i n c l u d i n g t h e orig i n of seve ral i ntercosta l a rteries is reattached to a fen estrati o n created o n the a o rtic g raft; o n the right, i n te rcosta l a rteries a re reattached sel ectively to t h e g raft via 6/8-m m i nterpos ition g rafts.

•

1 90 5

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

1 5 • Visce ral a rteries perfusion with b l ood, renal perfus i o n with co ld Custod i a l ® solution during branch a rtery re i m p l a ntat i o n .

FIG

is m oved below t h e ren a l a rteri es, a n d t h e a n e u rysm is opened across the d i a p h ra g m . The centrifu g a l p u m p m a i nta ins visce ral perfusion (400 m l p e r m i n ute) fo l l ow­ i n g i n se rtion of the 9-Fr i rrigation-pe rfusion cath eters (Le M a itre Vasc u l a r) i nto the ce l i a c tru n k and the superior mesenteric a rtery. Cold perfusion of Custod iol1 2 (histid i ne­ tryptophane-ketogl uta rate) is d i rected i nto the ren a l a rteries (FIG 1 5) . F o r visce ral a rtery re i m p l a ntation, a fen­ estration is created i n the g raft and the viscera l vessels a re reattached as a s i n g l e patc h . Usual ly, the left ren a l a rtery is reco n nected with an 8-mm polyester i nterposition g raft. If viscera l a rtery orifi c i a l stenosis is encou ntered, before placing the i rrigation perfusion catheter, the stenosis may be resolved by d i rect p l acement of an a ppropriate-sized b a l l oo n-expa n d a b l e ste nt with i n the a rtery1 3 (FIGS 16 and 1 7). If creation of the viscera l patch req u i res reta i n i n g a l a rge seg ment of n ative aorta, we p refer to p l ace a m u l­ t i b ra nched g raft i nstead. This p rosthesis, although some­ what more time cons u m i ng, s i g n ificantly red uces the risk of recurrent aortic patch a n e u rysm (FIG 1 8) . F i n a l ly, the d i sta l end-to-end a n astomosis with the d i stal aorta is per­ formed, the g raft fl ushed, a n d c l a m ps rem oved (FIG 1 9) .

FIG 1 7 • A mod ified tech n i q u e to s e p a rate ly reatta ch t h e l eft re n a l a rt e ry i s deta i l ed h e r e : T h e use of a hybrid t u b e g raft t h a t i n c l u d e s a s e l f-expa n d a b l e covered ste n t a l lows for a s u t u r e l ess a n a st o m o s i s . T h e a d v a n t a g e s a re t h e red uced isc h e m i a t i m e of t h e k i d n ey a n d k i n k p reve n t i o n o f t h e g raft after v i scera l d e rotat i o n at t h e e n d of t h e a o rt i c repa i r.

FIG 1 8 • Visce ral vessels a n d ren a l a rteries a re reattached sepa rate ly i n this patient with M a rfan syn d ro m e to red u ce a s m u c h a s poss i b l e the a o rtic native t i s s u e a n d p reve nt recu rrent a o rtic a n e u rysm format i o n .

FIG 1 9 • From left t o rig ht. I n case o f orifi c i a l stenosis, intra l u m i n a l stents a re p l aced under d i rect visu a l ization before i nsertion of the perfusion catheter and u ltimate re i m p l a ntati o n .

FIG 1 6

•

End-to-end d ista l anastomosis at t h e aortic b ifu rcation.

C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T

CLOSURE •

•

The entire a o rt i c repa i r (FIG 20) is i n s pected . A l l exposed a o rtic branch p u lses a re p a l pated after derotati o n a n d re p l acement o f the a b d o m i n a l viscera. A n y bleed i n g o r k i n k i n g of the a o rtic b r a n c h e s i s add ressed at t h i s j u n c­ t u re . The atri a l a n d fe m o ra l ca n n u lae a re removed; the pu rse-st r i n g sutu res a re tied a n d rei nforced. Antico­ a g u lation is reversed with p rota m i n e . The crus of the d i a p h ra g m is rea p p roxi m ated to restore the a o rtic h i a­ tus (FIG 2 1 ) a n d the l eft h e m i d i a p h ra g m loosely sutu red with a r u n n i n g polypropy l e n e suture. The l eft l u n g is tempora r i ly i nfl ated to check for a i r leakage. A c l osed-suct i o n a b d o m i n a l d r a i n is p l aced n ext to the a o rtic g raft i n the l eft retro perito n e a l spa ce, a n d two ch est tu bes a re p l aced in the posteroa pical a n d basal pleural space. Absorba b l e pericosta l sutu res a re p l aced to a p prox i m ate the ribs (FIG 22), and two stee l wi res a re used to sta b i l i ze the costa l m a rg i n . The l u n g is i nflated, and the correct expa n s i o n of a l l the segm ents is ca refu l ly ch ecked; the pericosta l a n d d i a p h ra g matic sutu res a re tig htened a n d l i gated . The steel wi res a re twisted a n d bu ried i n the carti l a g i n o u s costa l m a rg i n . T h e a b d o m i ­ n a l fascia is cl osed w i t h a ru n n i n g suture. The a b d o m i n a l a n d t h o ra c i c d r a i n s a re c o n nected t o suct i o n . T h e serra­ tus and latissi m u s dorsi m u scles a re a p p roxi m ated with sepa rate a bsorba b l e sutu res. S u b d e r m a l l ayer is sutu red, and the skin is cl osed with sta ples (FIG 23) .

• The p i l l a rs of the d i a p h ra g m (arrows) a re approximated with a bsorba ble sutu res to reshape the aortic hiatus.

FIG 21

FIG 22 • The thoracic wa l l i s repai red with pericosta l sutu res. The l eft l u n g is i nfl ated and checked for a i r leakage; two ch est tu bes a re positioned to d r a i n the u p p e r a n d lower thoracic space.

A

• The a b d o m i n a l a n d thoracic wa l ls a re sutu red; skin is closed with sta ples.

FIG 23

B FIG 20

• F i n a l repa i r of a type I I TAAA. A. Sta n d a rd i n c l u s i o n tec h n i q u e . B. Sel ective rei m p l a ntation w i t h m u ltibranched g raft.

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

PEARLS AND PITFALLS I n d i cations Preoperative p l a n n i n g

• • • • • •

S u r g i c a l access

• • • • • •

Tec h n ical adj u n cts fo r organ p rotect i o n

• • • • • • •

Aortic d i a m eter a n d a n e u rysm m o r p h o l ogy Signs a n d sym ptoms of acute a o rtic syn d ro m e Leve l o f i ntercosta l i n c i s i o n G raft sel ection I d e ntification of accessory ren a l a rteries a n d other viscera l a n o m a l ies (e . g . , h o rseshoe k i d n ey) Pote nti a l need for m u ltibranch g raft vs. Carrel patch Avo i d s k i n f l a p necrosis. R i b sect i o n L i m ited p h re n otomy (circumferent i a l d i a p h ra g matic i n cision) Tra nsperito n e a l a p p roach Careful a n d l i m ited lung m a n i p u lation N o n occlusive fe moral ca n n u l at i o n Spinal cord drainage Left h e a rt bypass Sequenti a l a o rtic c l a m p i n g Critica l i ntercosta l a rtery reattachment Viscera l perfus i o n from l eft h e a rt bypass ca n n u las Re n a l perfus i o n with cold Custo d i a l ® o r s i m i l a r sol ution D i rect stenti n g of ren a l and visce ral orifi c i a l lesions a s needed

renal replacement therapy may also be necessary in the early postoperative period.

POSTOPERATIVE CARE •

•

•

•

The main focus of immediate postoperative management is the early detection of neurologic or cardiovascular compli­ cation as prompt intervention may prevent substantial long­ term morbidity. As soon as baseline blood pressure and body temperature are restored, sedation is lightened regardless of ventilatory status. When SC or cerebral neurologic inj ury is suspected, CT imaging is performed immediately to address the possibility of intracranial or intradural SC hematoma. In case of paraparesis or paraplegia, mean arterial pressure is chemically maintained above 80 mmHg, CSFD is drained in order to lower the cerebrospinal fluid pressure below 10 mmHg, and methylprednisolone ( 1 g bolus followed by 4 g per 24 hours continuous infusion) and 1 8 % mannitol (5 mg/kg, four times a day) are administrated. If malperfusion develops in the lower limbs, renal or visceral circulation, efforts should be made to restore normal cir­ culation immediately. For a precise visualization of visceral organ perfusion, emergency arteriography (catheter-based or CT) is required. Blood pressure fluctuations, including recalcitrant hyperten­ sion, is common in the early postoperative period, especially in the chronically hypertensive patient; prompt attention should be paid to regulating the mean arterial pressure in a physiologic range. Immediate intervention may be required to reduce the risk of anastomotic bleeding, especially in the setting of dissection. In uncomplicated cases, drainage tubes are removed at 3 6 t o 4 8 hours postoperatively, whereas the intrathecal CSFD catheter is removed usually after 72 hours. A prolonged re­ quirement for ventilatory support is not unusual, especially after emergency operations, in patients with significant blood loss and after longer periods of circulatory arrest (if neces­ sary for concurrent arch or ascending aortic reconstruction ) . I n case o f severe chronic kidney disease, transient temporary

COMPLICATIONS • • • • • • •

Bleeding Multiorgan failure Dialysis Paraplegia Stroke Death Aneurysm recurrence

REFERENCES 1. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chap­ ter, International Society for Cardiovascular Surgery. J Vase Surg. 1 9 9 1 ; 1 3 :452-4 5 8 . 2. Coselli J S , Bozinovski J , LeMaire SA. Open surgical repair of 2 2 8 6 thora­ coabdominal aortic aneurysms. Ann Thorae Surg. 2007;83:S862-S864. 3. MacArthur RG, Carter SA, Coselli JS, et al. Organ protection dur­ ing thoracoabdominal aortic surgery: rationale for a multimodality approach. Semin Cardiothorae Vase Anesth . 2005;9: 143-149. 4 . Melissano G, Civilini E, Bertoglio L, et al. Angio-CT imaging of the spinal cord vascularisation: a pictorial essay. Eur J Vase Endovase Surg. 2 0 1 0;39:436-440. 5 . Kieffer E, Chiche L, Baron JF, et al. Coronary and carotid artery dis­ ease in patients with degenerative aneurysm of the descending tho­ racic or thoracoabdominal aorta: prevalence and impact on operative mortality. Ann Vase Surg. 2002; 1 6 : 679-6 84. 6 . Stevens LA, Coresh ], Greene T, et al. Assessing kidney function­ measured and estimated glomerular filtration rate. N Eng/ J Med. 2006;354:2473-248 3 . 7. Mills JL Sr, Duong ST, Leon L R Jr, e t a l . Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate. J Vase Surg. 2008;47: 1 14 1 - 1 1 4 9 .

C h a p t e r 1 2 EXPO S U R E A N D OPEN S U R G I CAL RECON STRUCT I O N I N T H E C H E S T

8 . Cina C S , Abouzahr L, Arena G O , e t a l . Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vase Surg. 2004;40: 3 6-44. 9. Engle J, Safi HJ, Miller CC III, et al. The impact of diaphragm manage­ ment on prolonged ventilator support after thoracoabdominal aortic repair. J Vase Surg. 1999;29 ( 1 ) : 1 50-1 56. 1 0 . Caselli JS. The use of left heart bypass in the repair of thoracoabdomi­ nal aortic aneurysms: current techniques and results. Semin Thorae Cardiovase Surg. 2003 ; 1 5 : 326-332.

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1 1 . Etz CD, Homann TM, Plestis KA, et al. Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? Eur J Cardiothorae Surg. 2007;3 1 (4 ) : 643-648 . 12. Schmitto J D , Fatehpur S, Tezval H , e t a l . Hypothermic renal protec­ tion using cold histidine-tryptophan-ketoglutarate solution perfusion in suprarenal aortic surgery. Ann Vase Surg. 2008;22(4 ) :520-524. 1 3 . LeMaire SA, Jamison AL, Carter SA, et al. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions. Eur J Cardiothorae Surg. 2004;26:599-607.

-

Chapter

13

Thoracic Aortic Stent Graft Repair for Aneurysm, Dissection, I

- -----------------------------------

�

and Traumatic Transection -----------------------------------------------------

Bra n t W Ullery

Jason T. Lee

DEFINITION •

•

•

In 1 994, Dake and colleagues/ at Stanford University, were the first to report the use of custom-designed thoracic aortic stem grafts for the treatment of descending thoracic aortic aneurysms in patients deemed high risk for conventional open surgery. Each of these devices was deployed through peripheral arterial access, successfully excluding the aneu­ rysm from systemic pressurization. This groundbreaking minimally invasive technique thereby avoided many of the physiologic insults associated with open surgery, including the need for thoracotomy, aortic cross-clamping, reperfusion inj ury, and acute hemodynamic changes. Results from the first multicenter U . S . Food and Drug Administration-sponsored trial for thoracic aortic stem grafts demonstrated significantly less perioperative mortal­ ity, respiratory failure, renal insufficiency, and spinal cord ischemia in patients after thoracic endovascular aortic re­ pair (TEVAR) compared to a matched cohort of patients undergoing open descending thoracic aortic aneurysm repair.2 After two decades of surgeon experience and endovascu­ lar technologic advancement, TEVAR has evolved to serve as a primary treatment strategy for an increasingly diverse group of acute and chronic aortic pathologies including thoracic aortic aneurysms, dissections, and traumatic tran­ sections .

•

DIFFERENTIAL DIAGNOSIS •

•

Depending on the type and extent of pathology, TEVAR may include the use of fenestrated or branched stent grafts, advanced snorkel/chimney/periscope techniques, or the need for hybrid debranching procedures . The deci­ sion to treat thoracic aortic pathology with stent grafts is based on individual patient comorbidity burden, de­ tailed analysis of thoracic aortic anatomy, and physician experience. Acute thoracic aortic pathologies often present with chest pain and therefore must be considered in the workup for acute coronary syndrome. The ubiquitous use of computed tomography ( CT) scanning for pain, shortness of breath, trauma, and to " rule out" many pathologies has led to an increase in the recognition of thoracic aortic pathology po­ tentially benefitting from TEVAR technology.

PATIENT HISTORY AND PHYSICAL FINDINGS •

Thoracic aortic aneurysms (TAAs ) are defined as local­ ized or diffuse dilation of 50% or more relative to the diameter of the adj acent normal-sized aorta. Common risk factors for aneurysmal degeneration include smok­ ing, hypertension, chronic obstructive pulmonary disease,

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atherosclerosis, and connective tissue diseases. Indica­ tions for repair of descending TAAs are similar to those for conventional open repair: maximum aortic diameter greater than 6 em, rapid aneurysmal growth ( > 5 mm of growth over 6 months ) , or symptoms such as persistent chest or back pain, rupture, or dissection. In most patients with TAA, the aneurysms were diagnosed following rou­ tine imaging ordered for other reasons and are therefore most commonly asymptomatic. Aortic dissection occurs when an intimal tear in the aorta causes blood to flow between the layers of the wall of the aorta and most often presents as tearing chest pain that radiates to the back. Potential etiologic factors leading to aortic dissection include poorly controlled hypertension, connective tissue disorders, trauma, or vasculitis. Medi­ cal management of uncomplicated type B thoracic aortic dissection serves as the current standard of care. These practice guidelines stem from the results of the INvestiga­ tion of STEm grafts in patients with type B Aortic Dis­ section (INSTEAD ) trial, the first prospective, multicenter randomized trial comparing optimal medical therapy ( e . g . , b l o o d pressure control) to TEVAR for uncomplicated type B dissection.3 This trial demonstrated no significant im­ provement in 2-year survival or adverse event rates with TEVAR despite favorable aortic remodeling, although re­ cently reported 5-year data suggest improved long-term survival in patients undergoing TEVAR. In contrast, for patients with complicated type B dissections involving rupture, malperfusion ( e . g . , visceral or limb ischemi a ) , or refractory back pain despite optimal medical management, TEVAR is indicated. The goal of TEVAR in this setting is to cover, or exclude, the primary entry tear and reexpand the true lumen while promoting thrombosis of the false lumen. Traumatic aortic transection results from a high-velocity or deceleration injury to the aorta. The tethering of the aorta by the ligamentum arteriosum makes this site most suscep­ tible to shearing forces during sudden deceleration. A high index of suspicion is necessary to help make the diagnosis. Trauma workups most often involve whole-body CT scan­ ning, which allows rapid triage for possible treatment. CT-A commonly demonstrates an irregular outpouching beyond the takeoff of the left subclavian artery at the aortic isthmus, which corresponds to the presence of an aortic pseudoan­ eurysm caused by the traumatic event. Extent of blunt trau­ matic aortic injury and the corresponding physiologic insult may range from clinically occult intimal inj ury to life-threat­ ening complete transection and rupture ( FIG 1 ) .4 Early diag­ nosis and endovascular treatment is generally recommended for those presenting with a traumatic aortic transection, par­ ticularly when there is a contour abnormality visualized on cross-sectional imaging.

C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R

GRADEl

1 91 1

GRADE II

GRADE Ill

GRADE V I

Pseudoaneurysm

Rupture

•

FIG 1 • Society for Vasc u l a r S u rgery cl assification of b l u nt tra u m atic a o rtic i nj u ry. (Ada pted from Lee WA, M atsu m u ra J S, M itch e l l RS, et a l . E n d ovasc u l a r repa i r o f tra u m atic t h o racic a o rt i c i nj u ry: c l i n ical p ractice g u i d e l i n es of the Soci ety for Vasc u l a r S u rg e ry. J Vase Surg. 2 0 1 1 ; 5 3 : 1 87-1 92.)

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Transesophageal echocardiography (TEE) may serve as a useful imaging tool, particularly in the setting of acute thoracic aortic pathology. TEE can confirm the presence of aortic dissection, distinguish between types A and B dissec­ tions, identify involvement of supra-aortic vessels, and as­ sess for contained rupture. High-resolution computed tomography angiography ( CT-A) with three-dimensional reconstructive software allows for the most complete anatomic analysis, including details regarding aneurysm morphology, diameter, dissection flap characteriza­ tion, thrombus burden, calcification, angulation, and branch vessel orientation. Familiarity and routine usage of three-dimensional worksta­ tions and the ability to customize measurements provide an accurate road map to guide endovascular strategy, device se­ lection, and stent graft sizing.

•

•

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SURGICAL MANAGEMENT Preoperative Planning •

Patients scheduled for elective TEVAR undergo routine pre­ operative cardiac evaluation. Based on cardiovascular risk

•

profile, symptomatology, and presence of electrocardiogram abnormalities, selected patients undergo further evaluation in the form of an exercise stress test, dobutamine stress echo­ cardiography, or Persantine thallium stress testing. Coro­ nary angiography is pursued in cases involving extensive or symptomatic coronary artery disease. Aortic transections or symptomatic dissections and an­ eurysms should have early and aggressive blood pressure control using intravenous beta-blocker or calcium channel blocker medications. After obtaining a reliable clinical ex­ amination, refractory chest, back, or abdominal pain should be treated with narcotic analgesics. Renal protective strategies should be employed preopera­ tively to minimize the risk of contrast-induced nephropathy. Intravenous hydration is initiated preoperatively and, in the setting of baseline renal insufficiency, may warrant early hospital preadmission and concomitant administration of Mucomyst and bicarbonate infusion. Suspected blunt aortic injury should prompt a referral to a level I trauma center in order to facilitate early evaluation by a vascular specialist and other pertinent members of a multidisciplinary trauma team. General anesthesia is routinely performed in TEVAR cases. Prophylactic lumbar cerebrospinal fluid (CSF) drainage is

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

considered in every case based on the relative risk of spinal cord ischemia, hemodynamic status, and acuity of clinical presentation. Arterial monitoring is performed via a right radial artery approach. Peripheral intravenous lines are typically adequate; however, more intensive central venous monitoring may be required in cases involving unstable trau­ matic transections, patients with significant baseline cardio­ vascular comorbidities, or any case involving hemodynamic instability. Preoperative imaging should be heavily scrutinized for the adequacy of iliofemoral access anatomy. An iliac conduit may be required in cases involving small-caliber, tortuous, or heavily calcified access vessels. Anticipated use of a conduit should prompt consideration of an autotransfusion or cell saver machine to be available during the procedure. Numerous variables have been identified as risk factors for the development of spinal cord ischemia after TEVAR. Given that hypoperfusion represents the primary etiol­ ogy of spinal cord inj ury following TEVAR, commonly cited risk factors involve those relating to the extent of impairment or exclusion of the collateral perfusion to the spinal cord. The European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair ( EUROSTAR) investigators reported results from the largest multicenter registry to date (N = 6 0 6 ) . 5 In the EURO STAR registry, the incidence of spinal cord ischemia was 2 . 5 % and inde­ pendent risk factors included left subclavian artery cover­ age without revascularization (odds ratio [OR], 3 . 9 ; p = . 0 3 7 ) , concomitant open abdominal aortic surgery (OR, 5.5; p = .037), and the use of three or more stent grafts (OR, 3 . 5 ; p = .043 ) . Based o n the principle that spinal cord perfusion pressure is approximated by the difference between the mean arte­ rial pressure (MAP) and CSF pressure, placement of a pro­ phylactic lumbar drain has the potential to increase spinal cord perfusion pressure by decreasing CSF pressure and may be beneficial in select patients at high risk for spinal cord ischemia. Percutaneous drainage of CSF is performed by in­ serting a silastic catheter 10 to 15 em into the subarachnoid space through a 1 4-gauge Tuohy needle at the L3-L4 verte­ bral interspace. The open end of the catheter is attached to a sterile closed circuit reservoir and the lumbar CSF pressure is measured with a pressure transducer zero-referenced to the midline of the brain. Lumbar CSF can be drained con­ tinuously or intermittently in the operating room to achieve target CSF pressures of 10 to 12 mmHg. Postoperatively, intermittent or continuous CSF drainage can be contin­ ued in the intensive care unit for CSF pressures exceeding 10 mmHg or at the first sign of lower extremity weakness. In the absence of neurologic deficits, the lumbar CSF drainage catheter can be clamped 24 hours postprocedure followed by continued monitoring of CSF pressure together with se­ rial neurologic assessments. The CSF drain can then be re­ moved at 4 8 hours after operation. Although prophylactic or therapeutic lumbar CSF drainage has an established re­ cord of safety, complications have been reported to occur in approximately 1 % of patients, which may include neur­ axial hematoma, subdural hematoma, catheter fracture, meningitis, intracranial hypotension, chronic CSF leak, and spinal headache.

Selection and Sizing of Thoracic Stent Graft

Landing zones •

•

•

•

Proximal and distal landing zones must be of sufficient length (usually at least 2 em) to enable safe and accurate deployment bracketing the area of thoracic aortic pathology, which often includes the subclavian artery proximally or the celiac artery distally. Intentional coverage of the left subclavian artery is some­ times required due to a very proximal extent of aortic pa­ thology, especially transections. Left subclavian artery revascularization may be required in select cases. The celiac artery rarely requires intentional coverage. Significant tortuosity, circumferential mural thrombus, and extensive calcification can compromise the proximal or dis­ tal landing zone, thereby predisposing to inadequate fixa­ tion and subsequent development of endoleak or migration. Site of proximal and distal landing zones should be selected in order to minimize the impact of these anatomic features, even if it requires extending the length of aortic coverage. A variety of anatomic measurements are taken from preop­ erative CT-A imaging to assist in the sizing and selection of the thoracic stent graft ( FIG 2 ) . Interventionalists should be proficient in accurate sizing and measuring of key thoracic aortic locations that influence device selection and ultimately determine patient outcomes.

Sizing of stent grafts •

•

•

•

The degree of stent graft oversizing can vary based on the in­ dication for intervention. Stent grafts are generally oversized by 1 0 % to 2 0 % based on the aortic diameter at the proximal and distal fixation sites for aneurysmal disease. Insufficient oversizing for the treatment of TAAs may predispose to in­ adequate exclusion and the potential for endoleak or migra­ tion. Aggressive oversizing, on the other hand, increases the risk for stent graft collapse, graft thrombosis, access arterial injury, and potential for peri- or postprocedural iatrogenic retrograde type A dissection. Chronic type B dissections are frequently characterized by a thick, nonmobile dissection flap, or septum, that separates true and false lumens into concave or convex discs of flow lumen. Such dissection flaps have limited compliance; there­ fore, minimal or no oversizing may be required in order to achieve a suitable proximal or distal seal. Aortic transections frequently occur in young trauma pa­ tients with normal or minimally diseased aortas. As such, minimal oversizing is needed to achieve an adequate seal and only recently did device manufacturers create devices meant for smaller diameter aortas. Note also that under­ rescucitated patients on admission will have smaller aortic diameters on their CT-A. Currently available stent grafts range in diameter from 22 to 46 mm. Given the traditional 1 0 % to 20% rule of device over­ sizing, these devices are designed to safely treat aortas with landing zones ranging from 19 to 43 mm in diameter.

Access vessel anatomy •

Current thoracic aortic stent grafts require large-caliber deliv­ ery systems, ranging from 1 8 to 26 Fr in outer diameter. Small,

Ch a pt e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R

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Measu rements t o b e taken during the pretreatment assessment of isolated lesions are described below: A, B, C. Proximal aortic neck diameter (minimum of 1 em apart) D. Maximum lesion d i ameter E, F, G. Distal aortic neck d i ameter (min imum of 1 em apart) H. R ight common i l i ac artery d i ameter I . Left common iliac artery diameter J. Right external i l i ac/femoral artery d i ameter K. Left external i l i ac/femoral artery d i ameter L. Distance between the left subclavian/left common carotid artery and the proximal end of the lesion (mi n imum of 2 em) M. Length of the lesion measu red along the g reater cu rvature of the flow l umen N. Distance between the d i stal end of the lesion and the cel i ac axis (min imum of 2 em) 0. Total treatment length

Measu rements to be taken d u ring the pretreatment assessment of dissections are described below: 01. Diameter a t proximal extent o f proximal landing zone (must be i n nondissected aorta) 02. Maximum transverse aortic diameter (combined true and false l umen) T1. Maximum true l umen diameter i n DTA T2. Min imum true l umen diameter in DTA F. Maximum false lumen d i ameter in DTA A1. Right access vessel diameter (common iliac, external i l i ac, femoral) A2. Left access vessel d i amter (common i l i ac, external i l i ac, femoral) L1. Proximal landing zone length from proximal end of primary entry tear to left subclavian or left common carotid L2. Distal neck length from distal end of primary entry tear to cel i ac TTL. Total treatment length from left subclavian or left common carotid

A

B FIG 2

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Anatomic measurements to assist i n tho racic stent graft device siz i ng and selectio n f o r the treatment of aneu rysms (A) a n d d issect i o ns (B) . DTA, descen ding tho racic ao rta.

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

tortuous, and heavily calcified iliofemoral arteries may prohibit sheath advancement and predispose to access site-related com­ plications, including groin hematoma, dissection, or rupture. Careful evaluation of access vessel anatomy on preopera­ tive imaging should be performed in order to assess the cali­ ber, tortuosity, thrombus burden, and extent of calcification of the iliofemoral arteries. Such anatomic information will serve as the basis for deciding laterality of femoral access as well as to determine the need for an iliac conduit. Serial dilation may be attempted for patients with small il­ iofemoral vessels. Iliac atherosclerotic lesions may be pre­ treated with balloon angioplasty and/or stent grafting in order to facilitate sheath advancement and introduction of the thoracic stent graft components. Iliac conduits serve as a safe and reliable technique to circum­ vent issues related to suboptimal access vessel anatomy. From either flank incision, a retroperitoneal exposure provides visu­ alization of the common iliac artery or distal abdominal aorta. A 10- or 1 2-mm Dacron graft is commonly used as the conduit of choice. The conduit can be modified by creating a patch at the distal end in order to further facilitate the delivery of large­ caliber sheath and enable additional degrees of torqueability ( FIG 3) . This modification involves creating a patch by cutting the Dacron graft along its long access, thereby enlarging the transition zone from the graft to artery.

A

B FIG 3

• A. 1 0- m m Dacron c o n d u i t b isected l o n g itu d i n a l ly to create a sew i n g patc h . B. Dacron i l i a c co n d u it sewn to native i l i a c a rtery a l l ows easy m o b i l ity of the c o n d u i t at m u lt i p l e a n g les o f entry for l a rge-ca l i be r device o r sheath. ( F r o m L e e JT, L e e G K, C h a n d ra V, et a l . Compa rison of fen estrated endog rafts a n d the s n o rkel/ch i m ney tec h n i q u e [ p u b l ished o n l i n e a h e a d of p r i n t Apri l 27, 2 0 1 4 ] . J Vase Surg. doi:1 0 . 1 0 1 6/j .jvs . 2 0 1 4.03.255.)

EARLY PROCEDURAL CONSIDERATIONS

•

Positioning •

The C-a rm is typica l l y confi g u red i n the " h ead " posit i o n . The left a r m may be a b d u cted to 75 to 90 deg rees a n d c i r­ cu mferenti a l l y prepped i nto the field if an e m b o l izat i o n o r s n o rkel/c h i m ney p roced u re involvi n g the l eft s u b c l a ­ v i a n a rtery is a ntici pated. The chest, a bdomen, a n d b i ­ l atera l g r o i n s s h o u l d be prepped . A s freq uently o n ly one g r o i n access i s req u i red for the perfo rmance of a rout i n e TEVAR, latera l ity of the o perator p o s i t i o n may vary based o n su rgeon p reference o r a ntici pated access site l ocat i o n .

Establishing Vascular Access •

The i psi l ateral fe moral a rtery is accessed either percuta ne­ ously o r from a n open exposure. Seco n d a ry access may be o bta i n ed from the contra l atera l femoral a rtery o r bra­ c h i a l a rtery as needed fo r a 5-Fr sh eath a n d flush catheter. S u rg i c a l exposure is obta i ned from a s m a l l o b l i q u e i nci­ sion at the level of the i n g u i n a l l i g a ment. The common femoral a rtery is exposed, with p roxi m a l control o bta i ned at the l eve l of the exte r n a l i l iac a rtery and d ista l control at the l eve l of the fe moral bifu rcation o r prox i m a l su perfi­ cial femora l and p rofu nda fe moral a rteries. Heavy calcifi­ cation may req u i re preem ptive e n d a rterectomy and patch a n g i o p l asty i n order to fac i l itate safe sheath p l acement.

INITIAL AORTOGRAM •

A 5-Fr 1 00-cm O m n iflush or p i gta i l catheter is i n se rted i nto a o rta and adva n ced to the level of the a o rtic a rch .

•

•

The fe m o r a l a rtery is p u nctured u s i n g a sta n d a rd m i cro­ p u n ct u re set, and if a rte r i a l access is obta i ned percuta ne­ ously, a s h eath ogram is performed to confirm a d e q u ate p u n ct u re site location ( m i d-co m m o n fe m o ra l a rte ry) . A sta n d a rd l e n gth B e ntson w i re is i n se rted i nto the a o rta t h r o u g h m icropu ncture sheath a n d exc h a n g e for a 7-Fr sh eath is then performed u s i n g S e l d i n g e r tech n i q u e . W i re exc h a n g e is t h e n d o n e f o r a 260-cm stiff L u n d e r­ q u i st wire. The L u n d e rq u i st w i re s h o u l d h ave a flexi b l e, cu rved prox i m a l e n d that s h o u l d be adva nced u n d e r f l u o roscopy across the a o rtic a rch to a b ut t h e a o rt i c va l u e . The l o c a t i o n of t h e d ista l end of t h e Lunderqu ist w i re s h o u l d be m a rked o n the operat i n g ta b l e and t h i s w i re position s h o u l d be m a i ntained t h ro u g hout t h e p roced u re . O v e r the stiff Lu n d e rq u ist w i re p l atfo rm, the 7-Fr s h eath is removed and seri a l d i lators are adva n ced to g ra d u a l l y e n l a rg e the su bcuta neous tract a n d a rteriotomy site i n order t o acco m m o d ate either t h e ste nt g raft device itse lf o r a l a rg e r 1 8- to 26-Fr i ntrod ucer s h eath req u i red for device d e l ive ry. After p l acement of the l a rg e r sheath, syste m i c h e p a r i n is a d m i n istered at a d o s e of 1 00 u n its/kg (g o a l activated c l ott i n g t i m e of >2 50 seco nds). Concom itant t ra u matic i nj u ri es, p a rticu l a r l y i n t racra n i a l h e m o rrhage, may a lter the dose o r decision to a d m i n ister h e p a ri n .

T h i s catheter m a y b e advanced v i a a contra latera l 5-Fr sheath o r it may be i nserted i nto a n a d d i t i o n a l i p s i l atera l 5-Fr sheath p l a ced d i st a l to the a rteriotomy for t h e m a i n body del ivery sheath.

C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R

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•

If satisfied w i t h ste nt g raft s i z i n g based o n ava i l a b l e pre­ operative i m a g i ng, the thoracic a o rtic ste nt g raft may be adva nced over the L u n d e rq u i st w i re and be positioned i n t h e p roxi m a l t o m i d portion o f t h e t h o racic a o rta p r i o r to i n it i a l a o rtog ra m . O pti m a l a n g i o g ra p h i c i m a g i n g o f t h e a o rtic a rch is ob­ t a i n e d by placing the f l u o rosco p i c C-a rm i n a l eft a nte­ rior o b l i q u e o r i e ntation, often 3 5 to 6 5 deg rees, and can be optim ized by refere n c i n g the preoperative CT-A. The l ocat i o n of the s u p ra-aortic vessels, p a rticu l a rly the left s u bclavian a rte ry, s h o u l d be n oted a n d m a rked on view­ i n g m o n itors (FIG 4A) . I ntravasc u l a r u ltraso u n d ( I V U S ) may be u s e d a n adju nct i n cases i nvo l v i n g d i ssection to assist i n the i d e ntification of true a n d false l u m e n s, a s we l l as to gain a d d i t i o n a l i nfo rmation o n a o rtic d i a m eter, branch vessel location, a n d m o r p h o l ogy of prox i m a l a n d d ista l l a n d i n g zones. IVUS a l so a i d s i n l i m it i n g i ntrave n o u s contrast exposure in t h ose patie nts with base l i n e i m p a i red re n a l f u n ct i o n . If n ecessa ry to g u ide d ista l exte nt of ste nt g raft p l ace­ m ent, the ce l i a c a rtery is best i m a g e d from a fu l l latera l p roj ect i o n . Ad d iti o n a l structu res to n ote a re l a rge, pa­ tent i ntercosta l a rteries at the level of the a o rtic h i atus. Efforts should be m a d e to avoid cove r i n g t h ese if at a l l poss i b l e d u r i n g t h e cou rse o f t h e repa i r.

A

c

Device Deployment •

•

•

•

Precise prox i m a l positi o n i n g of the ste nt g raft is fa­ c i l itated by either m a r k i n g the location of the l eft sub­ clavian a rtery o n the view i n g screen a n d/or u s i n g the road-m a p p i n g feature. The d ista l rad i o p a q u e line of the e n d otrach e a l t u b e seen o n f l u o roscopy at a bout 45 de­ g rees l eft a nterior o b l i q u e can sometimes corre l ate to the position of the l eft c o m m o n ca rotid a rte ry, t h ereby servi n g as a conve n i e n t l a n d m a r k in cases req u i r i n g l eft s u bclavian a rtery cove rage. I m m ed iately prior to ste nt g raft d e p l oyme nt, syste m i c a rte r i a l b l ood pressu re is red uced below 1 00 m m H g to reduce risk of ca u d a l m i g rati o n . T h e stent g rafts a re g e n e ra l ly d e p l oyed i n a p roxi m a l -to­ d ista l sequence. H owever, a d i stal-to-prox i m a l sequence may be p refe rred i n cases i nvolvi n g precise d e p l oyment n e a r the ce l i a c a rtery o r i n a o rtas with s i g n ificant d i a m ­ eter t a p e r a n d a l a rg e r p roxi m a l l a n d i n g z o n e compa red to the d ista l l a n d i n g zone (wh e re devices of d i ffe rent d i ­ a m eter may n e e d t o be sta cked u p o n e a c h other). D e p l oyed endog rafts w i l l natu ra l ly exte n d toward the outer cu rvature of the a o rta and p recision d e p l oyment is fac i l itated by gently p rovi d i n g forwa rd tract i o n o n the w i re toward the outer cu rve during d e p l oyment. This

B

FIG 4 • A. I n it i a l thoracic a o rtogram performed with C-a rm i n a 45-deg ree l eft a nterior o b l i q u e orientation i n a case i nvolvi n g a type B a o rtic d issect i o n . N ote h ow clearly the o r i g i n of the subclavi a n (arrow) is seen to accu rate ly decide if there is a d e q u ate p roxi m a l neck l e n g t h . B. Ao rtogram fo l l ow i n g d e p l oyment of t h o r a c i c ste nt g raft w i t h cove rage of the ost i u m of the l eft subclavian a rte ry. C. Posto perative th ree-d i m e n s i o n a l i m a g i n g d e m o n strat i n g successf u l exc l u s i o n of the p roxi m a l entry d i ssection tea r.

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

•

m a n euver a l so fac i l itates stra i g hte n i n g out of the tra ns­ verse a rch, w h i c h can be h e l pf u l in m i n i m i z i n g the " b i rd­ bea k i n g " effect at the p roxi m a l g raft m a r g i n , where the device may not fully o ppose to the " i n n er" a o rtic wa l l . B i rd bea k i ng, when p resent, c a n predispose t o prox i m a l type I e n d o l e a ks, endog raft co l l a pse, a n d potenti a l a o rt i c occ l u s i o n . Ad d i t i o n a l g raft co m p o n e nts a re added, w h e n n ecessa ry, by exch a n g i n g the fi rst device over the L u n d e rq u i st wire. A m i n i m u m ove r l a p of 5 em between p i eces i s reco m m e nded to e n s u re a d e q u ate a p position a n d m i n im ize risk of j u n ct i o n a l (type I l l) e n d o l e a k .

•

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Balloon Molding •

B a l loon m o l d i n g is often req u i red in cases i nvolvi n g TAAs. U n der f l u o rosco p i c g u i d a n ce, a n o n co m p l i a n t m o l d i n g

COMPLETION AORTOGRAM •

After stent g raft d e p l oy m e nt, t h e p i g ta i l catheter is w i t h d rawn a l o n g t h e outside of t h e d e p l oyed devi ce(s) over a w i re to b e l ow the level of the stent g raft. T h e c a t h e t e r i s t h e n readva nced over a w i r e with i n t h e

REMOVAL OF SHEATH AND ARTERIOTOMY CLOSURE •

I n cases i nvolvi n g pe rcuta n e o u s access, t h e two p revi­ ously p l aced Percl ose Pro G i i d e devices a re used to c l ose the a rteriotomy site(s) (see Pa rt 6, C h a pter 23 for de­ t a i ls). If open s u r g i c a l exposure was o bta i n ed, prox i m a l

LEFT SUBCLAVIAN ARTERY REVASCULARIZATION •

•

•

E n d ovasc u l a r p roced u res that req u i re cove rage of the l eft subclavi a n a rte ry h ave the pote n t i a l to i n crease the risk of spinal cord i nj u ry by co m p ro m i s i n g b l ood flow to the i p s i l atera l vertebral a rte ry, a n i m portant co l l atera l pathway for a rte r i a l flow to t h e a nterior s p i n a l a rte ry. S u bc l a v i a n a rtery revascu l a rization the refore se rves as a n a d d iti o n a l strategy to decrease the risk of s p i n a l cord isch e m i a i n sel ect patie nts deemed high risk. Tec h n i q ues to revasc u l a rize the l eft subclavian a rtery i n c l u d e transposition of the subclavian onto the l eft ca­ rotid a rtery o r l eft ca rotid-subclavian bypass g raft i n g w i t h su bseq uent e m b o l i zation o f the l eft subclavian a r­ tery proxi m a l to the bypass g raft (FIG 5) . These revas­ c u l a rization p roced u res may be pe rfo rmed a s p a rt of a sta ged repa i r or at the t i m e of TEVAR. The existi n g c l i n ica l evidence to s u p p o rt the efficacy of ro utine l eft subclavian a rtery revasc u l a rization re m a i n s controvers i a l ; t h e r e a re advocates fo r rout i n e revascu­ l a rization, sel ective reva sc u l a rization, o r n o revasc u l a r­ izat i o n . A m eta-a n a lysis of p u b l ished stud ies showed a

•

balloon (Coda [Cook Medical, B l o o m i n gton, IN, U SA] o r Tri-Lobe [W. L. G o re, F l a g staff, AZ, U SA]) is adva nced u p to the p roxi m a l edge of the ste nt g raft and b a l loon m o l d i n g is performed in a p roxi m a l -to-d ista l seq uence. B a l loon m o l d i n g should be pe rfo rmed at the p roxi m a l a n d d i sta l fixati o n sites, a s we l l as at a reas o f ste nt g raft ove r l a p in those cases req u i ri n g m u lt i p l e ste nt g rafts. Agg ressive b a l l o o n i n g can cause component fract u re a n d a o rtic i n j u ry, a n d ca re m ust be taken d u r i n g i nfla­ t i o n with consta nt v i s u a l ization a n d knowledge of the tension a p p l i ed to the b a l l o o n . B a l loon m o l d i n g is n ot typica l ly req u i red i n cases i nvo lving aortic d i ssection o r transection, p a rticu l a rly i n cases where no obvious endoleak is visu a l i zed. B a l loon m o l d i n g may i ncrease risk for iatrog e n i c retrograde type A convers i o n if perfo rmed i n a reg ion o f fri a b l e o r fra g i l e a o rta a n d is genera l ly not recom mended during d i ssection cases.

stent g raft l u m e n a n d p o s i t i o n e d at the level of t h e aortic a rc h . Ad d i t i o n a l a o rtograms may be pe rfo rmed at t h i s t i m e a s necess a ry i n order t o e n s u re a d e q u ate stent g raft posi­ tion a n d pate n cy of the s u p ra-aortic a n d ce l i a c a rteries and to assess for the presence of e n d o l e a ks.

a n d d i sta l vasc u l a r control is obta i n e d i n t h e respective g r o i n . All wi res and s h eaths a re rem oved . The a rteriot­ omy is cl osed tra n sverse ly u s i n g a polypropyl e n e sutu re in either a r u n n i n g cont i n u o u s or i nterru pted fas h i o n . Anteg rade a n d retro g ra d e f l u s h i n g m a n e uvers s h o u l d be perfo rmed p r i o r t o co m p l et i o n o f t h e a rteriotomy c l o s u re .

t r e n d towa rd i n creased risk of s p i n a l c o r d isch e m i a w h e n the l eft subclavian a rtery was covered, s u g g esti n g a po­ tent i a l benefit for l eft subclavian a rtery revasc u l a riza­ tion, but the f i n d i n g was not statistica l ly s i g n ifica nt.4-6

• Left su bclavi a n a rtery transposition is performed by l i g at i n g the l eft s u bclavian a rtery p roxi m a l to the verte bral a rtery a n d m ovi n g it ce p h a l a d i n order to perform a n end­ to-side a n a stomosis between the l eft subclavian a n d l eft c o m m o n ca rotid a rteries. Alternative ly, a Dacron g raft can be used as a l eft ca rotid-subclavian bypass.

FIG 5

C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R

SPECIAL CONSIDERATIONS BASED ON

•

AORTIC PATHOLOG Y Aortic Dissection •

•

•

The p r i m a ry g o a l of TEVAR for the treatment of d i ssect i o n is cove rage of the p roxi m a l entry tea r (FIG 6A,B) . Stent g raft s i z i n g is based o n the d i a m eter o f the adjacent n o n d i ssected t h o racic a o rta. M i n i m a l o r n o ove rs i z i n g of the ste nt g raft is reco m m e n d e d . I n acute type B d i ssectio ns, the sept u m is relatively mo­ bile a n d com p l i a nt. Therefore, the d i a m eter of the sma l l true l u m e n i n t h e d i ssected port i o n often ret u r n s to n o r m a l d i a m eter fo l l owi n g successf u l exc l u s i o n of the prox i m a l entry tea r. C h r o n i c d i ssect i o n s have t h icker, less co m p l i a n t septa, w h i c h may l i m it expa n s i o n of the true l u m e n desp ite ad­ e q u ate entry tea r coverage. Ofte n, these patie nts h ave c h r o n i c false l u m e n a n e u rysm a l d i lation, a n d entry tea r a n d fe n estrati o n cove r i n g se rve s i m p l y to decrease fa lse l u m e n pressu rization and prom ote t h ro m bosis.

I V U S se rves as a u sefu l a dj u n ct i n d i ssect i o n ca ses, both in terms of i n it i a l i d e ntificat i o n of true and fa l s e l u m e n , a s we l l a s a s s i st i n g i n precise positi o n i n g of t h e device.

Aortic Transection •

• •

Tra u m atic a o rtic i n j u ries a re typica l ly l ocated a l o n g the inner cu rve of the p roxi m a l desce n d i n g t h o ra c i c a o rta (FIG 7). G i ve n the p roxi m a l locat i o n , l eft subclavian a rtery cove rage i s sometimes needed.4 I n the a bsence of concom itant hemorrhage o r b ra i n i n j u ry, rout i n e h e p a r i n i s reco m m e n d e d . Tra u m a patie nts a re freq uently hypovo l e m i c a n d , a s a re­ su lt, may have an u n d e rd i ste nded a o rta o n p reope rative cross-sect i o n a l i m a g i n g . I n it i a l cross-sect i o n a l i m a g i n g can u n d e rest i m ate t r u e a o rtic m o r p h o l ogy at t h e reg i o n of the s u b c l a v i a n by as m u c h a s 1 0 % to 2 0 % . I n such set­ t i n gs, IVUS may assist in more accu rate ste nt g raft s i z i n g pe rfo rmed i n vivo.7

B A A. CTA reco nstruct i o n d e m o n strat i n g co m p l ex t h o racoa bdom i n a l a o rtic d i ssection with p roxi m a l entry tea r l ocated i n t h e proxi m a l desce n d i n g thoracic a o rta. B. I n it i a l a o rtogram docu m e n t i n g positi o n o f t h e s u p ra-aortic a rteries. N ote t h e ste nt FIG 6

•

g raft h a s been adva nced i nto a p p roxi m ate positi o n but is not yet d e p l oyed .

1 91 7

1 918

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A

c •

A. Th ree-d i m e n s i o n a l reco nstructed i m ages s h ow i n g the presence of t ra u matic a o rtic tra nsect i o n at the level of the l i g a m entum a rteriosum (arrow). B. Aortogram s h ow i n g foca l outpo u c h i n g (arro w) along the inner cu rve of the p roxi m a l

FIG 7

desce n d i n g thoracic a o rta, corre l a t i n g to the t ra u m atic transect i o n observed o n p reoperative i m a g i n g . N ote t h a t the ste nt g raft has been advanced i nto the proxi m a l desce n d i n g thoracic a o rta but is not yet dep l oyed . C. Aortogram fo l l owi n g t h o racic ste nt g raft d e p l oyment with successful exc l u s i o n of the transect i o n site.

C h a p t e r 1 3 THORACIC AORT I C STENT G RAFT REPA I R

1 919

PEARLS AND PITFALLS I n d icat i o n s

• •

Preope rative w o r k u p

• • •

Patient set u p

• •

T h o r a c i c a n e u rysms

• •

Type B d i ssect i o n

• •

Tra u m atic tra n sect i o n

• •

TEVAR fo l l ows g e n e ra l reco m m e ndations for e l ective repa i r o f desce n d i n g t h o racic a n d thoracoa b d o m i n a l a o rtic a n e u rysms a n d s h o u l d be offered to good a n ato m i c risk patie nts with a n e u rysms > 6 e m . Patient select ion s h o u l d t a k e i nto acco u n t t h e n eed f o r reg u l a r i nte rva l c l i n ica l a n d ra d i o l o g i c fo l l ow-u p i n order t o m o n itor f o r ste nt g raft-re lated co m p l icat i o n s a n d e n d o l e a ks . H i g h-qua l ity i m a g i n g a n d a b i l ity to confi g u re th ree-d i m e n s i o n a l reco nstructive softwa re a re essenti a l f o r successf u l p reope rative p l a n n i n g a n d device select i o n . Pre- a n d perio perative hyd rat i o n is a centra l p a rt i n the p rotect i o n f r o m contrast- i n d uced n e p h ropathy. Pati e nts s h o u l d be stratified accord i n g to base l i n e risk of s p i n a l cord isch e m i a . A prophylact i c l u m ba r d r a i n s h o u l d b e considered i n those a t h i g h risk. A h y b r i d e n d ovascu l a r su ite p rovides o pt i m a l opport u n ity f o r accu rate i m a g i n g a n d ca pa b i l ity t o perfo rm n ecessa ry o p e n s u r g i ca l exposure o r repa i r o f access-rel ated co m p l i cations. Antici pated adju nct procedu res, i n c l u d i n g l eft subclavian a rtery e m b o l ization o r revasc u l a rization, may req u i re p re p p i n g the l eft neck a n d/o r a r m i nto the s u r g i ca l f i e l d . Overs i z i n g of ste nt g rafts by 1 0 % to 20% a n d ba l l oo n m o l d i n g is g e n e ra l ly reco m m e n d ed i n order to maxim ize proxi m a l a n d d i sta l fixat i o n . Proxi m a l a n d d i stal l a n d i n g z o n e s s h o u l d be relatively free o f ste n osis, cal cification, a n d t h r o m b u s t o maxim ize d u ra b i l ity of t h i s m i n i m a l ly i nvasive tech n o l ogy. Accu rate i d entificat i o n of true a n d f a l s e l u m e n is essenti a l p r i o r to d e p l oyment of the ste nt g raft. IV U S may be a usefu l adj u n ct in t h i s sett i n g to confi rm true o r false l u m e n posi t i o n . Agg ressive ove rs i z i n g of stent g rafts is not reco m m e n d ed i n patie nts with a o rt i c d issect i o n . B a l loon molding is g e n e ra l ly rese rved o n ly for t h ose with type I o r Ill e n d o l e a k o n co m p l et i o n a n g iography and not a g a i n st the reg i o n w h e re t h e re i s a mobile septu m . Rout i n e h e p a r i n i s reco m m e n d ed u n l ess contra i n d i cated by conco m ita nt i ntracra n i a l o r s o l i d organ i n j u ry. S i m i l a r to d i ssections, a g g ressive overs i z i n g a n d b a l loon m o l d i n g is n ot routi n e l y performed d u r i n g the treatment of transections.

POSTOPERATIVE CARE •

•

•

Patients are typically extubated immediately following the procedure unless prohibited by concomitant physiologic in­ sults (e.g., hemodynamic instability, trauma patient) . Intensive care unit monitoring i s required for patients who require a lumbar drain for 24 to 48 hours. Immediate and frequent neurologic assessments are critical in the early peri­ operative period to assess for spinal cord ischemia. Raising MAP goals are an additional way to minimize risk of cord ischemia. Durability of TEVAR is reliant on routine imaging to evalu­ ate for stent graft-specific complications postoperation. Follow-up chest CT-A and plain x-rays are typically ob­ tained at 1, 6, and 12 months and at intervals thereafter. Consideration should be made between balancing risks for cumulative lifetime iodinated contrast and radiation expo­ sure versus the necessity for serial graft monitoring. In stable patients, chest x-rays may suffice to confirm device position, with CT scanning reserved for those with migration sug­ gested by CT or evidence of progressive aortic enlargement or onset of recurrent symptoms such as chest pain.

OUTCOMES •

The largest published series, which has reported 1 -year follow-up, included 443 patients treated with TEVAR for a variety of indications, both emergent and elective, as follows: TAA ( n = 249 ) , thoracic aortic dissection ( n = 1 3 1 ) , traumatic aortic inj ury ( n 5 0 ) , and false anasto=

•

motic aneurysm ( n = 13 ). 8 Technical success was achieved in nearly 9 0 % of patients, with an all-cause mortality among patients treated for aortic aneurysm and aortic dissection of 20% and 1 0 % , respectively. No randomized trials comparing TEVAR to open surgery have been published to date. However, multiple nonran­ domized comparisons suggest equivalent or better outcomes with TEVAR. In a single-center, retrospective study of over 700 patients who underwent either TEVAR or open surgery, mortality was not significantly different at 3 0-day ( 5 . 7 % vs. 8 . 3 % , respectively) or 1 -year ( 1 5 . 6 % vs. 1 5 . 9 % , respectively) follow-up. 9 Two smaller studies demonstrated a reduction in 3 0-day perioperative mortality with TEVAR compared with open surgery ( 1 . 9 % vs. 5 . 7 % ) . 1 0• 1 1

COMPLICATIONS •

Stroke continues to be a common complication following TEVAR and is associated with significant in-hospital mor­ tality. Recent clinical series have reported an incidence of stroke after TEVAR to range from 2% to 8 % . 12•13 The un­ derlying mechanisms contributing to acute ischemic stroke after TEVAR and the temporal relationship of stroke to the procedure are not completely understood. However, the constellation of preoperative risk factors, neurologic exami­ nations, and patterns of brain infarction observed in these patients has led most investigators to conclude that cerebral embolization and ischemic events are the primary mecha­ nisms for perioperative stroke in TEVAR.5•13•14 Embolic events are related to instrumentation of the aortic arch in

1 920

•

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

patients with severe atheromatous disease, whereas ischemia is a result of the planned or inadvertent endovascular cover­ age of supra-aortic vessels. Spinal cord ischemia and subsequent acute or delayed paraplegia represents the most devastating complication of TEVAR. The pathogenesis of spinal cord injury after TEVAR is likely multifactorial but still poorly understood. The deployment of thoracic stem grafts results in rapid com­ plete exclusion of varying lengths of segmental collateral vessels without the ability to surgically reimplant or revas­ cularize the intercostal arteries. Stent deployment and cath­ eter manipulation can predispose patients to dislodgement of thrombotic or atheromatous debris from the aortic wall into segmental vessels, with subsequent distal embolization and occlusion of arteries supplying the spinal cord. More­ over, endovascular coverage of the left subclavian artery may compromise spinal cord perfusion in patients with a dominant left vertebral artery, solitary vertebral artery, ca­ rotid artery disease, or an incomplete circle of Willis. Access site injuries to the iliofemoral vessels may further increase the risk of spinal cord ischemia by compromising collateral flow to the anterior spinal artery through the hypogastric and pelvic vascular plexus. Lastly, pharmacologic measures aimed at decreasing arterial blood pressure to enhance accu­ racy of device deployment in cases involving difficult aortic anatomy may lead to hypotension similar to that observed in open surgery. Due to the large sheath sizes required for the delivery of thoracic stent grafts, small-diameter, tortuous, or heavily calcified access vessels can predispose to iliofemoral arte­ rial injury. Postoperative CT-A often documents arterial dis­ sections and injury that can be followed with noninvasive duplex and managed expectantly until patients have claudi­ cation-like symptoms. Endoleaks are a relatively common finding after TEVAR, affecting nearly 1 5 % of patients in the early or late post­ operative periods. Type I or III endoleaks typically require additional stent placement or balloon molding in order to improve proximal, distal, or j unctional fixation. Most type II endoleaks observed on completion angiogram or early fol­ low-up cross-sectional imaging will resolve spontaneously. Persistent type II endoleaks, especially those with aneurysm sac expansion or failure to adequately seal a proximal entry tear or transection, warrant additional intervention. Retro­ grade flow from intercostal or left subclavian arteries can be treated using coil embolization or vascular plug placement.

REFERENCES 1.

2.

3.

4.

5.

6.

7. 8.

9.

10.

11.

12.

13.

14.

Dake MD, Miller DC, Semba CP, et al. Transluminal placement of en· dovascular stent·grafts for the treatment of descending thoracic aortic aneurysms. N Engl ] Med. 1 9 94;3 3 1 : 1 729-1 734. Bavaria JE, Appoo JJ, Makaroun MS, et al. Endovascular stent graft· ing versus open surgical repair of descending thoracic aortic aneu­ rysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007; 1 3 3 : 3 69-3 77. Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized com­ parison of strategies for type B aortic dissection: the INvestigation of STEm Grafts in Aortic Dissection (INSTEAD ) trial. Circulation. 2009; 120:25 1 9-252 8 . Lee WA, Matsumura J S , Mitchell R S , e t a l . Endovascular repair o f traumatic aortic injury: clinical practice guidelines o f the Society for Vascular Surgery. ] Vase Surg. 2 0 1 1 ; 5 3 : 1 8 7-1 92. Buth ], Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stem/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vase Surg. 2007;46 : 1 1 03-1 1 1 0 . Rizvi A Z , Murad M H , Fairman RM, et a l . The effect of left subcla­ vian artery coverage on morbidity and mortality in patients undergo­ ing endovascular thoracic aortic interventions: a systematic review and meta-analysis. J Vase Surg. 2009;50 : 1 1 59-1 1 69 . Pearce BJ, Jordan W. Using IVUS during EVAR a n d TEVAR: improv­ ing patient outcomes. Semin Vase Surg. 2009;22 : 1 72-1 80. Leurs LJ, Bell R, Degrieck Y, et al. Endovascular treatment of tho· racic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vase Surg. 2004;40: 670-679. Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008; 1 1 8 : 8 08-8 17. Matsumura ]S, Cambria RP, Dake MD, et al. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1 -year results. J Vase Surg. 2008;4 7(2): 247-257. Bavaria JE, Appoo ]], Makaroun MS, et al. Endovascular stent graft­ ing versus open surgical repair of descending thoracic aortic aneu­ rysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007; 1 3 3 : 3 69-377. Feezor RJ, Martin TO, Hess PJ, et al. Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR) . J Endo· vase Ther. 2007; 1 4 : 5 6 8-573. Gutsche ]T, Cheung AT, McGarvey ML, et al. Risk factors for periop· erative stroke after thoracic endovascular aortic repair. Ann Thorac Surg. 2007;84 : 1 1 95-1 200. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006; 1 3 2 : 3 32-3 3 9 .

I

Chapter

14

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Exposure and Open Surgical Management at the Diaphragm 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Peter H. U. Lee

DEFINITION •

Ra m in E. Beygui

PATIENT HISTORY AND PHYSICAL FINDINGS

Thoracoabdominal aneurysms and complicated descending aortic dissections are the two most likely reasons for requir­ ing surgical exposure of the diaphragm in vascular surgery. The need to expose the aorta both above and below the diaphragm requires an extended incision spanning the left thorax to the abdomen, the length and exact location of which depends on the location of the targeted aortic pathol­ ogy. Often, the diaphragm must be divided, necessitating an awareness of the regional anatomy as well as various surgi­ cal management considerations.

•

•

DIFFERENTIAL DIAGNOSIS •

•

�

Thoracoabdominal aneurysm: The Crawford classifica­ tion categorizes thoracoabdominal aneurysms accord­ ing to the extent of the aneurysm and is the most widely used 1 ( FIG 1 ) . The classification is as follows : type I, from the left subclavian artery to j ust above the renal arteries; type II, from the left subclavian artery to the infrarenal aorta; type III, from the mid-descending thoracic aorta to below the renal arteries; type IV, from the diaphrag­ matic aorta to the iliac bifurcation; and type V (modified classification by Safi et aJ.2 ) : from the mid-descending thoracic aorta. Descending (type B) aortic dissection: Two classifications systems are commonly used to describe the extent of aortic dissections ( FIG 2 ) . Stanford type A dissections involve the ascending aorta with or without involving the descending aorta, whereas type B dissections only involve the descend­ ing aorta beyond the left subclavian artery. The DeBakey classification includes type I, which involves both the ascending and descending aortas; type II, which involves only the ascending aorta; and type III, which involves only the descending aorta.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

Ill

II

FIG 1

•

•

Most patients who are referred for surgery for a thoracoab­ dominal aneurysm present with no symptoms. However, when they do have signs and/or symptoms, they may present with pain in the chest, abdomen, or lower back; a mass in the abdo­ men, which may be pulsatile, or rigid abdomen; and evidence of atheroembolism distally. The aforementioned symptoms, with signs of hypovolemic shock, may indicate a ruptured aneurysm. Uncomplicated descending aortic dissections are generally managed medically. However, if the dissection is compli­ cated, such as when it is associated with significant symp­ toms or leads to visceral or distal malperfusion, rapid surgical intervention is warranted. A more complete discussion regarding indications for interven­ tion in aortic dissections and thoracoabdominal aortic aneu­ rysm can be found in a number of relevant reference textbooks.

Imaging is used to determine the proximal and distal extent of repair required. It impacts the type of exposure required (i.e., thoracotomy vs. laparotomy vs. thoracoabdominal incision) as well as the level of incision. If the exposure is for the repair of thoracoabdominal aortic pathology, all patients require adequate preoperative imag­ ing, ideally consisting of a computed tomography aortography (CTA) with or without 3-D reconstruction. Magnetic resonance aortography (MRA) may also provide the necessary informa­ tion, but this generally requires more time, is more expensive, and requires more extensive postprocessing. However, MRA is the study of choice when CTA is contraindicated or unsafe, such as in patients with a contrast allergy or renal insufficiency. Catheter-based invasive aortography has generally been sup­ planted by CTA and MRA as the primary preoperative imaging

V I

v

Mod ified Crawford c l a ssificati o n .

192 1

1 922

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

•

• •

Assess the need for spinal cord protection, including the use of lumbar drainage of cerebrospinal fluid ( CSF), distal aortic perfusion, epidural cooling, and distal aortic perfusion. Given the expected amount of blood loss, a Cell Saver and rapid infuser should be available. Double lumen endotracheal tube should be used for single­ lung ventilation of the right lung. Bronchial blockers are not reliable adjuncts for this purpose.

Positioning •

II

DeBakey A

Stanford

FIG 2

•

•

•

Ill B

Stanfo rd/DeBa key cl assificat i o n .

•

Initially, place the patient supine on a deflated beanbag (FIG 3). Roll the left chest upward and toward the right and place a shoulder roll under the right axilla and a bump under the left scapula while also gently pulling and securing the right arm over to the right side. Ideally, the upper back should be rotated about 60 degrees to the table with the pelvis remaining flat, such that the trunk is twisted to the right. Position the patient with the break located halfway between the left costal margin and the left iliac crest. Jackknife the table and then inflate the beanbag. Be sure to support and secure the arms ( "airplane" splint for the left arm) and pad all pressure points on the body and extremities. Prep the left chest with the following boundaries: the axilla superiorly, the spine posteriorly, and the sternum and abdo­ men beyond the right of midline anteriorly. Keep the groins in the field for surgical access to the femoral vessels for pos­ sible cannulation if necessary.

modality o f choice, as i t i s more cumbersome and does not pro­ vide a complete assessment of the aneurysm, including throm­ bus volume and adjacent anatomic structures. If the surgery is elective, as in the case of an incidentally found aneurysm, extensive preoperative evaluations are nec­ essary to minimize postoperative morbidity and mortality. Thorough evaluations of the cardiac, pulmonary, and renal sys­ tems are necessary, especially because these systems are most commonly affected when there are complications. Depending on the risk factors and prior history, further testing may be re­ quired and patients should be referred to appropriate specialists for proper evaluation. A good neurologic evaluation is also war­ ranted, particularly if the patient has a prior history or symp­ toms suggestive of a lower extremity weakness or spinal injury.

SURGICAL MANAGEMENT Preoperative Planning •

Determine the possible need for adj uncts such as cardiopul­ monary bypass and neurophysiologic monitoring. In some instances, pulmonary artery catheters may be warranted for monitoring cardiovascular hemodynamics.

PLANNING THE INCISION •

T h i s c h a pt e r d e a l s w i t h d i sta l t h o r a c i c a o rt i c p a t h o l ­ ogy req u i r i n g e x p o s u r e of t h e d i a p h ra g m w h e re a s i m ­ p l e t h o ra coto m y i n c i s i o n wo u l d n ot b e a d e q u at e . S u c h m o re l i m ited p a t h o l o g i e s a re d e s c r i b e d e l se w h e r e .

FIG 3

•

•

Positi o n i n g .

The p roxi m a l extent of the path o l ogy a n d the a ntici­ pated location of the p roxi m a l clamp determ i n e t h e l evel of the t h o ra c i c port i o n of the i n c i s i o n . • If the p roxi m a l c l a m p is to be p l aced between the a o rtic a rch a n d j u st beyond the l eft s u bclavian a rte ry, the ch est is e ntered through the 4th or 5th i ntercos­ tal spaces (e . g . , Crawford types I l l and V a n e u rysms) .

C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M

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•

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If t h e p rox i m a l c l a m p is to be p l aced j u st a b ove or at the d i a p h ra g m , the 8th or 9th i nterspace s h o u l d be ente red (e . g . , Crawford type IV a n e u rysms). Consider the possi b l e use of p a ra l l e l or " d o u b l e " t h o ra­ coto my i n cisions if expos u re of both the proxi m a l a n d d ista l extent o f the thoracic a o rta i s needed. I n t h i s case, the s k i n i n c i s i o n i s p l aced between the l evels of the two i nterspaces a ntici pated to be e ntered . The l e n gt h a n d locat i o n of a b d o m i n a l i n c i s i o n is deter­ m i ned by d i sta l extent of the a o rtic pathol ogy. • A mod ified t h o racoa bdom i n a l i n c i s i o n that does n ot exte n d to m i d l i n e is a d e q u ate if l i m ited exposu re of the a b d o m i n a l a o rta to the level of the ce l i ac a rtery is req u i red. • Exte n d the i n c i s i o n to the m i d l i n e for exposure of the viscera l a o rt a . • The i n c i s i o n s h o u l d be exte nded down the a b d o m i ­ n a l m i d l i n e f o r m o re extensive exposu re of the i n ­ fra re n a l a bdom i n a l a o rta (types I I , I l l, a n d IV) to t h e a o rtic b ifu rcation o r com m o n i l i a c a rteries (FIG 4).

External oblique muscle

Serratus anterior muscle

I nternal oblique muscle

Costal margin

FIG 4

THE INITIAL INCISION AND EXPOSURE

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•

•

•

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M a rk w h e re t h e i n ci s i o n is to be m a d e i n c l u d i n g f i n d i n g the a p p ro p r i ate i nterspace a n d the extent o f the a b d o m ­ i n a l i n c i s i o n a s described e a r l i e r. Sta rt with the t h o racic i n c i s i o n ove r the a p p ropriate i nterspace and then exte nd it across the costa l m a rg i n . Depe n d i n g o n t h e deg ree o f t h e a b d o m i n a l exposu re re­ q u i red, exte nd this i n c i s i o n o b l i q u ely to the m i d l i n e of the a b d o m e n . The m i d l i n e i n c i s i o n can t h e n be extended to the l evel of the symphysis p u b is, if n ecessa ry. The a b d o m i n a l i n c i s i o n is carried t h r o u g h the su bcutane­ ous tissu es, the exte r n a l a b d o m i n a l o b l i q u e a p o n e u rosis, and t h e a nterior rectus sheath.

• •

•

ABDOMINAL EXPOSURE • •

Deve l o p the a b d o m i n a l port i o n of the i n c i s i o n before entry i nto the l eft p l e u r a l cavity The a o rta may be exposed by an extra perito n e a l or trans­ perito n e a l a p proa c h . • Extra perito n ea l : T h i s a p p roach is i d e a l for repa i r i n g t h o racoa bdom i n a l a n e u rysms, especia l ly t h ose i n volvi n g the u p p e r a b d o m i n a l a o rta (FIG S) . Deve l o p the p l a n e between the tra n sversa l i s fasc i a a n d the pariet a l perito n e u m .

•

•

•

Thoracoabd o m i n a l i n c i s i o n .

S p l it the exte r n a l a b d o m i n a l o b l i q u e m uscle i n the d i rec­ t i o n of its fi bers. Divide t h e u n d erlyi n g i nternal o b l i q u e a n d t ra n sversus a b d o m i n u s m u scles between the cost a l m a r g i n and lat­ e ra l edge of the rectus sheath. Divide l eft rectus m uscle . The t h o racic i n c i s i o n s h o u l d p rovi de a d e q u ate exposu re posteriorly and s h o u l d be exte nded to the e rector s p i n a e fasc i a . Expose the i ntercosta l m u scles by i nc i s i n g t h r o u g h the su bcuta neous tissues a n d the exte r n a l o b l i q u e fasc i a .

Sepa rate the perito n e u m f r o m the l atera l a n d poste r i o r a b d o m i n a l wa l l s as we l l as from t h e d ia p h ra g m superio rly. Tra nsperito n e a l : T h i s a p proach provides better expo­ s u re for visce r a l a rtery revascu l a rization when req u i red, espec i a l l y when bypass i s req u i red to t h e right ren a l a rte ry. Ad d i t i o n a l deta i l s of these a p p roaches can be fo u n d e lse­ w h e re and a re beyo n d the scope of t h i s cha pter.

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• Abdom i n a l a o rtic exposu re via extra perito n e a l a p p roach.

FIG S

THORACIC EXPOSURE • • •

•

Deve l o p a p l a n e su perfi c i a l to the r i bs a n d i ntercosta l m uscles. H o l d venti lation to the l eft l u n g a n d a l low it to co l l a pse. E nter the l eft ch est by open i n g the i ntercost a l space a l o n g the s u p e r i o r edge of the lower r i b, m a k i n g s u re not to i n j u re the l u ngs. To maxi m i ze t h e exposu re, it may be n ecessa ry to per­ form a s u b p e r i oste a l resect i o n of t h e r i b a bove o r below the i nterspace entered, depen d i n g o n t h e target l ocat i o n .

•

•

• •

Ad d it i o n a l exposure can be o bta i n ed from " n otch i n g " a n adjacent r i b . T h i s is acco m p l ished b y exc i s i n g a 2-cm seg ment of t h e rib poste r i o r l y If t w o i nterspaces a re b e i n g entered, deve l o p a n ad­ e q u ate plane a nterior to the ribs. The s k i n a n d ove r l y i n g m uscles ca n be retracted to acco m m odate b o t h thoracic i nterspace exposures. Use a self-reta i n i n g retractor to m a i nta i n exposu re . Be awa re that there ca n be extensive adhesions with i n t h e p l e u ra that m a y pred ispose t o l u n g i n j u ry. U s u a l ly, these ad hesions can be m o b i l ized b l u ntly if t h i n but may need bovie ca ute ry o r scissors if m o re su bsta nti a l .

EXPOSURE AND DIVISION OF THE DIAPHRAGM •

• •

Release a n y ad hesions that may be p rese nt, m o b i l ize the lung by dividing the i nfe r i o r p u l m o n a ry l i g a m e nt, and retract the lung ce p h a l a d to expose t h e d i a p h r a g m . N ext, j o i n the l eft t h o racic cavity a n d the retro perito­ n e u m o r a b d o m e n by d ivid i n g the d i a p h ra g m . The diaphragm can be i ncised partia l ly or completely (FIG 6). • Part i a l i n c i s i o n : I ncise the m uscu l a r portion of the d i ­ a p h ra g m a n d p rese rve the centra l te n d i n o u s port i o n . T h i s a p p roach m i n i m izes respi ratory co m p l ications. • Co m p l ete d i v i s i o n : T h i s a p p roach p rovides the best exposu re of the a o rta. T h i s exte nds the i n c i s i o n from the d ivided costa l m a r g i n to the a o rtic h i atus. Divi­ s i o n ca n be acco m p l ished either rad i a l l y o r c i rcu mfer­ enti a l ly. B e s u re to leave a p p roxi m ately 2 to 3 em of d i a p h ra g m from the i ntern a l costa l m a rg i n to a i d i n t h e l ater c l o s u re o f d ia p h ra g m . T h e c i rcu mferenti a l a p p roach a lso theo retica l l y m i n i m izes d i s r u pt i o n of the p h re n i c n e rve a n d is g e n e ra l ly p refe rred .

FIG 6

•

Division o f t h e d i a p h ra g m .

C h a p t e r 1 4 EXPO S U R E A N D O P E N S U R G I CAL MANAG E M E N T AT T H E D I A P H RA G M

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CLOSURE • •

•

After co m p l et i o n of the core s u r g i ca l p roced u re, close the d i a p h ra g m . Ta ke patient o u t o f fl exed position a n d c l ose t h e d i a­ p h r a g m with heavy ru n n i n g suture.

•

1 92 5

P l a ce ch est tu bes . Rea p p roxi m ate the i nterspace with m u lt i p l e s i m p l e o r fig u re-of-e i g h t heavy (no. 1 ) n o n a bsorba b l e suture. C l ose t h e incision i n l ayers, i n c l u d i n g the m u scle with ru n n i n g Vicryl as we l l as the deep dermal layer. Close the skin with su bcutic u l a r sutu res o r sta ples.

PEARLS AND PITFALLS I n d icat i o n s

•

Preo perative CTA or M RA is m a n d atory to dete r m i n e the suita b i l ity of the a o rtic pathol ogy for s u r g i ca l repa i r.

P l a cement of i n c i s i o n

•

The p l acement of the i n ci s i o n s h o u l d be ca refu l ly considered preoperatively based o n i m a g i n g a n d the exte nt o f the pathol ogy. A s i n g l e thoractomy i n c i s i o n can b e p l aced even if two i ntercos­ tal spaces need to be entered . To m i n i m ize morbid ity, beg i n with a s m a l l e r i n c i s i o n because it can a l ways be exte nded w h e n n ecessa ry.

I nj u ry to p h r e n i c

•

A c i rc u m fe renti a l d ivision of the d i a p h ra g m can p rovi de the best exposure w h i l e a l so m i n i m i z i n g the risk o f i n j u ry to the p h re n i c n e rve.

C l o s u re

•

When carryi n g out a c i rcu mfrent i a l d ivision of the d i a p h ra g m , leave 2 to 3 em of d i a p h r a g m f r o m the i ntern a l costa l m a rg i n for t h e repa i r of the d i a p h ra g m when closi n g .

POSTOPERATIVE CARE • • •

• •

Monitor in the surgical intensive care unit as necessary for the extent of the aortic reconstruction required. Remove chest tubes when drainage is adequately low. Continuous spinal cord protection and neurologic monitor­ ing immediately postoperatively; continue CSF drainage for -3 days. Follow-up imaging with CTA to establish a baseline Standard postoperative incision and wound care

OUTCOMES •

•

It is proposed that pulmonary dysfunction associated with thoracoabdominal aortic surgery is to a large part associated with diaphragmatic dysfunction. Stickley and Giglia3 recom­ mend a new technique using a gastrointestinal stapler to di­ vide the diaphragm. This technique is proposed to be "rapid, hemostatic, and aids with reapproximation at the completion of the case" and that "this method of diaphragm division is quicker and less traumatic and has the potential to decrease the incidence of postoperative pulmonary dysfunction. " Huynh et al.4 conclude that renal failure, spinal cord deficit, and pulmonary complication were the major determinants of length of stay (LOS) in patients for thoracoabdominal aortic aneurysm (TAAA) repair. Their study has shown that the preservation of diaphragmatic function and the use of the adj unct distal aortic perfusion and CSF drainage may reduce hospital LOS.

COMPLICATIONS • • • • • • • • •

Bleeding; take back Phrenic nerve palsy or paralysis Diaphragmatic hernia Pulmonary complications, respiratory failure Wound complications Paralysis; spinal cord ischemic inj ury, associated with thora­ coabdominal aortic surgery Stroke/transient ischemic attack (TIA), associated with tho­ racoabdominal aortic surgery Multiorgan failure, associated with thoracoabdominal aor­ tic surgery Death, associated with thoracoabdominal aortic surgery

REFERENCES 1.

Crawford ES, Crawford JL, Safi HJ, et a!. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining imme­ diate and long-term results of operations in 605 patients. J Vase Surg. 1 9 8 6 ; 3 ( 3 ) : 3 8 9-404. 2. Safi HJ, Winnerkvist A, Miller CC III, et a!. Effect of extended cross­ clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 1 9 9 8 ;66(4): 1204-1209. 3 . Stickley SM, Giglia JS. Novel use of a gastrointestinal stapler for dia­ phragm division during thoracoabdominal aortic exposure. Ann Vase Surg. 2 0 1 3 ;2 7 ( 5 ) : 6 8 9-69 1 . doi: 1 0 . 1 0 1 6/j . avsg.20 1 2. 1 1 .005. 4. Huynh TT, Miller CC III, Estrera AL, et a!. Determinants of hospital length of stay after thoracoabdominal aortic aneurysm repair. J Vase Surg. 2002;35 ( 4 ) : 648-653.

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Chapter

15

Retroperitoneal Aortic r

Exposure

r

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responses (hives, rash) may be successfully tempered by pre­ medication with steroids and antihistamines, depending on the relative indication for contrast administration and the patient's overall medical condition. Adverse effects of intravenous or intraarterial contrast administration on creatinine clearance may be partially ameliorated by preprocedural oral or in­ travenous hydration and administration of N-acetylcysteine (Mucomyst) . Although sometimes considered a reasonable alternative under these circumstances, gadolinium-based con­ trast administration for magnetic resonance arteriographic in­ dications is also contraindicated in patients with a creatinine clearance less than 60 mL per minute. When contrast admin­ istration is absolutely out of the question, CT images acquired without contrast may provide adequate anatomic imaging to proceed with surgery, with the caveat that anomalies such as a retroaortic left renal vein may be present and unrecognized until exposed at surgery.

IMAGING AND OTHER DIAGNOSTIC STUDIES General Considerations •

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•

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Retroperitoneal aortic exposure may be desirable for a variety of vascular conditions, including abdominal aortic aneurysms, aortoiliac occlusive disease, and mesenteric or left renal artery occlusive disease. Retroperitoneal exposure may be preferred for patients with a hostile abdomen from previous intraabdominal infection, surgery, or radiation. Compared with transabdominal aortic exposure, retroperi­ toneal exposure may be associated with shorter postopera­ tive ileus, decreased pulmonary complications, decreased pain, and lower incidence of late complications including small bowel obstruction or aortoenteric fistulae. 1 Retroperitoneal aortic exposure can be converted, when necessary, to thoracoabdominal exposure with excellent visualization of the superior mesenteric artery (SMA), left renal artery, celiac axis, and descending thoracic aorta.2 Examination of intraabdominal contents is possible through a retroperitoneal approach by simply opening a peritoneal window as necessary.

SURGICAL MANAGEMENT Instrumentation •

Preoperative Imaging •

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•

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•

Prior to aortic reconstruction, detailed anatomic imaging derived from modern, multirow detector computed tomo­ graphic arteriography ( CTA) will greatly facilitate surgical planning. Image acquisition should extend from the normal proximal aorta to the common femoral artery bifurcations bilaterally. Runoff imaging may also aid decision making depending on clinical circumstances. Data derived from submillimeter imaging slices may be read­ ily reformatted into multiplanar and 3-D reconstructions, with excellent resolution of the peripheral mesenteric and renal vasculature. Noncontrast images should also be obtained to help assess the degree of mural calcification present in diseased proxi­ mal aorta. Recognition of extensive mural calcification may modify the location chosen for clamp placement, or prohibit safe clamping entirely in diseased segments. CTA may require larger contrast dose than that required for catheter-based contrast aortography. Contrast volumes re­ quired for CTA may be reduced significantly by modifying the field of view or imaging parameters required for the pro­ cedure. Consultation with the responsible radiologist will ensure optimal imaging of the necessary arterial anatomy with minimal contrast and radiation exposure. Contrast-based aortography, either CT or catheter-based, may be contraindicated for patients with reduced creatinine clear­ ance or an anaphylactic reaction to contrast. Milder allergic

1926

�

Ma tth e w Mel/

In addition to standard vascular instrumentation, additional equipment may aid in exposure of the aorta and its visceral branches from the retroperitoneal approach: Beanbag and airplane for positioning A fully articulated operative table, capable of flex and reflex at the level of the umbilicus Self-retaining, table-mounted retractor (e.g., Bookwalter, Omni, or other) Finochietto chest retractor Nos. 3, 4, and 5 Fogarty occlusion balloons Cold renal perfusion Arterial cannulas for renal perfusion

Positioning •

The patient is placed supine on a beanbag and all lines and tubes are placed. For exposure of the infrarenal aorta and iliac arteries, the left shoulder is lifted and protected with the beanbag and padding. The left arm can be abducted or ro­ tated to the patient's right with a padded airplane retractor for support. The table break and the kidney bar are used to open up the retroperitoneal space between the 1 2th rib and the iliac crest as the incision is developed. For this reason, it is essential that the patient be positioned with the umbi­ licus on the table break. An oblique incision is made from below the umbilicus to the tip of the 1 1th rib. With this loca­ tion, the incision can be extended into the 1 Oth intercostal space and the chest entered if additional proximal exposure is required ( FIG 1 ) . When additional iliac artery or pelvic ex­ posure is anticipated, the incision should be initiated distal to the umbilicus. Either way, in patients with considerable

C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E

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I I I I

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1 92 7

abdominal girth and redundant pannus, landmarks should be confirmed to ensure that the incision is not placed too far distally on the abdomen, as j uxtarenal aortic control can be extremely difficult when the incision is placed too far distally on the abdomen. For thoracoabdominal exposure, the patient is placed in the right lateral decubitus position using a beanbag and axillary role for support. The left arm is protected with adequate padding and an airplane-type retractor. It is important to secure the left arm such that the scapula rolls anteriorly, providing exposure of the posterior lateral chest. The inci­ sion will be made overlying the 8th intercostal space and extended toward the umbilicus.

• Patient position fo r t h o racoabd o m i n a l exposure with i n c i s i o n i n the 8th i ntercosta l space (dotted l i ne). Positi o n i n g is s u p p o rted with a bea n b a g and r i g h t axi l l a ry ro l l .

FIG 1

•

•

•

The i n c i s i o n is carried t h r o u g h the exte r n a l o b l i q ue, i ntern a l o b l i q ue, and tra n sversus a b d o m i n i s m uscles. The retroperito n e a l space is then entered l atera l ly near the tip of the 1 1 th rib by identifyi n g the cha racte ristic yel­ l ow p reperito n e a l fat. The retroperito n e a l space is then deve loped from l atera l to m ed i a l using a sponge stick o r h a n d s for blunt d issect i o n . Ante r i o rly, the perito n e u m t e n d s to be m o r e ad h e rent at the level o f the rectus sheath; ca re s h o u l d be taken to avo i d enteri n g the peri­ tonea l cavity i n t h i s a re a . The psoas fascia i s encou ntered as the d issect i o n is deve loped posteriorly in the cou rse of t h i s d i ssection, w h i c h leads d i rectly to t h e l eft i l iac vesse l s a n d u reter. D i ssect i o n is conti n u e d p roxi m a l ly a nterior to the u reter; the u reter is either l eft in situ to l i m it i n j u ry or gently retracted m ed i a l ly with s i l astic s l i n g s as the ret­ roperito n e a l space is deve l o ped. S u pe r i o rly, the kid ney is identified as the d issect i o n i s cont i n ued a nterior to G e rota's fasci a-a potenti a l space exists between desce n d i n g co l o n and G e rota's fascia in the retro perito n e u m , which is p rog ressive ly deve loped in a ce p h a l a d d i rect i o n from the psoas m uscle, adjacent to t h e a o rta. O n ce the re n a l ve i n is visu a l i zed i n this spa ce, the superior m a r g i n of the d issect i o n is co m p l ete. If su prare n a l a o rtic control a n d exposu re is req u i red, t h i s same d i ssect i o n p l a n e s h o u l d be deve l oped poster i o r to the k i d n ey, e l evat i n g the kid ney a n d u reters a l o n g with the perito n e a l contents and retract i n g all to t h e right to expose the s u bd i a p h ra g matic visce ral a o rta. Se lf-reta i n i n g retracto r syste m s a re best d e p l oyed ei­ t h e r afte r t h e psoas m u scle i s i d e ntified o r fo l l owi n g exposure o f t h e re n a l ve i n o r e l evat i o n of t h e l eft k i d -

•

n ey. D e p loyi n g t h e retracto r system e a r l i e r w i l l i nterfere with the d i ssect i o n n ecessa ry to access the a p p ro p r i ate retroco l i c space. F o l l o w i n g p l a c e m e n t of the i n it i a l pad­ ded retractor blade along t h e m ed i a l m a rg i n of t h e w o u n d , ci rcu mfere n t i a l retract i o n i s secu red by p l a ce­ ment of a d d i t i o n a l b l a d es, typica l ly o p posite each oth e r to p revent u n d u e t e n s i o n o n t h e retract i o n system, with seq uenti a l replacement with deeper b l a d e s and a d d i ­ t i o n a l retract i o n u n t i l t h e e n t i re p e r i a o rt i c retro pe rito­ neum i s exposed . The a o rta a n d i l i a c a rteries a re then d i ssected free of su rrou n d i n g tissue. C i rcu mferenti a l a o rtic control is a n essenti a l safety element o f a l l a o rtic procedu res, a n d care s h o u l d be taken to gently and patiently create a space betwee n the i nfe r i o r ve n a cava (IVC), a o rta, and verte­ bra l bodies poste riorly to pass an u m b i l ical tape a r o u n d the a o rta with a rig ht-a n g l e c l a m p . C i rcu mferenti a l c o n ­ trol of the co m m o n i l iac a rteri es, o n the o t h e r h a n d , is not n ecessary i n all circumstances. S uffi cient m ed i a l a n d l atera l d issect i o n to a l low f o r p l acement o f a Wyl i e hy­ pogastric c l a m p a r o u n d the co m m o n i l iac a rtery w i l l usu­ a l ly suffice. Avo i d a n ce of atte m pts at c i rcu mfere n t i a l i l i ac control will reduce the risk of r i g h t i l i a c ve i n i n j u ry. When c i rcumferenti a l control is req u i red, patience is n eces­ sa ry to g ra d u a l l y sepa rate the r i g h t co m m o n i l i a c a rtery from the d i sta l IVC a n d l eft common i l iac ve i n . When a ve n o u s i n j u ry is encou ntered d u r i n g t h i s m a n e u ver, d ivi­ s i o n of the co m m o n i l i ac a rte ry may be n ecessary to g a i n a d e q u ate exposu re f o r contro l . Alternative ly, a n occ l u ­ s i o n ba l l oo n may be i ntrod uced f r o m the right c o m m o n fe m o ra l o r exte r n a l i l i ac ve i n s w i l l t a m p o n a d e the ve n o u s

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

•

•

b l eed i n g u n t i l sufficient expos u re is g a i ned to repa i r t h e wo u n d . F i n a l ly, a cove red se lf-expa n d i n g endog raft may a lso be d e p l oyed over a w i re to g a i n contro l . Ag a i n, readj ustment of the retractor syste m with each consecu­ tive sta g e of exposure w i l l o pt i m ize o perative effi ciency. Freq uently, to opti m i ze d ista l exposu re, the p roxi m a l re­ tractor b l a d es need to be tempora r i l y rel axed a n d vice versa. T h i s exposu re provides a d e q u ate exposu re to the i nfrare­ nal a o rta (and i nfe r i o r mesenteric a rtery if re i m p l a ntat ion is a ntici pated), r i g ht a n d l eft co m m o n a n d l eft exte r n a l i l i ac a rteries. The r i g ht exte r n a l i l iac a rtery is n ot we l l visua l i zed from t h i s a p p roach, a l t h o u g h tu n n e l i n g t o the right fem o r a l a rtery is read i l y a c h i eved for a o rtofe m o r a l bypass g raft i n g when n ecessa ry. Ca re s h o u l d be t a k e n to deve l o p the t u n n e l i m med iately a nterior to t h e i l i a c a rteries to a v o i d i nj u ry to the r i g h t u rete r o r tra p p i n g the u reter betwee n the g raft limb a n d adjacent a rte ry. When right exte r n a l i l i a c a rtery exposure i s req u i red d u ri n g a l eft retrope riton e a l exposu re, a cou nteri ncision may a lso be p l aced in the r i g h t lower q u a d ra nt, a lt h o u g h patient positi o n i n g a n d retractor syste m p l a cement may l i m it the potenti a l use of t h i s m a n e uver. For p roced u res req u i ri n g m o re proxi m a l , viscera l a o rt i c exposu re, the latiss i m u s dorsi i s identified a n d d i ssected from su rrou n d i n g s u p e rfi c i a l and deep tissues and re­ tracted l atera l ly. The 8th i ntercosta l space is opened pos­ teriorly to the parasp i n a l m uscles and a nteriorly to the costa l m a r g i n , w h i c h is d ivided. As the retroperitoneal space is deve loped, the perito n e u m is b l u ntly sepa rated from the i nfe r i o r su rface of the d i a p h r a g m . The d i a­ phragm is d ivided i n a ci rcumferenti a l m a n n e r 1 to 2 em from its atta c h m e nts to the ch est wa l l to avo i d i n j u ry to the p h r e n i c n e rve (FIG 2) . The m e d i a n a rcuate l i g a ment is i d e ntified a n d d ivided. Prox i m a l a o rtic control can n ow be obta i n e d u n d e r d i rect vision, a g a i n fo l l ow i n g strate­ g i c p l a cement of self-reta i n i n g retractor b l a des, t a k i n g ca re to identify a n d a v o i d i n j u ry to the eso p h a g us.

• The d i a p h ra g m is i n cised c i rcu mferenti a l ly (d otted l i ne) to p rotect the p h re n i c n e rve a n d t h e reby preserve d i a p h ra g matic f u n ct i o n . A o n e-to two cent i m eter cuff of d i a p h ra g m is l eft attached to the ch est was to a i d e in closure.

FIG 2

•

D i ssect i o n of t h e p l a n e poste r i o r t h e G e rota's fascia a l l ows for expos u re of t h e l eft renal a rte ry, which i s a n i m p o rt a n t l a n d m a r k i n f u rt h e r d i ssect i o n of t h e vis­ cera l a o rt a . O n ce t h e o r i g i n of t h e l eft renal a rtery i s i d e ntified a n d t h e m e d i a n a rcuate l i g a m e n t h a s b e e n d iv i d e d , t h e v i scera l a o rta a n d o r i g i n s of t h e c e l i a c a x i s a n d S M A ca n be i s o l ated with s h a r p d i ssect i o n . W i t h t h e l eft k i d n ey rotated a nt e r i o r ly, t h e S M A c a n be exposed over a d i st a n ce of a p p ro x i m a t e l y 5 em (FIG 3) .

• Exposu re o f the viscera l a o rta with the l eft k i d n ey l i fted to expose the l eft renal a rtery a n d the entire poste r i o rlatera l a o rta. N ote that the l eft re n a l ve i n ro l ls off t h e a o rta.

FIG 3

C h a p t e r 1 5 RETROPERITONEAL AORT I C EXPOS U R E

A d d i ti o n a l exposu re c a n be o bta i n e d by rotat i n g t h e k i d n ey poste r i o r to expose t h e S M A a s it cou rses b e h i n d t h e p a n c reas (FIG 4). Fol lowing vascu l a r repa i r, the retro perito n e a l space s h o u l d be i n spected fo r hem ostasis. The u reter s h o u l d be i n s pected, and any suspected i n j u ry o r leak ca n be i n ves­ tig ated with i ntrave n o u s methyl e n e b l u e . If needed, the perito n e u m can be opened for i nspect i o n of a b d o m i n a l contents. Remov i n g t h e ta b l e break or lowe r i n g the k i d n ey bar if used will a i d i n a p p roxi m a t i n g tissue l ayers without tension. If d ivided, the d i a p h ra g m can be rea p p roxim ated with a cont i n u o u s ru n n i n g a bsorba b l e suture. The suture can be secu red at t h e a nterior costa l m a r g i n and w i l l h e l p a p p roxi m ate these structu res a s we l l . If t h e t h o rax was entered, a l a rge-bore ch est tube i s p l aced dependently a n d secured w i t h U stitches. A l a rg e B l a ke or Jackson-Pratt d r a i n can be p l aced in the retroperito n e a l space to avo id early posto perative f l u i d co l l ections. The m uscu l a r l ayers a re cl osed with cont i n u o u s a bsorb­ able sutu res and the s u bcuta neous tissue and skin c l osed with sta n d a rd tec h n i q ues.

•

•

•

• •

•

1 929

FIG 4

• Exposu re of the viscera l a o rta with the l eft k i d n ey l eft in situ. T h i s a p p roach a l l ows for a d d i t i o n a l exposu re of the p roxi m a l s u p e r i o r mesente ric a rtery.

PEARLS AND PITFALLS •

Choosi n g the m ost a p p ro p r i ate p roced u re for a n y g iven patient with m esenteric or re n a l a rtery occ l u sive d i sease is dependent o n a m u ltitude of factors, especia l ly w i t h the w i despread ava i l a b i l ity of percuta neous i nterventions. Open surgical p roced u res c o n ­ t i n u e to rem a i n a n exce l lent a ltern ative f o r patie nts with m u ltivessel d i sease, with coexist i n g a o rto i l i ac occ l u sive o r a n e u rysm a l d i sease, a n d with d isease too extensive t o b e adeq uately treated with wi re-based tec h n i q ues. When select i n g from t h e va riety of open p roced u res, patient comorbid ity, body h a b itus a n d its i m pact on a d e q u ate exposu re, q u a l ity of the i nflow a n d outflow ves­ sels, a n d a b i l ity to safely c l a m p vessels s h o u l d a l l be taken i nto co n s i d e rat i o n . Havi n g a work i n g knowledge of a l l a lternatives is i m porta nt, as occa s i o n a l ly, i ntraoperative fi n d i ngs d i ctate a deviation from the preoperative p l a n .

•

I ntraoperative m a n a g e m e n t is s i m i l a r to t h a t f o r other abdom i n a l vascu l a r p roced u res. When the d issect i o n i s co m p l ete, patie nts a re g iven h e p a r i n at a dose of 1 00 u n its/kg prior to c l a m p i n g vessels, a c h i evi n g a ta rget activated clott i n g t i m e (ACT) of 200 to 250 secon d s . For cases where renal perfus i o n is i nterrupted, 0 . 2 5 to 0.5 g/kg of m a n n itol is g iven p r i o r to cross-c l a m p i n g . As soon as poss i b l e, the k i d n ey i s perfused with 300 to 400 m l of sa l i n e cooled to 4"C. T h i s may be d o n e at the ren a l a rtery ost i u m i m me­ d i ately after a renal e n d a rte recto my, o r d i rectly i nto t h e renal a rtery at the level of the d i stal a n a stomosis. Renal a rtery ca n n u l as, w h i c h come in a variety of si zes, a re used for perfu s i o n . U s i n g a size that m ost closely matches the d i a meter of the ren a l vessel assu res that the perfusate w i l l g o i nto the k i d n ey and not s p i l l onto the operative f i e l d .

•

When revasc u l a rization is co m p l ete, h e p a r i n is reversed w i t h p rota m i n e w h i l e checking for h e m ostasis. The patency of revascu­ l a rization may be checked with i ntraoperative d u p lex i m a g i n g . Confi rmation of a n a d e q u ate e n d p o i nt is especi a l ly i m porta nt w h e n e n d a rterectomy h a s been perfo rmed, as i n t i m a l f l a ps may p resent a s a d e l ayed vessel occ l u s i o n a n d end-organ l oss.

POSTOPERATIVE CARE •

In addition to the standard postoperative strategies for patients undergoing aortic surgery, including serial hema­ tocrit and hemoglobin, electrolytes, creatinine, and lactic acid, it is important to monitor renal and intestinal func­ tion. Patients undergoing renal revascularization commonly have an obligatory diuresis for the first 12 hours after sur­ gery. This phenomenon may be due to residual effects of operative mannitol as well as a response to transient renal

ischemia. During this time, urine output is not reflective of the patient's overall volume status, and crystalloid should be given at rates sufficient to maintain central filling pres­ sures. Also, serum creatinine should be serially measured. It is common for the serum creatinine to increase slightly in the first 1 or 2 postoperative days, but increases of more than 20% or 3 0 % warrant further investigation, especially if associated with oliguria. Sudden changes in renal function that are unexplained or unresponsive to corrective measures warrant duplex imaging to determine renal perfusion.

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Patients after mesenteric revascularization often develop hyperactive peristalsis, sometimes while the incision is still open. Under these circumstances, serial examination for bowel sounds in the first 24 hours can provide clues to the continued patency of the revascularization. Serial lactate levels are also checked. Although immediate postoperative lactate levels are elevated, they should return to normal as the patient is warmed and resuscitated. Coagulation param­ eters may also be elevated initially in response to blood loss and transient hepatic ischemia. These parameters should be monitored and corrected for active bleeding; normal values are usually present by the first postoperative day.

the anastomosis. Additionally, the anastomotic site should be chosen in a similar coronal plane to prevent kinking once the end organs assume their natural position. Injury during Endarterectomy •

COMPLICATIONS General Considerations •

•

As with all aortic surgery, potential complications after vis­ ceral artery revascularization include myocardial infarction, respiratory failure, and postoperative bleeding. Addition­ ally, renal failure is always a potential complication during visceral revascularization, although its incidence is low.3-5 Potential causes of renal failure include generalized hypo­ perfusion from cardiac dysfunction or hypovolemia, pro­ longed intraoperative ischemia, or thrombosis of the repair. Progressive or unexpected renal failure should initiate a prompt workup including duplex imaging of the kidneys to identify potentially treatable causes. Thrombosis with absence of flow to the kidney is generally irreversible unless identified immediately. Intestinal ischemia is the major concern after mesenteric revascularization. Signs and symptoms may include severe abdominal pain, continued acidosis, and hematochezia. Ischemia may be secondary to vessel or graft thrombosis or may result from distal embolization during or follow­ ing the repair. Patients with evidence of peritonitis should be promptly reexplored, and those treated initially for acute mesenteric ischemia should have a planned second look at 12 to 24 hours if there was any question of intestinal viabil­ ity at the time of the original operation. Arterial duplex may confirm the viability of the repair but cannot rule out embo­ lization as a cause for postoperative intestinal ischemia. At exploration, nonviable intestine can be resected, and issues with the revascularization can be addressed.

Graft or Vessel Twisting or Kinking •

When performing a bypass to the SMA, it is important to re­ tract the mesentery in a caudal direction to adequately assess graft length. Inadequate positioning will result in excessive graft length and potential kinking and thrombosis once the peritoneal contents are reduced to the abdomen and the inci­ sion is closed. Additionally, for retrograde bypass, the graft should be placed with enough slack to allow the distal end­ point to be in-line with the SMA with caudal retraction of the intestines. This positioning will prevent both kinking of the graft and tenting and narrowing of the anastomosis. Bypass to the renal arteries should similarly be constructed with appropriate graft length as it will lay in the retroperi­ toneum after retraction is released. For cases of arterial reimplantation, it is important to maintain orientation of the target vessel to prevent twisting during construction of

Identifying the appropriate endarterectomy plane is usually straightforward in the aorta, renal arteries, and SMA. The celiac artery can be challenging, as it may be thin-walled, and plaque removal may injure the arterial wall. Limited injuries can be repaired with interrupted 4-0 or 5-0 Prolene sutures supported with Teflon pledgers, but larger injuries or those with severely attenuated vessel walls may not be suc­ cessfully repaired with this technique. If the integrity of the artery is in doubt, it may be safer to transect it and perform a bypass from the aorta to the transected celiac artery using an 8 -mm or 1 0-mm graft. The celiac artery stump can be over­ sewn with pledgeted 3-0 Prolene suture placed into healthy aorta. Unacceptable endpoints after renal endarterectomy are best treated with conversion to a bypass.

Inadequate Distal Endarterectomy Endpoint •

•

Plaque extending to the infrapancreatic SMA may be dif­ ficult to entirely remove with standard thoracoabdominal exposure. Intraoperative duplex can confirm an adequate endpoint, and if there is any uncertainty, the abdominal cav­ ity can be entered and the SMA exposed by dividing the liga­ ment of Treitz. This maneuver will provide exposure of the SMA as it emerges from behind the pancreas, usually at a place distal to the diseased segment. Inspection by palpation or with duplex ultrasound can evaluate the repair. Incomplete endarterectomy or intimal flaps can be managed through an arteriotomy at this location. A reasonably sized SMA can be transected and the retained plaque removed; reapproxima­ tion with interrupted sutures will secure the intima distal to the endarterectomy. Exposing the endpoint in a smaller ves­ sel is most safely performed with a lateral arteriotomy and subsequent patch angioplasty closure to prevent narrowing. Problematic endarterectomy endpoints in the celiac artery or renal arteries may be best managed with placement of a bypass graft. Conversion to bypass will require enough ex­ posure of the target vessel to allow for revascularization dis­ tal to the diseased segment. Either end-to-end or end-to-side reconstruction is acceptable and should be performed, mak­ ing certain that the intima is secured with the suture line.

REFERENCES 1.

2. 3.

4.

5.

Leather RP, Shah DM, Kaufman JL, et al. Comparative analysis of retroperitoneal and transperitoneal aortic replacement for aneurysm. Surg Gyneeol Obstet. 9 8 9; 1 6 8 ( 5 ) : 3 8 7-39 3 . Mell MW, Acher CW, Hoch J R , et a l . Outcomes after endarterectomy for chronic mesenteric ischemia. ] Vase Surg. 2008;48 ( 5 ) : 1 1 32-1 1 3 8 . Kasirajan K , O'Hara PJ, Gray BH, e t al. Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and scenting. J Vase Surg. 200 1 ; 33 ( 1 ) :63-7 1 . Rapp JH, Reilly LM, Qvarfordt PG, e t a l . Durability of endarterectomy and antegrade grafts in the treatment of chronic visceral ischemia. J Vase Surg. 1 9 8 6 ; 3 ( 5 ) : 799-806. Wei bull H, Bergqvist D, Bergentz SE, et al. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vase Surg. 1 9 9 3 ; 1 8 (5 ) : 84 1-850; discussion 850-842.

I

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Chapter

16

Hybrid Revascul arization Strategies for Visceral/Renal Arteries

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

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�

Benja m in W Sta rn es

DEFINITION •

•

The term " hybrid" in vascular surgery traditionally refers to the use of both traditional open surgical and endovascular techniques for remedy of the vascular condition ( FIG 1 ) . Two hybrid approaches are described i n this chapter. Complete visceral debranching and endovascular tube graft repair Partial visceral debranching and physician-modified fenes­ trated endovascular repair

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

DIFFERENTIAL DIAGNOSIS •

Paravisceral aortic aneurysms may develop due to the following conditions: Degenerative aneurysm Aortic dissection Mycotic aneurysm Paraanastomotic j uxtarenal aneurysm Connective tissue disorders (Marfan's syndrome) Beh 7 mm) Location of left renal vein Aberrant anatomy (e.g., replaced right hepatic artery) Quality of gastroduodenal artery for possible celiac artery ligation or sacrifice Renal cortical thickness

Indications for repair include aortic aneurysms of more than 5 . 5 em, symptoms, or evidence of rapid expansion ( > 0 . 5 em per 6 months) .

Preoperative Planning •

As formal open repair would often include a bicavitary incision (chest and abdomen, as in a formal thoracoabdominal repair), the standard preoperative assessment should focus on the pa­ tient's fitness to undergo major vascular surgery. This includes assessment of heart, lung, and kidney function and reserve.

FIG 1 • " Hybrid repa i r " refers to the use of both trad iti o n a l open s u r g i ca l and e n d ovascu l a r tech n i q u es to m a n a g e the same p ro b l e m . S M A, superior m esenteric a rtery. A. I ntraoperative p h oto. B. Post operative CTA after co m p l eted repa i r.

193 1

1 932

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 2 • CTA axial i m ages d e p i ct i n g (A) a 7 .4-cm paraan asto motic j uxta rena l a o rtic a n e u rysm a n d (B) a hea lthy a o rtic seg ment in the reg i o n of the SMA. I

I I I I I I I ...

Positioning •

Proper and precise positioning should be as follows ( FIG 3 ) : Patient supine o n standard operating room table o r imaging table Hair properly clipped over entire abdomen and both groins Both arms tucked ( option to have right arm at 90 degrees if planning brachial access) Foley under one leg and padded

I

r "' I I I I I I I

FIG 3

•

Depict i o n of positi o n i n g a n d i ntended i n c i s i o n in the

m i d l i ne.

COMPLETE VISCERAL DEBRANCHING AND

•

ENDOVASCULAR TUBE GRAFT REPAIR­ STAGE 1 First Step-Exposure • •

•

•

Sta n d a rd m i d l i ne l a pa rotomy a n d positi o n i n g of retractor system U po n e ntry i nto the a bdomen, the fa l ciform l i g a m ent is d ivided between c l a m ps a n d l i g ated . The tria n g u l a r l i game nts a bove the l iver a re d ivided to fac i l itate a d e q u ate exposu re/retract i o n w h i l e m i n i m i z i n g risk of hepatic cap­ s u l a r i n j u ry, a ntici pati n g syste m i c a nticoa g u l at i o n l ater in the p roced u re . A nasogastric tube is positi oned in the sto mach to provide temporary deco m p ress i o n . The common hepatic a rtery is identified fo l l owi n g d ivision of the gastrohepatic l iga­ ment a n d traced back to origin of celiac a rtery. Once iden­ tifi ed, the ta rget a rtery is e n c i rcled with a si lastic vessel loop. Space is created a l o n g the l eft side of the a o rta with b l u nt/fi nger d i ssection, beg i n n i n g at the level of the ce l i a c a rtery, to create the retrograde bypass t u n n e l posterior t o the pancreas (FIG 4). The colon a n d omentum a re l ifted i n a ce p h a l a d d i rec­ tion, the s m a l l bowel swept to the patie nt's right a n d packed i n m o i st towe ls. Self-reta i n i n g retractors (Om n i o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to m a i nta i n exposu re, with ca re taken to a p propriately pad the retractor b l ades as n ecessa ry.

•

•

•

The t h i rd a n d fo u rt h port i o n s of the d u o d e n u m a re mo­ b i l ized to the right fo l l owi n g d ivision of the l i g a m ent of Tre itz, expos i n g the a nterior su rface of t h e a o rta. The in­ ferior m esenteric ve i n is l i g ated and d ivided a s we l l and the d i ssect i o n conti n u e d along the prox i m a l a o rta u n t i l the l eft renal ve i n is clearly identified (FIG S) . Widely m o b i l ize t h e l eft r e n a l ve i n s h a r p l y a n d e n c i rc l e w i t h a m o i st u m b i l i cal tape. The self-reta i n i n g re n a l ve i n retractor b l a d e is used t o retract t h e l eft re n a l vei n ce p h ­ a l a d a s necess a ry to fac i l itate f u rther exposure. The origin of the re n a l a rteries is identified by ca refu l posterol atera l d i ssection a ro u n d the aorta, j ust cep h a l a d o f the overlyi n g re n a l vei n . Exposure o n the r i g ht is com­ p l i cated somewhat by the overlyi n g i nfe rior ve n a cava/ l eft ren a l ve i n confl uence. At l east 2 em of re n a l a rtery s h o u l d be exposed b i l atera l ly. E n c i rcle the ren a l a rteries with s i l astic vessel loops. O n the l eft, finger d issect b l u ntly along the aorta i n a cep h a l a d fas h i o n to com p l ete the ret­ ropa ncreati c t u n n e l for the ce l i a c l i m b of the bypass g raft. The SMA is i d e ntified n ext by pa l pation with i n the base of the sma l l bowe l mesente ry, d i rectly a nterior to the pancreas. D o p p l e r u ltrasonography may assist identifi­ cation when the pu lse is fa i nt. O n ce id entified, a 3-cm seg ment of SMA is isol ated as p roxi m a l as possi ble to the root of the m esentery. B eg i n n i n g with the m i d d l e co l i c a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from the S M A as it e m e rges from the pancreas, u n dersco r i n g the n e e d for proxi m a l identification a n d isolat i o n . T h e S M A is contro l led w i t h vessel loops.

C h a pt e r 1 6

H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S

• D rawi n g of exposu re of the ce l i ac a rtery t h r o u g h the lesser sac. N ote the b l u nt f i n g e r d issect i o n a l o n g the l eft side of the a o rta a n d b e h i n d the pancreas.

FIG 4

•

T h e n ext step is t o prepare t h e d o n o r a rtery f o r hybrid by­ pass. The specific a rtery-m ost com m o n l y the com m o n or exte r n a l i l iac a rteri es-s h o u l d be sel ected from the p re­ ope rative i m a g i n g study. The retroperito n e u m is opened d i rectly over the sel ected d o n o r a rte ry, w h i c h is exposed w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r

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a rtery exposu re may be a c h i eved via m e d i a l-visce ral rota­ tion, deve l o p i n g the entire retro perito n e a l p l a n e o n the l eft. The l atte r a p p roach provides the added ben efit of exc l u s i o n of the g raft from the viscera a n d abdom i n a l contents o n c e the viscera a re retu rned to t h e i r orig i n a l posit i o n . T h i s m a neuver a d d s s i g n ificantly m o re t i m e to

Left renal vein

_..-L---'---

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I nferior mesenteric vein

I nferior mesenteric artery

FIG S • D rawi n g of exposu re of t h e l eft re n a l ve i n a n d a nterior su rface of the a o rtic a n e u rysm . Dashed line d e p i cts i ntended incision line to avo i d n ervi e r i g e ntes.

1 933

1 934

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

the case, h oweve r, a n d contri b utes to i ncreased b l ood loss. G raft cove rage can a l so be obta i n ed without deve l ­ o p i n g the e n t i re retroperito n e a l p l a ne, e i t h e r via d i rect t u n n e l i n g a l o n g the p refe rred cou rse of the g raft or cre­ ation of an omental tongue affixed d i rectly to the g raft .

Second Step-Anticoagulation •

System i c a nticoa g u lation is achieved with a bolus i njec­ tion of u nfractionated heparin, 50 u n its/kg . M o n itori n g activated clott i n g t i m e is a usefu l method of m a i nta i n i ng adequate a nticoa g u lation d u ri n g the p roced ure.

Third Step-Multivisceral Bypass •

• •

Trifu rcated g rafts exist for the pu rpose of fa c i l itati n g m u ltivessel hybrid revasc u l a r ization, b u t the u s e o f these a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e w h e n "squeezed " betwee n the outside l i m bs d u r i n g g raft rout i n g a n d a bdom i n a l closure. In m ost circumstan ces, a sta n d a rd 1 2 x 7 bifu rcated, co l l a g e n - i m preg n ated kn it­ ted po lyester g raft provides exce l lent condu its for b i l at­ e ra l renal revasc u l a rization, with a sepa rate 8-mm l i m b c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass g raft confi g u rations a re s h own in FIGS 6 and 7. The prox i m a l ( i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst with ru n n i n g 4-0 or 5-0 polypropy l e n e suture. The n ext a nasto mosis to be completed should be o n e an­ tici pated to be the tec h n ica l ly m ost d iffi cu lt, g iven expo­ s u re and g raft routi n g issues. M ost co m m o n ly, this is the right re n a l a rte ry. This is d ivided fo l l owing p l a cement of a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is

• Aortob i i l i ac a n d su bseq uent d e b ra n c h i n g for a patient with a sol itary l eft kid ney a n d i nfra renal a n e u rysm .

FIG 7

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FIG 6 • D rawi n g of a fou r-vesse l debra n ch i n g based off of the l eft co m m o n i l i a c a rte ry. N ote that the l eft renal ve i n was d ivided in t h i s case, a n d su bseq uently repai red, for bette r exposure of the r e n a l a rteries.

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p u l led t o l e n gth a n d a n a stomosed end-to-e nd with 5-0 polypropylene suture. The l i m b and a rtery a re flushed j u st prior to co m p l etion of the g raft, after which the c l a m ps are released to reperfuse the kid ney. Following t h i s se­ q u e nce, warm re n a l isch e m i a t i m e is g e n e ra l ly l ess t h a n 1 2 m i n utes. The stu m p o f the r i g ht re n a l a rtery is then suture l i g ated; avo i d c l i p d islodgement. Note: Excessive tract i o n o n the confl uence of the l eft re n a l ve i n and vena cava may cause cava l i n j u ry and massive hemorrhage d u r­ i n g preparation a n d co m p letion of the right re n a l a rtery a nastomosis. Retractor posit i o n i n g needs to acco u nt for potentia l ve nous i n j u ry d u r i n g exposure and s i g n ificantly relaxed fo l l owi n g comp leti o n of the a n asto mosis. The left ren a l anastomosis is com p l eted in nearly identica l fashion, m i n u s m a ny of the exposure l i m itations present o n the rig ht. The S M A g raft is ca refu l ly sized to length so that it fol­ l ows a " ( " -sha ped confi g u ration without k i n k i n g . I nflow can be obta i n e d either from the m a n y bodies of the g raft or either of the co m p l eted r e n a l l i m bs . The S M A-g raft a n asto mosis is co m p l eted e n d-to-s ide with i nterru pted o r ru n n i n g 5-0 polypropylene suture. The e n d-to-s ide a rteri otomy l e n gt h is 1 . 5 to 2 t i m e s the width of the bypass g raft ( 1 2 to 16 m m ) . Alternatively, end-to-e nd a n asto motic co nfi g u ration may reduce the l i ke l i h ood of g raft k i n k i n g depen d i n g o n final confi g u rati o n . Fol l ow­ i n g com p l et i o n of the a n asto m osis, the proxi m a l SMA is l i g ated with a l a rg e c l i p o r c i rcu mference suture. Ag a i n , isc h e m i a t i m e s h o u l d be u n d e r 1 0 to 1 2 m i n utes. Typical ly, fo l l owi n g S M A a n d ren a l g raft co m p letion, repo­ siti o n i n g of the retraction system is n ecessa ry to reobta i n a n d opt i m ize celiac a rtery expos u re . Prior t o reexposi n g

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H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S

the celi ac, a vascu l a r c l a m p is repassed through t h e ret­ ropancreatic t u n n e l l eft of the a o rta. This position is then m a i nta i n ed u n t i l the tra nsverse colon a n d mesoco l o n a re reduced to t h e i r usual locati o n . T h i s reexposes the " l ooped " ce l i a c a n d co m m o n h e patic a rteries previously isol ated i n the Jesser s a c . T h e c l a m p t i p exit i n g the retroh e patic tunnel is identified, a n d a m o i st u m b i l ical tape is p u l led through the tunnel. Following t h i s, the ce l i a c l i m b

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0.035-in stiff (e . g . , L u n d e rq u i st®, C o o k M e d i c a l , B l oom­ i n gton, I N) w i re t h rou g h t h e a bdom i n a l a n d thoracic a o rta. O pt i m a l f i n a l w i re positi o n i n g i s at/j u st d i sta l to the l eft subclavian a rtery orifice.

COMPLETE VISCERAL DEBRANCHING AND ENDOVASCULAR TUBE GRAFT REPAIR­ STAGE 2 First Step-Percutaneous Access •

F o l l o w i n g the "debranch i n g " p roced u re descri bed i n sta g e 1 , e n d ovascu l a r a n e u rysm repa i r (EVAR) m a y be pe rfo rmed either at the same sett i n g o r with i n seve ra l weeks of the i n it i a l p roced u re . The risk of potential a n ­ e u rysm r u pt u re associ ated w i t h a sta ged a p p roach needs to be b a l a n ced with the a d d i t i o n a l operative risk i n h e r­ ent i n t h e l o n g e r a n esthetic t i m e req u i red to co m p l ete both sta ges in one sitt i n g . For the EVAR p roced u re itself, sta n d a rd percuta neous access to an a p p ro p r i ately sized access vessel is obta i n e d using S e l d i n g e r tech n i q u e and a w i re adva nced i nto the a o rta under f l u o rosco p i c g u id­ a n ce. I n o u r p racti ce, t h i s i s m ost co m m o n ly o bta i n e d percuta neous ly, u s i n g u ltraso u n d g u i d a n ce a n d preplace­ ment of polypropy l e n e suture p r i o r to d i lation of the access sites (a lso known a s the " p reclose" Perc l ose® tech­ n i q u e (Abbott Vascu l a r I n c, Redwood C ity, CA) . 1 An 1 1 -F r sta n d a rd s h eath is p l aced i nto the com m o n fe moral a r­ tery a n d fl ushed with hepa r i n ized sa l i n e . W i re adva nce­ ment from the fe moral a rtery to the a o rtic a rch m u st be visu a l i zed ra d i o g ra p h ica l ly t h roug hout its cou rse, as the w i re may p referenti a l ly enter the debra n c h i n g g raft a n d c a u s e end-organ i nj u ry o r hemorrhage without rea l -t i m e position m o n ito r i n g a n d g u i d a nce.

Second Step-Stiff Wire Exchange •

Third Step-Intravascular Ultrasound •

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PARTIAL VISCERAL DEBRANCHING AND •

REPAIR-STAGE 1 First Step-Exposure • •

Sta n d a rd m i d l i ne l a p a rotomy a n d positi o n i n g of retractor syste m . U po n entry i nto the a bdomen, the fa lciform l i g a ment is d ivided between c l a m ps a n d ligated . The tria n g u l a r l iga­ ments above the l iver a re d ivided to fac i l itate adequate ex­ posu re/retraction w h i l e m i n i m izing risk of hepatic caps u l a r

An 8.2-Fr Visions® catheter (Volcano Therapeutics, I rv i n e, CA) is used to confirm a p p ropriate p roxi m a l a n d d ista l l a n d i n g zones for endovascu l a r g raft placement. The opti­ mal g raft size a n d config u ration is dete r m i ned by a n a lysis of CTA i m ages reformatted and visu a l i zed o n a dedicated 3-D i m a g e workstation (Aq uariusNet®, Te raRecon, I nc, S a n M ateo, CA) . G raft d i a m eter s h o u l d be ove rsized by 1 0 % to 1 5 % for t h i s a p p l icat i o n . D u r i n g adva ncement of the device, the orig i n of the debra n c h i n g g raft ca n a l so be visua l i zed either t h rou g h f l u o rosco p i c confi rmation o f a meta l l ic c l i p p l aced d u r i n g the debra n c h i n g p roced u re o r u n d e r i ntravasc u l a r u ltra­ sound (JVUS) rea l-t i m e g u i d a nce. Using IVUS, the posi­ tion of the IVUS catheter is m a rked o n the f l u o roscopic m o n itor when the cath ete r itself reco g n i zes the orifice of the debranched g raft. Alternative ly, a contrast powe r i nject i o n can be performed t h ro u g h an a p p ro p r i ately po­ sitioned a rte r i o g ra p h i c catheter with 30 m l of contrast i nj ected at 1 5 ml per seco n d to confirm the proxi m a l a n d d i sta l l a n d i n g zones.

Fourth Step-Endograft Deployment

After w i re advancement to the transverse a o rtic a rch, sta n d a rd w i re exc h a n g e tec h n i q u e is used to position a

PHYSICIAN-MODIFIED ENDOVASCULAR

is tied to the u m b i l ical tape, w h i c h is then p u l led cepha­ lad beh i n d the p a ncreas a n d i nto position for either end­ to-end o r end-to-side a n astomosis. Care a g a i n needs to be taken to o pt i m ize limb rout i n g a n d length to m i n i m ize risk for k i n k i n g . After coverage of rem a i n i n g exposed g raft l i m bs with omentum o r parieta l perito n e u m as a p p ropriate, sta n d a rd abdom i n a l closure is performed.

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The e n d ovascu l a r g raft is d e p l oyed fo l l ow i n g device­ specific i nstruct i o n s for use ( J F U ), cove r i n g the native o r i g i n s of the viscera l vesse l s a n d exc l u d i n g the a o rtic a n ­ e u rysm . The fem o ra l a rteriotomy i s t h e n closed.

inju ry, a nticipating syste m i c a nticoagu lation later i n the proced u re. A nasogastric tube is positioned i n the stomach to provide temporary decompression. The com mon hepatic a rtery is identified fol lowi n g d ivision of the gastrohepatic l i g a ment and traced back to origin of celiac a rtery. Once identified, the target artery is encircled with a sil astic vessel loop. Space is created along the left side of the aorta with blu nt/finger dissection, beg i n n i n g at the leve l of the celiac a rtery, to cre­ ate the retrograde bypass tunnel posterior to the pa ncreas. The colon and omentum a re l i fted in a cep h a l a d d i rec­ tion, the s m a l l bowel swept to the patie nt's r i g ht a n d

1 93 5

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

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packed i n moist towe ls. Self-reta i n i n g retractors (O m n i o r Bookwalter) s h o u l d b e positioned a t t h i s j u n ct u re to m a i nta i n exposu re, with care taken to a p p ropriately pad the retractor b l ades as necessa ry. The t h i rd a n d fo u rt h portions of the d u o d e n u m a re mo­ b i l ized to the r i g h t fo l l owi n g d ivision of the l i g a m ent of Tre itz, expos i n g the a nte r i o r s u rface of t h e a o rta. The in­ ferior m esenteric ve i n is l i g ated a n d d ivided a s we l l and the d i ssect i o n cont i n ued along the prox i m a l a o rta until t h e l eft re n a l ve i n is clearly identifi e d . Widely m o b i l ize the l eft r e n a l ve i n s h a r p l y a n d e n c i rcle with a m o i st u m b i l i ca l tape. The self-reta i n i n g re n a l ve i n retractor b l a d e is used t o retract t h e l eft re n a l ve i n ce p h ­ a l a d a s necess a ry to fac i l itate f u rther exposure. The orig i n of the ren a l a rteries is identified by ca refu l pos­ terol atera l d i ssection a ro u n d the a o rta, j u st ce p h a l a d of the overlyi n g re n a l vei n . Exposu re on the right is com p l i ­ cated somewhat b y the overlying i nferior v e n a cava/l eft re n a l vei n confluence. At least 2 em of ren a l a rtery s h o u l d be exposed b i l atera l l y. E n c i rcle the re n a l a rteries w i t h si­ l astic vessel loops. O n the l eft, f i n g e r d i ssect b l u ntly along the a o rta i n a cep h a l a d fash ion to com p l ete the retro pan­ creatic t u n n e l for the ce l i ac limb of the bypass g raft. The SMA is i d e ntified n ext by pa l pation with i n the base of the sma l l bowe l mesente ry, d i rectly a nterior to the pancreas. D o p p l e r u ltrasonography may assist i d e ntifi­ cat i o n when the pu lse is fa int. Once i d entifi ed, a 3-cm seg ment of S M A is isol ated as p rox i m a l as possi ble to the root of the mesentery. B eg i n n i n g with the middle co l i c a rte ry, m u lt i p l e mesenteric a rteries q u ickly branch from the S M A as it e m e rges from the pancreas, u n dersco r i n g the n e e d f o r proxi m a l identification a n d isolat i o n . T h e S M A is contro l led w i t h vessel loops. The n ext ste p is to p re p a re the d o n o r a rtery fo r hybrid by­ pass. The specific a rtery-most com m o n ly the co m m o n or exte r n a l i l iac a rteries-s h o u l d be sel ected from the p re­ operative i m a g i n g study. The retro perito n e u m is opened d i rectly over the sel ected d o n o r a rte ry, w h i c h i s exposed w h i l e p rotect i n g the adjacent u reter. Alternatively, d o n o r a rtery exposu re may be a c h i eved via m e d i a l-visceral rota­ tion, deve l o p i n g the entire retroperito n e a l p l a n e o n the l eft. The l atte r a p p roach provides the added benefit of exc l u s i o n of the g raft from the viscera a n d abdom i n a l contents once the viscera a re returned to t h e i r orig i n a l posit i o n . This m a n euver adds s i g n ificantly more time to the case, h oweve r, and cont r i b utes to i ncreased b l ood

PARTIAL VISCERAL DEBRANCHING AND PH YSICIAN-MODIFIED ENDOVASCULAR REPAIR-STAGE 22 First Step-Creation o f a Fenestrated Graft for the Celiac and Superior Mesenteric Artery •

The a p p ro p r i ate e n d ovascu l a r device is chosen accord i n g t o sta n d a rd I F U s i z i n g g u i d e l i nes, typ i ca l ly i ncorporat i n g 1 0 % to 1 5 % oversi z i n g . The ste r i l e g raft is u n s heathed

loss. G raft cove rage c a n a l so be obta i n ed without deve l ­ o p i n g the e n t i re retroperitoneal p l a ne, e i t h e r via d i rect t u n n e l i n g a l o n g the p referred cou rse of the g raft or cre­ ation of a n omental tongue affixed d i rectly to the g raft .

Second Step-Anticoagulation •

System i c a nticoagu lation is achieved with a bolus i njec­ tion of u nfractionated heparin, 50 u n its/kg . M o n itoring activated clott i n g t i m e is a usefu l method of m a i nta i n i n g adequate a nticoa g u lation d u r i n g the p roced u re.

Third Step-Multivisceral Bypass •

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Trifu rcated g rafts exist for the pu rpose of fac i l itati n g m u ltivessel hybrid reva sc u l a r ization, b u t the u s e o f these a re l i m ited by the tende n cy of the m i d d l e l i m b to occ l u d e w h e n squ eezed betwee n the outside l i m bs d u ri n g g raft rout i n g a n d a bdom i n a l closure. In m ost circumstances, a sta n d a rd 1 2 x 7 bifu rcated, co l l agen-i m p re g n ated kn it­ ted polyester g raft provides exce l l ent co n d u its for b i lat­ e ra l renal revasc u l a r i zation, with a sepa rate 8-mm l i m b c o n n ected t o t h e ce l i a c a n d S M A . Exa m ples o f bypass g raft confi g u rations a re s h own in FIGS 6 and 7. The prox i m a l (i l i ac/i nfl ow) a n a stomosis is co m p l eted fi rst with ru n n i n g 4-0 or 5-0 polypropy l e n e suture. The n ext a n asto mosis to be completed s h o u l d be o n e a n ­ tici pated to be the tec h n i c a l l y m ost d iffi cu lt, g iven expo­ s u re and g raft routi n g issues. M ost co m m o n ly, this is the right re n a l a rte ry. This is d ivided fo l l owi n g p l a cement of a l a rg e c l i p at the orig i n . The a p p ropriate g raft l i m b is p u l led to length a n d a n asto mosed end-to-end with 5-0 polypropylene suture. The l i m b a n d a rtery a re fl ushed j u st prior to c o m p letion of the g raft, after w h i c h the c l a m ps a re released to reperfuse the k i d n ey. F o l l o w i n g t h i s se­ q u e n ce, warm ren a l isch e m i a t i m e is genera l ly less t h a n 1 2 m i n utes. The stu m p of the r i g ht ren a l a rtery is then suture l i g ated; avoid clip d islodgement. N ote: Excessive traction o n the confl uence of the l eft ren a l vei n and vena cava may cause cava l i nj u ry a n d massive hemorrhage d u r­ i n g preparation a n d comp letion of the r i g ht ren a l a rtery a n astomosis. Retractor positi o n i n g needs to account for potential venous i n j u ry d u r i n g exposure and s i g n ifica ntly rel axed fo l l owi n g co m p l etion of the a n astomosis. The renal a n a sto m osis is co m p l eted i n nearly identical fash ion, minus m a n y of the exposu re l i m itat i o n s p resent o n the r i g ht.

o n a ded icated ste r i l e table in t h e operat i n g room and m a rked with t h e relat ive l ocat i o n s ( l e n gth from p roxi­ mal e n d and c l ockface measurements) of the ce l i a c a n d S M A fen estrati o n s a s p revi ously d ete r m i ned via Ter­ a Reco n ® workstation a n a lysis. M i n o r adj u st m e nts a re a l l owed to m i n i m i ze strut ove r l a p of p l a n ned fen estra­ tion l ocat i o n s . Fen estrat i o n s in the po lyester e n d o g raft fa b r i c a re created with a d isposa b l e ophth a l m i c ca utery to m i n i m i ze fray i n g . The fen estrations a re o u t l i ned a n d rei nfo rced with 1 5- m m g o l d A m p l atz Gooseneck®

C h a pt e r 1 6

H Y B R I D REVAS C U LARIZAT I O N STRATEG I ES FOR V I S C E RAL/RENAL ARTE R I E S

• Photog raph o f a t h o racic endog raft w i t h two fenestrations created for the ce l i ac (struts p rese nt) a n d S M A (strut free), p r i o r to resheat h i n g a n d d e p l oyment.

FIG 8

s n a res (ev3 E n d ovasc u l a r, I n c, Plymouth, M N) . These a re h a n d sewn i nto p l ace u s i n g 4-0 Prolene sutu re in a d o u ­ b l e r o w ci rcumferent i a l l y (FIG 8) . D i a m eter-red u c i n g t i e s w e r e t h e n u s e d to constra i n t h e device a l o n g i t s poste­ rior border (op posite the SMA and o r ce l i a c fen estrati o n at 6 o'clock) by rerouti n g t h e exist i n g p roxi m a l t r i g g e r w i re t h r o u g h a n d t h r o u g h t h e g raft mate r i a l at t h e m i d ­ port i o n of each of t h e top t w o Z ste nts. The constra i n i n g ties a re t h e n t i e d down i nto p l a ce over t h e t r i g g e r w i re . The enti re g raft is t h e n wetted with h e p a r i n ized sa l i n e a n d t h e n reloaded i nto t h e exist i n g sheath .

FIG 9 • N ote the d o u b l e densities dep icti n g the o r i g i n s of the c e l i a c a n d S M A on t h i s f l u s h a o rtog ra m .

Second Step-Percutaneous Access •

Sta n d a rd percuta n e o u s access to an a p p ro p r i ately s i zed access vesse l i s obta i n ed u s i n g S e l d i n g e r tech n i q u e . The i n it i a l g u i d e w i re i s adva n ced i nto the a o rta u n d e r fluo­ rosco p i c g u i d a n ce . I n o u r p racti ce, this i s m ost co m m o n ly o bta i n ed percuta n e o u s ly, u s i n g u ltraso u n d g u i d a n ce a n d p r e p l a c e m e n t of polypropy l e n e sutu re p r i o r to d i ­ l a t i o n of t h e access s ites ( a l s o k n own a s t h e " p reclose" Percl ose® tech n i q u e (A bbott Vasc u l a r I n c, Redwood C ity, CA) . 1 A n 1 1 - F r sta n d a rd s h eath i s p l aced i nto the co m m o n fe m o r a l a rtery and f l u s h e d with h e p a r i n ized sa l i n e . W i re advancement from t h e fe m o r a l a rtery to t h e a o rt i c a rc h m u st be v i s u a l ized rad i o g ra p h i ca l ly t h ro u g h o ut its cou rse, as t h e w i re may p refe re n ti a l l y enter t h e d e b ra n c h i n g g raft a n d cause e n d - o rg a n re n a l i n j u ry, r u pt u re o f G e rota's fa scia, a n d retro perito n e a l h e m o r r h a g e w i t h o u t rea l -t i m e p o s i t i o n m o n ito r i n g a n d g u i d a n ce.

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Sixth Step-Access Site Closure •

Third Step-Stiff Wire Exchange •

7 - F r Raa be® s h eaths (Cook M e d i c a l , B l o o m i n g t o n , I N ) a re adva nced toget h e r t h r o u g h t h e 1 8- F r s h e a t h . Work­ ing t h ro u g h t h ese s h eaths, t h e SMA and ce l i a c vesse l s a re s e l ected t h r o u g h t h e fen estrat i o n s u s i n g sta n d a rd catheter a n d g u i d e w i re tec h n i q u es, with t h e s h e a t h s u l t i m ately adva nced i nto t h e ta rget vesse l s over stiff w i res. After sheath adva ncement a n d confirmation of target vesse l acqu isition, the m a i n body is d iste nded flush with the su rrou n d i n g a o rta with a m o u l d i n g ba l l oo n (e . g . , Coda®, C o o k M e d i c a l , B l o o m i ngton, I N ) . T h i s i nflation represents the final o p po rtu n ity to d iste n d the endo­ g raft i n the reg i o n of the viscera l ste nts. Late ra l posit i o n ­ i n g of the i m a g e i n t e n s i f i e r g u ides ste nt p l acement i nto the SMA and ce l i ac a rteries (typica l ly 8- to 9-mm stents; FIG 1 0) . FIG 11 s h ows fo l l ow-u p computed tomography (CT) i m a g i n g of a patient 1 yea r after successf u l treat­ ment with t h i s tec h n i q u e .

The access sites a re closed with the p revi ously p l aced sutu res.

A sta n d a rd 4- or 5-Fr catheter is used to pe rfo rm a w i re exc h a n g e to a stiff 0.035-in L u n d e rq u i st® w i re (Cook Medical, B l o o m i ngton, IN). The w i re is positioned so that its tip is j ust d i stal to the l eft subclavian a rtery.

Fourth Step-Marking of the Target Vessels and Graft Deployment •

A contrast power i njection can be pe rfo rmed with 1 0 mL of contrast i njected at 25 mL per second to m a rk the precise orig ins of the ce l iac and SMA (FIG 9). The mod ified g raft is positioned over the target vessels, oriented, and dep loyed .

Fifth Step-Cannulation of the Target Vessels •

An 1 8- F r s h eath is a d va n ced from t h e contra latera l g ro i n a n d i nto the d i sta l g raft over a stiff w i re . Two

• Latera l i m a g e d e p i ct i n g p l acement of a covered b a l l o o n-expa n d a b l e ste nt i nto the S M A prior to d e p l oyment.

FIG 1 0

1 93 7

1 938

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• A.B. F o l l ow-up CT i m ages of a patient successfu l ly treated with p a rti a l viscera l debra n c h i n g a n d physi c i a n -mod ified e n d ovascu l a r fen estrated repa i r.

FIG 1 1

PEARLS AND PITFALLS C h o i ce of operati n g room (OR) ta b l e

•

Use sta n d a rd O R ta b l es f o r open s u r g i c a l p roced u res a n d i m a g i n g ta b l es f o r i m a g e- g u i ded o r h y b r i d p roced u res. Adva nced p l a n n i n g is essenti a l to o pt i m i ze outco m e . N ever sacrifice exposu re !

Exposu re of co m m o n i l i a c a rtery

•

I d e ntify a n d p rotect the u rete r.

P l a cement of wi res after d e b ra n c h i n g p roced u re

•

Pass g u idewi res u n d e r cont i n u o u s f l u o rosco p i c g u i d a nce fo l l ow i n g d e b ra n c h i n g . An adva n c i n g a o rtic w i re may p refe renti a l l y e n t e r a n d trave rse the debra n c h i n g g raft, c a u s i n g end-org a n i n j u ry, d i so r i e ntation, a n d possi b l e endog raft m a l d e p l oyment if n ot recog n i ze d .

Ti m i n g of ste nt g raft ba l l oo n m o u l d i n g d u r i n g fe n estrated EVAR

•

A lways seat the endog raft with ba l l oo n i nflation p r i o r to p l acement of viscera l bridg i n g ste nts. I n st r u m e ntat i o n o r d iste ntion of the fen estrated endog raft fo l l owi n g branch vesse l ste n t i n g may compromise ste nt positi o n i ng, i nteg rity, and paten cy.

POSTOPERATIVE CARE

COMPLICATIONS

•

•

Open aortic debranching procedures are not benign; almost all patients will require intensive care postprocedure. Spi­ nal drainage is used selectively for aortic coverage extending more than 10 em cephalad to the celiac artery. Postoperative anuria or persistent acidosis/rising lactate require immediate investigation to prove branch vessel patency.

OUTCOMES •

•

Contemporary hybrid debranching procedures for complex abdominal aortic aneurysmal disease are associated with a 1 3 % operative mortality rate, 2 % permanent paraplegia rate, and 1 % stroke rate.3 Hybrid approaches offer the advantage of versatility, avoid­ ance of extensive operative exposures, and potentially offer a broader range of therapies to a patient population that would not otherwise be considered for aortic surgical repair.

• • • • •

Access-related complications Hemorrhage requiring transfusion Paraplegia Stroke Renal failure Death

REFERENCES 1.

Starnes BW, Andersen CA, Ronsivalle JA, et al. Totally percutaneous aortic aneurysm repair: experience and prudence. J Vase Surg. 2006;43 (2) :270-276. 2. Starnes BW, Quiroga E. Hybrid-fenestrated aortic aneurysm repair: a novel technique for treating patients with para-anastomotic juxtarenal aneurysms. Ann Vase Surg. 2 0 1 0;24( 8 ) : 1 1 50-1 1 5 3 . 3 . Starnes BW, Tran NT, McDonald J M . Hybrid approaches to repair of complex aortic aneurysmal disease. Surg Clin North Am. 2007;8 7(5 ) : 1 0 8 7-1098, ix.

I

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Chapter

17

Snorkel/Chimney and Periscope Visceral Revascul arization during Compl ex Endovascul ar Aneurysm Repair 1

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Jason T. Lee

Ronald L. Dalm a n

treatment. Careful attention during the history and physi­ cal examination to cardiac and renal comorbidities aids in risk-stratifying the patient for potential repair of their JAA. Because most patients are asymptomatic and aneurysms are repaired to prevent future rupture, some reasonable quality of life must be present for the patient to enjoy the survival advantage.

DEFINITION •

•

•

Although routine endovascular aneurysm repair (EVAR) has gained widespread acceptance as the procedure of choice for patients with suitable aortic neck anatomy, the optimal ap­ proach to the j uxtarenal aortic aneurysm (JAA), often with challenging anatomy at the visceral neck, remains contro­ versial. 1 Although open repair is an effective and durable option for patients with JAA, particularly in centers of excel­ lence for low physiologic risk patients,2 endovascular tech­ niques including fenestrated and branched EVAR (FBE) have emerged as effective, potentially less invasive alternatives.3 In the United States, however, lack of widespread availabil­ ity of FBE has allowed other techniques to emerge, and in this chapter, we describe the increasingly popular " snorkel " or " chimney" technique, defined as a parallel stent graft ad­ j acent to the endograft main body to maintain perfusion to renal and visceral branches during EVAR and placed from a cranial direction, and the "periscope" technique, where the parallel stent graft is placed from the caudal direction. First described by Greenberg and associates,4 the snorkel strategy can be employed either as a bailout from accidental coverage of vital side branches during deployments requir­ ing close approximation of the main body to the branch ar­ tery in question, or the intentional cranial relocation of the EVAR seal zone for JAAs.5-8

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

DIFFERENTIAL DIAGNOSIS •

The challenge for the vascular specialist in treating JAAs revolves around an increasing number of choices for inter­ vention, including traditional suprarenal repair, hybrid type debranching procedures, fenestrated and branched devices in clinical trials or certain centers, and snorkel/chimney/ periscope techniques. The choice is most often based on pa­ tient physiologic parameters, physician experience with the multitude of techniques, and a very individualized approach to complex aortic anatomy.

·

•

High-quality computed tomography angiography ( CT-A) on a modern 64-slice scanner able to produce at least 2-mm-thin cuts is a requirement for treatment with snorkel techniques. These imaging algorithms allow the creation of virtual mod­ els of the aneurysm for the surgeon to better appreciate the relationship of branches and potential areas of technical challenge ( FIG 1 ) . Patients with compromised kidney func­ tion who cannot undertake iodinated contrast are poor can­ didates for snorkel procedures, as noncontrast scans fail to elucidate thrombus volume, branch artery patency, and lumi­ nal diameter in the preoperative planning that is paramount to success. Access to a three-dimensional ( 3 -D ) workstation/program and familiarity with reconstruction software by the implant­ ing surgeon for manipulation of the images and creating cen­ terline pathways should be mandatory to most accurately plan device orientation, selection, and sizing ( FIG 2) . Because the snorkel technique usually involves access of the brachial artery for delivery of the parallel visceral stent grafts, visualization of the arch and proximal subclavian is

PATIENT HISTORY AND PHYSICAL FINDINGS •

Most patients present electively and essentially without symptoms for consideration of repair of their JAA, as it is most often discovered during radiographic workup for vague abdominal discomfort, back pain, or as part of a screening program. A pulsatile, nontender abdominal mass can be elicited on careful abdominal exam. Any signs of per­ sistent abdominal or back pain or hemodynamic instabil­ ity or compromise should suggest the possibility of an acute aortic pathology and prompt more urgent workup and

• 3-D reco nstruct i o n of j uxta renal a n e u rysm with i nfra­ renal neck l e n gt h of 5 m m .

FIG 1

1939

1 940

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

SURGICAL MANAGEMENT Preoperative Planning •

FIG 2 • Te raRecon workstation view h i g h l i g ht i n g a b i l ity to m a n i p u l ate i m ages in m u lt i p l e user-defi ned p l a nes. •

•

most conveniently obtained by including the chest in the standard CT-A of the abdomen and pelvis. The presence of a challenging type III arch, where the subclavian inserts below the inner curve of the aortic arch, makes the procedure more challenging and many times prohibitive due to concerns about arch manipulation, cerebral emboli, and deliverability of stent grafts ( FIG 3 ) . If the patient has already undergone an adequate CT-A abdomen and pelvis and one wishes to avoid the additional contrast load of repeating the study, a noncontrast chest computed tomography ( CT) can be per­ formed to visualize the arch but then should be combined with arterial duplex and waveforms of the upper extremities to ensure patency of the axillosubclavian arterial system. For patients with chronic kidney disease, high-grade renal stenosis, atretic kidneys, or multiple visceral and renal ves­ sels involved in the endovascular plan for snorkeling, nu­ clear medicine split renal function tests can help determine if it is reasonable to sacrifice one of the renal arteries. This can be done in order to simplify the snorkel strategy and keep the number of cranially oriented stent grafts to two, which may have an influence on overall morbidity and mortality from the procedure. 1 •7•8

•

•

•

All patients considered for snorkel/chimney or periscope tech­ niques should have undergone an extensive informed consent discussion related to off-label use of endograft components for treatment of their complex aneurysm. Alternatives often dis­ cussed include open surgery with suprarenal clamping, hybrid de branching, referral to a center with access to fenestrated or branched devices, or no surgery at all. Once the decision is made to proceed with the snorkel strategy, we prefer a two­ surgeon approach with one performing the femoral access portion and one the brachial access portion. Both surgeons should have reviewed on the 3-D workstation the anatomy, the endovascular plan, and the sequence for deployment. Access to a hybrid endovascular suite is highly recommended, although not mandatory, for successful completion of these pro­ cedures. Fixed imaging provides improved accuracy, reliability, and reproducibility of the anatomy throughout the sequence of the snorkel procedure. Knowledgeable operating room and cath-angio staff should be assigned to these cases and available endografts and wires/catheters as well as backups should all be arranged ahead of time to provide the safest working environ­ ment for the patient as well as the operative team. Choosing the main body endograft, its configuration, and size has been described by numerous authors who all report excellent results overall with a wide variety of devices and formulas. 9 In general, we often " oversized" to about 2 5 % to 3 0 % instead of the typical 1 5 % to 2 0 % for standard EVAR to account for the additional fabric infolding to accommo­ date the snorkel stent ( s ) . Given the amount of dye often used as well as renal artery manipulation during the most complex of snorkel cases, we prefer to admit the patient the evening before or several hours prior to surgery for additional intravenous hydration when possible. General anesthesia is preferred, with consideration for pre­ operative lumbar drainage based on risk of spinal cord ische­ mia. Arterial monitoring, when necessary, is achieved via the right arm. Adequate venous access can consist of either large­ bore peripheral intravenous lines (IVs) or a central line. There is usually not a need for autotransfusion or cell saver setups unless an iliac or axillary conduit is planned where there is more potential for early blood loss during the procedure.

Positioning •

FIG 3 • Type I l l a o rtic a rch with o r i g i n of subclavian a rtery b e i n g l ower t h a n i n n e r cu rve of a o rtic a r c h . The a b i l ity to adva n ce a snorkel s h eath from the l eft a r m is seve rely comprom ised i n t h i s confi g u ration a n d g e n e ra l ly n ot reco m m e n d ed if a ltern ative repa i r methods a re ava i l a b l e .

The hybrid room can be set up as either "head" position ( FIG 4) or "right side, table rotated" depending on the type of imaging equipment. With the right arm tucked, the left arm is prepped circumferentially and placed on an armboard at about 75 to 90 degrees while the chest and abdomen down to the groins are prepped. Surgeon A, who will stand at the patient's right hip, has control of the C-arm and imaging functions and is in charge of obtaining femoral access and delivery of devices from the groins. Surgeon B stands above the outstretched left arm, with an additional sterile table extending off the left hand to allow for wires and catheters to remain sterile and available for arm access during the procedure. The monitor is placed at a slight angle toward the foot of the bed to allow both sur­ geons to visualize, or a slave monitor can be employed.

C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR

FIG 4 • E n d ovasc u l a r su ite set u p for s n o rkel/ch i m ney EVAR with l eft arm p repped and outstretched, C-a rm at rig ht-si d ed/ta b l e rotated posit i o n to a l l ow for latera l i m a g i n g, and m o n itors at foot of bed. S u rgeon A sta nds at patient's right h i p and controls C-a r m . S u rgeon B sta nds a b ove patie nt's l eft a r m to d e l iver wi res a n d catheters from side table.

SNORKEUCHIMNE Y ENDOVASCULAR

•

ANEURYSM REPAIR

For the s i m p l est of all snorkel cases, when j u st o n e renal a rtery n eeds stenting, a l ower brach i a l i n ci s i o n can be m a d e to a l low i nsert i o n of a single 7-Fr sheath (FIG SC) .

Arm Access •

•

A 5-cm tra nsverse i n c i s i o n s l i g htly b e l ow t h e l eft axi l l a over t h e p a l p a b l e brach i a l p u lse affo rds seve ra l centi­ m eters of l o n g i tu d i n a l expos ure of t h e h i g h brach i a l a rtery (FIG SA) . Stay i n g p roxi m a l to t h e d e e p brach i a l a rtery takeoff a l l ows a l a rg e e n o u g h ca l i be r o f bra­ c h i a l a rtery for typ i c a l d e l ivery of two 7-Fr sheaths for a d o u b l e re n a l snorkel p roced u re . At l e a st 7 to 8 em of h e a lthy bra c h i a l a rtery s h o u l d be d i ssected free a n d s l u n g w i t h vessel l o o p s to a l low accu rate p u n ct u re o f t h e vesse l . The t w o p u n ctu res s h o u l d be p l a ced at least 2 em a p a rt, a n d n ot n ext to each other, to fa c i l itate later s i m p l e r, i n d iv i d u a l p r i m a ry c l o s u r e . For cases w h e n l a rg e r d e l ivery s h e a t h s may n e e d to b e i n se rted o r i n cases w h e re potent i a l l y u p to th ree o r fo u r snorkel stents n eed d e l ive ry, then a n i nfra c l avicu­ lar incision a n d exposu re of the axi l l a ry a rtery for pos­ s i b l e 1 0- m m Dacron c o n d u i t p l acement is reco m m ended (FIG SB) . When t h i s is p l a n ned, a 20-Fr o r 22-Fr s h eath can be i nserted to get around the a rch and then th ree 6-Fr o r 7-Fr sheaths can be used to ca n n u l ate the visce ral vesse ls.

Renal/Visceral Cannulation and Sheath Advancement •

•

A 5-Fr m i cropu ncture access is o bta i n e d u n d e r d i rect visua l i zation i nto the brach i a l a rte ry. A B e ntson w i re is advanced, u n d e r f l u o rosco p i c g u i d a n ce, m ost often i nto the ascend i n g a o rta. The use of an O m n iflush catheter and g l idewire (either a 260-cm Rosen o r A m p l atz [Cook Medical, B l oom i n gton, I N ] ) co m b i nation, to d i rect the w i re toward the viscera l a o rta, a l l ows a w i re exc h a n g e fo r a stiffe r p l atfo r m . Ove r t h i s stiffer p l atfo rm, two 7-Fr 90-cm P i n n a c l e Desti nation sheaths (Te r u m o M e d i ­ cal, Some rset, NJ) a re positioned n e a r the visce ral target branches to fa c i l itate ca n n u lation attem pts (FIG 6A) . T h ro u g h t h e 7 - F r sheaths, t h e targeted re n a l a n d vis­ cera l branches a re ca n n u l ated using 260-cm-l ength hy­ d r o p h i l i c g u idewi res and a 1 2 5-cm J B 1 catheter (Cook M e d i c a l , B l o o m i ngton, I N) . An a n g i o g ra p h i c run ca n be pe rfo rmed from a flush catheter a d v a n ced from fe m ­ o r a l access to a i d i n re n a l ca n n u l a t i o n (FIG 68) . T h o r­ o u g h k n o w l e d g e of t h e preope rative a n atomy, d e r ived from refo rmatt i n g from the 3-D workstati o n fa c i l itates

• A. Skin i n c i s i o n via a h i g h brach i a l i n c i s i o n n e a r the axi l l a exposes the p rox i m a l b rach i a l a rte ry, often g i v i n g a d e q u ate size for d o u b l e pu nctu re. B. I nfracl avicu l a r i n c i s i o n to expose the axi l l a ry a rtery n ecessa ry w h e n t h ree or fo u r sno rkel/c h i m ney sheaths needed. A 1 0- m m o r 1 2- m m Dacron conduit can be sewn i nto the axi l l a ry a rtery i n t h i s posit i o n . C. S m a l l i n c i s i o n over p a l p a b l e brach i a l a rtery n e a r a ntecubital crease ca n be used w h e n o n ly single s n o rkel/c h i m ney sheath n ecessa ry.

FIG S

1 941

1 942

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

• A. Two 7 - F r Te r u m o sheaths p l aced from a r m access down desce n d i n g t h o racic aorta ready to be positioned near vi scera l a o rtic reg i o n . B. R i g h t ren a l a rtery ca n n u l ated w i t h g l idew i re a n d J B 1 catheter. O m n if l u s h catheter from below reve a l s i n a n a n g iogram t h e position o f t h e l eft renal a rtery to be ca n n u lated n ext.

FIG 6

•

t h i s p o rt i o n of t h e p roced u re, g u i d i n g opti m a l a n g u l a ­ t i o n o f t h e C-a r m . O n ce ca n n u l ated, the sheaths a re adva n ced coaxi a l ly i nto the ta rget a rtery orifice. When n ecessa ry, or i n cases w h e re t h e re is a s l i g ht turn to the h o rizonta l rath e r t h a n downward a n g led, the soft hydro p h i l i c g u idewire needs to be exc h a n g e d for a 260-cm J-t i p Rosen w i re (Cook Medical, B l o o m i n gton, I N) or A m p l atz S u p e rstiff (1 -cm t i p) to fa c i l itate s h eath advancement i nto the ta rg et renal a rte ry. Confi rmation a n g iog raphy, t h r o u g h the sheath, i s performed to e n s u re patency of t h e renal a r­ teri es, ca n n u lation of the m a i n renal a rte ry, a n d avo i d ­ a nce of a c c i d e n t a l s i d e branch ca n n u lati o n .

•

Positioning o f Main Body Endograft and Snorkel Stent Grafts •

Sta n d a rd fe m o ra l access for EVAR is e m p l oyed for s n o r­ kel tech n i q u e . T h i s is we l l descri bed i n other cha pters. B r i efly, a s m a l l transverse i ncision, below the i n g u i n a l l i g a m e nt, ca n be used to expose the c o m m o n femora l a rtery to the b ifu rcat i o n for del ivery of endog raft components. The percuta neous a p p roach i n vo lves the " p reclose" tech n i q u e a n d e m p l oys two Perclose ProG i i d e

•

devices (Abbott Va sc u l a r, Sa nta C l a ra, CA) orie nted at 10 o'clock and 2 o'clock posit i o n s 1 0 The m a i n body endog raft ca n then be del ivered up the chosen fe moral side to the pa ravisceral a o rta at the same t i m e as the i CAST (Atri u m Medical, H u dson, NJ) o r Via­ bahn (Gore Medical, Flagstaff, AZ) stents a re adva n ced through the snorkel sheaths out to the ta rget re n a l a rter­ ies (FIG 7A} . The typical length of the i CAST is 59 m m , w i t h the d i a m eter si zed a p p ropriately to sea l i n the ta rget ren a l a rte ry, m ost often 5, 6, o r 7 m m . For Viaba h n stents, s i m i l a r d i a m eters a re used in 50- o r 1 00- m m l e n gths as a p p ro p riate. To p reve nt th eoretica l com p ress i o n of the Viaba h n stent by the main body of the endog raft, the Viaba h n can be reinforced from the inside with a ba re­ m eta l, b a l l oon-expa n d a b l e stent a l o n g the a reas of over­ lap with the m a i n body. The positi o n i n g of the snorkel stent req u i res that at least 10 m m of fixation i nto the ren a l a rtery be p resent a n d that the p roxi m a l exte nt of the g raft is a bove the fa bric of the main body endog raft. In a latera l p roj ect i o n a n g i o g ra phy, the superior mes­ enteric a rtery (SMA) is visua l i zed (wh e n perfo r m i n g the typica l d o u b l e renal s n o rkel) a n d the main body fa bric edge p l aced i m m ed iately below the origin of the S M A

(FIG 7B) .

7 • A. I n t h e a nterior-posterior view, both snorkel iCAST stents in position from arm a p p roach a l o n g with m a i n body endog raft being put i nto position. B. Lateral view a n g iogram shows ta keoff of SMA (red arrow) a n d positi o n i n g o f the m a i n body endog raft fa bric e d g e (white arrow) immediately below SMA. FIG

C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR

FIG 8 • A. M a i n body endog raft d e p l oyed in a ntero poste r i o r (AP) view with snorkel stents in posit i o n . B. After ca n n u lation of contra l atera l gate a n d adva ncement of p roxi m a l m o l d i n g balloon i nto a o rtic stent, the two snorkel stents a re f u l l y i nflated . C. The m o l d i n g b a l l o o n is then maxi m a l ly infl ated to p rofi l e a n d to m i n i m ize g utters. D. The m o l d i n g b a l loon is co m p l etely defl ated prior to snorkel ste nt ba l l oo n defl ati o n .

•

At t h i s poi nt, f i n a l s m a l l adj u stme nts can be m a d e as we l l a s further a n g i o g r a p h y to e n s u re that t h e s n o rkel stents a re i n good posit i o n . To avo i d the issue of the i CAST ste nt b e i n g u n sta b l e off its b a l loon, we often l eave t h e 7-Fr sheaths i n p l ace to p rotect them until f i n a l d e p l oyment.

the re n a l snorkel bal loons a re deflated to a l l ow perfu­ sion of the k i d n eys.

Completion of Distal Components •

Sequence of Stent Graft Deployment and Balloon Molding •

•

•

•

The m a i n body endog raft is d e p l oyed at the ta rget l oca· tion with its fa bric edge being i m med iately below the S M A edge (FIG SA) . Depe n d i n g o n the endog raft system used, d e p l oyment p roceeds down to the contra latera l gate open i n g . From the contra l atera l fe m o r a l access, ca n n u l at i o n of the gate is confirmed and a noncom p l i · a n t m o l d i n g ba l l oo n (32- o r 40- m m C o d a b a l loon; Cook Medical, B l o o m i n gton, I N ) is p l a ced u p to the level of the re n a l vesse ls. The 7-Fr sheaths a re s l owly withd rawn from the brach i a l a p proach s o the t i p i s j u st p rox i m a l t o t h e e d g e o f t h e re n a l snorkel stents a n d d e p l oyment o f the i CAST occu rs, most often s i m u lta neously a n d to a n o m i n a l pressure of e i g h t atmos p h e res (FIG SB ) . At the same t i m e that the i CAST stents a re b e i n g d e p l oyed by b a l loon i nflation, s l ower i nflation of the Coda occu rs to slowly m o l d the main body fa bric a r o u n d the snorkel stents to m i n i m ize g utte r formati o n . O n ly w h e n the renal snorkel stents a re maxi m a l l y i nfl ated can the Coda bal loon g o up to fu l l m a i n body endog raft d i a m eter (FIG SC). T h i s step ca n n ot be ove re m p h a s i zed, as defl ation of the snorkel stents w h i l e the Coda is i n ­ flated is l i kely to c r u s h the b a l l oo n-expa n d a b l e cove red ste nts. With the renal snorkel stents sti l l maxi m a l ly i nfl ated, the Coda b a l loon can finally be l et down after a few seco nds of ba l l oo n molding to co m p l ete the sequence (FIG SD) . Afte r t h e p roxi m a l m o l d i n g bal loon i s co m p l etely defl ated,

•

•

Prior to losi n g w i re a ccess to the re n a l vesse ls, a p roxi­ mal a o rtog ram is pe rfo rmed to look for a l a rg e type I e n d o l e a k or poor perfus i o n of either targeted k i d n ey. If this is satisfactory, the d i st a l compon ents of the e n d o­ g raft can be adva n ced a n d d e p l oyed i n the u s u a l fas h i o n . Repa i r of the access sites, p a rticu l a r l y the brach i a l site, req u i res ca refu l i nterru pted 6-0 o r 7-0 P ro l e n e sutu res, and a d e q u ate h a n d and foot perfus i o n is verified prior to co m p letion of t h e case. Postope rative CTA d e m o n strates the typ i c a l a p pearance of the snorkel stents adjacent to the m a i n body e n d o­ g raft with m i n i m a l g utters (FIG 9A), a n d the 3-D reco n­ struct i o n s h ows exce l lent a l i g n m ent a n d confi g u ration of the snorkel EVAR components (FIG 9B).

• A. Postoperative CTA axial v i e w s h ow i n g m o l d i n g o f m a i n b o d y endog raft a r o u n d t w o widely patent snorkel ste nts. B. 3-D reco nstruct i o n demo nstrat i n g exce l l ent perfus i o n of both k i d n eys a n d no evidence of e n d o l e a k .

FIG 9

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1 944

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

PERISCOPE ENDOVASCULAR ANEURYSM REPAIR/THORACIC ENDOVASCULAR AORTIC REPAIR Femoral Access for Introduction of Main Body Endograft •

•

•

Periscope EVAR/t h o racic e n d ovascu l a r a o rtic repa i r (TEVAR) b u i lds o n t h e concept a bove o f p a ra l l e l e n ­ dog rafts but p l a ces the visce ral stents f r o m a fe moral a p p roach, req u i r i n g b l ood flow to g o t h r o u g h the m a i n body ste nt g raft, t h e n t u r n a r o u n d a n d retu rn cra n i a l ly to the vi scera l or re n a l vesse l . " T h e fe m o ra l access f o r periscope, i n contra d i sti n ct i o n to sno rkel/c h i m n ey strate g i es, often i nvolves the use o f l a rg e r ca l i be r t h o r a c i c o r fen estrated m a i n b o d y compo­ n ents (often 22 F r to 2 6 F r), lea d i n g to a s l i g htly h i g h e r u s a g e o f o p e n o r e n d ovascu l a r i l i a c c o n d u its. One usefu l mod ification to a n i l iac con d u it that can be helpful i n del ivering and torq u i n g l a rge-ca l i ber main body com ponents or sheaths d u r i n g periscope EVARITEVAR i n ­ volves creating a patch at the d ista l end (FIG 1 0). This patch reg ion is created by cutting a 1 0- o r 1 2-mm Dacron g raft a l o n g its long access, creating a sewing patch that e n l a rges the tra nsition from g raft to vessel, and not l i m iting the flexi b i l ity of the branch to the i n itial a n g l e it is sewn i nto.

FIG 11 • 22-Fr sheath with m u lt i p l e p u n ctu res a l l ows th ree sepa rate 6-Fr sheaths to be i n se rted without leakage.

•

Contralateral Access and Cannulation of Target Visceral Branch(es) •

After the femora l access side has been chosen and p re­ pa red for m a i n body endog raft del ivery, the contra latera l femoral site is used to ca n n u l ate the p l a n ned viscera l or ren a l branches from the bottom . I n the periscope confi gu­ ration, the para l le l stent g raft is often req u i red to make a U-turn, so the more flexible covered stent, the self-expand­ i n g Viaba h n (G o re Medical, Flagstaff, AZ), is preferred. This

req u i res l a rger sheath access (up to 1 2 Fr) than the i CAST described earlier; however, for a double periscope config u ­ ration, a l a rger 20-Fr or 2 2 - F r sheath is usua l l y necessa ry t o perform m u ltiple pu nctu res i nto (FIG 1 1 ). The typical periscope EVARITEVAR i nvolves the need for a d ista l landing zone (FIG 1 2). In this particu lar case, the celiac and one renal artery were a l ready occluded, so the periscope tech nique was used to revascu la rize the SMA and rem a i n i n g renal a rtery, with a n 1 1 -mm Via bahn i n the SMA req u i ring a 1 2-Fr sheath (blue arrow) and an 8-m m Via bah n as the renal periscope req u i ring a n 8-Fr sheath (orange arrow) (FIG 1 3).

Sheath Advancement and Periscope Stent Graft Positioning •

S i m i l a r to the s n o rkel/c h i m ney EVAR p roced u re e a r l i e r, the g e n e ra l p r i n c i p les of adva n c i n g the s h eath i nto the target vi scera l vesse l a re repeated, but i n periscope EVAR/ TEVAR, a l l is performed from the fem o r a l a p p roach. The S M A a n d renal periscopes a re positioned seve ral centi­ meters i nto the target vessel o r i g i n , with the d ista l end (blue a rro w) below the bottom end of the m a i n body ste nt g raft (white a rrow) (FIG 14) .

Sequence o f Deployment and Balloon Molding •

FIG 1 0 • A. 1 0- m m Dacron con d u it b isected l o n g itud i n a l ly to create a sew i n g patc h . B. Dacron i l iac co n d u it sewn to native i l iac a rtery a l l ows easy m o b i l ity of the co n d u it at m u lt i p l e a n g les of entry f o r l a rge-ca l i be r device o r sheat h . ( F r o m L e e JT, Lee G K, C h a n d ra V, et a l . Compa rison of fenestrated endog rafts a n d the snorkel/ch i m ney tec h n i q u e [ p u b l ished o n l i n e a head of p r i nt Apri l 27, 2 0 1 4 ] . J Vase Surg. do i : 1 0 . 1 0 1 6/j .jvs.201 4.03 .255.)

•

The m a i n body endog raft is d e p l oyed with the periscope sheaths sti l l i n posit i o n (FIG 1 5A) . The sheaths a re t h e n s l o w l y withdrawn to a l l ow the periscope ste nt g rafts (Vi a b a h n s) to d e p l oy a g a i n st the m a i n body endog raft (FIG 1 5 8) . Because there is often some co m p ress i o n of the self-exp a n d i n g periscope ste nts, an a d d i t i o n a l b a l ­ loo n-exp a n d a b l e b a re ste nt is p l aced a l o n g w h e re there is contact with the main body endog raft a n d a s i m i l a r seq uence as e a r l i e r o f b a l loon m o l d i n g is pe rfo rmed to m i n i m ize g utte r fo rmation (FIG 1 6) . The re m a i n d e r o f the p roxi m a l aspect o f the a n e u rysm is visua l i zed and a p p ropriately ste nt g rafted with proxi­ mal exte n s i o n s and b a l looned (FIG 1 7), and posto pera­ tive CT-A confi rms a n e u rysm exc l u s i o n with wide patency of the periscope ste nt g rafts a n d n o r m a l target vessel perfusion (FIG 1 8) .

C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR

FIG 1 3 • 22-Fr s h eath (white a rro w) h o u ses 1 2-Fr periscope sheath (blue a rro w) i nto S M A as we l l as 8-Fr s h eath (orange a rro w) positioned to try to ca n n u late renal a rte ry.

•

Thoracoa bdom i n a l a n e u rysm formed a bove prior open repa i r with occl uded r i g h t r e n a l a n d ce l i a c a rteries. Periscope confi g u ration to keep S M A a n d right renal a rtery perfu sed .

FIG 12

•

A. M a i n body endog raft deployed while periscope sheaths sti l l i n place. B. After withd rawa l of sheaths, periscope FIG 1 5

stents (Viabah ns) a re deployed .

FIG 14 • Bottom of both periscope stents (SMA and right renal) are at blue arrow position and therefore lower than bottom of plan ned dista l component of m a i n body endog raft (white arrow).

FIG 1 6 • B a l loon m o l d i n g of m a i n body endog raft with co m p l i a n t a o rtic b a l loon a g a i n st ba l l oo n -expa n d a b l e bare ste nts p l aced with i n periscope stents at l evel of contact a n d d i sta l sea l .

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

FIG 1 7 • A. Prox i m a l a n g i og ra p h y s h ows reg ion of proxi m a l a n e u rysm to treat. B. Proxi m a l m a i n body endog raft is del ivered a n d ove r l a p is m o l d e d with co m p l i a n t a o rt i c b a l l o o n .

FIG 1 8 • C o m p l et i o n CTA show i n g exc l u ­ s i o n of a n e u rysm a n d periscope stents i n exce l lent position, perfu s i n g S M A a n d r i g h t re n a l a rte ry.

PEARLS AND PITFALLS I n d i cations

•

•

Preoperative workup

• •

Patient set u p

• •

Fol l ow g e n e ra l reco m m e n d at i o n s for e l ective repa i r of a bdom i n a l a o rtic a n e u rys ms (AAAs) and co n s i d e r ra i s i n g criteria w h e n a p p ly i n g com p l ex s n o rkel/c h i m n ey/periscope p roced u res to these often comprom ised patients. M ost of these p roced u res use a p p roved devices in an off- l a b e l m a n n e r so i nformed consent to d iscuss a l l ava i l a b l e options i s i m po rtant. H i g h - q u a l ity i m a g i n g a n d the a b i l ity to m a n i p u l ate i m ages on a 3-D workstati o n a re m a n d atory for successf u l p reope rative p l a n n i n g a n d device choices. Ad e q u ate preoperative and peri operative hydrat i o n is i m porta nt, g iven the a m o u nt of renal a rtery m a n i p u l ation that occurs d u r i n g these cases. The adva nced i m a g i n g affo rded b y a dedicated h y b r i d e n d ovascu l a r su ite a l l ows i m p roved v i s u a l i z a t i o n d u r i n g t h e s e ve ry tec h n ica l ly d e m a n d i n g p roced u res. A we l l -tra i n e d staff and two-s u rgeon a p p roach a re i m portant to e n s u re safe d e l ivery of endog raft co m p o n e nts from both the fe m o ra l a n d brach i a l positions.

Arm access

•

Two 7-Fr sheaths can be p l a ced in the h i g h brach i a l position from a transverse i ncision, and the p u ncture sites need to be at least 2 to 3 em away from each other to a l l ow safe a n d i n d e pendent a rteriotomy c l o s u re .

Ren a l ca n n u lations

•

A coaxi a l system with sheath a n d cove red ste nt i nto the target ren a l o r viscera l vessel from the brach i a l a p p roach opti m i zes safe a n d accu rate d e p l oyment of snorkel ste nts. Ca refu l w i re m a n i p u l ation i n d i sta l renal and u s i n g less stiff wi res with J-ti ps, if poss i b l e, m i n i m izes l i ke l i h ood of re n a l parenchym a l i nj u ry and theoretica l possi b i l ity of re n a l m icroem bol i .

•

B a l loon m o l d i n g seq u e n ce

•

Ca refu l atte ntion to seq u e n ce of s n o rkel/c h i m n ey/periscope ba l l oo n seq uence m i n i m izes g utter formation, promotes g ood neck a p position, and p revents c o m p ress i o n of vita l viscera l and ren a l branches.

POSTOPERATIVE CARE

OUTCOMES

•

•

At the conclusion of the procedure, patients are usually ex­ tubated, observed for 2 to 3 days in a monitored setting (in the intensive care unit overnight if lumbar drain present) , a n d discharged home when ambulating, tolerating a normal diet, and with stable renal function. Clopidogrel and aspirin are given if the patients are not already taking these medica­ tions for at least 6 weeks postoperatively.

•

Multiple reviews of the worldwide experience with snorkel/ chimney and periscope techniques continue to find it to be technically successful with target revascularization rates in the 95% to 1 0 0 % , mortality in the 2 % to 5% range, mor­ bidity up to 1 0 % , and midterm renal and branch patency rates of 92% to 9 6 % . 12•13 Rupture-free survival after snorkel/chimney or periscope EVAR is excellent in the small amount of literature published

C h a p t e r 1 7 S N O R K E L/CH I M N EY A N D P E R I SCOPE EVAR

on this new approach but will be important to observe in the mid- and long-term to ensure that this technique is durable as a strategy for endovascular repair of complex aneurysms.

REFERENCES 1. 2.

COMPLICATIONS •

•

•

•

•

Perioperative complications related to complex EVAR in general include cardiac ischemia, arrhythmias or exacerba­ tion of heart failure, groin wound seroma and infection, early thrombosis of endograft components, and bleeding is­ sues related to access site. Reported rates of these issues are not particularly different than the wealth of literature for routine EVAR. Particular to snorkel/chimney techniques involve the use of the arm access, which has the potential of leading to arm ischemia, nerve injury/irritation of the brachial plexus, and axillary seromas. Wire and catheter manipulation and poor wire hygiene can lead to inadvertent renal parenchymal inj ury that can lead to hematomas and excessive bleeding requiring transfusion. The rate of renal function decline is certainly more than in standard EVAR, although we do not believe it to be worse than open suprarenal surgery, fenestrated, or branched devices. Right arm access for multiple snorkel/chimney stems has been reported to lead to higher rates of cerebrovascular complications. 1 •8 This is likely due to moderate amounts of time that sheaths are across the aortic arch and the possibil­ ity of thrombus formation that can lead to cerebral emboli. Gutter leaks are a unique consequence of the parallel stent graft strategy and are poorly understood. Some general guidelines involve placing as long of stems as possible in parallel configuration to force gutter leaks to thrombose, and careful long-term imaging follow-up to ensure that the aneurysm is excluded.

1 947

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Lee JT, Greenberg Jl, Dalman RL. Early experience with the snorkel technique for juxtarenal aneurysms. J Vase Surg. 2012;55:935-946. Knott AW, Klara M, Duncan AA, et al. Open repair of juxtarenal aor­ tic aneurysms (JAA) remains a safe option in the era of fenestrated endografts. J Vase Surg. 2008;47:695-70 1 . Greenberg RK , Sternbergh WC ill, Makaroun M , et al. Intermediate re­ sults of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vase Surg. 2009;50:730-737. Greenberg RK, Clair D, Srivastava S, et al. Should patients with chal­ lenging anatomy be offered endovascular aneurysm repair? J Vase Surg. 2003 ; 3 8 : 990-996. Ohrlander T, Sonesson B, lvancev K, et al. The chimney graft: a tech­ nique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovase Ther. 200 8 ; 1 5 :427-432. Donas KP, Torsello G, Austermann M, et al. Use of abdominal chim­ ney grafts is feasible and safe: short-term results. J Endovase Ther. 2 0 1 0 ; 1 7 : 5 8 9-59 3 . Bruen KJ, Feezor RJ, Daniels MJ, et a l . Endovascular chimney tech­ nique versus open repair of juxtarenal and suprarenal aneurysms. J Vase Surg. 2 0 1 1 ;5 3 : 895-905. Coscas R, Kobeiter H, Desgranges P, et al. Technical aspects, current indications, and results of chimney graft for juxtarenal aortic aneu­ rysms. J Vase Surg. 2 0 1 1 ; 5 3 : 1 520-1527. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft technique for preserving visceral vessels during endovascular treat­ ment of aortic pathologies. J Vase Surg. 2012;55: 1497- 1 5 0 3 . Al-Khatib WK, Dua M M , Zayed MA, e t a l . Percutaneous EVAR in females leads to fewer wound complications. Ann Vase Surg. 2 0 12;26:476-482. Rancic Z, Pfammatter T, Lachat M, et al. Periscope graft to extend dis­ tal landing zone in ruptured thoracoabdominal aneurysms with short distal necks. 1 Vase Surg. 2 0 1 0 ;5 1 : 1 293-1296. Katsargyris A, Oikonomou K, Klonaris C, et al. Comparison of out­ comes with open, fenestrated, and chimney graft repair of j uxtare­ nal aneurysms: are we ready for a paradigm shift? 1 Endovasc Ther. 2 0 1 3;20:1 59-1 69. Donas KP, Pecoraro F, Bisdas T, et al. CT angiography at 24 months demonstrates durability of EVAR with the use of chimney grafts for pararenal aortic pathologies. J Endovase Ther. 2 0 1 3;20: 1-6.

-

Chapter

18

Branched and Fenestrated Endovascul ar Stent Graft Techniques �

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Gusta vo 5. Oderich

•

Anatomic constraints for endovascular management of abdominal aortic aneurysms include the presence of short or angulated surgical necks and aneurysmal degenera­ tion of the origins of the visceral arteries. Fenestrated and branched endografts were introduced to enable minimally invasive repair of complex j uxta- and suprarenal aortic aneurysms. 1 These devices incorporate reinforced fenes­ trations or directional branches, permitting incorporation of visceral artery origins into the proximal endograft seal zone without compromising end-organ perfusion or an­ eurysm exclusion.2 This chapter summarizes the technical features of endovascular aneurysm repair using fenestrated and branched stent grafts for pararenal and thoracoab­ dominal aortic aneurysms.

DIFFERENTIAL DIAGNOSIS •

•

•

The term fenestrated repair refers to deployment of an en do­ graft featuring custom orifices created and reinforced at pre­ cise locations around the aortic perimeter to enable branch artery access, cannulation, and placement of a bridging stent graft in the course of aneurysm exclusion. Fenestration sites are created from patient-specific cross-sectional image data to enable exclusion of aneurysms with short or angled in­ frarenal necks. In most circumstances, the target arteries (e.g., renal or mesenteric) must arise from normal aorta to enable fenestrated repair. As a rule, fenestrations must be able to deploy flush with the aortic wall to ensure adequate aneurysm exclusion. "Alignment" stents (covered or un­ covered, depending on individual patient circumstance) are deployed as needed to prevent target artery malperfusion as a consequence of misalignment between the fenestration and target artery orifice. Branched repair refers to endovascular aneurysm exclu­ sion employing covered stents to directly connect the main lumen of the endograft to the target visceral artery. These devices enable repair of aneurysms involving or ex­ tending proximal to the origins of the renal or visceral vessels ( e . g . , type IV thoracoabdominal aortic aneurysms [TAAAs] ) . Of necessity, some distance must be present between the main body of the endograft at full deploy­ ment and the aortic wall at the target visceral artery ori­ fice. Branched stent grafts are currently available in two distinct configurations: Fenestrated branches arise from reinforced fenestrations bridged by balloon-expandable covered stents. Directional or cuffed branch devices feature appended fabric cuffs, precisely located to enable straight, helical, down- or up-going guidewire egress, target vessel can­ nulation, and deployment of bridging covered stents. Self-expanding flexible nitinol stents are usually employed for this purpose.

1948

Most aneurysms are degenerative (previously characterized as " atherosclerotic, " based on a similar, although not identi­ cal, causal risk factor profile) . Other relevant etiologies include infection (e.g., mycotic aneurysms), inflammation (e.g., inflammatory aneurysm or aortitis), development of penetrating ulcers or asymmetric saccular enlargement, and related aortic pathologies (dissec­ tion or intramural hematoma) .

PATIENT HISTORY AND PHYSICAL FINDINGS •

DEFINITION •

·

Ka rina 5. Ka n a m ori

•

•

•

Most patients' aneurysms do not prompt symptoms prior to catastrophic rupture and are diagnosed incidentally or during screening. Indications for repair are size greater than 5 . 5 em for males and greater than 5 em for females or enlargement greater than 5 mm in 6 months.3 In approximately 5% to 10% of patients, aneurysms in­ duce periaortic inflammation and resultant retroperitoneal fibrosis involving adjacent structures, including the duode­ nal and ureters.4 These patients may present with abdomi­ nal or back pain, fatigue, malaise, or low-grade fever even at relatively small diameters. Commonly, these aneurysms also enlarge at accelerated and unpredictable rates. Other uncommon presentations of abdominal aortic aneurysm disease include the presence of distal embolization with " blue toe syndrome, " congestive heart failure from aor­ tocaval fistulae, or gastrointestinal bleeding from primary aortoenteric fistulae. A comprehensive history should be obtained to fully appre­ ciate the potential natural history of each patient's disease, including a comprehensive assessment of cardiovascular risk factors, current smoking habits, and a family history of aneurysmal disease or connective tissue disorders. Evaluation of perioperative clinical risk emphasizes cardiac, pulmonary, and renal functional status and reserve, includ­ ing baseline laboratory testing, noninvasive cardiac stress testing, pulmonary function assessment, and carotid duplex ultrasonography when indicated.

DIAGNOSTIC IMAGING •

Preprocedural aortic imaging studies provide fundamental and necessary guidance for endovascular repair strategies of all types. Aneurysm morphology is best analyzed through acquisition of high-resolution computed tomography an­ giography ( CTA) datasets.5 CTA with submillimeter slice acquisition is recommended for optimal acquisition, allow­ ing three-dimensional reformatting techniques, maximum intensity projections, and volume rendering.

C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S

•

•

Stent grafts are currently custom-made to conform to patient anatomy, based on estimates of longitudinal distance, axial clock position, arc lengths, and angles derived from center­ line of flow measurements. Anatomic limitations to be considered include difficult iliac access, excessive aortic tortuosity, visceral artery occlusive disease, and anatomic variants including multiple accessory renal arteries or early renal branch bifurcation.

•

•

TAAAs typically require four fenestrations (no scallops). Extensive TAAAs (types I to III) need directional branches, particularly if the aortic diameter is relatively large or aneu­ rysmal at the level of the visceral arteries. The combination of directional branches for celiac and SMA management with fenestrations for the renal arteries is increasingly popular. SURGICAL MANAGEMENT Ancillary Tools

STENT GRAFT DESIGN •

1 949

Device planning starts with selection of the proximal landing zone based on "healthy" aorta. The proximal landing zone should include at least a 2-cm length of "normal , " noncalci­ fied, parallel aortic wall. The outer-to-outer aortic diameter should be more than 1 8 mm and less than 32 mm for para­ renal aneurysms and more than 18 mm and less than 38 mm for TAAAs. 6 Landing zone diameter should be no larger than the diameter of the next most proximal aortic segment. Fenestrated stent grafts are currently manufactured with three fenestration options: small and large circles and more proximal scallops ( FIG 1 A) . Small fenestrations are 6 X 6 mm or 6 X 8 mm, created without crossing struts and reinforced by circumferential nitinol rings. Large fenestrations' diam­ eters are 8, 1 0 , or 12 mm and may incorporate stent struts crossing the edge or middle of the circular defect, limiting space available for alignment stents. Scallops are contoured indentations along the upper edge of the main body endograft fabric, 1 0 mm wide and ranging in height from 6 to 12 mm, depending on individual patient anatomy.5 Device designs vary with aneurysm extent. For pararenal aneurysms, 70% of patients are adequately treated with two small fenestrations for the renal arteries and a scallop for the superior mesenteric artery ( SMA).5 Suprarenal and type IV

A

B

•

These procedures require advanced endovascular skills and a comprehensive inventory of applicable catheters, balloons, and stents (Table 1 ) . Dedicated training in fenestrated and branched techniques is highly recommended for physicians already experienced in endovascular disease management and ancillary procedures including renal and visceral artery disease management.

Perioperative Measures •

•

•

Patients with difficult aneurysm anatomy, chronic kidney disease, or advanced age are preadmitted for bowel prepara­ tion and intravenous hydration with bicarbonate infusion. Oral acetylcysteine is administered to minimize risk of peri­ procedural renal dysfunction following administration of iodinated contrast. Hybrid, fixed imaging platforms are essential for optimal results of these complex procedures. Most are performed using general endotracheal anesthesia; local or regional an­ esthesia may be sufficient in select cases. Intraoperative blood salvage systems ( " cell saver" ) are recom­ mended for difficult cases and all TAAAs. The creation of large, impermeable pockets within dependent portions of the surgical drapes will facilitate pooling and collection via the cell saver.

c

6 mm wide 6 or 8 mm high > 1S mm from edge '

1

8 ·12 mm diameter No nitinolring > 10 mm from edge ..

.

FIG 1 • A. There a re th ree types of fen estrati o n s that can be m a n ufact u red: s m a l l , l a rge, a n d sca l l o p fe n estrations. The fen estrated ste nt g raft consists of a p roxi m a l fen estrated t u b u l a r component, a d ista l bifu rcated u n ive rsa l component, and a contra l atera l i l iac l i m b exte n s i o n . B. T h e Cook Zenith® stent g raft l i neage. C . Newer d e s i g n with two stra i g h t down-g o i n g branches a n d two fen estrations.

1 9 50

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Table 1 : List of Anci l lary Tools Recommended for Physicians Perform ing Fenestrated Stent G raft Procedures

Category

Manufacturer

Sheaths 20- to 24-Fr Check-Flo sheath (30 em) 7 -Fr Ansel sheath ( 5 5 em, flexible d i l ator) 7- or 8-Fr Raabe sheath (90 em long) 1 2-Fr Ansel sheath ( 5 5 em, flexible d i l ator) 5-Fr S h uttle sheath (90 em)

Cook Medical, Cook Medical, Cook Medical, Cook Medical, C o o k Medical,

Catheters Kumpe catheter 5 Fr (65 em) Ku mpe catheter 5 Fr (1 00 em) C1 catheter 5 Fr ( 1 00 em) M PA catheter 5 Fr ( 1 2 5 em) MPB catheter 5 Fr ( 1 00 em) Van Schie 3 catheter 5 Fr (65 em) Vertebra l catheter 4 Fr ( 1 2 5 em) VS 1 catheter 5 Fr (80 em) Simmons I catheter 5 Fr ( 1 00 em) Diagnostic fl ush catheter 5 Fr ( 1 00 em) Diagnostic pigtail catheter 5 Fr ( 1 00 em) Quick-cross catheter 0.0 1 4 in to 0.035 in ( 1 50 em) Renegade catheter ( 1 50 em)

M u ltiple M u ltiple M u ltiple M u ltiple M u ltiple Cook Medical, Bloomington, IN M u ltiple M u ltiple M u ltiple M u ltiple M u ltiple Spectra-Medics Boston Scientific, M i n neapol is, M N

Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Selective vessel catheterization Diag nostic ang iography Diagnostic angiogra phy, selective vessel catheterization Selective vessel catheterization Selective vessel catheterization

Guide catheters L I M A guide 7 Fr ( 5 5 em) Internal m a m m a ry (IM) guide 7 Fr ( 1 00 em) M PA guide 7 Fr ( 1 00 em)

Cordis Corporation, Bridgewater, NJ M u ltiple M u ltiple

Precatheterization Selective vessel catheterization Selective vessel catheterization

Balloons 1 0-mm x 2-cm angioplasty balloon 1 2- m m x 2-cm angioplasty balloon 5-mm x 2-cm angioplasty balloon

M u ltiple M u ltiple M u ltiple

Proximal stent fla re Proxi m a l stent fla re Adva nce sheath over balloon

Wires Bentson wire 0 . 0 3 5 in ( 1 50 em) Soft g l idewire 0 . 0 3 5 i n (260 em) Stiff g l idewire 0.035 i n (260 em) Rosen wire 0.035 i n (260 em) 1 -cm tip Amplatzer wire 0.035 i n (260 em) Lunderqu ist wire 0 . 0 3 5 i n (260 em) G lidegold wire 0 .0 1 8 i n ( 1 80 em)

M u ltiple M u ltiple M u ltiple M u ltiple M u ltiple M u ltiple M u ltiple

I n itial access Ta rget vessel catheterization Ta rget vessel catheterization Branch a rtery stenting Branch a rtery stenting Aortic stent graft Target vessel catherization

Stents iCAST stent grafts 5 to 1 0 m m B a l l oon -expandable stents 0 . 0 3 5 i n Self-expandable stents 0 . 0 3 5 i n Self-expandable stents 0 .0 1 4 i n

Atri u m , H udson, NH M u ltiple M u ltiple M u ltiple

Branch a rtery stenting Branch a rtery stenting or rei nforcement Distal branch a rtery stenti ng Distal branch a rtery stenting

MPA, main pulmonary catheter; VS 1, Van Schie

•

•

1;

Bloomington, Bloomington, Bloomington, Bloomington, Bloomington,

Appl ication IN IN IN IN IN

Femoral access for m u ltivessel catheterization Femoral access for branch a rtery stenting B rach ial access for branch a rtery stenting B rach ial access for tortuous aortic arch to facil itate branch a rtery stenting Branch a rtery access during difficult a rch

LIMA, left internal mammary artery

The use of iodinated contrast is minimized by avoidance of power injector digital substraction angiography (DSA) runs during device implantation and side stent placement. Whenever possible, hand injections of dilute contrast (70% saline) are used to locate the side branches. Completion aor­ tography is obtained only after all stents are positioned and postdilated, again using diluted contrast ( 50 % ) . To minimize contrast, precatheterization o f targeted visceral arteries or use of onlay computed tomography ( CT) images, when available, is recommended. In experienced hands, precatheterization adds little to the overall procedure time.

•

Arterial Access •

Positioning •

•

Patients are positioned supine with the imaging unit oriented from the head of the table. Both arms are tucked for repair of pararenal aneurysms requiring up to three fenestrations. Brachial artery access is used in patients treated by directional branches or those who need four fenestrations. The left arm

is abducted and prepped in the surgical field up to the axilla. A working sterile side table is oriented in the same axis of the abducted arm for optimal support of necessary wires and catheters. Electrocardiogram (EKG) leads, urinary catheter, and other monitoring cables and lines should be taped or secured so that they are not in the path of the x-ray beam of the fluoroscopic unit and do not impede movement of the C-arm gantry.

•

Access is established in the femoral arteries. Patients with small, calcified, or stenotic iliac arteries may require creation of an iliac conduit for safe device delivery. Total percutaneous femoral access is the preferred approach in patients with noncalcified arteries or mild posterior plaque. The standard "preclose " technique enables complete hemostasis in more than 9 5 % of patients irrespective of sheath diameter. 7 When femoral arteries are small, calcified,

C h a p t e r 1 8 BRAN C H E D A N D F E N E STRAT E D E N DOVASCULAR STENT G RAFT TECH N I Q U E S

•

•

o r bifurcate close t o the inguinal ligament, standard surgical exposure and access is obtained. Proximal and distal control is obtained using vessel loops. The left brachial artery is surgically exposed via small longi­ tudinal incision in the upper arm, j ust proximal to the origin of the deep brachial artery.

ENDOVASCULAR REPAIR USING FENESTRATED STENT GRAFTS •

•

•

Fenestrated-branched repa i r is cu rrently performed using the Cook Zenith® stent g raft l i neage. N ewer designs by E n d o l og i x (Venta n a). Te r u m o (Anaconda). a n d Cook Medical (p-Branch) a re under c l i n ical i nvestigation. The Cook Zenith® fenestrated stent g raft consists of a proximal fenestrated tubular com ponent, a d ista l bifu rcated uni­ versa l com ponent, and a contra l atera l i l iac l i m b extension (FIG 1A). The fenestrated tubular component is custom­ made to fit the patient's anatomy. Four to 6 weeks a re re­ q u i red for man ufacturing and del ivery in the U n ited States. B i l atera l percuta neous fem o r a l access is esta b l ished u n d e r u ltraso u n d g u i d a nce; each fe m o r a l p u n ct u re

•

Intravenous heparin ( 8 0 to 1 0 0 units/kg) is administered immediately after femoral and brachial access is established. An activated clotting time longer than 250 seconds is main­ tained throughout the procedure with frequent rechecks every 3 0 minutes. Prior to deployment of the stent graft, diuresis is induced with intravenous mannitol and/or furosemide.

is precl osed u s i n g two Percl ose devices. B i latera l 8-Fr sheaths a re i ntroduced to the exte r n a l i l i ac a rteries over B e nson g u i d ewi res (Cook Medical, B l o o m i n gton, IN). The g u i d ew i res a re exch a n g e d to 0.035-in soft g l i dewi res and K u m pe cath ete rs, w h i c h a re adva n ced to the asce nd­ i n g a o rta a n d exc h a n g e d for stiff 0.035-in L u n d e rq u i st g u i d ewi res (Cook M e d i c a l , B l o o m i ngton, I N ) . Cho ice o f access site is dependent on tortuosity a n d ves­ sel d i a m eter. Provided there a re no issues with both i l iac a rteries, the branches a re performed via the r i g ht femoral a p p roach, whereas the fen estrated a n d bifu rcated de­ vices a re i ntrod uced via the left femora l a p proach. A 20-Fr (two fen estrations) o r 22-Fr (th ree fenestrations) Check­ Flo sheath (Cook Medical, B loom i n gton, I N) is i ntroduced via the r i g ht fe moral a p p roach (FIG 2A) . The va lve of the

• A. A 20-Fr (two fenestrations) o r 22-Fr (th ree fen estrati o n s) Check- F l o sheath (Cook Medical, B l o o m i ngton, IN) is i ntrod u ced via the r i g h t fem o ra l a p proa c h . B. Precathete rization of the ren a l a rteries. C. Seq uenti a l ly reg a i n access i nto the fen estrated co m po n e nt, fen estration, a n d ta rget vess e l . D. An a l i g n ment stent i s adva nced u n d e r p rotect i o n of the sheat h .

FIG 2

1 95 1

1 9 52

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

•

•

•

•

•

Check-Flo sheath has fou r leaflets, wh ich a re accessed by two short 7-Fr sheaths at 2 o'clock a n d 7 o'clock positions. Precathete rization of the re n a l a rteries is performed u s i n g 0.035-in soft g l i dewi res a n d 5-Fr K u m pe or C 1 catheters (Cook Medical, B l oom i n gton, I N), w h i c h a re s u p p o rted by 7-Fr l eft i nternal m a m m a ry a rtery (LIMA) g u i de catheters (FIG 28) . Altern ative ly, on lay fusion CTA is recom m e n d ed to m i n i m ize contra st use. O nce the ta rget vesse ls a re cathete rized, the fen estrated stent g raft is oriented extracorporea l l y, i ntrod uced via the left femoral a p p roach, a n d deployed with opt i m a l a p posi­ tion between the fenestrations a n d the ta rget catheters. Proper device orientation, using the a nterior and posterior markers, is essentia l . It is usefu l to deploy the fi rst two or th ree stents and then rotate the imaging u n it latera l ly, confirm i n g a l i g n ment between the catheter and its respective fenestration. The device should be deployed s l i g htly h i g h e r than w h a t is a ntici pated, w i t h the catheter matc h i n g t h e lowest o f the fou r rad iopaque ma rkers i n the fen estrati o n . The d i a m eter-reducing wire on the fe nestrated component a l l ows for some rotational a n d cra n i a l- 6 0 % ) are determined by duplex-derived assessment of peak systolic velocity measurements across lesions. Baseline characteristics (i.e., kidney size, velocity, spectral waveforms, resistive indices) serve as reference points for future surveillance imaging following revascularization. Selective visceral and renal arteriograms are obtained to define normal and variant vascular anatomy, including lateral imaging of both the celiac and superior mesenteric arteries ( FIGS 1 and 2 ) . Computed tomography ( CT) arteriography o f the abdomen and pelvis, with arterial and venous pelvis, may provide additional useful information regarding the extent of aortic disease an d other associated abdominal pathology ( FIGS 3 and 4) . Catheter-based arteriography alone may not identify significant arterial wall disease or the presence of aneurys­ mal lesions. However, the expense, contrast load, and radia­ tion associated with complementary arteriographic imaging modalities may not be justified or appropriate in every patient, so anatomic information obtained from these examinations

FIG 2 • Abdom i n a l a n g iogram with latera l view s h ows a ste notic ce l i ac a rte ry.

•

•

•

should b e integrated into the operative plan o n a n iterative basis. Preoperative, imaging-based planning is combine d with direct intraoperative assessment to create the most effective and durable revascularization possible for each patient. Documentation of celiac, hepatic, splenic, and superior mes­ enteric artery patency is a mandatory prerequisite for these procedures. Significant stenosis of the celiac origin or hepatic or splenic artery occlusive disease will prevent successful renal revascularization from these arteries. Associated supe­ rior mesenteric artery disease also needs to be considered, particularly when the gastroduodenal artery provides signifi­ cant collateral flow from the celiac plexus to the mesenteric bed. Renal artery anatomy, including branch vessel involve­ ment and the presence of multiple renal arteries also needs to be documented. Bilateral lower extremity vein mapping is also necessary to identify potential graft conduit. Standard vein mapping tech­ niques, including imaging in a warm room with the patient in reverse Trendelenburg position, should be employed to ensure accuracy and reproducibility. For selected patients, a more extensive preoperative evalu­ ation for coronary artery or valvular disease should be considered. This may include both a transthoracic echocar­ diogram and cardiac stress evaluation. Selective pulmonary evaluation may be required in patients with chronic ob­ structive pulmonary disease ( COPD )-associated respiratory

FIG 4

•

Axi a l CT sca n i m a g e s h ows a d i seased ce l i a c a rtery o ri g i n .

1 988

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

compromise. Additional vascular assessments should be per­ formed as indicated, including carotid duplex ultrasonogra­ phy to assess the significance of carotid bruits identified on physical examination.

• •

SURGICAL MANAGEMENT Preoperative Planning •

•

•

The indications for hepatic and splenic artery-based renal revascularization are similar to those for aorta-renal revas­ cularization and are discussed elsewhere. 1 •4 Although aorta-renal bypass is most direct and generally most expeditious, extraanatomic renal revascularization may be preferable in selected circumstances as previously noted. Review of preoperative imaging is performed to determine variant vascular anatomy, if present. Anatomy of the exist­ ing renal artery disease is assessed.

•

The hepatic-right renal bypass requires a conduit, prefer­ ably autogenous vein. The spleno-left renal bypass may be performed with or without graft conduit. The native splenic artery is sufficient length, usually to extend directly to the left renal artery, when fully mobilized. When necessary due to variant anatomy, or prior inflammation or scarring around the pancreas, venous conduit can also be employed. Planning for availability of duplex ultrasonography in the operating room ( OR) will facilitate intraoperative confirmation of adequate target revascularization and renal perfusion.

Positioning • • •

HEPATORENAL B YPASS

Patient is placed in supine position with both arms tucked. A small bump is placed under the respective flank. The operative field is prepped from the nipples to the knees.

•

Placement of Incision •

•

O pti m a l access is g a i ned through a right su bcosta l I nCI­ sion extending from the m i d l i n e to the tip of the 1 2th rib. I n l a rge or obese patie nts, the med i a l extent of the incision can be exte nded across the m i d l i n e as a chevron (FIG S). When n ecessa ry, an u p p e r m i d l i n e i n c i s i o n may a l so p ro­ vide sufficient exposure.

Hepatic Artery Exposure •

•

•

•

The h e patod uoden a l l i ga m e n t is exposed by retract i n g the r i g h t l o be of the l iver ce p h a l a d .

The r i g h t colon a n d d u oden u m a re reflected a nteriorly and to the l eft (Koc h e r m a n e uver) . The sma l l i ntest i n e is packed toward the pelvis with m o ist l a p a roto my pads. The he patod u o d e n a l l i g a ment is i n cised l o n g itud i n a l ly. The hepatic a rtery is l ocated i n the porta hepatis med i a l t o the co m m o n b i l e d u ct (FIG 6) . T h e gastrod uodena l artery is identified as t h e fi rst large branch cou rsing ca udad and encircled with a silastic loop. The gastrod uodena l artery should be preserved i n the pres­ ence of superior mesenteric a rtery occlusive disease as it pro­ vides i m po rtant col l atera l circulation to the small i ntesti nes. The hepatic a rtery is contro l led proxi m a l ly and d i sta l ly with s i l a st i c loops (FIG 7) .

Right Renal Artery Exposure • •

• t t t t ,

. . ..

•

,..

The right co lon and duodenum are reflected as deta i led earlier to expose the i nferior vena cava and right ren a l vei n . The r i g h t renal a rtery is l ocated poste r i o r a n d superior to the m a i n ren a l ve i n . Depe n d i n g on its position, the renal ve i n is retra cted either ce p h a l a d o r ca u d a d . To e n s u re the m a i n renal a rtery is exposed, the d i ssect i o n s h o u l d be carried to its a o rtic o ri g i n . T h i s req u i res m ed i a l retract i o n of the i nfe r i o r vena cava a n d d ivision of l u m ba r ve i n s when n ecessa ry. The r i g h t re n a l a rtery is contro l led u s i n g a s i l astic loop. The main re n a l a rtery is exposed c i rcu mferent i a l ly a n d then d i sta l ly to the t h ree segm enta l renal a rtery branches. Each branch is identified a n d contro l led with a s i l astic loop. This is a critica l operative m a n euver that exc l udes the p resence of branch d isease and ensu res a successf u l renal a rtery revascu l a rization (FIG 7) .

Distal Anastomosis •

•

FIG S

•

1 2th r i b .

R i g h t su bcosta l i n c i s i o n exte nded to the t i p of

The d i st a l a n asto mosis is pe rfo rmed fi rst to take adva n­ tage of the a d d iti o n a l deg rees of freedom provided by the mobile g raft. An a p p ro p r i ate length of g reater s a p h e n o u s ve i n is h a rvested from the t h i g h . The patient is h e p a r i n i zed 1 00 u n its/kg. The ve i n itse lf is reve rsed before p l acement.

C h a pter 21

H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N

I nferior vena cava

1 989

Gastrod uodenal artery Left gastric artery

Portal vein

Right gastric artery

Gall bladder

Splenic artery

Proper hepatic artery Liver Right renal artery

Right kidney Right renal vein U reter

Duodenum

B

A FIG 6 •

•

•

A,B. Koch e r m a n e uver with porta hepatis d i ssected . IVC, i nfe rior vena cava .

The proxi m a l re n a l a rtery is m o b i l ized fo l l ow i n g its d ivi­ sion from the a o rta, at its o ri g i n . The proxi m a l stu m p i s oversewn with 5-0 polypropy l e n e suture. Red u n d a nt ren a l a rtery is t r i m m e d d i sta l l y from its origin until the d i sease-free segment is rea ched. The m o b i l e

•

renal a rtery is then transposed a nterior to the i nfe r i o r vena cava . The ve i n g raft a n d re n a l a rtery a re spatu l ated a n d the e n d-to-en d a n astomosis created w i t h cont i n u o u s 6 - 0 polypropy l e n e sutu re, kn otted at o p posite ends o f

Proper hepatic artery Gastrod uodenal artery Right gastric artery

Right renal artery

Proximal renal artery stu m p (behind the IVC}

Right kidney

Right renal vein U reter

Duodenum

A FIG 7

•

A.B. R i g h t re n a l a rtery a n d d ista l branches e n c i rcled with s i l a st i c loops. D i stal a n asto mosis is perfo rmed fi rst.

IVC, i nfe rior vena cava . (contin ued)

1 990

P a r t 6 OPERATIVE TECH N IQUES I N VASCULAR SURGERY

•

m a g n ificati o n is n ecessa ry to e n s u re opti m a l results re­ g a r d l ess of w h i c h suture tech n i q u e is chosen (FIG 7) . O n ce the d i sta l a na stomosis is co m p l eted, the ve i n g raft is o r i e nted l o n g itud i n a l l y to p revent twist i n g o r k i n k i n g p r i o r to c o m p leti o n o f the proxi m a l a n asto mosis.

Proximal Anastomosis

Hepatic artery • • •

S m a l l vasc u l a r c l a m ps or remova b l e c l i ps a re used to con­ trol the p roxi m a l and d ista l hepatic a rtery. An a rteriotomy is m a d e on the hepatic a rtery a n d exte nded u s i n g Potts scissors. The vei n is spatulated and an end-to-side a nastomosis is again performed with ru nning polypropylene suture (FIG SA).

Gastroduodenal artery •

B FIG 7

•

(con tinued)

the a n a stomosis to p reve nt pu rse-stri n g i n g . Alternatively, depen d i n g on re n a l a rtery d i a m eter, e i g ht interrupted sutu res may be d istr i b uted c i rcu mferenti a l l y a r o u n d the l u m e n . The s m a l l e r the re n a l a rtery d i a m eter, the m o re advantageous the i nterru pted tec h n i q u e . Lo upe Right renal artery

The gastrod uoden a l a rtery may be used as an a ltern ative i nflow vesse l if sufficiently l a rg e (4 to 6 mm i n d i a m eter). This a n a sto m osis may be perfo rmed either end-to-e nd o r end-to-s ide, but p r i o r to d iv i s i o n o f the g a strod u o d e n a l a rte ry, consideration s h o u l d be g iven toward i t s contri­ bution to the mesenter i c circulation (FIG 88) .

Intraoperative Duplex Ultrasonography •

We reco m m e n d i nsonation of the g raft a n d both a n as­ tom oses u s i n g a ppropriately sized 7-M H z sca n heads to e n s u re tec h n ica l p rofi ciency fo l l owi n g com p letion of the bypass. I n recent yea rs, o u r practice h a s come to rely o n

Proper hepatic artery

Gastrod uodenal artery

Proximal renal artery stu m p (behind the inferior vena cava)

Right renal vein

Right kidney U reter

A

B

FIG 8 • A. The p roxi m a l a n asto mosis between the hepatic a rtery a n d ve i n g raft. B. Anter i o r-posterior a n g i o g ra p h i c i m a g e demonstrates a h e pato-re n a l a rtery bypass.

C h a pter 21

H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N

d u p l ex u ltraso n o g ra p h y f o r i ntraoperative assessment of all sma l l a n d m ed i u m size a utog e n o u s reconstruc­ tio ns, espec i a l l y in l i g ht of the red u ced freq u e n cy of such p rocedu res i n the era of e n d ovascu l a r and hybrid reco nstructions. Ren a l a rtery reco nstruct i o n is u nforg ivi n g in that fa i l u re in the perioperative period ca n n ot be

exped itiously add ressed after the a b d o m e n is cl osed, a l m ost a lways p rec i p itat i n g kid ney i nfarct i o n and per­ m a n e n t red u ct i o n s in creati n i n e c l e a ra nce. S p ectra l wavefo r m s , v e l o c i t i es, a n d B - m o d e a re a l l e m p l oyed t o d etect te c h n i c a l e r r o rs re q u i r i n g i m m e ­ d i ate r e p a i r.

•

SPLENIC-RENAL B YPASS Placement of Incision •

•

Exposure is obta ined through a left su bcosta l i ncision exte n d i n g from the m i d l i n e to the t i p of the 1 2th rib. I n l a rge or obese patients, the medial extent of the i ncision can be extended across the m i d l i n e as a chevron (FIG 9). As was the case on t h e right side, the u p p e r m i d l i n e i n c i s i o n m a y a l so p rovi de suffi cient access depe n d i n g o n b o d y h a b itus, p r i o r s u rgeries, a n d operator expe rience.

Splenic Artery Exposure •

The g reater omentum is e l evated expos i n g the tra n s­ verse mesoco l o n . The l i g a m e n t of Tre itz is taken down and the i nferior m esenteric ve i n is l i g ated and d ivided . The p l a n e betwee n the pancreas a n d k i d n ey is entered and the pancreas e l evated. The s p l e n i c ve i n i s em bed­ ded in the body of the p a n c reas-avo i d i nj u ry d u ri n g m o b i l ization o f the d ista l p a n creas. The s p l e n i c a rtery s h o u l d be p a l p a b l e a l o n g t h e ce p h a l a d border of the p a n creas. It is m o b i l ized free of s u r ro u n d i n g pa renchyma movi n g m ed i a l ly a n d latera l ly until suffi cient length is obta i n e d to fa s h i o n either a p r i m a ry bypass o r s u p port a n a utog e n o u s ve i n c o n d u i t (FIG 1 0).

FIG 9

•

Left su bcosta l i ncision extended to the t i p of 1 2th r i b .

Splenic artery Splenic vein

adrenal vein

Su perior mesenteric artery ----�--tk��·

Left renal artery (coursing posterior to renal vein)

U reter Lumbar vein

I nferior mesenteric vein (distal stu m p)

Left gonadal vein

• Left re n a l a rtery a n d ve i n exposu re . Division of the i nfe r i o r mesenteric ve i n a l l ows ce p h a l a d retract i o n of the retro pancreatic p l a ne, which a l l ows visu a l ization of the splenic a rte ry.

FIG 10

1 99 1

1 992

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Splenic artery (proximal end) Pancreas

Splenic vein Splenic artery (distal stu m p)

Left renal artery (proximal stu m p)

Left renal artery (distal end) Left adrenal vein (stump)

Su perior mesenteric artery -----'-+:.... Left renal vein Lumbar vein Left gonadal vein Duodenum

A FIG 1 1

•

\

Ureter I nferior mesenteric vein (distal stu m p) Left colon

B A.B. The splenic a rtery and l eft ren a l a rtery a re d ivided. The gonadal, adrenal, a n d l u m ba r veins a re l i g ated and d ivided,

a l lowing com p l ete mobil ization of the left ren a l vei n . d ista l a n asto mosis is performed fi rst, fo l l owed by end-to­ end o r e n d -to-side a n a stomosis to the s p l e n i c a rte ry. The ve i n g raft i s positioned poste rior and i nfer i o r to the body of the pancreas.

Left Renal Artery Exposure • •

•

After m o b i l i z i n g the d ista l p a n creas, the l eft re n a l ve i n is l ocated j ust i nfe r i o r a n d s l i g htly ca u d a d . The left ren a l vei n is circumferent i a l ly mobil ized. This req u i res d ivision of its nonrenal tributaries: the gonadal, adrenal, and lumbar ve ins. D ivid i n g these veins g reatly en­ hances ren a l vei n mobil ity, fac i l itating renal a rtery exposure from its position j ust cephalad and posterior to the vei n . As previously described on the rig ht, the l eft re n a l a rtery is d i ssected to its a o rtic o r i g i n a n d contro l led with a s i lastic loop. The d ista l a rtery and its th ree seg me nta l branches are identified a n d encircled with s i l astic loops. The i m por­ tance of m o b i l i zation is a g a i n e m p h asized (FIG 1 1 ) .

Intraoperative Duplex Ultrasonography •

As descri bed e a r l i e r

Splenic artery

Splenic-Renal Anastomosis •

•

•

•

The patient is h e pa r i n ized with 1 00 u n its/kg of u nfrac­ tionated h e p a r i n . The l eft rena l a rtery is c l a m ped at the origin a n d d ivided. The ren a l stu m p is oversewn with a 5-0 polypropylene suture. The d ista l m a i n re n a l a rtery is spatu l ated d i sta l to the exist i n g re n a l a rtery d isease. The m o b i l ized s p l e n i c a rtery is d ivided with sufficient length to exte nd beh i n d the p a n creas to the l eft re n a l a rtery without u n d u e tension. T h e d ista l s p l e n i c a rtery is oversew n . The m o b i l ized s p l e n i c a rtery is spatu l ated a n d a n a sto­ mosed e n d-to-e n d to the l eft re n a l a rte ry, a g a i n with either r u n n i n g o r i nterru pted polypropylene suture depe n d i n g on the respective a rte r i a l d i a m eters (FIG 1 2). Alternatively, w h e n s p l e n i c a rtery l e ngth is i n sufficient, reversed s a p h e n o u s ve i n may be e m p l oyed a s a bridge g raft. Ag a i n , to opti m i ze t h e deg rees of freed om, the

FIG 12 • Co m p l eted a n a stomosis betwee n the s p l e n i c a rtery a n d l eft ren a l a rte ry.

C h a pter 21

H E PATIC- A N D S P L E N I C-BAS E D R E N A L REVASCU LARIZAT I O N

FINAL INSPECTION •

With co m p l et i o n of the revasc u l a rization procedu res, a l l a n a stomoses and oversewn re n a l a rtery orig i n s a re i n s pected fo r h e m ostasis. H e p a r i n a nticoa g u l at i o n i s reversed w i t h p rota m i n e, i n a q u a ntity suffi c i e nt to n o r m a l ize the activated c l ott i n g t i m e (ACT) . Pa l pation

1 993

of the S M A at the base of the m esentery is performed to confirm a pu lse. Operative tract i o n a n d/o r preexist­ i n g d i sease may compromise SMA flow or p rec i p itate an occ u l t d i ssect i o n . If the SMA pu lse is a bsent, o r t h e i ntest i n a l v i a b i l ity u n ce rta i n , m esenteric a rtery revascu­ J a rization may be n ecessa ry.

PEARLS AND PITFALLS Preope rative i m a g i n g

• •

S u rg i c a l p l a n n i n g may req u i re CT a n d catheter-based a rte r i o g ra p h y as c o m p l e m entary refe rences for s u rg i ca l p l a n n i n g . Ce l i ac a rtery ste nosis is a n absol ute contra i n d i cation f o r he patic- a n d s p l e n ic-based re n a l revasc u l a rizat i o n .

Preope rative ve i n m a p p i n g

•

Exposure of the re n a l a rtery

•

C i rcu mferent i a l exposure of the e n t i re m a i n r e n a l a rtery a n d the th ree seg m e nta l branches is i m p e rative fo r p l acement of the re n a l a n asto mosis d i stal to exist i n g d isease

G raft o r i e ntation

•

Lo n g itu d i n a l orientation needs to be confi rmed repeated ly d u r i n g g raft tu n n e l i n g a n d orientat i o n . Excessive re l i a nce o n g raft m a r k i n g o r "stri p i n g " as the s o l e method o f orientat i o n may lead to i n a dvertent k i n k i n g o r twist i n g .

I ntraoperative d u p l ex

•

C o m p letion d u p lex sca n n i n g is easy, q u ick, a n d i n va l u a b l e i n identifyi n g tec h n ical e rro rs, w h i c h may comprom ise g raft patency a n d renal via b i l ity. U n l i ke l ower extrem ity bypass p roced u res, perio perative g raft occ l u s i o n ca n n ot typica l ly be identified exped itiously to p reve nt end-org a n comprom ise.

•

•

Autog enous v e i n is the p refe rred cond u it for ren a l revasc u l a rizati o n . Lower extrem ity ve i n m a p p i n g a l l ows assessment f o r suitable cond u it .

POSTOPERATIVE CARE

OUTCOMES

•

•

•

•

• •

•

Postoperative care typically involves central venous and arterial pressure monitoring in an intensive care unit (ICU) environment, at least for the first 24 to 4 8 hours. Serial monitoring of serum creatinine, urine output, and acid-base status is essential in the early postoperative period. Unexplained changes in acid-base or elevation of serum creatinine could indicate occlusion of the revascularization itself or progressive mesenteric ischemic. Blood pressure is maintained in a physiologic range with vasoactive medications as necessary. Oral antihypertensives are resumed on postoperative day 1 and adj usted depending on the response to renal revascularization. Diet is resumed as bowel function returns; nasogastric suc­ tion is usually not required. Blood pressure and antihypertensive medication require­ ments may decrease after renal revascularization and should be adjusted prior to discharge. Follow-up surveillance duplex ultrasonography is performed at 6 and 12 months then annually thereafter. Detected abnormalities suggesting stenosis of the renal reconstruction may be addressed with remedial endovascular intervention or surgical revision when indicated.

•

•

Large case series documenting the outcomes following iso­ lated hepatorenal and splenorenal artery bypass are sparse. Published results are derived from two relatively large series, generally demonstrating acceptable perioperative morbidity and mortality with improved renal function and blood pres­ sure and durable patency. Moncure et a!. reported 77 patients who underwent 79 procedures (29 hepatorenal, 50 splenorenal bypass) for the treatment of renovascular hypertension and renal preservation. The perioperative mortality was 6 % . Dete­ rioration in renal function occurred on three occasions but only in patients with bilateral simultaneous repair. Cure or improvement in hypertension was observed in 52 of 6 3 patients. Renal function was preserved or improved in 6 7 of 77 patients .2 Another series by Geroulakos et a!. document similar out­ comes with extraanatomic renal artery revascularization for atherosclerotic renal artery disease. Forty-five hepatore­ nal and/or splenorenal bypasses were performed in 38 pa­ tients for the treatment of renovascular hypertension, renal preservation, or both. There was one postoperative death from myocardial infarction and two cases of early graft

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thrombosis. There was a significant decrease in postoperative mean serum creatinine as well as the average number of anti­ hypertensives. Over a median follow-up of 33 months, there were 10 deaths all from cardiac issues. 3

• •

Pancreatitis, splenic infarction, common duct injury Incisional hernia

REFERENCES 1.

COMPLICATIONS • • • •

Bypass graft thrombosis Intestinal ischemia due to preex1stmg disease or traction inj ury to SMA during operative procedure Bleeding from renal, hepatic, splenic anastomosis, ligated renal artery stump, portal vein if injured Acute renal failure requiring temporary or permanent dialysis

Benjamin ME, Dean RH. Techniques in renal artery reconstruction: part II. Ann Vase Surg. 1 9 9 6 ; 1 0 ( 4 ) :409-4 1 4 . 2. Moncure A C , Brewster DC, Darling R C , e t a l . U s e of the splenic and hepatic arteries for renal revascularization. J Vase Surg. 1 9 8 6; 3 ( 2 ) : 1 96-203 . 3. Geroulakos G, Wright JG, Tober JC, et al. Use of the splenic and hepatic artery for renal revascularization in patients with atheroscle­ rotic renal artery disease. Ann Vase Surg. 1 9 9 7; 1 1 ( 1 ) : 85-8 9. 4 . Weaver FA, Kumar SR, Yellin AE, et al. Renal revascularization in Takayasu arteritis-induced renal artery stenosis. J Vase Surg. 2004;39:749-75 7.

I

Chapter

22

Advanced Aneurysm Management Techniques: Open Surgical Anatomy and Repai r

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Eliza b e th Blazick

�

Ma rk F. Conra d

DEFINITION

PATIENT HISTORY AND PHYSICAL FINDINGS

•

•

•

•

•

•

An aneurysm is defined as a permanent, focal dilation of an artery to a size that is greater than 5 0 % of the normal or expected transverse diameter of the vessel. Although dimen­ sions differ slightly for men and women, practically speak­ ing the normal diameter for the abdominal aorta is 2 em; therefore, the abdominal aorta is considered aneurysmal when it reaches 3 em in transverse dimensions. Fusiform aneurysms are the most common configuration and are a symmetric enlargement of the entire vessel, whereas a saccular aneurysm is a focal outpouching that results in an asymmetric bulge of the vessel wall. Aneurysms may occur in virtually any vessel in the body but are most commonly seen in the infrarenal abdominal aortic aneurysm (AAA). The neck is the length of normal aorta be­ tween the osteum of the lowest renal artery and the begin­ ning of the aneurysmal aorta. The term juxtarenal is used to describe AAAs that do not involve the renal arteries but be­ cause of proximity ( < 1 em neck) require clamping above the renal arteries to complete the proximal aortic anastomosis. In a suprarenal aneurysm, at least one of the renal arteries arises from aneurysmal aorta, implying the need not only for a prox­ imal clamp but also renal artery reconstruction at the time of the repair (FIG 1 ) . This chapter will focus on the indications and techniques for repair of infrarenal and juxtarenal AAA. AAA size and/or expansion rate is an important predictor of rupture, and as such guides indication for repair in asymp­ tomatic patients. 1 Other predictors for increased risk rupture include female gender, positive family history of aneurysms, smoking status (higher for current smokers versus never smokers and previ­ ous smokers ), hypertension, and chronic obstructive pulmo­ nary disease ( COPD ) .2-5

Pararenal/Juxtarenal (less than 1 em neck)

•

Potential cross-clamp sites

•

•

•

•

•

•

A thorough history and physical exam is imperative in the evaluation of a patient being considered for aneurysm repair. History of present illness: Determine how the aneurysm was discovered. Often, AAAs are an incidental discovery on an imaging test done for another purpose. Be sure to ask about abdominal or back pain, which may indicate this is a symp­ tomatic aneurysm that would require more urgent repair. Past medical history: Patients with concomitant renal, car­ diac, or lung disease tend to have more complications peri­ operatively and should be medically optimized prior to proceeding with elective repair. Although there is no benefit to preoperative cardiac revascularization in asymptomatic patients, those with known cardiac disease or risk factors should be evaluated by a cardiologist. 6 Family history: Close to 1 5 % of patients with AAA will have a first-degree relative with aneurysmal disease. Patients with AAA should be counseled to alert their siblings and children to this condition, so they may be screened appropriately.3 Social history: Smoking has been linked to increased risk of aneurysm formation and rate of expansion. Patients should be counseled on smoking cessation. Review of systems: In addition to the generalized systems re­ view appropriate for all patients undergoing maj or surgery, particular attention should be directed to other vascular comorbidities. In particular, query about previous cerebro­ vascular accident ( CVA) or transient ischemic attack (TIA) symptoms, amaurosis fugax, mesenteric ischemia, lower ex­ tremity ischemic symptoms (claudication, rest pain, ulcers), and work up positive symptoms as appropriate. On physical exam, perform a thorough abdominal exam, although be aware that the positive predictive value for localizing a small- to moderate-sized AAA on exam is poor.

Su prarenal (including at least one renal artery)

FIG 1 • Anatomic differences between a j uxta rena l AAA, where the neck of normal aortic d i a meter is less than 1 em, and a s u p rarenal AAA, where the ta keoff of at least one ren a l a rtery a rises from the a n e u rysm .

1995

1 996

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

A small proportion ( 1 % to 1 0 % ) of patients with AAA will have a concomitant aneurysm elsewhere, so be cognizant that those patients with known AAA and a prominent femo­ ral or popliteal pulse may need further imaging to exclude an aneurysm in these locations.7 Conversely, patients who initially present with peripheral aneurysms such as femoral ( 8 5 % ) or popliteal aneurysms ( 6 0 % ) have a much higher rate of concomitant AAA and aor­ tic screening should be performed in these patients. 7•8

SURGICAL MANAGEMENT •

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Of all imaging techniques used for AAA surveillance, B-mode ultrasonography is the least expensive and does not expose the patient to radiation. Currently, the U.S. Preventative Ser­ vices Task Force (USPSTF) recommends an ultrasound as a screening test for males between the ages of 65 and 7 5 years who have ever smoked 1 0 0 or more cigarettes over a life­ time. There are no official recommendations for women. It is generally accepted that a negative screening ultrasound exonerates the patient from further screening or surveillance imaging, as the likelihood of new aneurysm development of clinical significance after the age of screening is extremely low. If a screening ultrasound detects a small aneurysm, yearly ultrasounds are indicated until the sac approaches a size where repair may be indicated, at which time further im­ aging with computed tomography ( CT) is recommended.7•9 Computed tomography angiography ( CTA) provides a more accurate assessment of aneurysm size, extent, branch ves­ sel proximity and involvement (which may determine if the aneurysm is amenable to endovascular or open repair, and if open repair is to be done, where the proximal clamp should be applied) and is the test that should be used for planning open AAA repair. A thorough exam should include thin ( 1 .5 em or smaller) cuts of the chest, abdomen, and pelvis with contrast administered in the arterial phase ( FIG 2 ) . I t i s important t o note the location o f the aneurysm and its relationship to the renal arteries. Renal anatomy should be noted as well, including any accessory renal arteries and the presence of a pelvic or horseshoe kidney. The renal vein usu­ ally travels anterior to the aorta but can be posterior and this should be noted as it may influence operative approach. Other venous anatomy such as a duplicated or left-sided inferior vena cava (IVC) should be noted as well.

•

•

•

The decision to operate on an asymptomatic patient is based on three primary factors: the risk of the aneurysm's ruptur­ ing, the risk associated with aneurysm repair, and the pa­ tient's life expectancy. The operative risk and overall life expectancy should be assessed. Assuming that a patient is fit enough to proceed with repair, size is currently our best pre­ dictor of rupture. The UK Small Aneurysm Trial and ADAM VA Trial recommend treatment for all patients with an in­ frarenal AAA larger than 5 . 5 em in size, with consideration for repair in women with AAA of 5 . 0 em given their higher risk of rupture and likely smaller baseline aortic size. These studies also support repair for those patients who have an increase in diameter of greater than 0.5 em over a 6-month period (Table 1 ) . 10• 1 1 Although there are n o large trials looking specifically at iliac aneurysms, repair is generally recommended when they reach 4 em or greater in size. Iliac aneurysms are more often seen in patients with a concomitant aortic aneurysm and only a quarter of patients with iliac aneurysms will have iso­ lated disease. All open repairs should be performed under general anes­ thesia. It is preferable for the anesthesia team to evaluate the patient prior to the day of surgery so that appropri­ ate time for developing an anesthetic plan, lines, and other means of hemodynamic monitoring is allowed. The use of an epidural for pain control in the postoperative period is useful. In addition, arrangements should be made for auto­ transfusion given the unavoidable amount of intraoperative blood loss. Preoperative understanding of anatomy is of the utmost im­ portance. The surgeon must understand the proximity of the aneurysmal aorta to the renal and visceral vessels and if these branch vessels are affected, as this will impact where the proximal cross-clamp will be applied. If at all possible, clamping should only be done on nonaneurysmal aorta with minimal thrombus or calcification to minimize risk of distal embolization of debris or clamp inj ury, and all aneurysmal aorta should be resected even if this means involvement of the visceral or iliac segment. If the aorta contains a signifi­ cant amount of debris or there is little space between branch vessels, a more proximal clamp site in the supraceliac aorta should be considered. It is important to discuss the proposed clamp site with anesthesia preoperatively, as this will af­ fect their management of the patient. The choice of clamp site should be made during the preoperative stage, as the intraoperative need to move the clamp higher is associated with adverse outcomes.

Table 1 : I n d i cations for Repa i r of Abdo m i n a l Aortic Aneurysm • •

•

Axi a l cut of a CTA s h ow i n g the takeoff or t h e r i g h t renal a rtery a n d t h e m o re com m o n l y seen re n a l vei n l y i n g a nterior to t h e a o rta.

FIG 2

• • •

Leak or fra n k rupture Size ( 5 . 5 em in males, 5 em in females for aortic aneurysm, 4 em for i l i a c aneurysms) I n crease i n size of > 0 . 5 em over a 6-month period Symptomatic (pain, compression on adjacent structures) Dissection with i n aneurysm

C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECH N I Q U E S : Open S u r g i c a l Anatomy a n d Repa i r

•

•

Planning for the distal anastomosis requires review not only of the aortic bifurcation but the iliacs as well. If there is aneurysmal or occlusive disease within the iliac arteries, concurrent repair with a bifurcated graft may be appropri­ ate; otherwise, the maj ority of AAAs are repaired with a tube graft to the iliac bifurcation. Anastomosis may predi­ cate method of distal control, which can be obtained with a single clamp across the bifurcation or both iliac origins, or occlusion balloons (Foley catheters or Pruitt occlusion balloons) for heavily diseased vessels. Key pre-operative planning concerns are summarized in Table 2 .

•

There a re two a pproaches for the open repa i r of the in­ frarenal o r j uxta re n a l aortic a n e u rysm : transperitoneal or retroperitoneal (FIG 3). Which a p p roach is used for a n i nfra­ ren a l AAA is based o n several factors: body h a b itus (obese patients a re often best approached via retroperitoneal),

Table 2: Operative P l a n n i n g • •

• •

•

•

•

Is a retroperitoneal or transperitoneal a pproach better? Where is the best location for p roxim a l contro 1 7 Are there any alternatives should i ntraoperative findings preclude using this site? Will clamping i nvolve renal or visceral isch e m i a ? Will the r e n a l or visceral a rteries n e e d to be reconstructed as part of t h e repair? If s o , w h a t s i z e g rafts should be u s e d f o r the bypass? Where is the renal vei n 7 Does it pass a nteriorly or posterior to the aorta ? Will the kidney be taken up or left down ? How will distal control be obtained? Will reconstruction involve the i l i a c a rteries or can the dista l a nastomosis be to the b ifurcatio n ? W h a t size/type graft s h o u l d be used?

prior su rgery (co ncern for i ntraperitoneal adhesions), and l ocation of clamp (above the ren a l a rteries may favor a ret­ roperitoneal a p p roach), whereas p l a n ned i ntervention o n the r i g h t r e n a l o r i l iac a rtery wou l d be better a p p roached from the front (tra nsperitoneal).

• Incision for the two a p p roaches to a n e u rysm repa i r. A. Tra nsperito n e a l a n d (B) ret­ roperito n ea l . The retro perito n e a l a p p roach ca n be mod ified for h i g h e r exposu re on the viscera l a o rta.

FIG 3

B

A

TRANSPERITONEAL APPROACH •

•

Positi o n i n g : The patient is positioned s u p i n e on a sta n ­ d a rd operat i n g r o o m ( O R ) t a b l e w i t h b o t h a r m s ex­ te n d e d . The a rea from the n i p p l e l i n e to m i d t h i g h s s h o u l d be i n c l uded i n the prep field to a l low exposu re for a h i g h i n c i s i o n as we l l as the g r o i n s s h o u l d access to the fe m o ra l vesse l s be needed. The h a i r is c l i p ped and a towe l is p l aced over t h e peri n e u m . Any previous i n cisions with i n the prep field a re m a rked . A Steri-Drape o r l o b a n is u s e d to secure the d ra pes i n posit i o n . O n ce i n positi o n , check p u lse vo l u m e record i n g (PVRs) a n d/o r d ista l p u l ses. I n c i s i o n : A g e n e rous m i d l i n e i n c i s i o n from the x i p h o i d to the p u b i s is m a d e a n d d i ssected u n t i l the perito n e a l

•

1 997

cavity is ente red (FIG 3) . It may be n ecessa ry to exte n d the i n c i s i o n cep h a l a d l atera l a l ongside the x i p h o i d if h i g h e r exposu re is needed o r i n e m e rgent situations such as a rupt u re w h e re i m med iate su prace l i a c control is needed. A self-reta i n i n g retractor syste m s h o u l d t h e n be posit i o n e d . W e p refer the O m n i retractor as the open confi g u ration of the system does n ot l i m it the width of exposure. D i ssect i o n : Refl ect t h e g reater omentum and t r a n s­ verse co l o n ce p h a l a d a n d p a c k t h ese structu res away i n a m o i stened towel o r lap pad o n top of t h e patie nt's ch est. The s m a l l bowel s h o u l d be retracted to t h e r i g h t a n d p a c k e d with i n a sepa rate m o i stened towe l .

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P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Su perior mesenteric artery •

f-+--- Left

renal vein

Duodenum

� Inferior mesenteric artery

FIG 4 • Division of the l i g a ment of Tre itz (LOT) . After reflect i n g the colon cep h a l a d a n d the s m a l l bowe l to the patie nt's rig ht, the LOT ca n be d ivided to expose the i nfra re n a l aorta.

T h e s m a l l bowel i s g e ntly p l aced b e h i n d a self-reta i n i n g retractor, ta k i n g ca re n o t t o co m p r o m i se t h e s u p e r i o r mesente r i c a rtery ( S M A ) . T h i s exposes t h e l i g a m e n t o f Tre itz, w h i c h ca n be d ivided a l o n g t h e j ej u n u m to t h e l e v e l of t h e a o rta (FIG 4) . R e p o s i t i o n t h e retractor t o a l low a s m u c h s m a l l b o w e l to be out of t h e f i e l d a s poss i b l e, a n d take down t h e l i g a m e n t of Treitz with e l ectrocautery, ta k i n g care not to i nj u re t h e bowe l . T h e i nf e r i o r mesente r i c ve i n i s u s u a l ly l i g ated d u r i n g t h i s

Renal vein

d i ssect i o n . T h i s a l l ows a ccess to t h e i nfraren a l a o rta where t h e ove r l y i n g retro p e r i to n e a l tissue can be d i s­ sected free. D e pe n d i n g o n how m u c h a o rta i s needed for a n a d e q u ate cuff of t h e p rox i m a l a n a stomosis, an a nt e r i o r renal ve i n m a y need to be m o b i l ized ce p h a l a d , w i t h l i g a t i o n of t h e g o n a d a l a n d/o r a d re n a l ve i n f o r bette r exposu re (FIG S) . Exposure o f t h e su prace l i a c a o rta (FIG 6) : T h e m a n e uver is o n ly needed in cases w h e re h i g h a b d o m i n a l a o rt i c ex­ posu re is needed, such a s in a rupture. The l eft l o b e of the l iver m u st be retracted l atera l ly by t a k i n g down t h e t r i a n g u l a r l i g a m e nt. N ext, i d e ntify a n d d i ssect f r e e t h e g a stroeso p h a g e a l j u n ct i o n after d ivid i n g t h e g a stro­ hepatic l i g a m e nt, w h i c h is m ost exped i t i o u s l y done by p a l pati n g for the n a sogastric t u b e a n d a p p l y i n g ca u d a l tract i o n . D i v i s i o n of t h e g a stro hepatic l i g a m e n t m u st be d o n e with t h e t h o u g ht that a repl aced l eft h e patic a rtery wo u l d be co u r s i n g beneath this struct u re . The eso p h a g u s can be retracted to t h e patie nt's l eft, and t h i s m a n e uver will expose t h e a o rt a . An a o rt i c co m p res­ sor can be used in extreme c i rc u m sta n ces; h oweve r, d i s ­ sect i o n of t h e a o rta c i rcumferenti a l ly a n d su rrou n d i n g t h e a o rta w i t h a shoest r i n g if t h e patie nt's co n d i t i o n a l ­ l ows i s p refe r a b l e . T h i s exposu re, a lt h o u g h usefu l w h e n u rg e n t s u p race l i a c c o n t r o l i s n e e d e d , w i l l n ot a l low a c ­ c e s s to t h e visce ra l seg m e n t of t h e a o rt a . I n o r d e r t o g a i n t h i s exposu re, a r i g ht o r l eft m ed i a l viscera l rota­ t i o n s h o u l d be i n co r p o rated i nto the d i ssect i o n . The use of a r i g h t m e d i a l visce r a l rota t i o n w i l l a l low access to t h e r i g ht re n a l a rte ry, a s we l l a s p l a c i n g the SMA on 90-deg ree t e n s i o n and i s usef u l for c l e a r i n g a c l a m p site i n those patie nts with a j u xta re n a l a n e u rysm w h o h ave very l itt l e room between the re n a l s a n d S M A (FIG 7) . The u s e o f a l eft med i a l visce r a l rota t i o n a l so a l l ows for exposure to t h e e n t i re viscera l seg m e n t of t h e a o rta a s we l l a s t h e l eft re n a l a rte ry. Care i n t h i s a p proach m u st be m a d e to avo i d i n j u ry to t h e s p l e e n a n d ta i l of t h e p a n c reas.

SMA

Left renal artery

Right renal artery

Aorta

FIG S • (i l l ustration a n d p h oto): M o b i l i zation of the l eft re n a l ve i n . Cep h a l a d o r ca u d a l m o b i l i zation o f the l eft renal ve i n to expose t h e o r i g i n o f the re n a l a rteries. Ligation o f severa l ve n o u s sidebra nches may be needed for safe m o b i l izat i o n . (contin ued)

C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECH N I Q U E S : Open S u r g i c a l Anatomy a n d Repa i r

Left renal artery

Adrenal vein

Renal vein retracted su periorly

Inferior

Aorta

FIG 5

A

•

Gonadal vein

Renal lum bar vein

(con tinued)

c

B

• G a i n i n g control of the s u p ra c e l i a c a o rta. A. Dotted line s h ows the locat i o n for d ivision of the gastro hepatic l i g a m e nt. B. O n ce the l i g a m ent is d ivided, the crus is encou ntered . C. B l u ntly d ivide the fibers of the crus. D. Using f i n g e rs for retraction, control of the a o rta can be g a i ned with a c l a m p, a l t h o u g h ci rcumferenti a l control i s opti m a l .

FIG 6

1 999

2000

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

Liver

Right k id ney

Right renal artery

• Exposu re of the a o rta and right re n a l a rtery via r i g h t medial viscera l rotat i o n .

FIG 7

RETROPERITONEAL APPROACH •

Positio n i n g : Once asleep, position the patient in the latera l position with the left side up at an a p p roxi m ately GO-deg ree a n g l e (FIG 8). Extend the right arm o n an arm boa rd, being sure to leave room for an O m n i or other self-reta i n i n g re­ tractor post. The upper left arm should be placed o n an­ other arm boa rd and padded to p revent neural i nj u ry. The bed should be fl exed at the patient's f l a n k to open u p the a rea between the ribs and the a nterior superior i l iac spine. Position the legs so that the lower leg is stra i g ht and the upper leg is bent. Use two p i l lows as padd i n g between legs. A bea nbag can be i nfl ated to keep the patient i n p lace, and u s e t h i c k cloth t a p e over t h e h i p t o secure t h e patient o n his or her s i d e . Ideal ly, the patient s h o u l d b e p l aced on a bea n bag; however, b l a n ket rol l s c a n be used a nteriorly and posteriorly to further secu re the patient. Be sure to a l l ow access to prep from the spine posteriorly to the u m b i l icus a nteriorly and from the n i pple line to the groins. A l l bony promi nences and p ressu re poi nts should be we l l padded to avoid injury. Use c l i p pers to remove hair

shoulder elevated at 60"

•

•

with i n t h e prep a rea. Prep from t h e axi l l a a n d n i p p l e l i n e to the upper t h i g h . M a rk a l l previous incisions and use a Steri­ Drape or laban over the entire p repped a rea to secu re the dra pes. Once i n position, check PVRs a n d/or d ista l pu lses. I nc i s i o n : U n less c l a m p i n g is p l a n ned at o r above the level of the S M A, a sta n d a rd retroperito n e a l i n cision over the 1 1 th rib w i l l provide adeq uate exposu re (FIG 3) . Ca rry the i n cision from the posterior axi l l a ry l i n e to the anterior border of the rectus. Avo id entry i nto the pleural cavity if poss i b le, b e i n g cog n izant that the f u rther poste rior the i ncision is carried, the h i g h e r l i ke l i h ood t h i s w i l l occu r. Divide the tra nsversa lis fascia and enter the retroperitoneal space down to but not violating Gerota's fascia. This space can be more easily identified by resecting a d ista l seg ment of the 1 1 th rib, as the tra nversa l i s fascia and tra nsversus abdom i n a l m uscu lature i nserts a long the i nferior border of this rib. It is possible to stay entirely wit h i n a retroperi­ toneal pla ne; however, if the peritoneum is violated, the abdom i n a l contents can be packed away with retractors or the peritoneum can be repa i red with a ru n n i n g 3-0 chromic

FIG 8

•

Posit i o n i n g for retro peritoneal i ncision.

C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r

suture. The aorta may be approached via an a nterore n a l

Left lobe

(col loq u i a l ly referred to as " leavi ng the kid ney dow n " ) or

Left crus

retroren a l p l a n e ("ta king the kidney u p " ) (FIG 9). Gen­

Su perior mesenteric artery

eral ly, the aorta i s a p p roached via a retrore n a l a p p roach u n less there is a ren a l ve i n r u n n i n g posterior to the aorta . As the retroperitoneal d issection cont i n u es, the left u reter

Inferior mesenteric vein

should be identified and swept toward the m i d l i n e a n d placed b e h i n d a retractor to avo id injury d u r i n g d i ssection of the a o rta. The ren a l a rtery is identified a n d d i ssected

Left kidney Inferior mesenteric artery

back to its origin to identify the aorta •

Dissection: The ren a l a rtery should be cephalad to the vei n , a n d o n c e this is identified, it can be u s e d as a l a n d m a rk a n d d issected b a c k to the aorta.The ren a l l u m ba r vei n should b e identified a n d l igated t o avoid injury a n d excessive bleed­ ing. Once the origin of the renal a rtery is identified, a right

U reter

a n g l e can be placed a l o n g the s u rface of the aorta a n d the overlying retroperitoneal tissue d ivided with e lectroca utery. It is i m perative here to get on the aorta a n d stay on the

Left lobe Divided crus Spleen

Cel iac axis Su perior mesenteric artery Left renal artery

,___..,.____ Inferior

�

B

mesenteric vein Gonadal vein U reter

FIG 9 • The a o rta ca n be a p p roached in an a nterore n a l p l a n e (A) o r a retrore n a l p l a n e (B) .

aorta to avoid excessive b l eed i n g from the retroperitoneal tissue. The aorta is exposed to the bifurcation a n d ca n be d issected c i rcu mferentia l ly here if a c l a m p site is p l a n ned; h owever, the left i l iac vei n can cou rse posterior to the bi­ fu rcation a n d should be avoided. It is often easier to expose a n a rea of the l eft common i l iac a rtery for c l a m p i n g a n d control the r i g h t c o m m o n i l iac a rtery w i t h a n occlusion b a l ­ l o o n from with i n . It is u nwise t o g a i n circu mferential con­ trol of the i l iacs i n this situation as the i l iac vei n s a re often a d herent to the posterior aspect of the a rtery and a re easily i nj u red, lead i n g to rapid exsa n g u i nating b l ood loss. Identify a n d isolate the i nferior mesenteric a rtery (I MA) with a vessel loop. Pay particular attention to i dentifyi ng and not injur­ i n g the u reters, which w i l l eventua l ly cross a nterior to the i l iac vessels. If n ecessary a n d if the i ncision is p l aced a l o n g a h i g her rib space, the d i ssection can be carried ca u d a l t o expose the e n t i r e viscera l seg ment if n e e d be (FIG 1 0).

Shoestring for supraceliac control Celiac axis

Left renal artery

SMA

Left kidney Right renal artery

Left renal vein

Aortic bifurcation

FIG 10 • Expos u re of the entire a bdo m i n a l a o rta from a retroperito n e a l a p proach. H e re, the k i d n ey is " left d ow n " in an a nterore n a l p l a n e . A l l vesse ls a re su rro u nded w i t h vesse ls loops.

2001

2002

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

AORTIC CLAMPING AND REPAIR •

•

Reg a r d l ess of a p p roach, it is i m p o rtant d u r i n g c i rc u mfer­

rysm a n d t h e vici n ity o f t h e viscera l vesse ls. I n t h e m ost

e nt i a l d i ssect i o n of t h e a o rta to avo i d i nj u ry to t h e poste­

stra i g htforwa rd sce n a r i o, an a d e q u ate cuff of n o r m a l

rior l u m ba r a rteri es, w h i c h a re u s u a l ly pa i re d . If t h ey a re

a o rta i s present b e l o w t h e rena I s to a l low for i nfra r e n a l

encou ntered a n d req u i re l igation, ca refu l l y c i rcu mfere n ­

c l a m p i n g a n d a n e n d -to-e n d a n a stomosis. A s u p r a re n a l

t i a l l y d issect out t h e a rte ry, tyi n g t h e proxi m a l s i d e of the

c l a m p ca n b e u s e d to p rovide s p a c e to s e w to a s h o rt

vesse l, a n d using a n oth e r tie, double clip o n t h e d i st a l

i nfra r e n a l cuff. If a n e u rysm a l tissue extends to t h e vis­

s i d e p r i o r to d ivid i n g . W h e n d i ssect i n g o n t h e a o rta, c a r e

cera l b r a n c h es, o r if t h e re i s s i g n ificant a nt h e roscle rot i c

m u st be taken to m i n i m i ze a g g ressive m a n i p u l a t i o n a n d

d i sease of t h e b r a n c h es, a beve l e d a n asto mosis may be

su bseq u e n t atheroe m b o l ization, p a rti c u l a rly if preopera­

req u i red, poss i b ly i n c l u d i n g a n e n d a rte rectomy of the

tive i m a g i n g s h ows exte nsive m u ra l d e b r i s . •

o r i g i n of a branch vesse l o r a bypass to t h e l eft re n a l a r­

Choice of g raft: There a re seve r a l choices for con d u it d u r­

tery (FIG 1 2) . T h i s s h o u l d be a p p a rent based on ca refu l

i n g repa i r. G e n e r a l ly, a polytetrafl u o roethy l e n e (PTFE) o r

review of preoperative i m a g i n g a n d p l a n ned for we l l be­

Dacron t u b e g raft i s sewn from t h e p roxi m a l a o rta to t h e

fore c l a m p i n g of t h e a o rt a . From t h e retroperito n e a l ap­

bifu rcat i o n . I n th ose patie nts w i t h extensive b i f u rcation

p roach, every effort s h o u l d be made to i ncorporate the

o r i l ia c d i sease, a bifu rcated g raft may be used. If t h i s i s t h e case, the prox i m a l s i n g l e l u m e n p o r t i o n of the g raft s h o u l d be as short as poss i b l e to prevent k i n k i n g , i d e a l l y

C h o o s i n g t h e site of t h e p rox i m a l a n astomosis: T h i s w i l l d e p e n d o n t h e q u a l ity o f t h e proxi m a l neck o f t h e a n e u ­

r i g ht re n a l a rtery i nto the a n a sto mosis. •

I n preparation for c l a m p i n g , t h e patient should be sys­ temica l ly h e p a r i n ized at a dose of 70 u n its of h e p a r i n

l e s s t h a n 4 e m . Tu n n e l i n g the l i m b to the femora l level

per k i l o g ra m a n d a l l owed t o ci rcu l ate for 3 to 5 m i n utes.

s h o u l d be done only if n ecessa ry, and if so, care m ust be

It is i m p o rtant to com m u n i cate with a n esthesia prior to

taken to r u n the g raft poste r i o r to the u reter. The a o rta

c l a m p i n g and u n c l a m p i n g so they may a nt i c i pate a n d

can be m e a s u red for the a p propriate g raft with a o rtic

a d d ress s u bse q u e n t h e m odyn a m i c sh ifts. G e n e r a l ly, t h e

sizers, but often, a n est i mation of size ca n be m a d e from

syste m i c p ress u re s h o u l d be d ropped i n p repa rat i o n

t h e preoperative CTA. Reg a rd l ess, the majority of patients

for t h e prox i m a l c l a m p i n g . I f t h e viscera l seg m e nt i s i n ­

can be repa i red with an 1 8- to 22-mm g raft (FIG 1 1 ).

volved, b u l l d o g c l a m ps s h o u l d be a p p l i e d to t h e viscera l vesse ls p r i o r to aortic c l a m p i n g to avo i d e m bo l izat i o n . The p roxi m a l c l a m p i s ca refu l ly a p p l i e d a n d secu red with a shoest r i n g around t h e c l a m p . The a o rt i c sac i s then opened with e l ectroca utery and h eavy scissors p roxi m a l ly a n d d i st a l ly. M u ra l d e b r i s s h o u l d be ca refu l ly removed to i d e ntify a l l patent l u m b a r a rteries. D ista l control can then be o bta i n ed with b a l l o o n occ l u s i o n i nto each i l i a c with F o l ey catheters if exte r n a l control was n ot p revi­ ously done due to c a l cific d isease. All l u m b a r vesse l s with back-bleed i n g i nto t h e a o rta s h o u l d b e s u t u re l i g ated with 2-0 s i l k in a f i g u re-of-e i g h t fash i o n . In heavi ly c a l c i ­ fied a o rtas, foca l e n d a rterectom ies m a y be necess a ry f o r effective l i g a t i o n of each vesse l . •

Sew i n g o f t h e prox i m a l a n asto moses: T h e re a re seve r a l w a y s to co m p l ete t h e a n asto mosis, a n d c h o i ce i s based o n a com b i n a t i o n of surgeon preference and tissue q u a l ity. Reg a r d l ess of tech n i q ue, t h e poste r i o r row of su­ tu res should b e d o n e fi rst. E n s u re that t h e re i s a d e q u ate expos u re of the p roxi m a l a o rta; t h i s may req u i re the use

B

of a self-reta i n i n g retracto r with i n the opened sac o r stay sutu res on the edges of the sac. Place the g raft o n the pa­ t i e nt's ch est u p s i d e d own, so the poste r i o r as pect of t h e g raft l i es a nterio rly. If t h e poster i o r r o w is to be d o n e i n a n i nterru pted fas h i o n , t h e fi rst m attress sutu re i s p l aced in t h e m i d d l e of t h e g raft from outside to in, p l a c i n g a s n a p on t h e n e e d l e d e n d s of t h e s u t u res. Place fo u r more m attresses, two o n each s i de, wo r k i n g y o u r way to t h e 3 o ' c l o c k a n d 9 o ' c l o c k p o s i t i o n s o n t h e g raft. Care m ust be taken to e n s u re t h e re a re no g a p s betwee n sutu res; a l l travel m u st be with i n a m attressed stitch a n d n ot be­ twee n stitches. O n ce a l l s u t u res a re p l a ced in the g raft, beg i n p l a c i n g t h e a o rt i c s u t u res from i n s i d e to outside o n

FIG 1 1 • A. Tu be g raft from i nfra re n a l a o rta to b i f u rcati o n a n d ( B ) bifu rcated g raft f r o m i nfrare n a l a o rta to i l i a c o r

t h e a o rta. The p roxi m a l a o rta i s usua l ly n o t co m p l etely

fe m o ra l vesse ls.

transected and t h e poste r i o r wa l l can be used to create

C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r

Right renal artery

Su perior mesenteric artery

Cel iac artery

graft

Anterior

a Creech b ite that uses the a o rt i c wa l l as a p l e d g et. Once

Lateral

FIG 1 2 • Beve l e d a n asto mosis with bypass to t h e l eft re n a l a rte ry. The sutu re l i n e r u n s j u st i nfer i o r to t h e r i g h t re n a l a rte ry.

d ista l a n a stomosis is in p l a c e . It is u nwise to atte m pt to

all s u t u res a re p l aced, each i n d iv i d u a l stitch i s p l e d g eted

p l ace stitches on a fu l ly perfused a o rta, a n d t h e p roxi m a l

and tied down s n u g ly. The a nterior row i s then com­

c l a m p s h o u l d be rea p p l i ed if repa i r stitches a re n ecessa ry.

p l eted, sta rti n g from each side and work i n g yo u r way

I n a d d it i o n , p l e d g ets s h o u l d be used with these stitches.

to the center, such that the a nterior-m ost stitch i s t h e

A r u n n i n g a n a stomosis c a n a lso be pe rfo rmed with a 3-0

fi n a l stitch p l aced. T h e s e a re a l so p l e d g eted a n d tied i nto

P ro l e n e and a n atra u m atic n e e d l e . The back row i s a g a i n

p l ace. Once the proxi m a l a n asto mosis i s co m p l eted, a n

b e g a n i n t h e m i d d l e o f t h e g raft w i t h d e e p Creech b ites

atra u matic c l a m p s h o u l d b e a p p l i e d t o t h e body o f t h e

o n the a o rta. The g raft can b e parach uted in to m a ke

g raft, a n d t h e proxi m a l a o rt i c c l a m p slowly r e l eased t o

t h e suture l i n e taut. The back row s h o u l d be i nspected to

test for i ntegrity of t h e re p a i r. Any l e a ks i n t h e sutu re

e n s u re that it is s n u g a n d a d d i t i o n a l s u t u res a re used at

l i n e s h o u l d be a d d ressed at t h i s t i m e, p a rti c u l a rly a l o n g

t h e 3 o'clock a n d 9 o'clock positions to secu re t h e back

the poste r i o r row, as t h i s w i l l be i n access i b l e o n c e t h e

row and r u n to t h e top of t h e a o rta (FIGS 1 3 and 1 4) .

• Construct i o n o f t h e poste r i o r row o f t h e p roxi m a l a n a stomosis. N ote t h a t t h e a nterior a n d l atera l aspects of t h e a o rta is d ivided b u t t h e poste r i o r wa l l is l eft i ntact i n t h i s f i g u re, u s i n g " Creec h " s ut u r i n g tec h n i q u e .

FIG 1 3

2003

2004

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

a n asto m oses a re co m p l et e d , c o m m u n i cate w i t h the a n est h e s i o l o g ist t h a t t h e c l a m ps a re ready to b e re­ m oved . T h e re i s oft e n a s u bsta nt i a l d ro p in syste m i c b l o o d p r e s s u r e a s t h e l ow e r extre m it i e s a re r e p e rfused, and t h e y w i l l n e e d to p r e p a re to react accord i n g l y. It i s m o re a p p ro p r i ate to t o l e rate a s l i g ht l y l o n g e r c l a m p t i m e a n d a l low t h e a n est h e s i o l o g ist to reg u l ate t h e b l o o d p ress u re accord i n g l y t h e n u n c l a m p a hypote n ­ s i ve p a t i e n t . As t h e s u rg e o n s l ow l y u n c l a m ps, t h e a s ­ s i st a n t c a n h o l d m a n u a l p ress u re at t h e l e v e l of t h e fe m o ra l a rt e r i e s to a l l ow a n y d e b r i s to f l u s h i nto t h e p e l v i s, w h i c h m a y t o l e rate e m b o l i z a t i o n better d u e t o t h e exte n s i ve c o l l a te ra l n etwo r k . Press u re i s t h e n re­ l e a se d o n the fe m o r a l vesse l s and syste m i c p re ss u re is m o n i t o re d . If t h e re is a s u bsta n t i a l hypote n s i ve re­ s p o n se, p a rt i a l o r co m p l ete recl a m p i n g m a y need to b e p e rfo r m e d to a l l ow the a n es t h e s i a team t i m e to treat the h e m o d y n a m ics. O n ce u ndam p e d , i n s pect t h e a n asto m o s i s a n d s a c for b l e ed i n g . T h e re m a y b e n ew l u m b a r b l e e d i n g as a res u lt of p e l v i c r e p e rf u s i o n t h a t was not a p p a re n t d u r i n g t h e g ra ft p l a c e m e nt. D i ffuse ooz i n g c a n b e treated w i t h S u rg i c e l and G e lfoa m . O n ce u nda m pe d , c h e c k p u l s e s a n d D o p p l e r s i g n a l s in i l i a cs

FIG 1 4 • Aortic cuff. The a o rta can be tota l l y transected a n d stay sutu res a p p l ied i n preparation f o r t h e a n asto mosis.

a n d a ny c l a m ped b r a n c h vesse ls, as we l l as d i sta l p u l ses a n d/o r PVRs. I f l ow e r ext r e m ity PVRs a re s i g n ifica n t l y worse t h a n p re o p e rative l y, t h i s s h o u l d r a i s e c o n c e r n

•

I M A i m p l a ntati o n : A l th o u g h t h e I M A c a n g e n e ra l ly be

for e m b o l i z a t i o n a n d m a y w a r r a n t a g r o i n exp l o ra t i o n a n d t h r o m becto my.

l i g ated without c l i n i c a l conseq u e n ce, t h e re a re certa i n s i t u a t i o n s w h e re it m a y be b e n efi c i a l t o re i m p l a nt t h e

•

vess e l to avo i d bowe l i sc h e m i c co m p l icat i o n s . Patie nts

•

perito n e a l a p proach, as a n u n c o m m o n but d isastro u s

with a ltered p e l v i c b l ood fl ow, such a s those with p r i o r

l ate co m p l icat i o n f r o m o p e n a o rt i c su r g e ry i s t h e a o rta­

g a stroi ntest i n a l s u r g e ry o r occ l u d e d hypogastric a rter-

enteric fist u l a, w h i c h occu rs when g raft a n d/o r a n a sto­

i es, s h o u l d espec i a l ly be co n s i d e red for I MA re i m p l a n ­

mosis erodes i nto the bowe l . To h e l p p revent t h i s, t h e

tati o n . F u rt h e r m o re, v i s u a l i n spect i o n o f t h e s i g m o i d

wa l l s of t h e now deco m p ressed a o rt i c sac s h o u l d be

co l o n p r i o r to c l o s u r e s h o u l d b e d o n e , a n d I M A re i m ­

c l osed over t h e g raft, and sewed i n a r u n n i n g fas h i o n

p l a ntat i o n d o n e if t h e re a p p e a rs to be q u est i o n a b l e v i ­

w i t h a l o n g 3 - 0 s i l k o r c h r o m i c s u t u re . If t h e re i s i nsuf­

a b i l ity o f t h e bowe l . Ad d i t i o n a l ly, p r i o r to I M A l i g a t i o n ,

ficient sac to c l ose, a f l a p of o m e n t u m ca n be m o b i l ized

a n assess m e n t of back-b l ee d i n g (a n d t h u s t h e co l l atera l

and p l aced ove r t h e g raft prior to retu r n i n g t h e visce r a l

c i r c u l a t i o n to t h e I M A territory) s h o u l d be p e rfo r m e d

to i t s a n ato m i c locat i o n . The sac of t h e a o rta can be a not

a n d re i m p l a ntation co n s i d e red i n c a s e s w h e re t h e b a c k ­

i ns i g n ificant sou rce of b l e e d i n g , so e l ectroca utery s h o u l d

b l e ed i n g i s poor.

be u s e d a l o n g t h e cut e d g e of t h e sac to e n s u re h e m osta­

Creat i n g t h e d i sta l a n a stomosis: After t h e p roxi m a l

sis p r i o r to sac closu re, and persistent b l e ed i n g s h o u l d be

a n a sto m o s i s i s co m p l eted a n d h e m osta s i s i s e n s u red, t h e g raft s h o u l d be p u l l e d taut to t h e location of t h e d ista l a n asto m o s i s (or a n astomoses if a bifu rcated g raft

•

Sac closure: T h i s is espec i a l ly i m p o rtant d u ri n g t h e trans­

sutu re l i gated. •

D ra i n a g e and c l o s u r e : I f the p l e u ra l cavity was e n t e r e d , d r a i n a g e w i l l b e req u i re d e i t h e r by u s e of a red r u b­

is to be used). The g raft s h o u l d be m e a s u red to e n s u re

b e r s u c t i o n catheter p l a c e m e n t d u r i n g d i a p h ra g m a t i c

no red u n d a n cy or k i n k i n g occu rs b u t n ot so t i g h t as to

r e p a i r o r posto p e rative c h est t u b e p l a c e m e n t . Ad d i ­

p u t u n d u e stra i n on t h e p roxi m a l a n stomosis. T h e d i s-

t i o n a l p l a c e m e n t o f a c l osed s u ct i o n J a c k s o n - P ratt (J P)

ta l can b e d o n e in a r u n n i n g or i nterru pted fash i o n , as

or B l a ke d ra i n in t h e p e r i to n e a l or retro p e r i to n e a l ( R P)

described prev i o u s ly. W h e n sewi n g , t h e assista nt s h o u l d

cavity c a n be d o n e on a s e l ective b a s i s; we g e n e r a l l y

use a forceps to p u l l t h e g raft d i sta l l y a n d rem ove ten­

p l a c e a d ra i n i f t h e re i s s o m e c o n c e r n ove r excessive

s i o n o n t h e a n a stomosis, d ecrea s i n g t h e c h a nce t h e s u ­

m o b i l i za t i o n n e a r the ta i l of the p a n c re a s and t h o u g ht

t u res w i l l be t o o l o o s e .

a p a n c r e a t i c l e a k m a y occ u r, or i n c o a g u l o pa t h i c p a ­

F l u s h i n g a n d u n c l a m p i n g : J u st p r i o r to t h e co m p l et i o n

t i e nts w h e re o n g o i n g b l e e d i n g m a y b e of c o n c e r n .

of t h e d i sta l a n a st o m o s i s , t h e g raft w i l l n e e d to b e

S p ec i a l atte n t i o n s h o u l d b e p a i d to i n s p e ct i n g t h e

f l u s h e d proxi m a l l y a n d d i sta l l y to r e m ove c l ot, a i r, a n d

s p l e e n , a n d we h ave a l o w t h re s h o l d for s p l e n ecto my

d e b r i s . Aft e r f l u s h i n g , i r r i g ate t h e g ra ft w i t h h e p a r i n ­

i f t h e re i s a n y i nj u ry to t h e o r g a n . T h e a b d o m i n a l wa l l

i z e d sa l i n e a n d co m p l ete t h e a n a st o m o s i s . O n ce both

s h o u l d t h e n b e c l osed i n layers.

C h a p t e r 22 ADVA N C E D A N E U RY S M MANAG E M E N T TECHN I Q U E S : O p e n S u r g i c a l Anatomy a n d Repa i r

2005

PEARLS AND PITFALLS •

I d e a l ly, p roxi m a l c l a m p t i m e s h o u l d be l ess t h a n 30 m i n utes. It is t h e refo re i m p e rative to h a ve a l l too l s a n d g rafts ready a n d a l l tea m m e m bers b r i efed o n t h e ope rative p l a n p r i o r t o c l a m p i n g . H owever, for a n i nfra r e n a l c l a m p, t h e o p e rator w i l l have seve r a l h o u rs if n ecessa ry to co m p l ete t h e a n a stomosis. I f t h e c l a m p is s u p ra r e n a l , co m p l icati o n s beg i n with m o re t h a n 40 m i n utes o f isch e m i a .

•

I nj u ry to t h e c o m m o n i l i a c ve i n o r d i staiiVC d u r i n g d issect i o n i s a potent i a l l y l et h a l co m p l icati o n . It i s i m portant to co m p l etely m o b i l ize t h e ve i n and p e rform a p r i m a ry repa i r under d i rect vision. B l i n d sutu r i n g i n a b l e ed i n g field wi l l o n ly l e a d to d isaste r. I f e x p o s u r e ca n n ot be obta i ned, it i s acce pta b l e to transect t h e ove r l y i n g a rtery (aorta o r i l i a c) to a l l ow a ccess to t h e ve i n . T h i s i s a co m p l i cation that is m uc h better to avo i d t h a n treat.

•

The u reters c a n b e i nj u red d u ri n g t h e transperito n e a l o r retro pe rito n e a l a p p roach, and every time t h e retracto rs a re repositi o n e d o r as you beg i n to d i ssect a new p l a ne, t h e u reters s h o u l d be i d e n t i f i e d .

POSTOPERATIVE CARE •

• •

•

•

Patients should be monitored in an intensive care unit (ICU) postoperatively, with blood pressure goals generally of a sys­ tolic blood pressure from 100 to 140 mmHg for a straight­ forward infrarenal or j uxtarenal repair. Blood pressure goals should be higher for thoracoabdominal repairs to promote spinal cord perfusion. Patient may be weaned to extubated as soon as possible after the operation, even in the OR if appropriate. An NGT is kept in place given the bowel manipulation, and this is left in place for the first postoperative day. Although it is not imperative to keep in place until there is full return of bowel function, we will keep in place an additional day if outputs are unusually high. We generally start standing rectal suppositories on the first postoperative day. If there is a chest tube in place, we leave this to suction until removal, which is done when output is less than 1 5 0 m L per 2 4 hours and the chest x-ray ( CXR) shows n o large effusion. Mobilization should be done as soon postoperatively as pos­ sible. These patients will require physical therapy and many will ultimately require inpatient rehab.

OUTCOMES •

•

•

Mortality for an elective, open infrarenal AAA repair is less than 5 % , and although the risk increases for those with a j uxtarenal or suprarenal repair, our recent experience shows that 3 0-day mortality in patients with j uxtarenal repair is 2 . 5 % . Mortality increases in the instance of an urgent or rupture to as high as 70 % . 1•5 Patient-specific predictors of postoperative complications include older age, COPD, chronic renal disease (creatinine > 1 . 8 ) or history of myocardial infarction (MI)/congestive heart failure (CHF ) .1 Operative-specific predictors of postoperative complications include long OR or clamp times, hypothermia, high blood turnover, and a high perioperative fluid requirement.

COMPLICATIONS • •

Bleeding Infection

• • • • • • • •

Splenic inj ury (consider adding splenectomy to operative consent) Renal failure MI CVA Spinal cord ischemia ( increased risk with suprarenal and thoracoabdominal repairs ) Anastomotic breakdown Aortoenteric fistula Pancreatitis

REFERENCES 1. Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. j Vase Surg. 2003;37:1106-1117. 2. Cronenwett JL, Sargent SK, Wall MH, et al. Variables that affect the expansion rate and outcome of small abdominal aortic aneurysms. J Vase Surg. 1990;11(2):260-269. 3. Darling RC III, Brewster DC, Darling RC, et al. Are familial abdomi­ nal aortic aneurysms different? J Vase Surg. 1989;10(1):39-43. 4. Strachan DP. Predictors of death from aortic aneurysm among middle­ aged men: the Whitehall study. Br J Surg. 1991;78(4):401-404. 5. Tsai S, Conrad MF, Patel VI, et al. Durability of open repair of juxtare­ nal abdominal aortic aneurysms. J Vase Surg. 2012;56(1):2-7. 6. McFalls EO, Ward HB, Moritz TE, et al. Clinical factors associated with long-term mortality following vascular surgery: outcomes from the Coronary Artery Revascularization Prophylaxis (CARP) Trial. J Vase Surg. 2007;46(4):694-700. 7. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vase Surg. 2009;50(4):880-896. 8. Dawson I, Sie RB, van Boeke! JH. Atherosclerotic popliteal aneurysm. Br J Surg. 1997;84(3):293. 9. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chap­ ter, International Society for Cardiovascular Surgery. J Vase Surg. 1991;13(3):452-458. 10. Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Coop­ erative Study Investigators. Arch Intern Med. 2000;160:1425-1430. 11. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Eng/ J Med. 2002;346(19):1437-1444.

-

Chapter

23

Advanced Aortic Aneurysm Management: Endovascular Aneurysm Repair-Standard and Emergency Management 1

I - -----------------------------------------------------------------------------------------

Vinit N. Varu

Ronald L. Dalman

DEFINITION •

•

•

•

An abdominal aortic aneurysm (AAA) is defined as a localized enlargement of more than 1 .5 times the diameter of the most adj acent, proximal uninvolved aorta; by consensus, this represents more than 3 . 0 em in most persons. Defini­ tions vary somewhat between men and women, most likely normalized by body surface area or body mass index (BMI ) . The most common etiology o f AAAs is progressive, trans­ mural degeneration of the aortic wall. The full scope of pathogenetic considerations and relevant mechanisms is be­ yond the scope of this chapter but, in summary, although aneurysm disease shares many important risk factors for aortic and peripheral vascular occlusive disease, important differences exist, and current thinking regarding pathogen­ esis recognizes that aneurysmal and occlusive disease of the aorta are distinct pathologic processes. Hence, the colloquial term " atherosclerotic aneurysm, " although in common use, is an inaccurate and potentially misleading characterization of the most common clinical presentation for AAA. Risk factors for development, expansion, and rupture are multifactoriaP (Table 1). Smoking is the only modifiable risk factor that has been associated with all three. The risk of AAA rupture increases with progressive diameter en­ largement.2 Rupture and subsequent aneurysm-related mortality

•

•

Table 1: Risk Factors for Aneurysm Development, Expansion, and Rupture

Symptom

Risk Factors • • • • •

AAA expa nsion

• • • • •

AAA rupture

• • • • •

• •

Tobacco u s e Hypercho l estero l e m i a Hypertension Male gender Fa m i ly h i story ( m a l e predo m i n a nce) Advanced a g e Severe c a r d i a c disease Previous stroke Tobacco use C a rd i a c o r re n a l tra n s p l a n t Female gender .J. FEV1 Larger i n it i a l AAA d i a m eter H i g h e r m e a n blood pressure C u rrent tobacco use ( l e n gth of time smoking > > a m o u nt) C a rd iac o r renal tra n s p l a n t C ritical wa l l stress-wa l l strength relati o n s h i p

AAA, abdominal aortic aneurysm; FEV1, forced expiratory volume i n 1 second. From Chaikof EL, Brewster DC, Dalman RL, et a/. The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines: executive summary. J Vase Surg. 2009;50(4):880-896.

2006

may be prevented by elective surgical repair, either by open in­ terposition grafting or endovascular aneurysm repair (EVAR) . EVAR provides similar long-term survival versus traditional open repair, as well as enhanced perioperative survival. The perioperative survival benefit is sustained for several years following surgery. 3 EVAR is now the de facto standard of care for both elective and ruptured AAA repair in patients who are anatomically suited to receive currently available devices.

PATIENT HISTORY AND PHYSICAL FINDINGS

•

AAA deve l o p m e n t

·

•

•

Patients may be entirely asymptomatic despite suffering from large, advanced AAAs. Most commonly, AAAs are found incidentally on imaging studies obtained for other reasons. Occasionally, they may be identified by the presence of prom­ inent aortic pulse, proximal to the umbilicus, on physical exam. Less frequently, AAAs may cause distal limb ischemia secondary to embolization, or fulminate congestive heart failure if they rupture into the adj acent inferior vena cava, creating an acute aortocaval fistula. Only 3 0 % to 4 0 % are noted on physical examination, with detection of pulsatile abdominal mass dependent on aneurysm size. As noted by Sir William Osler, prior to the era of ubiquitous availability and use of cross-sectional abdominal imaging in the evalua­ tion of abdominal pain: "There is no disease more conducive to clinical humility than aneurysm of the abdominal aorta . " Patients with a ruptured AAA may present with moderate or extreme back and abdominal pain, syncope, hypotension, and mottling of the lower extremities, in conjunction with progres­ sive abdominal distension. When sufficiently stable to remain conscious and conversant, pain is reproducibly elicited by direct palpation of the abdominal aorta. Many patients with ruptured AAA present in extremis, others with progressively hemodynamic deterioration and pain of several hours dura­ tion. Patients may actually linger for several days with "con­ tained" retroperitoneal hemorrhage following AAA rupture. A thorough vascular history should be noted and modifiable risk factors, including smoking, hyperlipidemia, and hyper­ tension, addressed in patients with AAAs. Smoking cessa­ tion is recommended to reduce the risk of aneurysm growth and rupture, and statins may also be beneficial in this regard. AAAs occur almost exclusively in the elderly (mean age of repair 72 years of age) and male patients outnumber female by 4 to 6 is to 1 . 1 When AAA is recognized in younger patients, it is usually in association with hereditary risk, syndromic aortic conditions such as Marfan syndrome, or in the setting of focal aortitis or mycotic aneurysms. The latter tend to occur most frequently in the suprarenal abdominal aorta, at or directly proximal to the origin of the celiac artery, underneath the crus of the diaphragm. Aneurysmal degeneration of the abdominal aorta may also occur late following thoracic and abdominal aortic dissection.

C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r

•

Factors associated with increased risk of rupture include female gender, large initial diameter, low forced expiratory volume m 1 second (FEV 1 ) , current smoking history, and el­ evated mean blood pressure.

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Screening decreases aneurysm-related mortality in AAA dis­ ease.4 Current guidelines recommend a screening ultrasound for 65- to 75-year-old at-risk individuals, defined as men who have smoked more than 1 0 0 cigarettes in their lifetime or men or women with a family history of AAAs.5 Thin-slice computed tomography ( CT) imaging, with in­ travenous contrast injection timed to opacify the abdomi­ nal aorta and runoff vessels, remains the standard modality for operative planning. The extent, morphology, and acces­ sibility of the aneurysm via retrograde iliofemoral access determine the suitability for an endovascular repair. Other relevant anatomic considerations include the location and volume of laminar intraluminal thrombus in the region of the " surgical" neck ( defined as the length between the lowest renal artery and the start of the aneurysm); angulation of the surgical neck, size and tortuosity of access vessels; presence and significance of anomalous and accessory renal arteries; dtameter at the aortic bifurcation; and diameter of the more proximal abdominal aorta (provides useful guidance as to the likely long-term diameter of the surgical neck ) . F o r cases of suspected AAA rupture, bedside transcutaneous ultrasonography may be used to detect the presence of intra­ or retroperitoneal fluid ( or blood) or assess for confounding condtttons ehettmg abdominal pain. When sufficiently he­ modynamically stable, however, CT aortography should be obtained to assess for suitability for endovascular repair.6

•

•

•

�

•

•

Patients with "symptomatic " AAAs (e.g., pain likely originat­ mg from the aneurysm despite absence of retroperitoneal hem­ orrhage on CT aortography) are at increased risk of rupture and urgent intervention is recommended. Of those AAAs that rupture, more than half will die prior to hospitalization. Of those that undergo attempted operative repair, approximately 5 0 % mortality is to be expected. The latter estimate is highly dependent on hemodynamic conditions, duration of symp­ tom� , and comor id conditions present at the time of surgery and IS not useful m predicting survival of individual patients. 1 For asymptomatic AAAs, management is determined by the maximal orthogonal transverse diameter at the time of evaluation or rate of aneurysm enlargement over time. AAAs less than 4 . 0 em are at low risk of rupture and should be monitored with serial imaging; those larger than 5 . 4 em are at high risk of rupture and should be repaired. Surveillance is recommended for most patients in the range of 4 . 0 to 5 . 4 e m , although young healthy patients a n d especially women may benefit from repair in AAAs between 5 . 0 and 5.4 cm.1

?

•

Preoperative Planning •

Anatomic measurement obtained from high-quality CT aor­ tography, preferably reconstructed with millimeter or sub­ millimeter slices, is paramount to successful endovascular

repair. Ideally, precise diameter and path length measure­ ments are derived from three-dimensional ( 3 - D ) recon­ struction of the two-dimensional (2-D) source images (via TeraReconTM, OsiriX™, or similar software) . Precision i s most essential i n determining diameter through­ out the surgical neck and common iliac landing zones proxi­ mal to the bilateral iliac bifurcations. Graft oversizing of 1 0 % to 20% is typically used in the region of the surgical neck. Length measurements are obtained from the lowest renal artery to the iliac bifurcation, using path lengths, when available, from image reconstruction software noted earlier. Multiple aortic endografts are approved for use in the United States at the current time, and device selection should be tai­ lored to individualized anatomic requirements. Contraindi­ cations to endovascular repair may include inadequate neck length, diameter, and angulation; thrombus volume and dis­ tribution in the neck; insufficient iliac artery diameter, and ex­ cessive iliac or aortic tortuosity. It is the responsibility of the operating surgeon to ensure that for each selected device the instructions for use (IFU) are understood and appropriat for the planned repair. Experienced operators, with careful plan­ mng, may knowingly place devices in off-label circumstances depending on the patient-specific anatomic and physiologi nsk assessment, with the expectation of reasonably long-term results. In off-label applications, however, the onus is on the surgeon to confirm that sufficient proximal and distal fixa­ tion and sealing zones exist to ensure a reasonable result. 7 Femoral access must also be evaluated with ultrasound or CT imaging to determine if the patient is a candidate for per­ cutaneous repair. The "preclose " technique (see the follow­ ing text) can be used for arteriotomy closure for devices up to 21 French (Fr) in diameter. Contraindications to percutane­ ous repair include calcification of the anterior femoral artery wall, diameter less than 7 mm, the presence of an aneurysmal femoral artery, and excessive scaring at the access site. The superior mesenteric artery ( SMA) and celiac arteries should be examined for patency and the presence of flow­ limiting stenosis or occlusion; if found, revascularization of the SMA and celiac artery should be considered prior to at­ tempted EVAR, or open repair is considered as an alternative approach. In planning for EVAR, attention must be paid to the status of the inferior mesenteric artery and the total vis­ ceral vascularity assessed in terms of consequences of obli­ gate inferior mesenteric artery (IMA) coverage during EVAR. Occasionally, depending on anatomic circumstances, custom fenestration or parallel grafting options may be considered as alternatives, allowing for EVAR management despite the presence of significant celiac or SMA disease. The latter op­ ttons agam, however, should only be considered by opera­ tors experienced in these techniques or facile with rapid open conversion when indicated to preserve intestinal perfusion. Facilities are an essential consideration. Fixed imaging is the preferred option for procedural guidance and aortography, preferably when available in a "hybrid" operating room config­ uration. This is especially true when tolerances are low regard­ mg IFU status and related anatomic considerations. Anesthesia can be either general or local with conscious sedation, depend­ mg on the habitus of the patient, their suitability for conscious sedation, and the potential likelihood of open conversion. In our practice, all patients are consented for open conversion, even though in practice this happens in less than 1 % of cases.

�

SURGICAL MANAGEMENT Indications

2007

•

2008

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

device. The wire is t h e n t e m p o r a r i l y rem oved a n d t h e de­

ENDOVASCULAR ANEURYSM REPAIR

vice advanced u nt i l p u lsat i l e b l ood i s v i s u a l ized t h r o u g h

STANDARD

t h e p i l ot t u b e l u m e n . The fi rst device i s t u r n e d to t h e 1 0 o ' c l o c k p o s i t i o n a n d foot p l ate a ctivated. H o l d i n g b a c k

Percutaneous Access •

tension o n t h e device, t h e sutu re i s d e p l oyed, a n d t h e

U s i n g u ltraso u n d g u i d a nce to determ i n e t h e location of

e n d s a re re m oved f r o m t h e d e v i c e a n d contro l led w i t h

t h e fe m o r a l b i f u rcation a n d pote nti a l presence of a nte­

a padded s u t u re c l a m p . After t h e w i re i s reposit i o n e d

rior c a l cified athe rosc l e rotic p l a q ue, b i l ateral c o m m o n

t h r o u g h t h e w i re p o rt i nto t h e a o rta u n d e r f l u o rosco p i c

fe m o ra l a rteries (CFAs) a re accessed with 0 . 0 1 8-i n m i ­

g u i d a nce, t h e foot p l ate i s released a n d t h e device i s

c ro p u n ct u re k i t s . F e m o ra l a rteriog ra p h y i s pe rfo rmed t o

b a c k e d out of t h e fe m o r a l a rte ry. Press u re i s rea p p l i e d

c o n f i r m s u i ta b i l ity of t h e sel ected access s i t e with i n the CFA p r i o r to seri a l d i l a t i o n . •

A 0 . 0 3 5 - i n g e n e r a l p u rpose w i re (e . g ., B e ntson, C o o k

ove r t h e p u nctu re site d u r i n g t h i s m a n e uver (FIG 1 ) . •

loaded o n t h e wire and the afore m e n t i o n e d ste ps a re re­

M e d i c a l , B l o o m i n gton, I N ) i s a dva n ced i nto t h e a o rta t h r o u g h the m i cropu n ctu re sheath

and

1 1 -cm, 7-Fr

sheaths a re exch a n g e d ove r t h e B e ntson i nto t h e ex­

peated with t h e device t u rned to t h e 2 o'clock posit i o n . •

ta i n h e m ostasis. The sutu re c l a m ps a re positi o n ed con­

g u i d a nce. F u l l i ntrave n o u s a nticoa g u lation i s esta b l ished

s i stent with t h e c l ockface o r i e ntation of each suture

with u nfract i o n ated heparin (at least 1 00 u n its/kg) a n d c l ott i n g time (ACT) g reater than 2 5 0 seco n d s .

After both ProGiid esrM (Ab bott) a re d e p l oyed, t h e 7 - F r s h e a t h i s refo rmed a n d repl aced o v e r t h e w i re to m a i n ­

tern a l i l i a c a rteries ( E IA) u n d e r conti n uo u s f l u o rosco p i c

confirmed b y su bse q u e n t dete r m i nation o f a ctivated

A seco n d Perclose ProGiideTM (Abbott) device i s back­

p l acement. •

The p roced u re i s t h e n repeated for t h e contra l atera l fe mora l a ccess site.

Preclose Technique

Delivery and Deployment of Endograft

•

•

•

I n a l l c i rc u m st a n ces, t h e s u rg e o n s h o u l d c o n s u l t t h e

W i re exc h a n g e i s p e rformed t h r o u g h a g u i d i n g cath­

respective I F U s f o r a l l d e v i c e s e m p l oyed d u r i n g t h e s e

eter (e . g . , 1 00-cm G l i d ecathrM, Te r u m o M e d i c a l , Som­

p roced u re s .

e rset, NJ) for a stiffe r access w i re (e . g ., L u n d e rq u ist'M,

W h i l e t h e assista nt m a i nta i n s d i rect co m p ress i o n p roxi­

Cook M e d i c a l ) . S e r i a l d i l a t i o n i s p reformed ove r t h e stiff

mal to t h e i n g u i n a l l i g a m e nt to m a i nta i n h e m osta sis, the

wi re, u n d e r f l u o rosco p i c g u i d a nce, to g e ntly d iste n d a n d

7-Fr sheaths a re i n d iv i d u a l l y rem oved over each respec­

e n l a rg e t h e respective a rteriotomy sites. F o l l o w i n g d i l a ­

tive w i re and re p l a ced with a Perclose ProGiideTM (Ab­

t i o n to at least 1 4 Fr, t h e p r i m a ry a n d seco n d a ry access

bott, Abbott Park, I L) device. This i s back- l o a d e d o n the

sheaths a re adva n ced u n d e r f l u o rosco p i c g u i d a nce i nto

w i re and advanced u n t i l t h e g u i d ew i re exit l i n e o n the

the a o rt a .

Closed arteriotomy

• Preclose tec h n i q u e . Two ProGi i d esrM a re de­ p l oyed, o n e at t h e 10 o'clock position and t h e oth e r at t h e 2 o'clock posit i o n before beg i n n i n g seri a l d i l a t i o n m a n e uvers a n d d e p l oyment of d e l ivery catheters. O n ce the p roced u re i s co m p l ete, and l a rg e d i a m eter devices a re rem oved, both k n ots a re seated to c l ose t h e a rteri otomy ( s e e i nset) . U nt i l closu re, t h e f r e e sutu res a re contro l l ed o n sutu re boots. O n ce the proce d u re is co m p l ete, both k n ots a re p u s h e d down to c l ose t h e a rteri otomy.

FIG 1

C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r

•

The m a i n b o d y e n d o g raft i s p l a ced u p t h e i p s i l atera l i l i a c

Gate Cannulation

a rtery to the level of t h e re n a l a rteries. Late r a l ity of m a i n

•

body d e p l oyment i s dete r m i n e d based o n t h e tortuosity

i cs) o r G l i d eTM catheter (Te r u m o), t h e gate is ca n n u lated

s i red a n g l e at which t h e m a i n body w i l l i nterface with

with a n a n g l e d G l i dewi reTM (Te r u m o ) . W h e n s u ccessf u l ,

t h e re n a l a rteries. The m a i n body s h o u l d be o r i e nted so

the O m n if l u s h catheter s h o u l d b e exc h a n g e d ove r a w i re

that the gate d e p l oys in a nterol atera l fas h i o n for easy

a n d rei ntroduced i nto t h e e n d o g raft. The t i p is a l lowed

contra latera l l i m b access. The i m a g e i ntensifier s h o u l d be

to refo rm by with d rawi n g t h e w i re and t h e c u r l e d f l u s h

adj usted to l i m it p a ra l l a x by acco u n t i n g for some deg ree

catheter i s s p u n 360 d e g rees seve r a l t i m e s to confirm

of a nterior a n g u l at i o n ( u s u a l ly in t h e range of 1 0 % , oc­

gate ca n n u l a t i o n . Fa i l u re to confirm t h i s step may res u l t

cas i o n a l ly m o re) and l atera l a n g u l a t i o n in the s u rg i c a l

i n d e p l oyment o f t h e contra l atera l l i m b o u t s i d e of t h e

neck, b a s e d o n preproce d u r a l assessment f r o m t h e refor­

g a t e , l i ke l y g e n e ra t i n g " e n dotra s h " (e . g . , g raft l i m b free

m atted CT a o rto g r a m (FIG 2A) . •

in t h e a n e u rysm, outside t h e m a i n body, w h i c h w i l l n ot

An O m n i F l u s h catheter (An g i oDyn a m i cs, Lat h a m , NY)

re m a i n in c i rc u l at i o n ) (FIG 2C) .

i s p l aced up the contra l atera l i l i a c a rtery to the level of

•

the r e n a l a rteries. The g a ntry position i s t h e n confirmed to be a p p ro p r i ate for t h e patient's a n atomy, e n s u r i n g

( d i fferent-s h a pe d catheters s h o u l d b e e m p l oyed, a s we l l a s reposit i o n i n g t h e s h e a t h i n r e l a t i o n to t h e c o n ­

l owest re n a l a rte ry. U s u a l ly, a " 2 0 for 1 0 " contra st r u n

tra l atera l g ate), ca n n u l a t i o n m a y b e acco m p l i s h e d b y

i s pe rfo rmed d u ri n g b reath - h o l d u n d e r m a g n ificati o n

a d va n c i n g a s n a re u p t h e contra l atera l s h e a t h i nto t h e

vi ews, d e l ive r i n g 1 0 m L of contra st at a rate of 20 m L per

a n e u rysm a n d e n g a g i n g t h e m a i n body e n d o g raft b i ­

seco n d , to confirm t h e device position vis-a-vis t h e renal

fu rca t i o n w i t h a 5os O m n i o r s i m i l a r c u rved catheter.

a rtery o r i g i n s .

T h e i ps i latera l w i re is t h e n adva n ced t h r o u g h t h e g ate,

The m a i n b o d y e n d o g raft i s t h e n d e p l oyed accord i n g

to b e s n a re d from the contra latera l s i d e . O n ce the w i re

t o t h e I F U , w i t h t h e p roxi m a l fa b r i c m a rg i n posit i o n e d

is w i t h d rawn t h r o u g h t h e contra l a t e ra l s h e a t h , a cath­

j ust b e l ow t h e l owest re n a l a rte ry. D e p l oyment co n t i n ­

eter m a y b e b a c k- l oa d e d and adva n ced i nto t h e m a i n

ues u nt i l t h e contra l atera l g a t e i s fu l ly o p e n (a lth o u g h

body, w h i c h i n t u r n a l l ows a n exch a n g e t o a stiffe r

tech n i q ues may va ry between devices). Depen d i n g o n

w i re t h r o u g h t h e g a t e . W h e n n ecessa ry, a w i re c a n a l so

the device-specific I F U , t h e m a i n b o d y may be resheathed

b e adva n ced from bra c h i a l a rte ry access for the s a m e

and reposit i o n e d , if n ecessa ry, to o bta i n opti m a l posi­

p u rpose.

t i o n i n g (FIG 28) . •

Repeat a o rtog ra phy i s pe rfo rmed t o e n s u re a d e q uate

Limb Extension

p l acement. The s i d e - h o l e, a o rtic flush catheter i s with­ d rawn i nto t h e a n e u rysm through t h e prox i m a l l a n d i n g

•

zone, ove r a w i r e . If t h e device u s e s s u p r a re n a l ste nt fixa­

Retro g ra d e i l i a c a n g i o g r a p h y is pe rfo rmed t h r o u g h t h e s h e a t h , w i t h t h e g a ntry positi o n i n t h e contra late r a l

tion, t h e s u p r a re n a l stents a re d e p l oyed when m a i n body

o b l i q u e posit i o n . T h i s w i l l i d e ntify t h e o r i g i n of t h e i n ­

p l a c e m e n t i s d e e m e d suffi c i e nt. Care s h o u l d b e taken to

tern a l i l i a c a rte ry. O n ce t h i s i s confi rmed, d i st a n ce from

prevent p u l l i n g the m a i n body of the e n d o g raft down

t h e gate to t h e i ntern a l i l i a c i s measu red using a m a rker

i nto t h e a n e u rysm .

A

If t h e contra latera l gate c a n not be s u ccessfu l l y ca n n u ­ l ated u s i n g sta n d a rd g u i d e w i re a n d catheter tec h n i q u e s

t h a t t h e i m a g e p l a n e i s o rth o g o n a l to t h e takeoff of t h e

•

The contra late ra l sheath is p l aced 1 to 2 em d i st a l to t h e contra late r a l g ate. U s i n g a n O m n if l u s h T M (An g iodyna m ­

a n d d i a m eter of the access a rteri es, a s we l l a s the de­

catheter and a n a p propriately sized l i m b i s chose n .

B

c

D

FIG 2 • D e l ivery a n d d e p l oyment of e n d o g raft. A. The m a i n body is broug ht up the i ps i late r a l i l i a c a rte ry to t h e l evel of t h e ren a l a rteries. An O m n i F l u s h catheter i s b r o u g h t u p t h e contra l atera l i l i a c a rt e ry a n d a n a n g i og r a m i s p e rfo r m e d . B. The m a i n b o d y e n d o g raft i s d e p l oyed u n d e r f l u o rosco p i c . g ui d a n ce u ntil t h e contra l atera l g a t e i s o p e n e d . C. The contra late r a l g a t e i s ca n n u lated. D. An exte n s i o n l i m b is p l aced p roxi m a l to the i l i a c b i f u rcati o n o n t h e contra latera l s i d e a n d t h e i ps i latera l e n d o g raft is f i n ished b e i n g d e p l oyed (o n e d o c k i n g l i m b systems) or an exte n s i o n l i m b is p l a ced (two d o c k i n g l i m b systems) to t h e l evel of t h e i ps i latera l i l i a c bifu rcat i o n .

2009

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P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

devi ces (e.g., TriVasc u l a r

m a n e uvers to e n s u re sea l . T h i s may i n c l u d e d e p l oyment

Ovat i o n 1M, C o o k Zen ith 1M), t h i s p roce d u re h a s to b e

of proxi m a l e n d o g raft cuffs, p ro l o n g e d m o l d i n g b a l l o o n

For t h ree-p i ece

•

bifu rcated

perfo rmed o n both s i d es . O pti m a l l i m b d e p l oyment

i nf l a t i o n t i m e, o r, o n occa s i o n , p l acement of e m b o l i s m

m a i nta i n s s uffi c i e nt contact with t h e gate to m a i nta i n

co i l s i n reca lcitrant l e a ks. W h e n s m a l l l e a ks persist, even

sea l (see respective I F U ) a n d suffi cient d i sta l cove rage to

when a n at o m i c cove rage seems a d e q u ate, a n t i coag u l a ­

co m p l etely excl u d e the com m o n i l i a c a rtery without i m ­

t i o n s h o u l d be reversed a n d sheaths rem oved w i t h t h e

p i n g i n g o n t h e o r i g i n o f t h e i ntern a l i l i a c a rtery (FIG 20) .

p l a n f o r fo l l ow-up C T a o rtography with i n a few days.

Occa s i o n a l ly, w h e n t h e d i stance req u i red for proper l i m b

Care s h o u l d be taken to ca refu l ly eva l u ate t h e n a t u re

placement d oes n o t precisely correl ate with t h e s i zes

of a l l l e a ks (type, vo l u m e, l ocat i o n i n regard to l u m b a r

ava i l a b l e , the n ext s ize-l o n g e r l i m b may be d e p l oyed

b r a n c h es, stat u s o f g raft l i m b d e p l oyme nt, a d e q u acy

i nto t h e gate and slowly a l o n g its l e ngth . D u r i n g d e p l oy­

of m o l d i n g , etc.) before seco n d a ry i nterve n t i o n s a re

m e n t (once out of t h e g ate), conti n u ed u pward p ressure

c o n s i d e red for pe rsistent l e a ks . The majo rity of type I I

o n t h e d e p l oyment h a n d l e i s m a i nta i n ed to encourage

e n d o l ea ks resolve i n t h e fi rst year. I n o u r practice, we

t h e g raft to take a somewhat m o re serpig i n o u s route,

never resort to d e p l oy m e nt of a l a rg e d i a m eter, ba l l oo n ­

ta k i n g up some of the a d d i t i o n a l l e a k . P a rt i a l cove rage

expa n d a b l e stent i n t h e p rox i m a l neck-accu rate s i z­

of t h e i ps i l atera l i ntern a l i l i a c a rtery orifice i s a l so a p pro­

i n g a n d d e p l oyment of t h i s ste nt may be d iffi c u l t a n d

pri ate when d e p l oyment can be p recisely m o n itored i n

" stretc h i n g " t h e p rox i m a l orifice o f t h e m a i n b o d y i n

t h e contra l atera l o b l i q u e g a ntry posit i o n .

t h i s way m a y d a m a g e t h e g raft, without sufficient as­ s u r a n ce that t h e p roxi m a l type I leak w i l l b e a d e q u ately a d d ressed .

Balloon Molding •

An a p p ro p riately sized semicom p l i a nt b a l l o o n (e . g ., Coda1M, Cook M e d i c a l ) is expa n d e d with d i l ute contrast s o l u t i o n at a l l t h ree l a n d i n g zones and ove r l a p a reas

Closure •

polypropy l e n e sutu res a re d e p l oyed seq u e n t i a l ly in each

(FIG 3). W h e n exist i n g common i l i a c a rtery ste nosis i s

access site and c i n c h e d down with a k n ot p u s h e r ove r

p rese nt, k i ss i n g b a l l o o n s s h o u l d be d e p l oyed to o bta i n

a w i r e . W h e n i n it i a l h e m osta s i s a p p e a rs a d e q u ate, t h e

o pt i m a l i ntern a l d i a m eter a n d prevent l i m b k i n k i n g o r

w i re i s rem oved a n d s l i g htly m o re p ress u re i s a p p l i e d t o

occl u s i o n . S i m i l a rly, t h e a o rt i c b i f u rcati o n s h o u l d a l so

t h e k n ot p u s h e r. After b o t h sutu res a re d e p l oyed i n o n e

b e d i l ated w h e n n e cessa ry. Occa s i o n a l ly, se lf-expa n d i n g

g r o i n , dete r m i n a t i o n i s m a d e a s to w h i c h of t h e t w o a p ­

b a r e meta l n it i n o l stents m a y be d e p l oyed at a reas of

pea rs to prov i d e more effective h e m ostas i s a n d m a n u a l

ste nosis or from the d ista l l i m b i nto exte r n a l i l i a c a rte ry,

pressure i s h e l d t o t h i s suture f o r 5 a d d i t i o n a l m i n utes.

to p revent k i n k i n g of t h e e n d o g raft o r native exte r n a l i l i a c a rtery d i sta l to t h e device.

This is repeated for t h e i p s i l ateral s i d e . •

Proced u ra l a nticoa g u l a t i o n is reve rsed once a l l sheaths and c l a m ps a re rem oved . It is essentia l to wait for f i n a l

Completion Arteriography •

The contra lateral sheath is rem oved ove r t h e w i re a n d m a n u a l p ress u re i s h e l d . The p revi o u s l y p l a ced p reclose

with i n t h e gate(s) as a p p ro p r i ate fo r t h e specific device

i ntrod ucer device rem ova l before revers i n g t h e a nt i co­

Co m p l et i o n a rteriography is p e rformed with h i g h e r

a g u l at i o n , beca use the l a rg e d i a m eter sheaths used to

vo l u m e a n d l o n g e r i nj e ct i o n t i m e t o co m p l etely fi l l t h e

d e l iver EVAR devices may a l m ost entirely occl u d e t h e

e n d o g raft, e n s u re l i m b patency, a n d i d e n tify e n d o l ea ks

i ps i l atera l exte r n a l i l i a c a rte ry, ca u s i n g potent i a l ly cata­

(FIG 4) . A l l type I or I l l e n d o l ea ks, w h e n p resent at t h e

stro p h i c g raft l i m b and i l i a c a rtery t h ro m bosis i n t h e ab­

e n d of t h e c a s e , s h o u l d be a d d ressed with a d d i t i o n a l

sence of fu l l a nticoa g u l at i o n .

3 • B a l loon m o l d i n g . A se m i co m p l i a nt b a l l o o n i s i n f l ated at prox i m a l a n d d i sta l l a n d i n g z o n e s as we l l as at a l l ove r l a p p i n g e n d o g rafts. FIG

C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r

A

B

c

D •

Co m p l et i o n a rte r i o g r a p hy. Speci a l atte ntion is p a i d to e n s u re t h e re n a l a n d i l i a c a rteries a re patent, as we l l as to i d e n tify if an e n d o l e a k is present. The e n d o g raft itself s h o u l d be scrut i n ized for a n y evidence of l i m b k i n k i n g . A. R e n a l a rtery patency confi r m e d . B. No Type 1 A e n d o l e a k confi r m e d . C. Exte r n a l a n d i nt e r n a l i l i a c a rtery pate n cy confi r m e d a n d e n d o g raft itse lf s h o u l d be scruti n i zed f o r a n y evidence o f l i m b k i n k i n g . D. N o type 1 B, 2, 3, o r 4 e n d o l e a k i d e ntified w i t h d e l ayed i m a g i n g .

FIG 4

ENDOVASCULAR ANEURYSM REPAIR FOR

•

RUPTURED ANEURYSMS, OR REVAR

The use of i ntrave n o u s a nticoag u l at i o n i s controvers i a l i n t h i s sett i ng-a g a i n i t i s h i g h ly d e p e n d e n t o n t h e h e m o ­

Percutaneous Access •

dyn a m i c statu s of t h e patient, p resence of a ctive b l ee d ­

B i l atera l CFA access is o bta i n e d u n d e r loca l a nesth esia.

i n g , a n d exist i n g consu m ptive coa g u l o pathy. Often w h e n

The preclose tech n i q u e (descri bed i n the p revi o u s section)

treat i n g r u pt u red a n e u rysms, t h e c a s e beg i n s without

can be e m p l oyed when t i m e a n d co n d itions perm it, but if

a nticoa g u l at i o n , which is s u bseq u e ntly i n stituted once

n ot poss i b l e, the case ca n p roceed percuta neously i n it i a l ly, with conversion to open femoral closure when the endo­ g raft is fu l ly d e p l oyed a n d i nter n a l bleed i n g h a s sto pped.

R a p i d catheter a n d g u i d ewi re exch a n g e s a re pe rfo rmed, with sheath u p s i z i n g as n oted i n t h e p revi o u s sect i o n .

t h e m a i n body and exten s i o n l i m bs a re d e p l oyed. •

In t h e case of r u pt u re proced u res, preoperative CT a o r­ tography may not exist or may n ot p rovide s uffi cient

201 1

201 2

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

a n ato m i c deta i l to g u i d e d e p loyment. In t h i s c i r c u m ­ sta n ce, catheter a rte riography with a m a rker f l u s h cath­ eter s h o u l d b e e m p l oyed to determ i n e path l e n gt h s, l a n d i n g zon es, a n d opti m a l g raft s i z i n g .

Aortic Balloon Control •

-

F o l l o w i n g access a n d w i re exch a n g e, a L u n d e rq u i stTM (Cook M e d i c a l ) o r s i m i l a r stiff w i re i s adva n ced i nto the a o rta, ove r w h i c h a 1 4- F r

x

5 5-cm b r a i d e d sheath i s ad­

vanced to the l evel of t h e r e n a l a rteries. O n ce loca l i za­ tion i s confi rmed, t h e s h eath i s sutu red to t h e skin at the access site. •

A semicom p l i a nt b a l l o o n (Co d a rM, Cook M e d i c a l ) o r s i m i l a r a o rt i c occl u s i o n b a l loon i s d i rected to a posi­ tion i m m ed i ately p roxi m a l to t h e visce r a l a rteries u n d e r f l u o rosco p i c g u i d a nce (FIG 5) . O n ce positioned, it c a n be m a i nta i n ed i n t h e defl ated s i t e u n t i l o r u n l ess t h e patie nt's h e m odyn a m i c status req u i res i nflation a n d a o r­ t i c occl u s i o n .

•

FIG 6 • M a i n body d e p l oyment for R EVAR. After a n a n g i o g r a m i s p e rformed to i d e ntify t h e re n a l a rteries a n d a o rt i c neck, t h e m a i n body i s d e p l oyed u p t h e i p s i latera l i l i a c a rte ry. T h i s can be d o n e with t h e s e m i c o m p l i a nt b a l l o o n i nfl ated .

O n ce b i l atera l t h e ra peutic sheath a ccess is o bta i n ed a n d t h e deflated occ l u s i o n b a l l o o n i s positioned proper ly, g e n e ra l a n esthesia may be i n d uced.

deflated a n d removed t h r o u g h t h e contra late r a l sheath. B a l l o o n p l acement should be p e rformed i n s u c h a way

Endograft Delivery and Deployment •

•

•

that t i m e without b a l l o o n cove rage i s kept to an a bso­

Ao rto g r a p h y is pe rfo rmed t h r o u g h t h e contra late r a l

l ute m i n i m u m . Retro perito n e a l h e m o r r h a g e can con­

s h e a t h b e l ow t h e ba l l oo n to l oca l ize t h e o r i g i n s of t h e

tinue at a r a p i d rate t h r o u g h out this proce d u re, a n d in

re n a l a rteries.

t h e a bsence of exte r n a l b l e e d i n g , neither t h e s u rg e o n s

The m a i n body e n d o g raft is p l aced u p t h e i ps i late r a l

n o r t h e a n esth e s i o l o g ists may a p p reciate t r u e m a g n it u d e

s h e a t h to t h e l e v e l of t h e re n a l a rteries. It s h o u l d be ori­

of b l o o d l o s s a n d ci rcu l atory reserve. U nd e r t h e s e c i r c u m ­

ented so that t h e gate d e p l oys i n a nterol atera l fas h i o n .

sta n ces, h e m odyn a m i c co l l a pse c a n be precip ito us a n d,

The m a i n body e n d o g raft is t h e n d e p l oyed accord i n g to

u nfort u n ate ly, ca l a m itous, u n l ess an occ l u s i o n b a l l o o n i s

t h e I F U , j ust d ista l to t h e l owest re n a l a rte ry. D e p l oy m e nt

properly positioned a n d i m m ed iately i nfl ated at t h e fi rst

cont i n ues u n t i l t h e contra l atera l gate is f u l l y d e p l oyed

i n d icat i o n of r a p i d h e m odyn a m i c dete r i o rati o n .

(FIG 6). •

The i ps i latera l l i m b of t h e e n d o g raft is ca n n u lated and t h e sheath advanced i nto t h e m a i n body of t h e e n d o g raft.

•

A seco n d Coda b a l l o o n is p l aced i n t h e i p s i l atera l s h eath and i n f l ated in t h e m a i n body (FIG 7) . The fi rst b a l l o o n i s

)

-

FIG 5 • Aortic b a l l o o n control for R EVAR. A semicom p l i a n t ba l l oo n i s p l aced u p t h e contra late r a l i l i a c a rte ry proxi m a l to the ce l i a c t r u n k . It c a n be i n f l ated d e p e n d i n g o n h e modyn a m i c i n sta b i l ity.

Figure 7 • B a l loon excha n g e a n d gate ca n n u lation for R EVAR. The entire ipsilateral gate is deployed prior to contra l atera l gate ca n n u lation. A secon d sem i-co m p l iant bal loon is placed u p the ipsilatera l endog raft l i m b (top of i m a g e) and p laced i nto the m a i n body of the endog raft. It ca n be i nfl ated depe n d i n g on hemodyna m i c i n sta b i l ity. The fi rst sem i-co m p l iant ba l l oo n is removed a n d the sheath is brought to d i stal to the contra latera l g ate to prepare for gate ca n n u latio n . Retrograde a n g iography with a marking catheter is performed through the contra latera l sheath to i dentify the i l iac bifurcation a n d desi red l i m b extension length.

201 3

C h a p t e r 23 ADVA N C E D AORT I C A N E U RYSM MANAG E M E NT: Endovascu lar Aneurysm Repai r

Gate Cannulation •

-

G ate ca n n u l a t i o n p roceeds i n a sta n d a rd fas h i o n d u r i n g

-�

R EVAR .

Limb Extension •

L i m b exte n s i o n proceeds i n a sta n d a rd fas h i o n d u r i n g R EVAR . Ti m e awareness i s critical d u ri n g sta n d a rd EVA R ste ps to e n s u re that a n e u rysm sea l i n g i s acco m p l i s h e d i n t h e m ost exped itious m a n n e r possi b l e .

Balloon Molding •

CodaTM b a l l o o n (Cook M e d i c a l ) m o l d i n g is pe rfo rmed at a l l s e a l zones to o pt i m ize h e m ostasis. O n ly after m o l d i n g

FIG 8

is co m p l ete i s h e m ostasis assured.

Completion Aortography

Closure

•

•

Co m p l et i o n a o rto g r a p h y is pe rfo rmed as p revi o u s l y de-

•

C o m p letion a o rto g r a p h y for R EVAR .

Closure proceeds as i n d i cated for sta ndard EVAR, with ca­

scribed. Atte ntion s h o u l d be p a i d to a l l t h e u s u a l co n ­

veat that if ProG l ides were not deployed prior to percuta ne­

s i d e ratio ns, i n c l u d i n g p resence a n d n a t u re o f e n d o l ea ks,

ous access, then surgical i ncisions will need to be made to

i l i a c l i m b o r a rteri a l k i n k i n g , suffi c i e n t ove r l a p in t h e

expose the femora l a rtery sites for control a n d closure under

l a n d i n g zones to m e et I F U , a n d so forth (FIG 8) .

d i rect vision as the therapeutic sheaths a re withd rawn .

PEARLS AND PITFALLS Access

•

U ltraso u n d g u i d a nce i s essent i a l to l i m it i n g a ccess co m p l i cations. Vis u a l ize the need l e tip enteri n g t h e a nterior a rtery wa l l , i n a n a rea d e e m e d a p p ro p r i ate for access.

G ate ca n n u l a t i o n

•

In g e n e r a l , m a i n body s h o u l d be adva n ced t h r o u g h the m o re tort u o u s of the two i l i a c a rteries to a l l ow a more " stra i g h t s h ot " for t h e contra l atera l gate ca n n u l at i o n . T h i s p reference is not a lways p ractica l, h owever, a n d late ra l ity may need to be decided based o n m o re pract i c a l co n s i d e rations (e . g . , I s t h e tortu­ osity suff i c i e nt to p revent m a i n body positi o n i n g and d e p l oyment a ltogether?).

Tort u o u s i l i a cs

•

Pe rfo rm t h e com p l et i o n a o rtog ram with soft cath eters i nstead of stiff wi res i n p l a ce . Stiff w i res may stra i g hten out a tort u o u s vesse l , which may e n d up k i n ked when t h e wi res a re removed and l e a d to l i m b occ l u s i o n . A lso, rete ntion o f stiff wi res a t t h e t i m e o f co m p l et i o n a o rtog raphy m a y mask t h e d eve l o p ­ m e n t of t y p e I p roxi m a l e n d o l e a ks, w h i c h may d eve l o p situati o n a l ly w h e n stiff wi res a re re m ove d .

C l o s u re

•

T i e d o w n t h e s u t u res of t h e c l o s u re device w i t h t h e w i re i n p l ace. If t h e re i s sti l l s i g n ificant b l e ed i n g , e i t h e r d e p loy a n ot h e r c l o s u re d e v i c e o r p l ace a n occ l u s ive sheath a n d p roceed with o p e n convers i o n o f t h e fe m o ra l a rtery c l o s u re u n d e r m o re contro l led c i rc u m stances.

R u ptu res

•

O utco m e s a re vastly i m p roved w h e n REVA R p rotoc o l s a re esta b l ished and p ra cticed. Abdom i n a l c o m p a rt­ m e n t syn d ro m e i s a rea l a n d freq u e nt com p l i cation fo l l ow i n g R EVAR-if t h e re i s any i n d i cation that ven­ t i l at i o n p ressu res a re rising o r a b d o m i n a l p ressu res a re s i g n ificantly e l evated at t h e e n d of t h e p roced u re by measu r i n g b l a d d e r p ressu re, strong c o n s i d e ration s h o u l d be g iven to d e co m p ressive l a p a rotomy at t h e i n it i a l sett i n g .

POSTOPERATIVE CARE •

•

Patients should remain supine for a minimum of 3 hours and are free to ambulate thereafter. Most elective EVARs can be discharged on postoperative day 1 or 2. For cases well within the IFU, same-day surgery is now a reality and can safely be offered to patients who can remain in reasonably close proximity to the hospital the evening after surgery. Following REVAR, consideration should be given to de­ compressive laparotomy whenever abdominal pressures are

•

elevated at the end of the initial procedure. When decompres­ sive laparotomy is performed, free peritoneal blood should be evacuated but retroperitoneal hematomas should not be explored or evacuated. Abdominal wound suction systems should be deployed to control drainage and provide a moist environment for intestinal viability. Dressing changes should be performed daily or every other day until the wound can be safely closed. Initial postprocedural CT aortography is performed at 1 month to document presence or absence of endoleaks

201 4

P a r t 6 OPERATIVE TECH NIQUES IN VASCULAR SURGERY

•

•

There is higher perioperative survival in patients undergoing EVAR, which is sustained for several years. 3 The loss of this is due to late ruptures in the EVAR group. Secondary interventions are similar in open and EVAR.3

COMPLICATIONS • • • • • • •

Endoleak Delayed rupture Renal dysfunction Thromboembolism Limb occlusion Colon ischemia Abdominal compartment syndrome (ruptured EVAR)

REFERENCES 1.

2. •

Posto pe rative i m a g i n g . 3-D reconstruct i o n of a CT a o rtog r a m in a patient w h o h a ve u n d e r g o n e su ccessf u l EVA R at 1 month fo l l ow-u p .

FIG 9

3.

4.

and graft position and confirm visceral perfusion ( FIG 9) . Follow-up imaging i s performed with either ultrasound + / ­ noncontrast CT scanning or by CT aortography, based on the last known status of endoleaks (presence or absence ) , symptomatic status, a n d comorbid conditions such a s chronic renal insufficiency. I n general, w e prefer serial ultra­ sound evaluations, with CT scanning reserved for aneurysms which are enlarging following endografting or evidence of significant changes in endoleak volume or location.

5.

6.

7.

8.

OUTCOMES •

All-cause mortality is similar in patients undergoing open or EVAR for AAA at 2 years.3•8• 9

9.

Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Sur­ gery practice guidelines: executive summary. J Vase Surg. 2009;50(4): 880-896. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large ab­ dominal aortic aneurysms in patients refusing or unfit for elective re­ pair. ]AMA. 2002;287(22):2968-2272. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term compari­ son of endovascular and open repair of abdominal aortic aneurysm. N Eng/ ] Med. 2012;367(21):188-197. Lindholt JS, Norman PE. Meta-analysis of postoperative mortality after elective repair of abdominal aortic aneurysms detected by screen­ ing. Br J Surg. 2011;98(5):619-622. Guirguis-Blake JM, Beil TL. Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;160(5):321-329. Mehta M. Endovascular aneurysm repair for the ruptured abdominal aortic aneurysm: the Albany Vascular Group approach. J Vase Surg. 2010;52(6):1706-1712. Lee JT, Ullery BW, Zarins CK, et al. EVAR deployment in anatomi­ cally challenging necks outside the IFU. Eur J Vase Endovase Surg. 2013;46(1):65-73. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or en­ dovascular repair of abdominal aortic aneurysm. N Eng/ J Med. 2010; 362:1881-1889. Greenhalgh M, Allison OJ, Bell PRF, et al. Endovascular versus open repair of abdominal aortic aneurysm. The United Kingdom EVAR Trial Investigators. N Eng/ J Med. 2010;362:1863-1871.

I

Chapter

24

Advanced Aneurysm Management Techniques: Management of Internal I liac Aneurysm Disease

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - "1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

�

W Anthony Lee

circumferential mural thrombus may appear to have a nor­ mal contour.

DEFINITION •

• •

Iliac aneurysm is defined as an iliac artery whose diameter is 20 mm or more. Iliac aneurysms are present in up to 2 0 % of abdominal aortic aneurysms, 1 and common iliac aneurysms occur far more frequently than internal iliac aneurysms. Isolated iliac aneurysms represent less than 5% of all aor­ toiliac aneurysms. External iliac aneurysms are extremely rare and mostly either associated with underlying connective tissue disorders or represent traumatic pseudoaneurysms.

SURGICAL MANAGEMENT • •

DIFFERENTIAL DIAGNOSIS •

Differential diagnoses of iliac aneurysm are limited to true degenerative aneurysms, which are most common; mycotic, traumatic, or surgical pseudoaneurysms; or aneurysmal en­ largement of the false lumen from a primary dissection.

•

PATIENT HISTORY AND PHYSICAL FINDINGS •

Most iliac aneurysms are clinically silent ( asymptomatic) . Rarely, i n very thin individuals with large aneurysms, a pul­ satile aneurysm may be palpable on physical examination. Even more rarely, a patient being evaluated for hydroureter may be determined to have an iliac aneurysm. Ureteral ob­ struction in this circumstance derives from perianeurysmal inflammation (similar to retroperitoneal fibrosis) rather than mechanical compression by the aneurysm.

Preoperative Planning •

IMAGING AND OTHER DIAGNOSTIC STUDIES •

•

•

Although a plain abdominal x-ray can detect an aortoiliac aneurysm if there is heavy mural calcification, the most common imaging modalities include ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI ) . Thin-cut ( 1 mm), intravenous contrast-enhanced, spiral C T (CT arteriogram) represents the "gold standard" for diagnosis and anatomic evaluation of abdominal aneurysms. Even in patients with stage III/IV chronic kidney disease, high-qualiry imag­ ing may be obtained relatively safely using reduced volumes of isoosmolar, nonionic contrast with multidetector (32, 64, 128, or 220) scanners, particularly following preprocedural intravenous hydration. The CT dataset is rendered into three­ dimensional (3-D) images for dimensional postprocessing, a critical requirement for complex endovascular case planning. Conventional arteriography adds little to the identification and analysis of iliac aneurysms; penetrating ulcers may appear like saccular aneurysms, and large aneurysms with

In general, iliac aneurysms are repaired when they reach 30 mm in diameter, become symptomatic, or rupture. Due to the relatively inaccessible location of iliac aneurysms, situated deep in the pelvis, as well as densely adherent pel­ vic veins posterior to the arteries and frequent co-occurrence of calcific occlusive disease, conventional surgical repair is challenging and fraught with risk of significant hemorrhage. Thus, evolving endovascular methods of repair have largely supplanted open surgical reconstruction. A variety of off-label devices and hybrid techniques have been applied to iliac aneurysm management. The variabiliry derives, in large part, from uncertainty regarding the need to preserve antegrade internal iliac artery flow in most patients. Indica­ tions for internal iliac preservation remain controversial due to the added complexity, cost, and uncertain benefit derived from such procedures; analysis of the relative merits of intentional unilateral occlusion versus preservation in the management of iliac aneurysm disease is beyond the scope of this chapter.

•

•

•

As in all things endovascular, high-quality imaging is critical for precase planning and, as previously mentioned, CT arte­ riography is optimal for this purpose. Using a combination of axial imaging and 3-D postprocessing, complete evalua­ tion should, note the following: Locations, diameter, and length of proximal and distal landing zones Iliac artery tortuosity and angulation Presence and severity of associated occlusive disease Ipsilateral and contralateral internal iliac artery patency Status of the ipsilateral deep femoral artery Concomitant abdominal or thoracic aortic pathology In general, landing zones are sited in nonaneurysmal arterial seg­ ments, manifesting minimal occlusive disease, with relative ab­ sence of angulation or tortuosiry. The allowable diameter range for treatment may vary, depending on the particular device to be deployed. In all circumstances, reference should be made to the "Instructions for Use" included in tlte package insert. Device selection is based on the need for durable aneurysm exclusion and endograft fixation, accomplished with the fewest component pieces possible. This chapter focuses on endovascular and hybrid manage­ ment strategies for the iliac bifurcation in the context of large common or internal iliac aneurysms. Standard techniques suf­ fice for management of smaller ( 15

m m length

Aortic cuff

Distal end of il iac limb in the external i l iac artery Embol ization coils

FIG 5 • N ote that in t h i s tech n i q ue, t h e d ista l segment of the co m m o n i l i a c a n e u rysm m u st f u n n e l down so that t h e a o rtic cuff w i l l c o a p t sec u re l y a g a i nst t h e i ntern a l i l i a c orifice. The a o rt i c cuff should be expa n d e d fo l l owi n g d e p l oyment with a com p l i a nt m o l d i n g b a l l o o n to securely seat i n position to prevent s u bseq u e n t i n a dvertent d is l o d g e m e n t w h e n adva n c i n g t h e i l i a c l i m b d e l ivery syste m .

FIG 6 • Not a l l e n d o g raft syste m s have an a o rto u n i i l i a c device o r converter. S i m i l a r ly, n o t a l l e n d o g rafts c a n b e d e p l oyed ex vivo a n d resheat h e d . Cu rrently, t h e o n l y system i s t h e Zenith F l ex® (Cook, B l o o m i ngton, IN). I f t h e o r i g i n of t h e contra late r a l com m o n i l i a c a rtery i s p a rt i a l ly covered and flow co m p rom ised for any reason, a bare meta l b a l l o o n ­ expa n d a b l e ste nt s h o u l d be d e p l oyed i n a " kiss i n g " m a n n e r.

C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES

spea k i n g , cuff d e p l oyment is essent i a l ly i n t h e a n e u ­

ENDOVASCULAR COMMON ILIAC

rysm itself; l ate outcomes f r o m t h e s e proce d u res a p p e a r

ARTERY ANEURYSM REPAIR WITH

favo ra b l e, w i t h a l ow re p o rted i n c i d e n ce of m i g ration o r

INTERNAL ILIAC PRESERVATION •

These tech n i q ues specifica l l y perta i n to c o m m o n i l i a c

type l b e n d o l e a k . •

a n e u rysms without a n associ ated i ps i latera l i nt e r n a l

the i p s i l atera l exter n a l i l i a c a rtery d i st a l to the i p s i l atera l

i l i a c a n e u rysm . I n c a s e s o f a n i ntern a l i l i a c a n e u rysm (see

e n d o g raft l i m b . Like a l l o p e n vasc u l a r p roced u res, expo­

except i o n b e l ow), preservati o n methods a re not poss i b l e a n d sel ective b r a n c h occ l u s i o n (see a bove) a n d e n d ovas­ c u l a r exc l u s i o n a re n ecessa ry. •

s u re i s t h e m ost critica l req u i re m e n t for tec h n i c a l s u ccess. •

safe i l i a c b i f u rcation exposure a n d m i n i m i z i n g post­

i n c l u d e t h e fo l l owi n g : Routi n e revasc u l a rization as p roced u r a l p refe rence

•

The p resence of contra l atera l intern a l i l i a c occl u s i o n

•

Active patient with concern/pote ntia I for b uttock

ope rative d i scomfort. For these exposu res, the p r i m a ry s u rg e o n sta n d s on opposite s i d e of t h e ta b l e . The i n c i ­ s i o n is centered ove r e i t h e r l ower q u a d ra n t a n d sta rts at a p a ra m e d i a n location at l evel of t h e u m b i l i cus a n d

c l a u d ication •

gently c u rves toward t h e m i d l i ne over t h e fi rst t h i rd of

D i a betic with d i seased i p s i l ateral d e e p fe m o r a l

the d i stance from the u m b i l icus to the sym p hysis p u b i s

a rtery (re d u ce d pote n t i a l co l l atera l s u p p ly) •

(FIG 8) . Exposu re p roceeds t h r o u g h t h e a nterior rectus

P r i o r t h o racic e n d o g raft repa i r (concern reg a rd i n g

sheath fo l l ow i n g t h e hockey-stick shape of t h e skin i n c i ­

a nterior s p i n a l a rtery co l l atera l flow a r i s i n g from

s i o n . Care i s taken not to d iv i d e t h e rect u s m uscle-t h i s i s

t h e i ntern a l i l i a c c i r c u l a t i o n and pote n t i a l for post­

a com p l ete " m uscl e-spa r i n g " tech n i q u e . The s h eath itse lf

o p e rative p a r a p l e g i a ) •

i s i n cised at l e a st 3 to 5 em m e d i a l to t h e se m i l u n a r l i n e .

The s i m p l est i ntern a l i l i a c p reservation tech n i q u e i n ­

Kee p i n g t h e rectus m uscle i ntact red u ces i n ci s i o n a l h e r­

volves d e p l oyment of f l a red o r so-ca l l ed b e l l - bottom d e ­ v i c e s . Alth o u g h a n ecd ota l l y a p p l ied to l a rg e r a n e u rysms, conventi o n a l ly, t h i s tech n i q u e is l i m ited to c o m m o n i l i a c

Proper i n c i s i o n placement and entry i nto the retro peri­ tonea l space i s tanta m o u nt to g a i n i n g a d e q u ate a n d

I n d icat i o n s for i ntern a l i l i a c a rtery preservati o n may •

D i rect i ntern a l i l ia c a rtery revasc u l a rization can a l so be acco m p l ished by s u rg i c a l bypass from o r tra nsposition to

n i a r i s k a n d decreases posto perative p a i n . •

The rect u s m uscle is d issected away from t h e sheath and retracted m e d i a l ly. The retroperito n e a l space is

a rtery a n e u rysms with 24- m m o r s h o rter d i a m eter d is­

deve l o ped below t h e a rcu ate l i n e (linea s e m i c i rc u l a ris)

t a l l a n d i n g zones. As an off- l a b e l m o d ification of t h i s

j ust s u p e r i o r to the i nfe r i o r e p i g astric vesse ls, w h i c h a re

tech n i q ue, f o r com m o n i l i a c a n e u rysms w i t h l a rg e r o r p o o r l y defi ned d i sta l l a n d i n g zon es, t h e maxi m a l d i a m ­ e t e r f l a red i l i a c l i m b i s i ntent i o n a l l y d e p l oyed a p p roxi­ mately 2 e m p roxi m a l to t h e i ntern a l i l i a c a rtery orifice. An a o rt i c exte n s i o n cuff without a p roxi m a l u n cove red ste nt (typ i ca l ly 28 mm) i s then d e p l oyed h a lfway i nto the u nsecured i l i a c l i m b a n d f l a red out i nto the d ista l a n e u rysm, essent i a l ly creat i n g a l a r g e r l a n d i n g zone t h a n t h a t conventi o n a l ly ava i l a b l e (FIG 7) . Alth o u g h strictly

Lateral border of rectus sheath

� I

I I I \ \

8 • I n some patients, t h e d ista nce betwee n t h e u m b i l i cus a n d t h e sym p hysis p u b i s may be q u ite s h o rt . If so, the l o n g it u d i n a l segment of the i n c i s i o n i s exten d e d more i nfe riorly than d e p i cted i n this d ia g r a m . The m ost i m p o rtant tec h n i c a l p o i n t of t h i s exposure i s to p l a ce t h e i n c i s i o n suffi c i e ntly m e d i a l ly as t h e late ra l b o r d e r of t h e rect u s s h eath i s not p a l p a b l e and t h e re a re n o obvious s u rface l a n d m a rks. FIG

•

In this i n st a n ce, t h e patient had b i l atera l c o m m o n i l i a c a n e u rysms. The r i g h t s i d e was l a rg e a n d l eft was s m a l l e r. The r i g ht i nt e r n a l i l i a c a rtery was occ l u d ed a n d the i l i a c l i m b extended to t h e exte r n a l i l i a c a rte ry. The b e l l - botto m tech n i q u e was a b l e to be used for t h e s m a l l e r l eft c o m m o n i l i a c a n e u rysm b e c a u s e it was o n l y 24 m m .

FIG 7

,_

201 9

2020

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

preserved a n d g e ntly swept i nferio rly. In w o m e n without p r i o r hyste rectomy, t h e ro u n d l i g a m e n t of t h e uterus i s often encou ntered as a f i b r o u s c o r d d u r i n g t h i s exposure and is d ivided betwee n ties. The perito n e a l sac i s swept b l u ntly m e d i a l l y u n t i l the exte r n a l i l i a c a rtery a n d t h e d ista l h a lf of t h e co m m o n i l ia c a n e u rysm a re expose d . The u reter i s v i s u a l ized cross i n g t h e i l i a c a rtery a n d s h o u l d be l eft u n d i st u rbed . Self- reta i n i n g retractors (e . g . , Bookwalter®) a re p l aced at t h i s poi nt. •

C h o i ce of retractors a n d proper p l acement a re esse n t i a l for proced u ra l s u ccess. The retractor p o s t i s p l aced o n t h e o p posite s i d e a bout t h e l e v e l of t h e costa l m a rg i n, a n d a s m a l l r o u n d r i n g is fixed a n d centered d i rectly over t h e i n c i s i o n . A B a lfour® b l a d e i s p l aced ove r t h e i n g u i n a l

I ntraluminal stent

l i g a m e nt, a n d a m ed i u m Kel ly® b l a d e o r i e nted toward t h e o p posite s h o u l d e r. A n a rrow m a l l e a b l e b l a d e i s orie nted m ed i a l ly to retract t h e b l a d d e r. Fol lowi n g retractor p l a c e m e nt, if the i n c i s i o n was sited properly, the i l i a c b i f u rcation s h o u l d be posit i o n e d d i rectly i n t h e c e n t e r o f the surgical field. •

The m i dsegment of t h e exte r n a l i l i a c a rtery is exposed and contro l l e d . The i nt e r n a l i l i a c a rtery i s n ext isol ated from t h e s u r ro u n d i n g tissue, from its o r i g i n to t h e b i f u r­ cat i o n of t h e a nterior a n d poste r i o r d iv i s i o n s, w h i c h a re i n d iv i d u a l l y contro l l e d . No atte m pt s h o u l d be m a d e to expose a n yt h i n g m o re t h a n a s m a l l a nterior aspect of t h e d i st a l c o m m o n i l i a c a n e u rysm d u ri n g t h i s m a n e uver.

•

The i ntern a l i l i a c a rtery o r i g i n is l i gated with a-polypro­ pyl e n e sutu re, and the a nterior and poste r i o r d iv i s i o n s of t h e i nt e r n a l i l i a c a rtery a re contro l led i n d e pe n d e ntly. Ad d it i o n a l s m a l l branches a r i s i n g from t h e m a i n tru n k a re c l i pped for h e m ostasis. T h e i ntern a l i l i a c a rtery i s d ivided a s proxi m a l ly a s poss i b le, a n d t h e stu m p c l o s u re

FIG 10 • A n 8 - m m g raft i s a n asto mosed to t h e d i sta l e n d of t h e i nt e rn a l i l i a c a rt e ry fi rst. D u e to t h e d e e p n a t u re of t h i s a rte ry, t h i s a n asto m o s i s ca n be d i ffi c u l t . An o p e n ( " p a ra c h ute " ) a n asto m o t i c tech n i q u e c a n b e h e l pf u l i n v i s u a l i z i n g t h e s u t u re l i n e t h r o u g h o u t p l a c e m e n t . T h e d i st a l a n asto m o s i s i s tested for h e m osta s i s a n d a n y l e a ks com p l et e l y r e p a i red before t h e p roxi m a l a n a sto m o s i s i s p e rf o r m e d , a s t h e fo r m e r m a y b e d iffi c u lt to see o n c e t h e l atter i s c o m p l eted . T h e exte r n a l i l i a c a n asto m os i s i s p e rfo r m e d at l e a st 5 e m d i st a l to i t s o r i g i n a l o n g its poste ro m e d i a l aspect.

is rei nforced a n d i m b r i cated with a 5-0 polypropy l e n e sutu re (FIG 9) . The d i sta l i ntern a l i l i a c a rtery i s t h e n m o b i l ized from t h e s u bjacent i ntern a l i l i a c ve i n . •

•

The patient is system ica l ly a nticoa g u l ated at t h i s p o i nt. An 8-mm

x

A segment of t h e i ps i latera l , adjacent exte r n a l i l ia c a rte ry, at least 5 em d ista l t o its o r i g i n , i s n ext m o b i l ized

1 0-cm g raft k n i tted, co l l a g e n - i m p re g n ated

and contro l l e d . F o l l ow i n g creati o n of a poste rome­

polyester g raft i s a n a stomosed to t h e d ista l stu m p of the

dial a rteriotomy, t h e g raft i s t r i m m e d and beve led to

i nt e r n a l i l i a c a rtery in a n e n d -to-e n d m a n n e r. The g raft

l e n gth and a nastomosed to the exte r n a l i l i a c a rtery i n

i s occ l u d ed at its o p e n end a n d d i sta l control r e l eased to

a n e n d -to-s i d e m a n n e r. T h e g raft i s f l u s h e d rout i n e ly a n d

test a n asto motic l e a ks . The g raft i s t h e n recontro l l ed j u st

flow restored t o t h e i ntern a l a n d exte r n a l i l i a c a rteries

(FIG 1 0). 3

prox i m a l to t h e d ista l a n asto mosis. •

A l a rg e c l i p is sewn tra n sve rsely at t h e h e e l of t h e exte r n a l i l i a c a rtery a n asto mosis to esta b l ish a f i d u c i a l p o i n t for t h e i ntern a l i l i a c bypass. After h e m ostas i s i s confi rmed, t h e retracto r system i s rem oved a n d retro­ perito n e a l contents a l l owed to co l l a pse back i nto t h e wo u n d . The e n d ovascu l a r p o rt i o n of t h e p roced u re c o m ­ p l eted t h r o u g h femora l a rtery a ccess s i t e s i n a sta n d a rd fash i o n .

•

After e n d o g raft d e p l oyment a n d satisfactory c o m p l e ­ t i o n a o rto g r a p hy, t h e retro perito n e u m i s r e i n spected f o r h e m ostas i s fo l l owi n g reversa l of a nticoa g u lati o n . T h e a nterior rectus sheath i s c l osed with a r u n n i n g 1 -0 PDS

FIG 9 • W h e n t h e incision i s properly posit i o n e d , t h e i l i a c b i f u rcat i o n s h o u l d be located d i rectly i n t h e c e n t e r of t h e wo u n d . The c o m m o n i l i a c a n e u rysm i s m i n i m a l ly exposed t o a l low t h e stu m p of t h e d ivided i nt e r n a l i l i a c a rtery to b e safe ly oversewn .

sutu re, fo l l owed by c l o s u re of Sca rpa's layer and s k i n . •

[Altern ate tech n i q ue] Occa s i o n a l ly, t h e co m m o n tru n k o f t h e i ntern a l i l i a c a rte ry i s l o n g a n d r u n s p a ra l l e l to t h e cou rse o f t h e exte r n a l i l i a c a rtery for some d ista nce. I f suffi cient l e n gth i s p resent, t h e i ntern a l i l i a c a rtery may

C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES

g e n e ra l a p p l i ca b i l ity of t h i s tech n i q ue, i n c l u d i n g a n acute exte r n a l-inte r n a l i l i a c bifu rcati o n a n g l e a n d s i g ­ n ificant d i a m eter d i screpancy ( > 2 m m ) betwee n t h e two a rteries. Al so, the d u ra b i l ity of t h i s tech n i q u e is not w e l l esta b l ished a n d may be l i m ited b y t h e propensity of t h e covered ste nt to back out of e i t h e r t h e o r i g i n o r dest i n a ­ t i o n a rtery o r k i n k . T h i s tech n i q u e a lso req u i res advanced catheter and g u i dewire ski l l s and a l a rg e device i nven­ tory to re l i a b ly com p l ete t h e p roced u re . •

[Alte rn ate tech n i q ue] M o re rece ntly, a va riation of t h e c h i m n ey (pa ra l l e l ) stenti n g tec h n i q u e h a s been d e ­ scribed for co m p l ete e n d ovascu l a r repa i r of c o m m o n i l i a c a n e u rysms • I n t h i s tech n i q ue, t h e p roxi m a l brach i a l a rtery i s exposed t h r o u g h a n axi l l a ry i n c i s i o n to a l l ow safe i ntroduction of a l o n g (90 em) b r a i d e d 9-Fr sheath. B ri efly, after t h e bifu rcated main body e n d o g raft i s de­ p l oyed, t h e l o n g 9-Fr sheath i s a dvanced from t h e l eft b rach i a l a rte ry, t h ro u g h t h e m a i n body, a n d positioned i nto t h e i p s i l atera l common i l i a c a rte ry. The i ntern a l

•

N ote that a n e n d ovasc u l a r exte r n a l -to-inte r n a l i l i a c bypass h a s been created o n t h e r i g ht s i d e w h i c h a lso exc l u d es t h e c o m m o n i l i a c a n e u rysm . The d u ra b i l ity of t h i s bypass i s comprom ised g iven i t s re l i a nce o n retro g ra d e perfu s i o n t h r o u g h t h e femora l-fe m o r a l bypass g raft, t h e a n g u lated n a t u re of the g raft posit i o n , and t h e propensity for one o r b o t h e n d s to " back out" o f t h e o r i g i n a n d ta rget a rteri es, g iven s uffi c i e nt t i me, pressu re, a n d move m ent.

FIG 11

i l i a c a rtery is cat h ete rized, fo l l owed b y w i re exch a n g e f o r a stiff w i r e . A covered se lf-exp a n d i n g stent g raft (e . g ., V i a b a h n®), sized for the ta rget i nt e r n a l i l i a c a rtery d i a m eter, is d e p l oyed from t h e i ps i latera l i l i a c g ate to t h e i nt e r n a l i l i a c a rtery l a n d i n g z o n e . A seco n d covered self­ expa n d i n g ste nt g raft is adva n ced from t h e i p s i l atera l fe m o r a l a rtery access retrog rade i nto t h e a n e u rysm a n d p roxi m a l exte r n a l i l i a c a rtery a n d d e p l oyed at t h e s a m e l evel as p r i o r i ntern a l i l i a c a rtery ste nt g raft. B o t h stent g rafts a re expa n d e d with i n t h e i psi late r a l i l i a c l i m b of

•

be tra n sposed to t h e exte r n a l i l i a c a rte ry, as l o n g as t h e

t h e a o rt i c e n d o g raft u s i n g a kissi n g - ba l l oo n tec h n i q u e .

a n asto mosis i s tension-free.

T h i s p roced u re can be repeated f o r t h e contra late r a l s i d e

[Alte rn ate tech n i q ue] Another hybrid a p p roach i s ava i l ­

i n cases o f b i l atera l co m m o n i l i a c a n e u rysms (FIG 1 2) .

a b l e t o preserve i nt e r n a l i l i a c fl ow. I n t h i s method, a cov­

Care s h o u l d be taken d u r i n g t h i s m a n e uver to d e p l oy

ered se lf-exp a n d i n g ste nt (e . g . , V i a b a h n®, W. L. G o re,

each ste nt g raft seq u e nt i a l ly, rath e r t h a n s i m u lta neously,

F l a g staff, AZ) is d e p l oyed to prov i d e retro g ra d e flow

i n order to position t h e covered stents accu rate l y rel ative

from t h e exte r n a l to i nterna l i l i a c a rte ry, i ps i late ra l to t h e

to each other.

c o m m o n i l i a c a n e u rysm to be excl u d e d . An a o rto u n i i l i a c e n d o g raft is t h e n d e p l oyed from t h e contra l atera l s i d e,

•

[Altern ate tech n i q ue] Alth o u g h o n ly ava i l a b l e u n d e r a n i nvest i g ati o n a l device exe m pt i o n ( I D E), U . S. Food

a n d t h e p roce d u re co m p l eted with a fem o ra l-fe m o r a l

and Drug Ad m i n i stration (F DA)-a p p roved c l i n i c a l t r i a l

bypass g raft (FIG 1 1 ) . Seve r a l c i rc u m st a n ces l i m it t h e

at t h e c u rrent t i me, a n i l i a c b r a n c h device ( I B D) i s u n d e r

A •

B

Like a l l " c h i m ney" tech n i q ues, t h e p roxi m a l seal i s d e p e n d e n t o n t h e l e ngth of t h e p a ra l l e l seg m e nt. I n t h i s i nsta nce, it s h o u l d be m o re than 5 em to promote t h ro m bosis of t h e " g utte rs" betwee n the p a ra l l e l ste nts. It i s not u n c o m m o n for a s m a l l type I l l e n d o l e a k t o b e seen o n t h e co m p l et i o n a n g i og ra m with t h e patient a nticoa g u l ated.

FIG 1 2

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2022

P a r t 6 OPERATIVE TECH NIQUES I N VASCULAR SURGERY

d eve l o p m e n t for tota l e n d ovasc u l a r repa i r of co m m o n i l i a c a n e u rysms (FIG 1 3) . B ri efly, t h i s bifu rcated d evice i s i n se rted i p s i latera l to t h e c o m m o n i l i a c a n e u rysm p r i o r t o m a i n b o d y d e p l oyment. It i s d e s i g n e d to be used i n con­ j u nction with a sta n d a rd bifu rcated aortic e n d o g raft. The p a rt i a l ly constra i n e d b r a n c h i n t h e i nvest i g at i o n a l device and adjacent i nt e r n a l i l i a c a rtery a re cath ete rized from t h e contra late r a l side e m p loyi n g a preloaded catheter i n t h e d e l ivery syste m a n d cross-fe m o r a l g u i d ewire a ccess. A b r i d g i n g cove red ste nt i s adva n ced from the b r a n c h to the i ntern a l i l i a c a rte ry. F o l l o w i n g t h is, a sta n d a rd b i f u r­ cated e n d ovascu l a r a n e u rysm re p a i r is com p l eted i n t h e usual manner s

• T h i s fig u re d e p i cts t h e I B D used i n t h e repa i r of a l eft co m m o n i l i a c a n e u rysm . A covered ste nt is req u i red to b r i d g e t h e i l i a c b r a n c h to t h e native i ntern a l i l i a c a rte ry. Alth o u g h t h i s b r i d g i n g ste nt i s typica l ly d e l ivered from t h e contra latera l s i d e, it m a y a lso b e i ntrod u ced t h r o u g h t h e l eft brach i a l a rte ry.

FIG 1 3

PEARLS AND PITFALLS C hoose t h e r i g h t p roced u re fo r t h e r i g h t patient.

•

Alth o u g h perfu s i o n i s opti m a l ly m a i nt a i n e d to at least one i n t e r n a l i l i a c a rte ry, p reservat i o n s h o u l d be atte m pted sel ectively, weig h i n g t h e risks and b e n efits of pote n t i a l isch e m i c co m p l icati o n s associated with i ntenti o n a l occ l u s i o n vs. t h e a d d i ti o n a l co m p l exity and l o n g-term d u ra b i l ity issues associated with p reservation tech n i q ues.

Exte r n a l -to- i ntern a l i l i a c bypass exposure

•

M a ke s u re t h e l o n g it u d i n a l segment of t h e s k i n incision i s suffi c i e ntly m e d i a l to t h e l atera l e d g e of t h e rect u s to acco m m o d ate a s i n g l e l a y e r fasc i a l closure. The p reserved rect u s m uscle p rovides a n a t u r a l b a r r i e r a g a i n st posto pe rative a b d o m i n a l wa l l h e r n i a form a t i o n .

Use a cross-over i nt ro­ d u c e r sheath for i nter­ n a l i l i a c e m b o l izati o n .

•

The cross-over s h eath a l l ows f o r i nterm ittent contrast i nject i o n a n d sta b i l ization of t h e e m b o l i zation cath eter. I nt e r n a l i l i a c sheath a ccess a lso m i n i m izes t h e proba b i l ity that d e p l oyed co i l s may refl ux retro­ g ra d e i nto the a x i a l i l i a c c i r c u l a t i o n , req u i ri n g ofte n p r o l o n g e d and frustrat i n g attem pts at retri eva l .

Pelvic b l ee d i n g

•

T h e i ntern a l i l i a c ve i n i s poste r i o r a n d a d h e rent t o t h e a rtery a n d m a y be t h e sou rce s i g n ifica nt, u n a nt i c i pated h e m o r r h a g e if i nj u red d u r i n g ci rcumferent i a l a rte r i a l d issect i o n .

I nflow t o t h e i nt e r n a l i l i a c bypass

•

C hoose a s i t e on the exte r n a l i l i ac a rtery sufficiently d i sta l to i t s o r i g i n so t h a t the ste nt g raft ca n l a n d i n a seg ment free from k i n k i n g a n d p revent subsequent deve l o p m ent o f a n i ps i latera l type l b e n d o l e a k .

typically associated with a clinically significant ileus, and the muscle-sparing exposure is well tolerated. Patients may be discharged typically on the second postoperative day.

POSTOPERATIVE CARE •

•

•

Postoperative care is similar to a standard endovascular aneurysm repair. A complete blood count and a basic meta­ bolic panel are checked the following morning. If the procedure was performed entirely using endovascular techniques, oral intake is started immediately, Foley catheter is removed, and patient is encouraged to ambulate and dis­ charged on following postoperative day. If the procedure involved a surgical internal iliac revas­ cularization, the patient is started on clear liquids and advanced as tolerated. The retroperitoneal approach is not

OUTCOMES •

Ipsilateral hip and buttock claudication develops in as many as 4 0 % of patients following acute internal iliac ar­ tery occlusion. Fortunately, more severe forms of postpro­ cedural pelvic ischemia, although potentially lethal, occur extremely rarely. Although claudication symptoms, when present, are reported to improve within 6 months following

C h a pter 24 ADVANCED ANEURYSM MANAGEMENT TECHNIQUES

•

the procedure, this improvement m a y be attributable t o life­ style alteration (e.g., walking less) rather than collateral ves­ sel formation. It is generally agreed, however, that complete symptom resolution rarely occurs. Internal iliac bypass grafting (surgical or endovascular) effectively maintains pelvic perfusion, with excellent long­ term patency. Most patients enjoy a symptom-free postop­ erative course in perpetuity. Thus, in active individuals, as a general recommendation, internal iliac circulation should be preserved whenever possible.

•

2 0 23

forms such as perineal necrosis, ischemic sacral plexopathy, and vasculogenic impotence. The internal iliac artery serves as an important outflow branch in maintaining patency of the iliac limb after endovascular aneurysm repair. Iliac limbs whose distal land­ ing zone is placed in the external iliac artery may have an increased risk of thrombosis. However, this is not an indica­ tion for any additional antiplatelet or anticoagulation treat­ ments beyond what is customary.

REFERENCES COMPLICATIONS •

•

•

Complications for management of common iliac aneurysms can be a result of internal iliac revascularization or occlusion techniques. The main complication associated with revascularization is bleeding. This can occur intraoperatively from venous injury and/or postoperative anastomotic or other arterial sources. Other less common complications include ureteral injury, bowel injury, ipsilateral leg ischemia, and early graft thrombosis. Complications associated with acute occlusion of internal iliac artery include the spectrum of ischemic symptoms ranging from hip and buttock claudication to more severe

1. Armon MP, Wenham PW, Whitaker SC, et al. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vase Endovase Surg. 1998;15(3):255-257. 2. Boules TN, Selzer F, Stanziale SF, et al. Endovascular management of isolated iliac artery aneurysms. j Vase Surg. 2006;44(1):29-37. 3. Lee WA, Nelson PR, Berceli SA, et al. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. j Vase Surg. 2006;44(6):1162-1168. 4. Lobato AC. Sandwich technique for aortoiliac aneurysms extending to the internal iliac artery or isolated common/internal iliac artery aneurysms: a new endovascular approach to preserve pelvic circula­ tion. J Endovase Ther. 2011;18(1):106-111. 5. Parlani G, Verzini F, De Rango P, et al. Long-term results of iliac an­ eurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur] Vase Endovase Surg. 2012;43(3):287-292.

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Chapter

25

Occlusive Disease Management: Isolated Femoral Reconstruction, Aortofemoral Open Reconstruction, and Aortoiliac Reconstruction with Femoral Crossover for Limb Salvage 1

I

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Na th a n /toga

E. John Ha rris, Jr.

DEFINITION

DIFFERENTIAL DIAGNOSIS

•

•

•

• • •

•

Aortoiliac occlusive disease falls under the umbrella of pe­ ripheral artery disease where atherosclerosis and chronic plaque accumulation leads to diminished blood supply to distal arterial beds. The aortic bifurcation near the level of the L4 disc space is one of many areas of decreased shear stress and is an area of early atherosclerosis. Peripheral arterial disease (PAD ) is usually classified into in­ flow and outflow disease. The infrarenal aorta and iliac vessels are of larger caliber and are classified as inflow vessels. The infrainguinal outflow from the common femoral ar­ tery is via the profunda femoral and superficial femoral arteries . The patterns o f arterial stenosis a n d occlusion can be broken up into five types (Table 1 ) . When a combination of both inflow and outflow disease exists, treatment is focused on the aortoiliac system first or femoral artery occlusive disease. Outflow occlusive disease is addressed in Part 6, Chapters 26-2 8 , 3 1-3 3 .

•

•

•

Table 1: Type of Lower Extremity Disease Patterns

Type

1

Type 2 Type 3

Type 4 Type 5

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Notes

Confi n e d to the d ista l infrarenal aorta a n d common i l iac arteries

1 0 % of disease patte rns­

Fou n d within i nfra ren a l a o rta, co m m o n a n d exte rnal i l i acs Occl usive d isease in the aorto i l iac segment is combined with femoropopl iteal or tibial d isease. Isol ated s u p e rficia l fe moral a n d popl itea l a rtery Diffuse d isease in the fe moral popl itea l a n d tibial vessels

fou n d in younger fe m a l e patie nts. Long-term patency after bypass is lower when d o n e i n patie nts