 PLEASE OBSERVE THE FOLLOWING INSTRUCTIONS TO INSURE A SAFE RECOVERY FROM  YOUR SURGERY.   2. Eat smallamounts of foods such as Jell-O, soup, crackers, as tolerated. Progress to normal  diet if you are not nauseated.   2. Ifpain is not relieved by your medication, call your physician.  3. Dizziness is not unusual.   4. Avoid drugs for allergies, nerves or sleep for 24 hours.    1. Rest at home; limit activity; do not engage in sports or heavy work until your doctor gives you  permission.  2. ALLOW 24 HOURS BEFORE:  — driving or operating hazardous machinery (sewing machine, drills, etc.).  — signing important papers.  — making significant decisions.  3. Children having had surgery should not be left unattended.    If you are concerned and are unable to reach your doctor, go to the hospital’s emergency room.    These instructions have been explained to the patient, family or friend and a copy has been given  to same.    of recovery from the anesthetic or any drugs that may have been given.  Most patients are cautioned to refrain from driving, operating hazardous  machinery, or making important decisions for 24 hours. T ey should be  instructed how to reach the surgeon and be given the telephone number  of the hospital emergency department in case of an urgent emergency. A  follow-up telephone call by the ambulatory surgery center or the surgeon  on the day after operation serves to verify that recovery is proceeding satis-  factorily. Most patients greatly appreciate this evidence of concern. A writ-  ten appointment time for return evaluation and checkup is given.   Patients having ambulatory surgery do surprisingly well, and most seem  to prefer this approach to the long-established tradition of hospitalization.  It must be admitted that this approach places more preoperative responsi-  bility on the patient, as well as on the surgeon, to meet all the requirements  for the performance of a procedure. T e patient must take the time not only  to be evaluated by the surgeon but to have all the laboratory and radio-  graphic examinations taken care of in advance. Since the tests and the phy-  sician’s final evaluation may precede the day of operation by several weeks,  the patient must take responsibility to inform the surgeon of any special  developments, such as a change in condition or the occurrence of an upper  respiratory infection.   T e period of recovery before the patient can return to work depends  on the extent and type of surgical procedure. It is hoped that ambulatory  surgery will shorten the period of disability and ensure more prompt cor-  rection of the indications for operation.    T e stomach has a very rich anastomotic blood supply. T e largest blood  supply comes from the celiac axis (1) by way of the left gastric artery (2).  T e blood supply to the uppermost portion, including the lower esopha-  gus, 1s from a branch of the left inferior phrenic artery (3). T e left gastric  artery divides as it reaches the lesser curvature just below the esophagogas-  tric junction. One branch descends anteriorly (2a) and the other branch  posteriorly along the lesser curvature. T ere is a bare area of stomach wall,  approximately l1to 2cm wide, between these two vessels which 1s not covered  by peritoneum. It is necessary to ligate the left gastric artery near its point  of origin above the superior surface of the pancreas in the performance of  a total gastrectomy. T is also applies when 70% or more of the stomach is  to be removed. Ligation of the artery in this area is commonly done in the  performance of gastric resection for malignancy so that complete removal  of all lymph nodes high on the lesser curvature may be accomplished.   A lesser blood supply to the uppermost portion of the stomach arises  from the short gastric vessels (4) in the gastrosplenic ligament. Several  small arteries arising from the branches of the splenic artery course upward  toward the posterior wall of the fundus. T ese vessels are adequate to  ensure viability of the gastric pouch following ligation of the left gastric  artery as well as of the left inferior phrenic artery. If one of these vessels  predominates, it is called the posterior gastric artery; its presence becomes  significant in radical gastric resection. Mobilization of the spleen, following  division of the splenorenal and gastrophrenic ligaments, retains the blood  supply to the fundus and permits extensive mobilization at the same time.  T e blood supply of the remaining gastric pouch may be compromised if  splenectomy becomes necessary. T e body of the stomach can be mobilized  toward the right and its blood supply maintained by dividing the thickened  portion of the splenocolic ligament up to the region of the left gastroepi-  ploic artery (5). Further mobilization results if the splenic fexure of the  colon, as well as the transverse colon, is freed from the greater omentum.  T e greater curvature is ordinarily divided at a point between branches  coming from the gastroepiploic vessels (5, 6) directly into the gastric wall.   T eblood supply to the region of the pylorus and lesser curvature arises  from the right gastric artery (7), which is a branch of the hepatic artery (8).  T eright gastric artery is so small that it can hardly be identified when it is  ligated with the surrounding tissues in this area.   One of the larger vessels requiring ligation during gastric resection is  the right gastroepiploic artery (6) as it courses to the left from beneath the  pylorus. It parallels the greater curvature. T e blood supply to the greater  curvature also arises from the splenic artery (9) by way of the left gastro-  epiploic artery (5).   Relatively few key arteries need to be ligated to control the major blood  supply to the pancreas. When the duodenum and head of the pancreas  are to be resected, it 1s necessary to ligate the right gastric artery (7) and  the gastroduodenal artery (10) above the superior surface of the duodenum.  T e possibility of damaging the middle colic vessels (11), which arise from    the superior mesenteric artery and course over the head of the pancreas,  must always be considered. T is vessel may be adherent to the posterior wall  of the antrum of the stomach, and it may course over the second part of the  duodenum, especially if the hepatic f exure of the colon 1s anchored high in  the right upper quadrant. T e anterior and posterior branches of the inferior  pancreaticoduodenal artery (12) are ligated close to their points of origin  from the superior mesenteric artery (13). Additional branches directly to the  third portion of the duodenum and upper jejunum also require ligation.   T e body and tail of the pancreas can be extensively mobilized with the  spleen. T e splenic artery located beneath the peritoneum over the superior  surface of the pancreas should be ligated near its point of origin (9). T e  dorsal pancreatic artery (14) arises from the splenic artery near its point  of origin and courses directly into the body of the pancreas. Following  the removal of the spleen, the inferior surface of the body and tail of the  pancreas can be easily mobilized without division of major arteries. When  the body of the pancreas is divided, several arteries will require ligation.  T ese include the inferior (transverse) pancreatic artery (15) arising from  the splenic artery and the greater pancreatic artery (16).   T e blood supply to the spleen is largely from the splenic artery arising  from the celiac axis. Following ligation of the splenic artery, there is a rich  anastomotic blood supply through the short gastric vessels (4), as well as the  left gastroepiploic artery (5). T e splenic artery is usually serpentine in con-  tour, as it courses along the superior surface of the pancreas just beneath the  peritoneum. Following division of the gastrosplenic vessels, it is advantageous  to ligate the splenic artery some distance from the hilus of the spleen. T e  gastric wall should not be injured during the division of the short gastric ves-  sels high in the region of the fundus. Small blood vessels entering the tail of  the pancreas require individual ligation, especially in the presence of a large  spleen and accompanying induration in the region of the tail of the pancreas.   T ecolon hasbeen displaced inferiorly as indicated by the arrow to allow  visualization of the Gastric, Hepatic, Pancreatic and Duodenal vessels. T e  blood supply to the gallbladder is through the cystic artery (17), which usu-  ally arises from the right hepatic artery (18). In the triangular zone bounded  by the cystic duct joining the common hepatic duct and the cystic artery,  Calot’s triangle, there are more anatomic variations than are found in any  other location. T e most common variations in this zone, which is no larger  than 3 cm in diameter, are related to the origin of the cystic artery. It most  commonly arises from the right hepatic artery (18) after the latter vessel  has passed beneath the common hepatic duct. T e cystic artery may arise  from the right hepatic artery more proximally and lie anterior to the com-  mon hepatic duct. Other common variations include origin of the cystic  artery from the left hepatic artery (19), the common hepatic artery (8), or  the gastroduodenal artery (10); additionally, these cystic arteries may have  uncommon relationships to the biliary ductal system. T e variations in the  hepatoduodenal ligament are so numerous that nothing should be ligated  or incised in this area until definite identification has been made. m=    T e venous blood supply of the upper abdomen parallels the arterial blood  supply. T e portal vein (1) is the major vessel that has the unique function  of receiving venous blood from all intraperitoneal viscera with the excep-  tion of the liver. It is formed behind the head of the pancreas by the union  of the superior mesenteric (2) and splenic (3) veins. It ascends posterior to  the gastrohepatic ligament to enter the liver at the porta hepatis. It lies in a  plane posterior to and between the hepatic artery on the left and the com-  mon bile duct on the right. T is vein has surgical significance in cases of  portal hypertension. When portacaval anastomosis is performed, exposure  is obtained by means of an extensive Kocher maneuver. Several small veins  (4) from the posterior aspect of the pancreas enter the sides of the superior  mesenteric vein near the point of origin of the portal vein. Care must be  taken to avoid tearing these structures during the mobilization of the vein.  Once hemorrhage occurs, it is difficult to control.   T ecoronary (left gastric) vein (5) returns blood from the lower esopha-  geal segment and the lesser curvature of the stomach. It runs parallel to the  left gastric artery and then courses retroperitoneally downward and medi-  ally to enter the portal vein behind the pancreas. It anastomoses freely with  the right gastric vein (6), and both vessels drain into the portal vein to pro-  duce a complete venous circle. It has a significance in portal hypertension in  that the branches of the coronary vein, along with the short gastric veins (7),  produce the varicosities in the fundus of the stomach and lower esophagus.   T e other major venous channel in the area 1s the splenic vein (3), which  lies deep and parallel to the splenic artery along the superior aspect of the  pancreas. T e splenic vein also receives venous drainage from the greater  curvature of the stomach and the pancreas, as well as from the colon,  through the inferior mesenteric vein (8). When a splenorenal shunt is per-  formed, meticulous dissection of this vein from the pancreas with ligation  of the numerous small vessels is necessary. As the dissection proceeds, the  splenic vein comes into closer proximity with the left renal vein where  anastomosis can be performed. T e point of anastomosis is proximal to the  entrance of the inferior mesenteric vein.   T e colon has been displaced inferiorly as indicated by the arrow to  allow visualization of the portal vein in the hepatoduodenal ligament and  the venous drainage of stomach, head of the pancreas, and duodenum.  T e venous configuration on the gastric wall is relatively constant. In per-  forming a conservative hemigastrectomy, venous landmarks can be used to  locate the proximal line of resection. On the lesser curvature of the stomach,  the third branch (5a) of the coronary vein down from the esophagocardiac  junction is used as a point for transection. On the greater curvature of the    stomach the landmark is where the left gastroepiploic vein (9) most closely  approximates the gastric wall (9a). Transection is carried out between these  two landmarks (5a, 9a).   T e anterior and posterior pancreaticoduodenal veins (10) produce an  extensive venous network about the head of the pancreas. T ey empty into  the superior mesenteric or hepatic portal vein. T e anterior surface of the  head of the pancreas is relatively free of vascular structures, and blunt dis-  section may be carried out here without difficulty. T ere is, however, a small  anastomotic vein (11) between the right gastroepiploic (12) and the middle  colic vein (13). T is vein, if not recognized, can produce troublesome bleed-  ing in the mobilization of the greater curvature of the stomach, as well as  of the hepatic fexure of the colon. T e pancreaticoduodenal veins have  assumed new importance with the advent of transhepatic venous sampling  and hormonal assays for localization of endocrine-secreting tumors of the  pancreas and duodenum.   In executing the Kocher maneuver, no vessels are encountered unless  the maneuver is carried inferiorly along the third portion of the duodenum.  At this point the middle colic vessels (13) cross the superior aspect of the  duodenum to enter the transverse mesocolon. Unless care is taken in doing  an extensive Kocher maneuver, this vein may be injured.   T e lymphatic drainage of the upper abdominal viscera is extensive.  Lymph nodes are found along the course of all major venous structures.  For convenience of reference, there are four major zones of lymph node  ageregations. T e superior gastric lymph nodes (A) are located about the  celiac axis and receive the lymphatic channels from the lower esophageal  segment and the major portion of the lesser curvature of the stomach, as  well as from the pancreas. T e suprapyloric lymph nodes (B) about the  portal vein drain the remaining portion of the lesser curvature and the  superior aspect of the pancreas. T e inferior gastric subpyloric group (C),  which is found anterior to the head of the pancreas, receives the lymph  drainage from the greater curvature of the stomach, the head of the pan-  creas, and the duodenum. T e last major group is the pancreaticolienal  nodes (D), which are found at the hilus of the spleen and drain the tail of  the pancreas, the fundus of the stomach, and the spleen. T ere are exten-  sive communications among all these groups of lymph nodes. T e major  lymphatic depot, the cisterna chyli, is found in the retroperitoneal space.  T is communicates with the systemic venous system by way of the tho-  racic duct into the left subclavian vein. T is gives the anatomic explanation  for the involvement of Virchow’ node in malignant diseases involving the  upper abdominal viscera. m=    Because of its embryologic development from both the midgut and hindgut,  the colon has two main sources of blood supply: the superior mesenteric (1)  and the inferior mesenteric arteries (2). T e superior mesenteric artery (1)  supplies the right colon, the appendix, and small intestine. T e middle colic  artery (3) is the most prominent branch of the superior mesenteric artery.  It arises after the pancreaticoduodenal vessels (see Chapter 5). T e middle  colic artery branches into a right and left division. T e right division anas-  tomoses with the right colic (4) and the ileocolic (5) arteries. T e left branch  communicates with the marginal artery of Drummond (6). T e middle and  right colic and ileocolic arteries are doubly ligated near their origin when a  right colectomy is performed for malignancy. T e ileocolic artery reaches  the mesentery of the appendix from beneath the terminal ileum. Angula-  tion or obstruction of the terminal ileum should be avoided following the  ligation of the appendiceal artery (7) in the presence of a short mesentery.   T e inferior mesenteric artery arises from the aorta just below the liga-  ment of Treitz. Its major branches include the left colic (8), one or more  sigmoid branches (9, 10), and the superior hemorrhoidal artery (11). Fol-  lowing ligation of the inferior mesenteric artery at its origin, the viability of  the colon is maintained through the marginal artery of Drummond (6) by  way of the left branch of the middle colic artery.   T e third blood supply to the large intestine arises from the middle and  inferior hemorrhoidal vessels. T e middle hemorrhoidal vessels (12) arise  from the internal iliac (hypogastric) (13), either directly or from one of its  major branches. T ey enter the rectum along with the suspensory ligament  on either side. T ese are relatively small vessels, but they should be ligated.   T eblood supply to the anus is from the inferior hemorrhoidal (14) ves-  sels, a branch of the internal pudendal artery (15). In low-lying lesions wide  excision of the area is necessary with ligation of the individual bleeders as  they are encountered.   T e venous drainage of the right colon parallels the arterial supply and  drains directly into the superior mesenteric vein (1). T e inferior mesen-  teric vein, in the region of the bifurcation of the aorta, deviates to the left  and upward as it courses beneath the pancreas to join the splenic vein. High  ligation of the inferior mesenteric vein (16) should be carried out before  extensive manipulation of a malignant tumor of the left colon or sigmoid in  order to avoid the vascular spread of tumor cells.   T e right colon can be extensively mobilized and derotated to the  left side without interference with its blood supply. T e mobilization is  accomplished by dividing the avascular lateral peritoneal attachments of  the mesentery of the appendix, cecum, and ascending colon. Blood ves-  sels of a size requiring ligation are usually present only at the peritoneal    attachments of the hepatic and splenic flexures. T e transverse colon and  splenic flexure can be mobilized by separating the greater omentum from  its loose attachment to the transverse colon (see Chapter 26). Traction  on the splenic flexure should be avoided lest troublesome bleeding could  result from a tear in the adjacent splenic capsule. T e abdominal inci-  sion should be extended high enough to allow direct visualization of the  splenic flexure when it is necessary to mobilize the entire left colon. T e  left colon can be mobilized toward the midline by division of the lateral  peritoneal attachment. T ere are few, if any, vessels that will require liga-  tion in this area.   T e descending colon and sigmoid can be mobilized medially by divi-  sion of the avascular peritoneal reflection in the left lumbar gutter. T e  sigmoid is commonly quite closely adherent to the peritoneum in the left  iliac fossa. T e peritoneal attachment is avascular, but because of the prox-  imity of the spermatic or ovarian vessels, as well as the left ureter, careful  identif cation of these structures is required. Following the division of the  peritoneal attachment and the greater omentum, further mobilization and  elongation of the colon can be accomplished by division of the individual  branches (8, 9, 10) of the inferior mesenteric artery. T is ligation must not  encroach on the marginal vessels of Drummond (6).   T e posterior wall of the rectum can be bluntly dissected from the hol-  low of the sacrum without dividing important vessels. T e blood supply of  the rectum is in the mesentery adjacent to the posterior rectal wall. Fol-  lowing division of the peritoneal attachment to the rectum and division  of the suspensory ligaments on either side, the rectum can be straightened  with the resultant gain of considerable distance (Chapter 57). T e pouch of  Douglas, which may initially appear to be quite deep in the pelvis, can be  mobilized well up into the operative f eld.   T e lymphatic supply follows the vascular channels, especially the  venous system. Accordingly, all of the major blood supplies of the colon  should be ligated near their points of origin. T ese vessels should be ligated  before a malignant tumor is manipulated. Complete removal of the lym-  phatic drainage from lesions of the left colon requires ligation of the infe-  rior mesenteric artery (2) near its point of origin from the aorta.   Low-lying malignant rectal lesions may extend laterally along the mid-  dle hemorrhoidal vessels (12) as well as along the levator ani muscles. T ey  may also extend cephalad along the superior hemorrhoidal vessels (11). T e  lymphatic drainage of the anus follows the same pathway but may include  spread to the superf cial inguinal lymph nodes (17). T e lower the lesion,  the greater the danger of multiple spread from the several lymphatic sys-  tems involved. m=    13 hypogastric art. and vein  14 Inf. hemorrhoidal art. and vein  15 Pudendal art. and vein    T e various vascular procedures that are carried out on the major vessels  in the retroperitoneal area of the abdominal cavity make familiarity with  these structures essential. Likewise, surgery of the adrenal glands and the  genitourinary system invariably involves one or more of the branches of  the abdominal aorta and inferior vena cava.   T e blood supply to the adrenals is complicated and different on the  two sides. T e superior arterial supply branches from the inferior phrenic  artery (1) on both sides. T e left adrenal receives a branch directly from  the adjacent aorta. A similar branch also may pass behind the vena cava to  the right side, but the more prominent arterial supply arises from the right  renal artery. T e major venous return (3) on the left side is directly to the  left renal vein. On the right side, the venous supply may be more obscure,  as the adrenal is in close proximity to the vena cava and the venous system  (2) drains directly into the latter structure.   T eceliac axis (A) is one of the major arterial divisions of the abdominal  aorta. It divides into the left gastric, splenic, and common hepatic arter-  ies. Immediately below this is the superior mesenteric artery (B), which  provides the blood supply to that portion of the gastrointestinal tract aris-  ing from the foregut and midgut. T e renal arteries arise laterally from the  aorta on either side. T e left renal vein crosses the aorta from the left kid-  ney and usually demarcates the upper limits of arteriosclerotic abdominal  aneurysms. T e left ovarian (or spermatic) vein (13) enters the left renal  vein, but this vessel on the right side (5) drains directly into the vena cava.   In removing an abdominal aortic aneurysm, it is necessary to ligate the  pair of ovarian (or spermatic) arteries (4), as well as the inferior mesen-  teric artery (C). In addition, there are four pairs of lumbar vessels that arise  from the posterior wall of the abdominal aorta (14). T e middle sacral ves-  sels will also require ligation (12). Because of the inflammatory reaction  associated with the aneurysm, this portion of the aorta may be intimately  attached to the adjacent vena cava.   T e blood supply to the ureters is variable and difficult to identify. T e  arterial supply (6, 7, 8) arises from the renal vessels, directly from the aorta,  and from the gonadal vessels, as well as from the hypogastric arteries (11).  Although these vessels may be small and their ligation necessary, the ure-  ters should not be denuded of their blood supply any further than is abso-  lutely necessary.   T e aorta terminates by dividing into the common iliac arteries (9),  which in turn divide into the external iliac (10) and the internal iliac (hypo-  gastric) (11) arteries. From the bifurcation of the aorta, the middle sacral  vessel (12) descends along the anterior surface of the sacrum. T ere is a  concomitant vein that usually empties into the left common iliac vein at  this point (12).   T e ovarian arteries (4) arise from the anterolateral wall of the aorta  below the renal vessels. T ey descend retroperitoneally across the ureters  and through the infundibulopelvic ligament to supply the ovary and sal-  pinx (15). T ey terminate by anastomosing with the uterine artery (16),    which descends in the broad ligament. T e spermatic arteries and veins  follow a retroperitoneal course before entering the inguinal canal to supply  the testis in the scrotum.   T e uterine vessels (16) arise from the anterior division of the internal  iliac (hypogastric) arteries (11) and proceed medially to the edge of the  vaginal vault opposite the cervix. At this point, the artery crosses over the  ureter (“water under the bridge’) (17). T e uterine vein, in most instances,  does not accompany the artery at this point but passes behind the ureter. In  a hysterectomy, the occluding vascular clamps must be applied close to the  wall of the uterus to avoid damage to the ureter. T e uterine vessels then  ascend along the lateral wall of the uterus and turn laterally into the broad  ligament to anastomose with the ovarian vessels.   T e lymphatic networks of the abdominal viscera and retroperitoneal  organs frequently end in lymph nodes found along the entire abdominal  aorta and inferior vena cava. Lymph nodes about the celiac axis (A) are  commonly involved with metastatic cancer arising from the stomach and  the body and tail of the pancreas. T e para-aortic lymph nodes, which sur-  round the origin of the renal vessels, receive the lymphatic drainage from  the adrenals and kidneys.   T e lymphatic drainage of the female genital organs forms an extensive  network in the pelvis with a diversity of drainage. T e lymphatic vessels of  the ovary drain laterally through the broad ligament and follow the course  of the ovarian vessels (4, 5) to the preaortic and lateroaortic lymph nodes  on the right and the precaval and laterocaval lymph nodes on the left. T e  fallopian tubes and the uterus have lymphatic continuity with the ovary,  and communication of lymphatics from one ovary to the other has also  been demonstrated.   Lymphatics of the body and fundus of the uterus may drain laterally  along the ovarian vessels in the broad ligament with wide anastomoses with  the lymphatics of the tube and ovary. Lateral drainage to a lesser extent fol-  lows a transverse direction and ends in the external iliac lymph nodes (18).  Less frequently, tumor spread occurs by lymphatic trunks, which follow the  round ligament from its insertion in the fundus of the uterus to the inguinal  canal and end in the superf cial inguinal lymph nodes (22).   T e principal lymphatic drainage of the cervix of the uterus is the  preureteral chain of lymphatics, which follow the course of the uterine  artery (16) in front of the ureters and drain into the external iliac (18), the  common iliac (19), and obturator lymph nodes. Lesser drainage is by way  of the retroureteral lymphatics, which follow the course of the uterine vein,  pass behind the ureter, and end in the internal iliac (hypogastric) lymph  nodes (20). T e posterior lymphatics of the cervix, less constant than the  other two, follow an anteroposterior direction on each side of the rectum  to end in the para-aortic lymph nodes found at the aortic bifurcation (21).   T e lymphatics of the prostate and bladder, like those of the cervix, are  drained particularly by nodes of the external iliac chain (18) and occasion-  ally also by the hypogastric (20) and common iliac lymph nodes (19). m    1 Inferior phrenic arteries  2 Rt. adrenal vein  3 It. adrenal vein    18 Ext. iliac 21 Para-aortic  19 Com. iliac 22 Inguinal  20 Int. iliac    T e gross anatomic features of both the lungs are shown in figure |. On  the right side the major division between the right lower (inferior) lobe (3)  and the two others is a major fissure (2) which parallels the course of the  fourth rib. T e height to which the superior segment extends posteriorly  behind the right upper (superior) lobe (1) should be noted, since the pres-  ence of the right lower lobe at this high level is important in interpreting  x-rays. Of similar importance is the position of the right middle lobe (4),  whose upper margin is demarcated by the approximately horizontal fissure  (5). Accordingly, the middle lobe is entirely in the anterior half of the chest.  In the left lung, the superior segment of the left lower (inferior) lobe (9)  extends to a similarly high posterior level beneath the left oblique fissure  (7) separating the left upper (superior) (6) and lower (inferior) lobes (9).  T e lingula (8) is, however, incorporated with the upper lobe and occupies  a relatively narrow, wedge-shaped area along the anteroinferior border of  that lobe.   After removal of the entire right lung, the thoracic cavity and medi-  astinum might appear as in figure 2. Superiorly, the mediastinum con-  tains the superior vena cava (1A) with the phrenic nerve (2) and the vagus  nerve (3), which enters between the superior cava and innominate artery  (4) and then crosses the trachea (5) to proceed along the lateral border of  the esophagus (6). After received intercostal tributaries, the azygos vein (7)  ascends lateral to the esophagus and then loops about the hilus of the right  lung to join the superior vena cava near its junction with the right atrium.  T e investing visceral pleura about the hilus of the lung 1s shown as a cut  edge as it joins the mediastinum and pericardium. Inferiorly this pleura  forms the interior pulmonary ligament (8), which contains an occasional  lymph node. T is enclosed space of the hilum contains the right mainstem  bronchus (9) in its posterosuperior position. Directly anterior to this is the  right pulmonary artery (10), and then inferiorly are the right superior (11)  and right inferior pulmonary veins (12), as well as a few hilar nodes. Other  important nodes are those about the azygos vein (7) and the right phrenic  nerve (2) on the superior vena cava. On the posterolateral chest wall  are shown the intercostal neurovascular bundies (13) proceeding in their    sheltered locations in grooves along the inferior border of each rib. T e  thoracic sympathetic nerve chain (14) is shown with its ganglia and with  the origins of both the greater (15) and lesser splanchnic nerves (16).   T e left thoracic cavity with the lung removed appears as in figure 3.  Arising from the arch of the aorta (17) are the innominate (4), the left com-  mon carotid (18), and left subclavian arteries (19). In close proximity to  the innominate we see the left phrenic nerve (20), artery, and vein, which  course down over the arch of the aorta and then along the anterolateral  border of the pericardium before innervating the diaphragm (21). T e  internal mammary artery and vein (22) are found along the anteromedial  aspect of the chest wall. T e left vagus (23) accompanies the left common  carotid through the mediastinum and proceeds laterally over the arch of  the aorta where it gives of the recurrent laryngeal nerve (24) lateral to the  ductus arteriosum. T e vagus then continues down along the esophagus  (6). T e venous drainage of the left chest wall is dif erent from that on the  right. A superior intercostal vein (25) receives tributaries from the first few  intercostal veins and then joins an accessory hemiazygos vein (26) and the  hemiazygos vein (27), which crosses posteriorly to join the azygos (7). T e  left thoracic sympathetic trunk with its ganglia (28) and the branches to the  greater (29) and lesser splanchnic nerves (30) are quite similar to those on  the right side.   T e structures of the left hilus are enclosed within the visceral pleura,  which extends to the diaphragm as to the left inferior pulmonary ligament  (31). In contrast to the right side, the left main pulmonary bronchus (32) is  directly posterior but in the midportion of the hilus. Superior and anterior  to this bronchus 1s the left main pulmonary artery (33), while the superior  (34) and inferior (35) pulmonary veins on the left are anterior and infe-  rior, respectively, to this bronchus. T ere are occasional lymph nodes in the  inferior pulmonary ligament, but the principal node areas about this hilus  are near the ductus arteriosum (36) where the recurrent laryngeal nerve  may be involved. Other nodes are found along the esophagus and trachea,  but in general the lymphatic chain on this side tends toward the anterior  mediastinum.    THE LUNG Figure  Right upper (superior) lobe  Right oblique fissure  Right lower (inferior) lobe  Right middle lobe  Horizontal fissure    |. Vena cava 12. Right inferior pulmonary vein  A. Superior (3. intercostal neurovascular bundle  B. Inferior 14. Right thoracic sympathetic trunk with ganglia  2, Right phrenic nerve and vessels 15. Right greater splanchnic nerve  3. Right vagus nerve I6. Right lesser splanchnic nerve  4. Innominote artery 17. Aortic arch  5. Trachea 18. Left common carotid artery  6. Esophagus 19, Left subclavian artery  7. Azygos vein 20, Left phrenic nerve and vessels  8. Right inferior pulmonary ligament 21. Diaphragm  9. Right main bronchus 22. Left internal mammary artery and vein  lO. Right pulmonary artery 23 Left vagus nerve  11. Right superior pulmonary vein 24, Left recurrent laryngeal nerve  RIGHT  MEDIASTINUM   . Left thoracic sympathetic trunk with ganglia  . Left greater splanchnic nerve    , Left superior pulmonary vein  . Left inferior pulmonary vein  . Ligamentum arteriosum    PREOPERATIVE PREPARATION Prior to bringing the patient to the oper-  ating room, the surgical site is marked with the patient’ co-operation by  the operating surgeon to ensure correct site surgery. T e patient is carefully  positioned on the operating table while taking into consideration the need  for special equipment such as heating pads, electrocautery grounding plates,  sequential compression stockings, and anesthesia monitoring devices. T e  arms may be positioned at the side or at right angles on arm boards, which  allows the anesthesiologist better access to intravenous lines and other  monitoring devices. It is important that the patient be positioned without  pressure over the elbows, heels, or other bony prominences; neither should  the shoulders be stretched in hyperabduction. T e arms, upper chest, and  legs are covered with a thermal blanket. Simple cloth loop restraints may be  placed loosely about the wrists, whereas a safety belt is usually passed over  the thighs and around the operating table. T e entire abdomen is shaved  with clippers, as is the lower chest when an upper abdominal procedure  is planned. In hirsute individuals, the thigh may also require hair removal  with clippers for effective application of an electrocautery grounding pad.  T e grounding pad should not be placed in the region of metal orthopedic  implants or cardiac pacemakers. Loose hair may be picked up with adhe-  sive tape, and the umbilicus may require cleaning out with a cotton-tipped  applicator. T e first assistant scrubs, puts on sterile gloves, and then places  sterile towels well beyond the upper and lower limits of the operative field  so as to wall off the unsterile areas. T e assistant vigorously cleanses the  abdominal field with gauze sponges saturated with antiseptic solution (see  Chapter 1). Some prefer iodinated solution for skin preparation. Prophylac-  tic antibiotics are administered intravenously within | hour of the incision.   After positioning, skin preparation, and draping, a TIME OUT is per-  formed as described in Chapter 3, table 1.   T eincision should be carefully planned before the anatomic landmarks  are hidden by the sterile drapes. Although cosmetic considerations may  dictate placing the incision in the lines of skin cleavage (Langer’ lines) in an  effort to minimize subsequent scar, other factors are of greater importance.  T e incision should be varied to fit the anatomic contour of the patient. It  must provide maximum exposure for the technical procedure and of the  anticipated pathology, while creating minimal injury to the abdominal  wall, especially in the presence of one or more scars from previous surgi-  cal procedures. T e most commonly used incision is a midline one that  goes between the two rectus abdominis muscles, around the umbilicus, and  through the linea alba (figure 1). For procedures in the pelvis, the incision  is extended to the pubis; whereas for upper abdominal operations, the inci-  sion may extend up and over the xiphoid. Following preparation, the abdo-  men is walled off with sterile towels placed transversely at the xiphoid and  pubis and longitudinally about either rectus muscle. Some surgeons prefer  further to seal the field with an adhesive plastic drape that may be impreg-  nated with an antiseptic solution. T is technique is particularly useful in  patients who have pre-existing intestinal stomas, tubes, or other processes  that may contaminate the operative field.    INCISION AND EXPOSURE In making the incision, the operator should  hold the scalpel with the thumb on one side and the fingers on the other.  T e distal portion of the handle rests against the ulnar aspect of the palm.  Some prefer to rest the index finger on top of the knife handle as a sensitive  means of guiding the pressure being applied to the blade. T e primary inci-  sion may be made in three ways. First, the surgeon may take a sterile gauze  pad in his or her left hand and pull the skin superiorly at the upper end of  the incision. T e taut skin immediately below the surgeon’ left hand 1s cut.  As the incision progresses, the gauze is shifted down the incision, always  keeping the skin taut such that the knife makes a clean incision. Second,    the surgeon may prefer to make the skin taut from side to side with the  forefinger and thumb (figur e 2) as he or she progresses sequentially down  the abdomen. T ird, the gauze-covered left hand of the surgeon and that of  the first assistant may exert lateral tension on the skin, thus permitting the  scalpel to create a clean incision. T e compressing fingers should be sepa-  rated and flexed to exert a mild downward and outward pull; however, it is  essential that the line of incision not be pulled to one side or the other (.e.,  off the true midline). T is technique allows the surgeon to have a full view  of the operative area as he or she cuts evenly through the taut skin along the  length of the incision.   T e incision is carried down to the underlying linea alba, which may  be dif cult to find in the obese patient. A most useful technique is for the  surgeon and first assistant to apply strong lateral traction to the subcutane-  ous fat which will then split (figure 3) directly down to the linea alba.  T is maneuver may be the only way to find the midline in morbidly obese  patients; however, it works equally well in most patients. T e linea alba  should be freed of fat (figure 4) for a width of approximately 1 cm such  that the margins can be easily identified at the time of closure. Bleeding  vessels are clamped carefully with small hemostats and are either ligated  or cauterized. As soon as hemostasis in the superficial fat layer has been  accomplished, moistened large gauze pads are placed in the incision such  that the fatty layer is protected from further desiccation or injury. T is also  aids in providing a clear view of the underlying parietes.   T e linea alba 1s incised in the midline (figur e 5). Preperitoneal fat may  require division to expose the peritoneum. T e surgeon and first assistant  alternatively pick up and release the peritoneum to be certain that no viscus  is included in their grasp. Using toothed forceps which lift the peritoneum  upward, the surgeon makes a small opening in the side of the tent of elevated  peritoneum rather than in its vertex (figure 6). Usually, the tent formation  has pulled the peritoneum away from the underlying tissue, and the side  opening allows air to enter such that adjacent structures fall away. A culture  is taken at this time if abnormal fluid is encountered. Large collections of  ascites within the abdomen may be removed by suctioning. T e volume of  ascites should be recorded, and it may be kept within a special bottle trap if  cytologic studies are planned to determine whether it is a malignant ascites.   T e edges of the linea alba fascia and the adjacent peritoneum are  grasped with Kocher clamps. Care is taken to prevent inclusion and injury  to underlying viscera. By continuously elevating the tissues that are to be  cut, the surgeon may enlarge the opening with scissors (figure 7). In cut-  ting the peritoneum and fascia with scissors, it is wise to insert only as much  of the blade as can be clearly visualized, so as to avoid cutting any internal  structures such as bowel that may be adherent to the parietal peritoneum.  Tilting the points of the scissors upward may afford a better visualization of  the lower blade. Having extended the incision to its uppermost limits, the  operator may insert the index and middle fingers of the left hand beneath  the peritoneum heading toward the pelvis. T e linea alba and peritoneum  may be divided with a scalpel (figur e 8) or scissors. Care must be taken in  the region of the umbilicus as there are often one or two significant blood  vessels in the fatty layer between the fascia and peritoneum. T ese may  be grasped with hemostats and ligated. Additional care must be taken at  the extreme lower end of the opening where the bladder comes superiorly.  T e peritoneal incision must stop just short of the bladder, which is seen  and identified as a palpable thickening. In general, the peritoneal incision  should not be as long as the facial opening since undercutting may make  the closure dif cult. Small incisions may be preferred by the patient; how-  ever, an inadequate incision may result in a prolonged and more dif cult  procedure for the surgeon.    CLOSURE More or less the same steps for closure are carried  out whether the incision is midline or transverse. If the peritoneum and  linea alba fascia are separate, the fascial edge may be grasped with toothed  forceps (figur e 9), exposing the edge of the peritoneum, which is grasped  with Kocher’ clamps. T e closure sutures may be absorbable or nonab-  sorbable. T e technique may use interrupted or continuous sutures that  approximate the peritoneum and linea alba either as separate layers, or as a  combined unified one. If a continuous suture is used, it is technically easier  to close from the lower end of the incision upward, particularly if the sur-  geon stands on the right side of the patient. T e suture is anchored in the  peritoneum just below on the end of the incision (figure 10). T e needle  is passed through the peritoneum and run superiorly in a continuous man-  ner. A medium width metal ribbon is often placed beneath the peritoneum  to ensure a clear zone for suturing and to avoid incorporation of visceral  or other structures into the suture line. T e placement of the continuous  suture is made easier if the assistant crisscrosses the two leading Kocher    clamps (figure ll) to approximate the peritoneum. At the superior end  of the incision, the looped and free ends of the suture are knotted together  across the line of incision (figure 12).T etype of knot and the number of  throws are determined by the characteristics of the suture material.   T e linea alba fascia may be closed, beginning at either end of the inci-  sion. Simple interrupted sutures may be placed (figur e 13) or figure-of-eight  sutures (figure 19, page 37) may be used. T e sutures are placed about Ito 2  cm apart whether interrupted or continuous (figure 14) technique 1s used.   Alternatively, the linea alba and peritoneum may be closed as a single  unified layer with either interrupted or continuous suture. T e most expedi-  tious closure may be made with a heavy looped suture on a single needle.  T e suture material may be either synthetic absorbable or a nonabsorbable  inaO or#Isize.T esuture begins with the transverse placement through the  peritoneum and fascia across the lower end of the incision (figure 15).T e  needle is then brought through the eye of the loop (figure 16). Upon tight-  ening, the suture is secured without the need of tying a knot.    CLOSURE T e double loop suture is run in a continuous  manner taking full thickness of the linea alba fascia and peritoneum on  either side of the incision (figure 17). After placement of the final stitch  superiorly, the needle is cut off and one limb of the suture retracted back  across the incision. T is allows the two cut ends to be tied along one side  of the incision.   Some surgeons prefer to use the figure-of-eight, or the so-called eight-  pound stitch, when closing fascia with the interrupted sutures. A full-thick-  ness horizontal bite is taken that enters the linea alba on the far side at A  and exits at B (figure 18). T e suture is advanced for a centimeter or two,  and an additional transverse full-thickness bite is taken that enters at C  and exits at D. When the two ends of the suture are tied, a crisscrossing,  horizontal figure-of-eight is created (figure 19).T eknot should be tied to  one side. In general, the figure-of-eight suture is placed snugly rather than  tightly where it may cut through the tissue with any postoperative swelling.   After each knot is tied during the closure, the ends of the suture are held  under tension by the assistant and are cut. Silk sutures may be cut within  2 mm of the knot, whereas many absorbable or synthetic sutures require  several millimeters be left, as the knots may slip. As the suture is held nearly  perpendicular to the incision by the assistant, the scissors are slid down  to the knot and rotated a quarter turn (figures 20 and 21). Closure of  the scissors at this level allows the suture to be cut near the knot without  destroying it. In general, the scissors are only opened slightly such that the  cutting occurs near the tips. Additional fine control of the scissors may be  obtained by supporting the midportion of the scissor on the outstretched  index, and middle fingers of the opposite hand just as the rest supports the  chisel on a wood-turning lathe. Following closure of the fascia, some sur-  geons reapproximate Scarpa’ fascia with a few interrupted 3/0 absorbable  sutures (figure 22), whereas others proceed directly to skin closure, the  details of which are shown later in this chapter.    Occasionally, it is necessary to use a retention or through-and-through  suture. T is is especially true in debilitated patients who have risk factors  for dehiscence such as advanced age, malnutrition, malignancy, or contam1-  nated wounds. T e most frequent use of retention sutures, however, is for a  secondary reclosure of a postoperative evisceration or full-thickness disrup-  tion of the abdominal wall. T rough-and-through #2 nonabsorbable sutures  on very large needles may be placed through all layers of the abdominal wall  as a simple suture or as a far-near/near-far stitch (figure 27). In this tech-  nique, the fascia is grasped with Kocher clamps and a metal ribbon retractor  is used to protect the viscera. T e surgeon places the first suture full thick-  ness through the far side abdominal wall. T e needle is then brought through  the near linea alba or fascia about 1cm back from the cut edge with the path  going from peritoneal surface toward the skin (figure 23). T e suture then  crosses the midline to penetrate the far side fascia in a superficial to deep  manner (figure 24). T e free intraperitoneal suture is then continued full  thickness through the near abdominal wall (figure 25). As seen in cross  section (figure 26), it is important that the abdominal wall full-thickness  bites taken at the beginning and end of this placement are not positioned  so laterally as to include the epigastric vessels within the rectus abdominis  muscles. Compression of these vessels when the suture is tied may lead to  abdominal wall necrosis. In addition, the intraperitoneal exposure of this  suture should be small so as to minimize the possibility of a loop of intestine  becoming entrapped when the retention is tied. In general, the entrance and  exit sites are approximately 1.5 or 2 inches back from the cut edge of the skin  (figure 27). Many surgeons use retention suture bolsters or simple 2-inches  sections of sterilized red rubber tubing in order to minimize the cutting of the  suture into the skin during the inevitable postoperative swelling. Because of  this swelling, the retention sutures should be tied loosely rather than snugly  such that the surgeon can still pass a finger between the retention suture and  the skin of the abdominal wall.    CLOSURE Following closure of the peritoneum and the linea  alba, Scarpa’ fascia may be approximated with 3/0 absorbable suture. Many  feel this lessens the subcutaneous dead space within the fat (figure 28). In  thin patients, this suture may be placed in an inverted manner (as shown),  with the knot at the bottom of the loop. However, in most patients, these  sutures are placed upright with the knot on top.   T e skin may be closed with interrupted fine 3/0 or 4/0 nonabsorbable  sutures using a curved cutting needle (figure 29). T e skin edge 1s elevated  with forceps in such a manner that the needle is introduced perpendicular to  the skin on the one side and exits perpendicularly on the opposite. T e sutures  are spaced such that the distance between them 1s approximately equal to their  width. T is creates a pleasing uniform pattern. As the individual sutures are  tied, the skin will rise, creating a slight ridge. When all sutures are tied, they  are held in the surgeon’ left hand and then sequentially cut with the scissors  (figur e 30). Some surgeons prefer an interrupted vertical mattress suture for  skin closure. T e vertical mattress suture is especially well suited for circum-  stances where the skin edges do not lie in level approximation. T e skin is  grasped with the toothed forceps. A wide lateral base is created as the needle  enters the skin about lcm or so lateral to the cut edge (figure 31). T e oppo-  site skin edge is then grasped with forceps and the needle brought through in  a symmetric manner (figure 32). A careful approximation of the skin edges  at equal levels is accomplished by a returning small bite that is approximately  a millimeter or two from the skin edge and only a millimeter or two deep. A  symmetric bite on the proximal skin edge completes the stitch (figure 33).  T is stitch is tied loosely, producing a gentle ridge effect (figure 34).    T e skin may also be closed with interrupted fine 4/0 or 5/0 synthetic  absorbable subcuticular sutures. With this method, the suture must lie in the  deepest layers of the cortum. T e skin edge is grasped with toothed forceps  and the suture is placed by either the continuous or interrupted horizontal  mattress technique. Multiple interrupted sutures are preferred for short inci-  sions, whereas continuous sutures are more suitable for incisions that are  more than a few centimeters long. In this technique, small horizontal bites  are taken in opposite sides of the skin margins (figur es 35 and 36). When  the knot is tied, a perfect approximation occurs (figure 37). After tying, the  sutures are cut as close to the knot as possible. T ereafter, the skin is cleaned  of the preparative antiseptic solution and a benzoin-like skin protector is  applied. When this becomes tacky, porous adhesive paper tapes are applied  transversely (figure 38). T is relieves tension in the incision and provides  a simple covering.   Conversely, some surgeons use metal staples for skin closure. T eir advan-  tage is speed of application (figure 39) and ease of removal (figure 40).  Special care must be taken, however, to approximate carefully the everted  skin margins with a pair of fine-toothed forceps. T e stapling instrument  should not press into the skin. A gentle light application will result in the  desired mounding up that keeps the two skin edges in good approximation.  Some prefer to place these staples widely and use the adhesive paper tapes  between them. Finally, a covering gauze dressing 1s necessary so as to absorb  the small amount of serum and blood that evacuates in the postoperative  period. In general, staples should be removed sooner rather than later as they  penetrate the skin and can result in localized inflammations. m=    IndIcatlIons T e first step in most abdominal laparoscopic procedures  is insufflation of the intraperitoneal space with CO, gas and the introduc-  tion of the videoscope system. T e original and the most established tech-  nique uses the Veress needle, described in the following Chapter 12, page 42.  T e Veress needle can be placed in any quadrant of the abdomen, but is  most frequently inserted just below the umbilicus, where a skin incision has  been made for the introduction of a large 10-mm port for the videoscope.  General surgeons, however, have been cautious in adopting this technique  of blind puncture, as their training has emphasized the importance of com-  plete visualization of anatomy and of the planned action of their surgical  instruments. Accordingly, the open or Hasson technique for entering the  abdomen under direct vision has become more popular and safer. T 1s tech-  nique can be used to enter into any quadrant of the abdomen but is most  commonly employed at the central umbilical site (figure 1). A vertical or  transverse skin incision approximately 10 to 12 mm in length is made just  below (figure 2) or above the umbilicus. T e choice of site may be based  on the surgeon’ preference or the presence of a previous regional incision  that may have adhesions. T e subcutaneous fat and tissues are bluntly dis-  sected apart using small narrow finger retractors or a Kelly hemostat. T e  white linea alba is visualized and grasped on either side with hemostats.  T e linea alba is elevated with the hemostats and a vertical 10-mm incision  is made through the fascia (figur e 2). Further dissection with a hemostat  will reveal the thickened white peritoneum, which is grasped with a pair  of laterally placed hemostats. T e peritoneum is elevated and opened cau-  tiously with a scalpel. A dark, empty peritoneal space is seen and a pair of  lateral stay sutures are placed (figure 3). T ese sutures incorporate the  peritoneum and linea alba and are later used to secure the Hasson port.   T enext step is to verify that the intraperitoneal space has been entered  freely. T e surgeon’ fit h finger is inserted (figure 4). T is maneuver sizes  the hole for the port and allows the surgeon to palpate the region. Usually  this space is clear, but occasionally there are some filmy omental adhesions  that can be swept away. T e Hasson port with its blunt, rounded-tip obtura-  tor is introduced into the abdomen (figure 5). T e spiral collar is screwed  into the fascia so as to provide a snug gas seal, and the lateral stay sutures  are secured to the notches on the collar. T e obturator is removed. T e CO,  line 1s attached and the stopcock opened. T e surgeon sets the rates of CO,  fow and maximum pressure (15 mm Hg). He or she observes the intra-  abdominal pressure and the total volume of CO, infused as the abdomen  enlarges and becomes tympanitic. T e videoscope is white-balanced and  focused. T e optical end of the instrument is coated with antifog solution.  T e videoscope is introduced into the port and advanced into the perito-  neal space. If an angled optical instrument, typically 30 degrees, is used,  it is important for the operator of the videoscope to establish the correct  orientation of the optics and the video head. Typically, the optical bevel  is downward-viewing (6 oclock) when the fiberoptic light cable is vertical    (12 oclock). T e video head is correctly oriented when its cable is positioned  at 6 oclock posteriorly. Rotation of either instrument from these positions  will produce a rotated view on the TV monitor.   In the presence of omental adhesions or an enlarged falciform ligament,  the intraperitoneal space may not easily be entered as the videoscope comes  to the end of the Hasson port. If this area was clear to palpation with the  surgeons fit h finger, careful angulation and rotation of the videoscope usu-  ally finds the right opening. When the opening cannot be found, the port  is removed and a repeat finger palpation is performed before reinsertion of  the Hasson port. In extreme cases, when finger palpation cannot find an  easy intraperitoneal entrance because of dense adhesions, an alternative site  for the Hasson port should be used.   T e usual alternative sites (figure 1) are in the four quadrants of the  abdomen, although the Hasson port can also be placed through the midline  linea alba in the epigastric or suprapubic regions. A transverse skin incision  is made and the subcutaneous fat spread with narrow finger retractors or a  Kelly hemostat. T e fascia of the external oblique muscle is incised with a  scalpel. Further deep dissection is performed through the internal oblique  and transversus muscles, whose thin fascia usually does not require inci-  sion. T e white peritoneum is grasped between hemostats and elevated. A  scalpel incises the peritoneum and a clear entry into the intraperitoneal  space 1s verified by the deep passage of a Kelly hemostat. A pair of lateral stay  sutures incorporating the peritoneum and fascia are placed. T e remainder  of this procedure is performed as described for the umbilical site.    suture of Port sIte Most 5-mm port sites do not require suture clo-  sure of the fascia, especially if the port is passed originally in a zigzag or  oblique manner through the muscle layers of the abdominal wall. On occa-  sion, however, a blood vessel of the intra-abdominal wall that was not seen  with transillumination may be cut by the trocar during the placement of a  port. Most small vessels will stop bleeding. However, some may continue  to drip into the intraperitoneal space and obscure visualization. A tech-  nique for the control of these vessels or for closure of a fascial defect is  shown (figure 6). A 00 delayed absorbable suture is placed into the tip  of a special suturing needle. T e needle and suture are passed through the  inner abdominal wall about 1 cm beyond the edge of the port entry site  (figure 6a). T esuture is released from the needle tip with a long free end  showing within the abdomen. T e special suturing needle is removed and  reinserted about 1cm beyond the opposite edge of the port entry site. T e  needle tip is opened and the suture is grasped (figure 6b). T e free end of  the suture and the needle are withdrawn. T e suture is tied down through  the skin opening. T 1s technique produces a mattress suture that can secure  abdominal wall blood vessels or close fascial defects created by the place-  ment of large ports. Both maneuvers are done under direct visualization  using the videoscope. m    AnesthesiA General anesthesia with endotracheal intubation 1s recom-  mended. Preoperative prophylactic antibiotics for anticipated bile patho-  gens are administered such that adequate tissue levels exist.    Position As laparoscopic cholecystectomy makes extensive use of sup-  porting equipment, it is important to position this equipment such that it is  easily visualized by all members of the surgical team (figure 1).    o Per Ative PrePAr Ation T e skin of the entire abdomen and lower  anterior chest is prepared in the routine manner.    incision And exPosure T e abdomen 1s palpated to find the liver  edge or unsuspected intra-abdominal masses. T e patient is placed in a  mild Trendelenburg position and an appropriate site for the creation of the  pneumoperitoneum is chosen. T e initial port may be placed by an open  or Hasson technique which is preferred. Alternatively, a Veress needle tech-  nique is used as described below. In the unoperated abdomen this is usu-  ally at the level of the umbilicus (figure 2); however, previous laparotomy  incisions with presumed adhesions may suggest a more lateral approach  site which avoids the epigastric vessels (figure 2 at X). A l-cm vertical  or horizontal skin incision is made and the abdominal wall on either side  of the umbilicus is grasped by the surgeon and first assistant either by  thumb and forefinger or by towel clips so as to elevate the abdominal wall  (figure 3). A Veress needle is held like a pencil by the surgeon who inserts  it through the linea alba and peritoneum where a characteristic popping  sensation is felt (figure 4). An unobstructed free intraperitoneal position    for the Veress needle is verified by easy irrigation of clear saline in and out  of the peritoneal space (figure 5) and by the hanging drop method where  the saline in the translucent hub of the Veress needle is drawn into the peri-  toneal space when the abdominal wall is lifted.   If one does not obtain a free flow or an unobstructed saline irrigation,  then the Veress needle may be removed and reinserted. In general it is safer  to convert the umbilical site into the Hasson open approach (Chapter 11)  if any difficulty is experienced with the placement, irrigation, or insuf a-  tion of the Veress needle. T e appropriate tubing and cables for the CO,  insuf ation, the fiber optic light source, and the laparoscopic videoscope  with its sterile sheath are positioned as are the lines for the cautery or laser,  suction, and saline irrigation. T e pneumoperitoneum begins with a low  flow of about 1 or 2 L/min with a low-pressure limit of approximately 5 to  7cm H,O. Once 1 to 2 Lof CO, are in, the abdomen should be hyperresonant  to percussion. T e flowrate may be increased; however, the pressure should  be limited to 15 cm HO. T ree to four liters of CO, are required to fully  inflate the abdomen and the Veress needle is removed. After grasping  either side of the umbilicus, a 10-mm trocar port is inserted with a twisting  motion, aiming toward the pelvis (figur e 6). If a disposable trocar port is  used, it is important to be certain that the safety sheath 1s cocked. A char-  acteristic popping sensation is felt as the trocar enters the peritoneal space.  T e trocar is removed and the escape of free CO, gas is verified.   Although the Veress needle technique has a long history and is preferred  by some, most general surgeons use the Hasson technique, as shown in the  preceding Chapter ll. m=    IndIcatIons Indications for diagnostic laparoscopy can be divided into  three broad groups. Gynecologic conditions include infertility, endometriosis,  primary amenorrhea, pelvic pain in the female, and to rule out appendicitis  in women with pelvic pain. In an effort to accurately diagnose or stage cancer,  patients with gastric, esophageal, or pancreatic cancer may undergo diagnostic  laparoscopy to stage the disease and determine resectability or direct further  treatment. In patients with intra-abdominal lymphadenopathy where lym-  phoma is a possibility, diagnostic laparoscopy is indicated to biopsy a represen-  tative lymph node to make the diagnosis. Benign conditions represent the third  group whom may benefit from diagnostic laparoscopy. Patients (typically those  who have undergone previous abdominal procedures) with chronic abdominal  pain and intermittent partial small bowel obstructions may benefit from diag-  nostic laparoscopy and adhesiolysis. Patients with symptoms suggestive of an  inguinal hernia but lack a clear inguinal hernia on physical examination may  benefit from diagnostic laparoscopy. T ese may then be repaired laparoscopi-  cally. In patients with a unilateral inguinal hernia, laparoscopy can diagnose  an inguinal hernia on the contralateral side to rule out a contralateral hernia.  T e laparoscopic incisions cause less pain and there is a faster return to normal  activities or work in the event no therapeutic maneuvers are undertaken.    Preo PeratIve PreParatlon T e patient must be optimized prior to  undergoing an operative procedure. Respiratory function should be optimized  with cessation of smoking and appropriate pulmonary function evaluation if  indicated. A discussion with the patient should occur preoperatively as the find-  ings at diagnostic laparoscopy may dictate further surgery and consent should  be obtained for these potential additional procedures prior to undergoing anes-  thesia. In the event the diagnostic laparoscopy is for adhesiolysis after previous  abdominal procedures, the preceding operative note, should be reviewed.    anesthesIa A general anesthetic with an endotracheal tube is required.  T e patient should be relaxed or chemically paralyzed with paralytics to  facilitate relaxation of the abdominal wall and visualization with insufflation.    PosItlon T epatient is placed in asupine position with a pillow placed to pro-  duce mild f exion of the hips and knees. T is helps to relax the abdominal wall. If  visualization of the upper abdomen is required (gastric, esophageal, or pancre-  atic cancers), the arms should be left “out” at 90 degrees. Video screens should be  placed at the head of the bed just over the patients’ shoulders for viewing by the  surgeons on the contralateral side (figur e 1). Patients undergoing laparoscopy  of the pelvis should have their arms tucked at their side to facilitate the position  ofthe surgeon to viewthe video screen(s) placed at the foot ofthe bed (figur e 2).    o Perat Ive PreParatlon T e patient is given perioperative antibiot-  ics. An orogastric tube is passed for gastric decompression. For pelvic lapa-  roscopy, a Foley catheter is placed and pneumatic sequential stockings are  applied. T e skin is prepared in the routine manner.    IncIslon and exPosure Typically placement of a 5 or 10-mm video-  scope port and two 5-mm operating ports are a function of what region of the  abdomen wishes to be explored and the preference of the surgeon (figur es |  and 2). T e general principle is that of triangulation. T e ports should be  about a hand’ breadth or more apart from each other and the two operat-  ing ports should be placed as widely apart as possible. One of the operating  ports should be 10-mm in size if a 5-mm videoscope is not available.   T e videoscope port is placed first, using the open Hasson technique or  an optical trocar may be used after preinsufflation of the abdomen using  a Veress needle when accessing the abdominal cavity laterally. In patients  undergoing upper abdominal exploration, an infraumbilical Hasson can-  nula (figure 1) is appropriate while patients undergoing pelvic or lower  abdominal exploration a supra-umbilical point of access should be under-  taken (figure 2). After the abdomen is entered safely and the port secured  with stay sutures, the intraperitoneal space is inf ated with carbon dioxide.  T e surgeon sets the gas fow rate and the maximum pressure (< 15 mm  Hg). T erising intra-abdominal pressure and total volume of gas infused is  observed as the abdomen distends. T e videoscope is white-balanced and  focused. T e optical end, typically a 30-degree angle, is coated with antifog  solution and the scope is advanced down the port into the abdomen under  direct vision. All four quadrants of the abdomen are explored visually  (figur es 3to 5). Omental and other adhesions to the abdominal and anterior  abdominal wall in the region to be explored are visualized and taken down  bluntly or with sharp dissection. Placement of the operating ports begins  with the infiltration of the skin with a long-acting local anesthetic. T e local  needle may be passed perpendicularly full thickness through the abdominal  wall and its entry site verified with the videoscope. T e skin is incised and  the subcutaneous tissues are dilated with a small hemostat. T e abdominal    wall is transilluminated with the videoscope to show any regional vessels  within the abdominal musculature. T e 5-mm operating ports are placed in  a location to facilitate dissection and exposure of the upper or lower abdo-  men with visualization of their clean entry into the intraperitoneal space.    detalls of Procedure In patients who have undergone previous  abdominal procedures or who present with chronic abdominal pain and  intermittent partial small bowel obstruction, the omentum or bowel will  have formed some adhesions to the abdominal wall and must be taken down.  Attention should be directed to the area in which the patient 1s experienc-  ing the pain as the adhesions in this location may be the etiology of the pain  and should be taken down completely. Placing the patient in reverse Tren-  delenburg position will facilitate visualization of the upper abdomen bringing  the abdominal contents down from the diaphragm. Conversely, placing the  patient in Trendelenburg position will facilitate dissection and exposure of the  pelvic organs. Rotation of the operating table side to side to bring the patients’  left or right side up will also allow the surgeon to visualize the lateral abdomi-  nal wall and lateral areas of the abdomen that need to be explored. For this rea-  son, the patient should be secured to the bed with belt(s) or a foot rest in the  event steep reverse Trendelenburg is required. T e omentum is grasped near  the abdominal wall with a blunt atraumatic instrument and gentle traction is  applied. Using laparoscopic scissors, the surgeon sharply incises the junction  of the omentum with the peritoneum of the abdominal wall. After each cut, a  blunt sweeping motion in the same area will open up the next zone for sharp  dissection. T ere should be minimal bleeding. Electrocautery or other heat-  generating coagulating systems (ultrasonic dissectors) should be used spar-  ingly and only with full visualization so as to minimize the chance of thermal  injury to the bowel. Extensive dense adhesions or an enterotomy that is not  easily repaired laparoscopically require conversion to an open laparotomy and  repair if necessary. T roughout this dissection, the surgeon must be vigilant  for the appearance of a loop of bowel hidden within adhesions. Small and  large bowel may also be cautiously cut away from the abdominal wall but less  sweeping and traction 1s applied, lest an enterotomy should occur. T e appear-  ance of bile or succus demands a search for the source, which may be repaired  laparoscopically or after conversion to an open laparotomy.   Once adhesiolysis is complete and exposure optimized, the region of the  abdomen in question is explored. T e anterior surfaces of the liver and the  diaphragm are examined. It is important for the diaphragm to be inspected  in patients with suspected or proven gastrointestinal or pancreatic cancer as  this is acommon site of metastatic disease. T e undersurface of the liver is  exposed by lifting the liver upward with a blunt forceps (figur e 4). Biopsy of  the liver can be obtained using laparoscopic instrumentation, or a “tru-cut”  needle can be passed through the abdominal wall under direct laparoscopic  visualization to the site/area to be biopsied. T e biopsy of diaphragmatic  lesions is best performed with a biopsy forceps or the lesion may be sharply  excised with laparoscopic scissors. Biopsies can be obtained and sent for  frozen or permanent section as desired.   Atraumatic/blunt instruments can be used to “run” the bowel to visu-  alize areas in question (figure 5). T e small bowel may be run by using  atraumatic instruments by passing the grasped intestine from one hand to  the other. Again, rotation or “airplaning” of the table can facilitate exposure.  T erapy can be instituted as directed by findings at laparoscopy.   For examination of the pelvis the patient should be placed in the Tren-  delenburg position. T is allows the bowel to move to the upper abdo-  men facilitating exposure of the pelvic organs (figure 6). T e ovaries are  exposed by lifting the uterus upward. T e peritoneal surface of the pelvis is  examined carefully in cases of suspected malignancy. Biopsies of suspicious  lesions should be obtained as described above.   Upon completion of the procedure, the abdomen is lavaged with the  suction irrigator and aspirated. Careful inspection is made for any bleeding  sites and bile or succus the source of which must be identified. Each of the  operating ports is removed under direct vision to be certain that there are  no bleeding sites in the abdominal wall. T e fascia of any 10-mm port site  is closed with 00 delayed absorbable sutures. Any 5-mm port sites do not  require fascial closure, only skin. T e skin is approximated with fine 4-0 sub-  cuticular sutures. Adhesive skin strips and dry sterile dressings are applied.    Posto PeratIvecare T ecorogastrictubeis removed before the patient  awakens and the Foley catheter is discontinued as indicated. Patients may  experience a moderate amount of pain for a few days. T e diet is advanced  as tolerated. Depending on the findings and therapy delivered at the time  of laparoscopy the patient may be discharged home the same day or require  inpatient admission. m    IndIcatlIons Placement of a chronic ambulatory peritoneal dialysis  (CAPD) catheter is usually indicated largely for patients with chronic kid-  ney disease (CKD) stages 4 or 5 or with a reduced glomerular filtration rate  of less than 20 to 30 cc/min. Such patients will have discussed the suit-  ability of peritoneal dialysis versus hemodialysis with their nephrologist.  In general, peritoneal dialysis is preferred over hemodialysis for patients  with poor cardiac function, prosthetic heart valves, significant vascular  disease, hemodialysis vascular access failure, difficult access to a hemo-  dialysis center, and young age OR small body habitus that makes vascu-  lar access for hemodialysis challenging. Candidates for CAPD insertion  should be deemed capable of maintaining appropriate sterile techniques  when using the catheter to avoid developing bacterial peritonitis due to  contamination of the catheter. Intra-abdominal adhesions resulting from  previous abdominal surgeries or peritonitis can complicate successful  CAPD insertion.    Preo Perat Ive PreParatlIon T e day of surgery the patient should  have electrolytes checked to verify the absence of hyperkalemia. Diabetic  patients should have their blood glucose checked prior to initiation of the  procedure, as well as during the procedure with correction of hyperglyce-  mia when identified. Antibiotic prophylaxis directed at covering skin flora  is administered within | hour of the procedure. Determination of the cath-  eter exit site is made with the patient standing to ensure the exit site can be  seen by the patient for ease of daily exit site care (especially important in the  obese patient) and to avoid the beltline.    anesthesIa Local anesthesia accompanied by sedation is adequate for  most patients. General anesthesia can be used for patients unwilling or  unable to tolerate local anesthesia.    PoslItIon T e patient is placed supine on the operating room table with  their arms extended out from the table 90 degrees allowing for easy access  to IV sites in the upper extremities and to facilitate the surgeon access to the  abdomen without interference from an arm that is tucked to the patient’  side.    o Perat Ive PreParatlon T e surgeon first verifies that the necessary  catheter and stylet are available (figur e 1). Any hair within the surgical field  is removed with clippers immediately prior to the procedure. T e abdomen  is prepped from the symphysis pubis to midway between the umbilicus and  xiphoid process (or more cephalad), and laterally to the midaxillary line.    IncIslon and exPosure A 3- to 5-cm midline, generally infraumbili-  cal skin incision (midline approach), or paramedian skin incision (para-  median approach) in made and dissection is carried down to the fascia.  A 2- to 3-cm incision is made through the fascia at the midline (midline  approach figure 2a) or through the anterior and posterior rectus sheath  with splitting of the rectus muscle (paramedian approach figure 2b). T e    peritoneum beneath the fascia is tented up and a small hole created, taking  great care to avoid injury to intra-abdominal structures.    detalls of Procedure Once a small hole, sized to permit insertion  of the CAPD catheter has been created, a purse-string suture of 4-0 absorb-  able suture is placed in the peritoneum around the opening. T e stylet  (figure 1) 1s placed into the catheter, ensuring the end with multiple side  holes will be placed within the abdominal cavity. T e catheter with stylet  is then inserted through the peritoneal opening and the catheter is ideally  directed into the pelvis to the right side of the rectum (figure 2a). Care  should be taken to limit the force used to insert the catheter to avoid injury  to adjacent structures. Avoidance of advancing the stylet tip beyond the  end of the catheter tip will also minimize adjacent structure injury. Irri-  gating the lumen of the catheter with saline prior to stylet insertion will  aid in stylet removal and avoidance of altering the catheter position after  proper placement within the pelvis. T e peritoneal purse-string suture 1s  then cinched around the catheter just below the deep dacron cuf closest  to the abdominal cavity (figure 2b). Alternatively, if the catheter has a  silastic ball or cuf, the peritoneal purse string 1s cinched just above this,  leaving the silastic attachment within the abdominal cavity. T e fascia is  closed snuggly around the catheter using a single layer of interrupted #1  nonabsorbable suture immediately above the deep Dacron cuf (midline  facial incision figures 2a and 6), or using two layers of #1 nonabsorbable  suture for the anterior and posterior rectus sheaths, closed snuggly below  and above the deep Dacron cuf (figure 2b), respectively. Saline 1s injected  into the catheter and allowed to drain to verify functionality.   A subcutaneous tunnel is created between the catheter insertion site  and the usual right lower quadrant skin exit using a long narrow hemostat  (figure 3). A heavy silk suture is grasped in the hemostat and it is secured  to the proximal free end of the catheter (figure 4) which is tunneled sub-  cutaneously to the skin exit site leaving the second or superficial Dacron  cuf 1 to 2 cm deep to the skin. T e catheter is anchored to the skin at the  exit site with a 3-0 nonabsorbable monofilament suture placed snuggly  around the catheter without constricting the internal lumen (figure 5).  T e catheter cap adapter and clamp are placed on the exteriorized end of  the catheter (figure 5). Cross-sectional views for the final positions of the  one and two cuf catheters and their securing sutures are shown in the inset  figures 2a,b and 6.T e catheter is flushed with heparinized saline (S00—  1,000 units/cc) to avoid fibrin clot formation within the catheter.    Posto Perat Ive care T e patient is discharged from the operative  facility the day of the procedure. T e catheter anchoring suture at the skin  exit site is removed 2 weeks after the procedure. T e surgical site is allowed  to heal for 2 weeks prior to CAPD catheter use. Premature catheter use  increases the risk of hernia formation and dialysate leakage around the  catheter, potentially precipitating wound infection. T e patient is instructed  in daily exit site care and appropriate catheter use and maintenance. m=    IndIcatlIons _ T is incision is ideal for a wide variety of elective as well as  emergency procedures. T rough the left side, the left lung, heart, descend-  ing aorta, lower esophagus, vagus nerves, and diaphragmatic hiatus are well  exposed, whereas both the vena cavas, the right lung, the superior exposure  of the hepatic veins, and the upper esophagus are approached through the  right chest.   T e height of the incision on the chest wall varies with the nature of  the procedure to obtain optimum exposure of either the apex, the middle,  or the basal portions of the chest cavity. One or more ribs may be divided  posteriorly and occasionally removed, depending on the mobility of the  chest wall and the exposure required. For optimum exposure of the upper  portion of the chest cavity, such as in closure of a patent ductus or resection  of a coarctation, the chest is entered at the level of the fifth rib. T 1s may  be divided posteriorly, along with the fourth rib, if necessary. For proce-  dures on the diaphragm and lower esophagus, the thoracic cavity should  be entered at the level of the sixth or seventh rib. If still wider exposure 1s  desired, one or two ribs above and below may be transected at the neck.    Preo PeratIve PreParatlon Preventative spirometry is preferably  started preoperatively to improve compliance postoperatively. Patients  should be advised not to smoke for several weeks before an elective opera-  tion. Pulmonary functions studies and a room air arterial blood gas analy-  sis should be performed on all patients being considered for thoracotomy.  A further evaluation can be obtained by noting the patient’ tolerance to  climbing stairs. For practical purposes, any patient able to walk up three  flights of stairs will tolerate a thoracotomy. When a patient has borderline  pulmonary function, aggressive preoperative pulmonary rehabilitation  may be appropriate. Because technical dif culties may arise necessitating  more extensive resection than planned, the surgeon must be thoroughly  familiar with the patient’ respiratory reserve.    anestheslIa Prior to undergoing a thoracotomy, all patients should  undergo fibro-optic bronchoscopy at the beginning of the case via a single-  lumen endotracheal tube to remove any secretions, verify the endobron-  chial anatomy, and survey for endobronchial masses. All thoracotomies  require thoracic anesthetic expertise and include the insertion of a tho-  racic epidural for adequate pain control, an arterial line, and the capacity  to perform single lung ventilation. Single lung ventilation can normally be  achieved by way of a double-lumen endotracheal tube appropriately posi-  tioned or an endobronchial blocker. T e position of the double-lumen tube  or the endobronchial blocker must be verified prior to deployment with a  fibro-optic bronchoscope.    PosItIon T e patient is placed in a lateral decubitus position with the  hips secured to the table by wide adhesive tape (figure 1). T e lower leg is  flexed at the knee, and a pillow is placed between it and the upper leg, which  is extended. A rolled sheet or blanket is placed under the axilla, referred to  as an “axillary roll” to support the shoulder and upper thorax. T e arm on    the side of the thoracotomy is extended forward and upward and placed in  a padded grooved arm holder in line with the head, permitting access to  the veins. T e lower arm is extended forward and rested on an arm board  perpendicular to the operating table.    o Perat Ive PreParatlIon T eskin is cleaned with antiseptic, and the  area of incision is either draped with towels or covered with an adhesive  plastic drape, followed by the large sterile thoracotomy sheet.    IncIslon and exPosure (Posterolateral) T e surgeon makes  the incision while standing posterior to the patient, with the first assistant  on the other side of the table across from the surgeon. T e incision begins  midway between the medial border of the scapula and the spine, proceeding  downward parallel to these two structures for the first few inches and then  curving in a gentle S one fingerbreadth below the tip of the scapula, and finally  extending down into or just below the submammary crease, if necessary. In  exposures of the fourth or fifth interspace, the medial end of the incision is  extended transversely toward the sternum. For lower openings of the seventh  or eighth interspace, or ones involving transection of the costal cartilages for  maximum exposure, the medial end of this incision curves gently toward or  into the epigastrium. T e surgeon then carries the incision directly down  through the latissimus dorsi and the serratus anterior muscles (figure 2).  During this process, each of the muscles may be elevated individually by the  surgeon’ index and middle fingers. T is is accomplished by entering the aus-  cultatory triangle formed by the superior border of the latissimus dorsi, the  inferior border of the trapezius, and the medial border of the scapula.   T e incision is extended anteriorly and posteriorly through the borders  of the trapezius and rhomboid muscles. Care must be taken to make this  posterior incision parallel to the spinal column and thus lessen the chance  of dividing the spinal accessory nerve, which innervates the trapezius.  Bleeders are cauterized as they appear. By palpating the widened interspace  between the first and second ribs and the insertion of the posterior scalene  muscle on the first rib, the surgeon may count down to the appropriate rib  level (figure 3). T e pleural space should be entered just over the superior  part of the rib to eliminate the potential for injury to the neurovascular  bundle (figure 4). T e periosteum is incised directly over the midpor-  tion of the rib (figure 4). T e sacrospinalis muscle and fascia are elevated  by a periosteal elevator, and a retractor is inserted in this space. A Coryl-  los periosteal elevator is swept anteriorly along the upper half of the rib  (figure 5). T e Hedblom periosteal elevator is then inserted under the  bared portion of the rib and slipped upward along the rib, stripping the  remaining periosteum from the upper half of the rib in a posterior-to-ante-  rior direction (figure 6). After ensuring that the patient is on single lung  ventilation (1.e., no ventilation to the side being operated upon), a small  incision 1s made entering the pleura (figure 7). T e lung drops away, thus  allowing the incision to be extended for the desired length. A cross section  of this approach is shown beneath figure S.    Trapezius  Adhesive tape Axillary roll Incision Auscultatory  Conductive strap triangle Rhomboid  4 Latissimus dorsi    IncIslon and exPosure (anterolateral) An alter-  native method is direct incision into the intercostal space. T e incision 1s  made through the intercostal muscles along the superior border of the rib.  Simple ligation of these is suf cient. Dissection is carried directly down and  into the pleura. T e incision in the pleura is extended anteriorly and poste-  riorly with cautery. T e internal mammary vessels, which join the intercos-  tals at the sternum, lie medial and deep to the costal cartilages and should  not be injured during this incision (figure 8). If additional exposure 1s  required, a rib may be divided or resected. T e periosteum along the lower  border of the rib is stripped to isolate the neurovascular bundle, which is  grasped between right-angled forceps, ligated, and divided. T e rib is then  transected at the costal cartilage of the neck with rib shears (figure 9). A  self-retaining retractor is inserted (figure 10) and opened gradually.    closure T eclosure of the thoracotomy incision requires stabilization  of the thorax for the entire length of the incision. Encircling no. | absorb-  able sutures (a) are placed and can be tied with or without a rib approxi-  mator to aid in the process (figure lla). If any ribs were transected or  fractured during spreading, sutures (b) must encircle both ribs and immo-  bilize all rib fragments (figure l|lb). Further hemostasis and stabilization  of the transected rib are accomplished by placing a suture (c) through the  sacrospinalis muscle, fixing it to the neck of the transected rib and the rib  above (figure llc). T e chest muscles are approximated using a running  or interrupted absorbable suture as shown in figure 12. Care must be  taken to approximate each of the layers separately—that is, rhomboids and  the serratus anterior above the trapezius and latissimus dorsi. Subcutane-  ous 000 nonabsorbable sutures will prevent disruption of the incision when  the skin staples are removed in 7 or 8 days.   All patients undergoing thoracotomy should have postoperative drain-  age of the pleural space. T e chest tube used must be of adequate size, and  anything less than a 32 French catheter will obstruct with blood clots. It is  often advantageous to have two chest tubes in the postoperative chest—one  lying over the diaphragm muscle in the posterior gutter along the spine  and the other directed anteriorly. T e posterolateral chest tube is brought  out through stab wounds in the skin as low as possible in a posterolateral  position (figure 12). T e chest tubes are to be placed prior to the closure  of the thoracotomy and should ideally be anterior to the midaxillary line  for patient comfort and ease of drainage. Single, untied skin nonabsorbable    sutures may be placed through the stab wound before the tube is inserted  to aid in closing when the chest tubes are withdrawn. In placing the chest  tube, the surgeon first grasps the lower cut edges of the latissimus dorsi  and the serratus anterior, and the assistant retracts them superiorly. T e  surgeon forms a tunnel through the chest wall with Kelly forceps, grasps  the chest tube, and draws it out through the wall. T e catheter serves two  main purposes: to remove escaping air from lung parenchymal injury and  to remove blood or serum. T e chest tubes are usually attached with under-  water seal with or without sutures for as long as there is drainage from the  pleural space or persistence of an air leak (figure 13). Should excessive air  leakage be present, another chest tube is placed in the second or third inter-  space anteriorly at the level of the midclavicular line (figure 13). A smaller  Silastic catheter will suf ce and will be the last chest tube to be removed.  T e catheters allow expansion of the lung with approximation of pleural  surfaces and thus prevent postoperative atelectasis and fluid accumulation  with infection. T e catheters are usually attached to an underwater-seal  device with or without negative suction (figure 14).    Posto PeratIvecare T epreoperative insertion ofa thoracic epidural  should help postoperative pain control. If an epidural is not possible due to  coagulation defects or anesthesia preference, intercostal blocks above and  below the incision using a long-acting local anesthetic can be placed at the  end of surgery. Intercostal blocks combined with the use of a patient-con-  trolled analgesic device are known to provide adequate pain control.   T e patient should be encouraged to cough vigorously and use incentive  spirometry. T e patient should be helped in coughing by supporting his  operative side with a pillow. T e patient should be encouraged to change  positions frequently. Ambulation should be early, and active exercise  should be encouraged.   T e chest tubes are usually removed when they have served their pur-  pose, as evidenced by normal breathing sounds on the operative side and  x-ray films showing complete expansion of the lung and the absence of  air leak and fluid accumulation. T is is usually on the second or third  postoperative day. Persistent air leakage may indicate improper position  of the catheter, leakage around the entrance of the thoracotomy tube,  or large bronchial air leaks. In these circumstances, early bronchoscopy  and radiologic imaging with plain films or computed tomography are  encouraged. m=    IndIcatlIons T is type of approach is ideal for a wide variety of elec-  tive and urgent procedures. T rough this approach, the lung, mediastinum,  pericardium, diaphragm, esophagus, sympathetic chain and chest wall are  well visualized. Over the last decade, minimally invasive surgical tech-  niques have gained widespread acceptance as technological improvements  in imaging systems and instrumentation have occurred. T oracoscopy has  become the procedure of choice for the management of early-stage non—  small-cell lung cancer, posterior and mediastinal masses biopsy or excision,  primary spontaneous pneumothorax, fibropurulent empyema, evacuation  of hemothorax, management of effusive pericardial disease, sympathetic  chain ablation for hyperhidrosis, pleural biopsy, and recurrent pleural effu-  sions. Depending on the indication, thoracoscopy can therefore be used  both as a diagnostic and/or therapeutic intervention. For successful tho-  racoscopy, a sound understanding of surgical anatomy is essential due to  limitation of viewing angles and reduction of tactile sense.    Preo PeratIve PreParatlon T oracoscopy is performed for the  most part in elective, non-emergency situations. T 1s allows for the pulmo-  nary function to be optimized with preoperative incentive spirometry and  smoking cessation. For thoracoscopy to be performed, the patient must be  able to tolerate contralateral single lung ventilation which must be trialed  prior to positioning the patient. Similarly, if the patient is on maximal ven-  tilator support prior to the operation, it is unlikely that thoracoscopy will be  well tolerated by the patient. A history of previous chest surgery including  pleurodesis or empyema must be ascertained.    anestheslIa Prior to undergoing thoracoscopy, the patient should have  bronchoscopy performed through a single-lumen tube. T is will eliminate  secretions, ensure normal anatomy, rule out endobronchial pathology, and  ultimately facilitate the insertion of the double-lumen endotracheal tube by  the anesthesiologist. Although thoracoscopic procedures are reported to be  less painful, a thoracic epidural should be offered to the patient prior to the  procedure and arterial blood pressure monitoring should be placed prior  to induction. A double-lumen endotracheal tube is ideal for securing sin-  gle lung ventilation, although an endobronchial blocker through a single-  lumen endotracheal tube is a possible alternative. Prior to positioning the  patient for thoracoscopy, the anesthesiologist should verify the position of  the double-lumen tube or the endobronchial blocker and secure it well so  it does not migrate during positioning. A trial of contralateral single lung  ventilation should be attempted prior to positioning the patient. Relative  contraindications to thoracoscopy include the presence of dense pleural  adhesions or pleural symphysis as well as large intrathoracic tumors and  hilar granulomatous disease that would preclude adequate visualization of  the hilar vascular structures.    PoslItIon T e patient is placed in a lateral decubitus position, facilitated  by a bean bag on the operating room bed, with the hips secured to the table.  T etable is flexed so to expand the intercostal spaces. T e lower leg is flexed  at the knee and a pillow is placed between it and the upper leg which is  extended. An axillary roll is placed under the axilla to protect the patient’  upper thorax and brachial plexus. T e patient’ head may need to be sup-  ported by additional blankets af er the flexing of the table. T e arm, on the  side of the operation, is extended forward and 90 degrees to the body and  placed on two pillows or a grooved arm board (figure |).    o Perat Ive PreParatlIon Prior to the operation, the appropriate surgi-  cal equipment must be assured for thoracoscopy. T e equipment consists of  both imaging systems and thoracoscopic instrumentation. Imaging systems  consist of a video thoracoscope, processor, and imaging tower with screen.  Zero- and 30-degree optical angulation scopes are most popular and appli-  cable. T e scopes can also be either 5 or 10 mm in diameter, with the smaller  scope being for diagnostic as compared to therapeutic interventions. T e  basic set of thoracoscopic instruments includes an atraumatic lung grasper,    scissors, blunt dissection, and forceps. T e skin is cleaned with antiseptic  and the area of the incisions is draped with adhesive plastic drape and a  large sterile thoracotomy sheet. T e video monitors with screens should be  positioned on either side of the patient near the head of the bed.    IncIslon and exPosure For thoracoscopy procedures, the surgeon  stands anterior to the patient and the assistant stands next to the surgeon  (figure l). T e assistant needs to be facing and operating in the same  direction as the surgeon, thus avoiding mirror imaging. T e placement of  what is referred to as “ports” is critical, with the placement of the camera  being most critical. When properly placed, the camera has a 180-degree  viewing angle of the region of interest. T e camera is usually positioned  over the seventh rib, in the midaxillary line, afer making a I-cm inci-  sion that is slightly tunneled and entering directly into the pleural space  (figure 2). Once the camera 1s positioned, the other port sites can be  placed under direct visualization. T e additional port sites should be within  the 180-degree viewing angle of the camera. T e additional ports are placed  at different levels from the thoracoscope so to allow for triangulation of the  instruments. Depending on the complexity of the thoracoscopic procedure,  one, two, or three more ports may be positioned and placed.    detalls of the Procedure T eplacement of the thoracoscope is the  first part of the procedure. T e patient is placed on single lung ventilation.  A small incision is made over the seventh rib that is approximately | cm in  size (figure 2). Local anesthetic can be instilled prior to incision, particu-  larly if a thoracic epidural has not been placed. A small amount of tunnel-  ing is advised. T is incision 1s carried down through the intercostal muscle  using cautery and the pleura is entered under direct visualization. Once the  chest cavity is entered, a finger should be gently placed to ensure that there  are no dense adhesions that would prevent safe introduction of the port. If  all clear, the port 1s placed then the camera is inserted. T e camera is used  to complete a surveillance of the entire chest so that an overall apprecia-  tion of the chest cavity is gained. Using the camera, the additional ports  can be placed under direct visualization. T ese additional ports should cre-  ate a triangle with the camera and be within the 180-degree viewing angle  (figur e 3). Care should be taken to place the ports or instruments on top of  the rib to avoid the intercostal vessels that course on the inferior portion of  the rib. T eir exact position will be dependent on the nature of the clinical  problem, body habitus, and intrathoracic pathology. In general, a second  port for instrumentation is placed over the sixth rib anteriorly and a third  port is placed over the fourth rib anteriorly or posteriorly relative to the  clinical scenario. figure 2 illustrates port placement over the fourth and  eighth ribs. Biopsies of superficial lesions may be obtained with a biopsy  forceps or the lesion may be excised with a portion of lung using a linear  stapler. At the completion of the surgical procedure, all operative sites must  be visualized for hemostasis. In addition, all ports must be directly visual-  ized so to ensure hemostasis prior to completion of the procedure. A single  32 French chest tube is placed through one of the ports and positioned to  the apex under visualization (figure 4). Concepts that must be remem-  bered to minimize complications include: extraction of all tissue containing  potential malignancy in a protected specimen bag, avoidance of instrument  leveraging and large diameter instruments so to lessen intercostal nerve  pressure, and a well-delineated preconceived plan for addressing potential  vessel injury and bleeding.    Posto Perat Ive care Most patients have a single chest tube placed  at the completion of the thoracoscopy. T is can of en be removed within  24 hours when the pleural drainage 1s less than 300 mL. T e incision sites  are all small and are closed primarily, so wound care is minimal. Pain  management is usually achieved with oral agents. Once the chest tube 1s  removed and the patient is discharged, the patient can normally return to  normal activities within 2 weeks. m    IndIcatlIons Gastrostomy is commonly utilized as a temporary proce-  dure to avoid the discomfort of prolonged nasogastric suction following such  major abdominal procedures as vagotomy and subtotal gastrectomy, colec-  tomy, and so forth. T is procedure should be considered during abdominal  operation in those poor-risk or elderly patients prone to pulmonary difficul-  ties or where postoperative nutritional difficulties are anticipated.   Gastrostomy is considered in the presence of obstruction of the esopha-  gus, but it is most frequently employed as a palliative procedure in nonre-  sectable lesions of the esophagus or as the preliminary step in treating the  cause of the obstruction. A permanent type of gastrostomy may be consid-  ered for feeding purposes in the presence of almost complete obstruction  of the esophagus due to nonresectable malignancy. T e type of gastrostomy  depends upon whether the opening is to be temporary or permanent.   As a temporary gastrostomy, the Witzel or the Stamm procedure is used  frequently and is easily performed. A permanent type of gastrostomy, such  as the Janeway and its variations, is best adapted to patients in whom it  is essential to have an opening into the stomach for a prolonged period  of time. Under these circumstances, the gastric mucosa must be anchored  to the skin to ensure long-term patency of the opening. Furthermore, the  construction of a mucosa-lined tube with valve-like control at the gastric  end tends to prevent the regurgitation of the irritating gastric contents. T 1s  allows periodic intubation and frees the patient from the irritation of a con-  stant indwelling tube.    Preo Perat Ive PreParatlIon If the patient is dehydrated, fluid bal-  ance is brought to a satisfactory level by the intravenous administration of  5% dextrose in saline. Since these patients may be malnourished, parenteral  nutrition may be warranted. Blood transfusion should be given if there is  evidence of symptomatic, physiologically significant secondary anemia or  for a hemoglobin < 7 g/dL. No special preparation is required for the tem-  porary gastrostomy since this is usually performed as a minor part of a  primary surgical procedure.    anesthesIa Since some patients requiring a permanent gastrostomy are  both anemic and cachectic, local infiltration or field block anesthesia is usu-  ally advisable. T ere is no special indication in anesthesia for a temporary  gastrostomy, since this is usually a minor technical procedure that precedes  the closure of the wound of a major operation.    PoslItIon T e patient lies in a comfortable supine position with the feet  lower than the head, so that the contracted stomach tends to drop below  the costal margin.    IncIslon and exPosure A small incision is made high in the left  mid-rectus region, and the muscle is split with as little injury to the nerve  supply as possible, if the gastrostomy is the lone surgical procedure planned  (figure l). T e high position is indicated since the stomach may be con-  tracted because of the long-term starvation that the patient may have expe-  rienced. T e usual temporary tube gastrostomy is brought out through a  stab wound some distance from the primary incision and away from the  costal margin. T e site of the stab wound must correspond exactly to the  area of the abdominal wall to which the underlying stomach can be attached  without tension (figure 1).    T is type of gastrostomy is most commonly utilized as a temporary pro-  cedure. T e mid anterior gastric wall is grasped with a Babcock forceps,  and the ease with which the gastric wall approximates the overlying peri-  toneum is tested. A purse-string suture using 00 nonabsorbable suture is  placed in the mid anterior wall of the stomach (figure 2). An incision  is made in the central portion of the purse string at right angles to the  long axis of the stomach is made in an ef ort to minimize the number of  arterial bleeders. T e incision with electrocautery, scissors, or a knife. A  mushroom catheter of average size, 18 to 22 French, is introduced into  the stomach for a distance of 10 to 15 cm. A Foley-type catheter also  may be used. T e purse-string suture is tied (figure 3). T e gastric wall  about the tube is then inverted by a second purse-string suture of 00  nonabsorbable suture (figure 3) or with interrupted Lembert’s stitches  (00 nonabsorbable suture). T e gastric wall should be inverted about the    tube to ensure rapid closure of the gastric opening when the catheter is  removed (figure 6).   A point is then selected some distance from the margins of the opera-  tive incision and the costal margin for the placement of the stab wound  and subsequent passage of the tube through the anterior abdominal wall  (figure 4). T e position of the catheter end should be checked to make cer-  tain that a sufficient amount extends into the gastric lumen to ensure efficient  gastric drainage. T e gastric wall is then anchored to the peritoneum about the  tube (figure 5) by four or five 00 nonabsorbable sutures. Occasionally, addi-  tional sutures are necessary. T e gastric wall must not be under undue tension  at the completion of the procedure. T e cross-sectional diagram in (figure 6)  shows the inversion of the gastric wall about the tube and the sealing of the gas-  tric wall to the overlying peritoneum. T e gastrostomy tube 1s snugged upward  and then secured to the abdominal skin with a nonabsorbable suture.    T is procedure is one of the many types of permanent gastrostomies utilized  to avoid an inlying tube and prevent the regurgitation of irritant gastric  contents. Such a mucosa-lined tube anchored to the skin tends to remain  patent with a minimal tendency toward closure of the mucosal opening.    detalls of Procedure T e operator visualizes the relation of the  stomach to the anterior abdominal wall and then with Allis forceps outlines  a rectangular flap, the base of which is placed near the greater curvature to  ensure an adequate blood supply (figure 7). Because the flap, when cut,  contracts, it is made somewhat larger than would appear to be necessary to  avoid subsequent interference with its blood supply when the flap is approxi-  mated about the catheter. T e gastric wall is divided between the Allis clamps  near the lesser curvature, and a rectangular flap is developed by extending  the incision on either side toward the Allis clamps on the greater curvature.  To prevent soiling from the gastric contents and to control bleeding, long,  straight enterostomy clamps may be applied to the stomach both above and  below the operative site. T e flap of gastric wall is pulled downward, and the  catheter is placed along the inner surface of the flap (figure 8). T e mucous  membrane is closed with a continuous suture or interrupted 0000 nonab-  sorbable sutures (figure 9). T e outer layer, which includes the serosa and  submucosa, is also closed either with continuous absorbable sutures or, pref-  erably, by a series of interrupted nonabsorbable sutures (figure 10). When  this cone-shaped entrance to the stomach has been completed about the  catheter, the anterior gastric wall is attached to the peritoneum at the suture  line with additional nonabsorbable 00 sutures (figure 11). A gastric tube  can be constructed with a stapling instrument.    closure After the pouch of gastric wall is lifted to the skin surface, the  peritoneum is closed about the catheter. T e catheter may be brought out  through a small stab wound to the left of the major incision. T e layers of  the abdominal wall are closed about this, and the mucosa is anchored to  the skin with a few sutures (figure 12). Catheters are anchored to the skin  with strips of adhesive tape in addition to a suture that has included a bite  in the catheter.    Posto PeratIve care When the temporary Stamm type of gastros-  tomy is used in lieu of prolonged nasogastric suction, the usual principles  of gastric decompression and fluid replacement are adhered to. Usually, the  tube is clamped of as soon as normal bowel function returns. T e tempo-  rary gastrostomy provides an invaluable method of fluid and nutritional  replacement; compared to the more tedious and less-efficient intravenous  route, it is the method of choice, especially in the elderly patient.   T e temporary gastrostomy should not be removed for at least 14 to  28 days to ensure adequate peritoneal sealing. In addition, it should not be  removed until alimentary function has returned to normal and all postop-  erative gastric secretory studies have been completed.   When a permanent gastrostomy is done because of esophageal obstruc-  tion, liquids such as water and milk may be injected safely into the cath-  eter within 24 hours, while parenteral nutrition continues. Liquids of a  high-calorie and high-vitamin value are added gradually, beginning with  small volumes that are diluted so as to minimize osmotic changes or diar-  rhea. After a week or more, the catheter may be removed and cleaned, but  it should be replaced immediately because of the tendency toward overly  rapid closure of the sinus tract in the Janeway type of gastrostomy. m    IndIcatlIons T eusual indications for gastrostomy include the need for  feeding, decompression, or gastric access. In feeding situations, the gastroin-  testinal tract must be functional and the need for enteral feeding must be for  a prolonged interval. Stamm gastrostomies are most commonly performed  at the conclusion of some other major gastrointestinal procedure while the  abdomen is open, however the percutaneous endoscopic gastrostomy (PEG)  allows the placement of a gastrostomy in adults and children without lapa-  rotomy. T is technique depends upon the safe passage of an endoscope into  the stomach, which can be dilated with air. Inability to pass the endoscope  safely and inability to identify the transabdominal lumination of the lighted  endoscope tip within the dilated stomach are contraindications to the proce-  dure. Ascites, partially corrected coagulopathy, and intra-abdominal infec-  tion are relative contraindications to the PEG method.    Preo PeratIve PreParatlon T e indications for the gastrostomy  dictate the extent and type of preoperative preparation. Passage of a naso-  gastric tube for gastric decompression is usually not needed if the patient  has been nothing by mouth (NPO) for several hours. A single dose of intra-  venous antibiotic may be given within lhour prior to the procedure because  the peroral passage of the special catheter may contaminate the abdominal  wall tract created as the catheter is brought out through the stomach.    anestheslIa A topical anesthesia for the oropharynx is needed for pas-  sage of the endoscope, and local anesthesia is used at the abdominal site  where the special catheter will be placed. An intravenous needle or catheter  is positioned for administration of sedatives.    PosItlIon T e patient is usually supine while the topical anesthetic is  sprayed into the oropharynx. He or she is allowed to gargle, swallow, or spit  into a basin. After satisfactory anesthesia is obtained, the patient is posi-  tioned supine on the table with the head slightly elevated.    o Perat Ive PreParatlon In adults as well as children, the smallest  possible gastroscope is used. After the endoscope is passed safely into the  stomach, the skin of the abdomen and lower chest is prepared with antisep-  tic solutions in the usual manner. Sterile drapes are applied.    detalls of Procedure During the placement of the gastroscope, any  pathology may be evaluated. T e stomach 1s fully inflated with air. T 1s dis-  places the colon inferiorly and places the anterior gastric wall against the    abdominal wall over a large area. A suitable zone is selected and the endos-  copist places the lighted gastroscope end firmly upward at this point. T is  is usually halfway between the costal margin and the umbilicus (figure 1).  T e room lights are dimmed and the transilluminated site is identified.  In very thin patients, the tip of the endoscope may be palpated. T e area  of transillumination is marked for incision (figure 1). T e endoscope is  backed away from the anterior gastric wall, and the appropriateness of the  site 1s verified as external palpation with a finger indents the chosen area.   Local anesthesia is injected and a l-cm skin incision is made. T e  endoscopist visualizes the site as a 16-gauge smoothly tapered intravenous  cannula/needle is introduced through the incision and abdominal and gas-  tric walls and into the lumen of the stomach. T is sequence should be done  quickly so as to minimize the chance for displacement of the stomach away  from the abdominal wall and peritoneum.   A guide wire 1s passed through the hollow outer cannula after the stif -  ening inner needle has been withdrawn. T e wire is grasped with a polyp-  ectomy snare passed through the endoscope and then all are withdrawn  through the patientS mouth (figure 2). T e PEG catheter (figure 3) 1s  secured to the wire. T e catheter has a tapered end. T e long wire and the  catheter assembly are covered with a sterile water-soluble lubricant. Gentle,  steady traction on the abdominal end of the long suture pulls the tapered  end of the assembly down the esophagus and then through the gastric and  abdominal wall (figure 4).   T e endoscope is reintroduced and the positioning of the intragastric  end of the catheter is verified. An external crosspiece (figure 5) or collar  is applied, and a nonabsorbable suture is used to secure the catheter and  crosspiece to the skin without pressure or tension that might cause necrosis  of the skin or gastric wall. T e small skin incision is left open, and topical  antiseptic may be applied.    Posto Perat Ive care T e gastrostomy catheter is opened for decom-  pression and gravity drainage for a day. T ereafter, feedings may start in  a sequential manner. T e catheter may be changed in a periodic manner  or may be converted to a silastic prosthesis (button) after 4 weeks or more  when the gastrostomy incision has solidly healed and the stomach has fused  to the anterior abdominal wall. T is prosthesis is stretched and thinned  over an obturator (figure 6) and inserted into the open gastrostomy tract  (figure 7). =    IndIcat Ions Perforation of an ulcer of the stomach or duodenum 1s a sur-  gical emergency; however, before performing the operation, sufficient time  should be allowed for the patient to recover from the initial shock (rarely  severe or prolonged) and for the restoration of the fluid balance. T e choice  for closure of the perforation versus a definitive ulcer procedure depends upon  the overall assessment of risk factors by the surgeon. Laparoscopic exploration  with or without definitive repair is often preferred especially in the setting of  anterior perforation of the duodenum with a plan for simple closure.    Preo PeratIve PreParatlon A narcotic is used to control pain only  after the diagnosis is established. T e intravenous administration of appro-  priate type and volume of fluid is necessary, depending upon the patient’  general condition and the length of time that has elapsed since perforation.  T e parenteral administration of antibiotics and the institution of constant  gastric suction are routine.    PoslItlIon T e patient is placed in a comfortable supine position with the  feet slightly lower than the head to assist in bringing the field below the  costal margin and to keep gastric leakage away from the subphrenic area.    IncIslon and exPosure Since the majority of perforations occur in the  anterior-superior surface of the first portion of the duodenum, a small, high,  midline is made. A culture of the peritoneal fluid is taken, and as much exu-  date as possible is removed by suction. T e liver is held upward with retrac-  tors, exposing the most frequent sites of perforation. T e site may be walled  of with omentum ifthe perforation has been present several hours; therefore,  care is exercised in approaching the perforation to avoid unnecessary soiling.    detalls of Procedure T ce easiest method of closure consists of plac-  ing three sutures of fine silk through the submucosal layer on one side with  extension through the region of the ulcer and then out a corresponding dis-  tance on the other side of the ulcer (figur e 1). Starting at the top of the ulcer,  the sutures are tied very gently to prevent laceration of the friable tissues. T e  long ends are retained (figure 2). T e closure is reinforced with omentum  by separating the long ends of the three previously tied sutures and placing  a small portion of omentum along the suture line. T e ends of these sutures  are loosely tied, anchoring the omentum over the site of the ulcer (figur e 3).   T e tissue may be so indurated that the ulcer cannot be closed success-  fully, making it necessary to seal the perforation by anchoring omentum  directly over the ulcer.   In the presence of a perforated gastric ulcer, the area surrounding the  ulcer can be completely excised often with a stapler and sent for frozen sec-  tion to exclude malignancy. T is is determined by the site of ulcer perfora-  tion. Alternatively, a small biopsy of the margin of the perforation is taken  because of the possibility of malignancy (figur es 4 and 5). T e omentum  may be anchored over the suture line (figure 6). Closure of a gastric ulcer  may be reinforced with a layer of interrupted silk serosal sutures since there  is little danger of obstruction.   In the presence of perforation of an obvious carcinoma, resection is pre-  ferred; however, in cases of high operative risk or metastatic disease requir-  ing palliation, it may be acceptable to close the perforation, to be followed  by resection upon recovery. If the patient’ general condition is good and  the perforation has lasted only a few hours, a gastric resection may be justi-  fied. Vagotomy and pyloroplasty or antrectomy for an early perforated duo-  denal ulcer in a good-risk patient is preferred by some surgeons.    closure All exudate and fluid are removed by suction. Repeated irriga-  tion of the peritoneal cavity with saline should be considered when there is  gross contamination by food particles. T e wound is closed without drain-  age. A temporary Stamm gastrostomy (Chapter 17) can be considered since  prolonged obstruction of the pylorus may occur.    Posto PeratlIve care T e patient, when conscious, is placed in  Fowler’ position. Nasogastric suction can be employed for the first 24 hours  or as needed. T e fluid balance is maintained by intravenous infusions.  Antibiotics are continued. Proton pump inhibitors should be given IV until  PO intake is started. Consideration should be given to eradicate Helicobacter  pylori as well. Simple closure of the perforation has not cured the patient’    ulcer or the patient’ tendency to form another. It must be remembered that  a subphrenic or a pelvic abscess may complicate the postoperative period.    IndIcatlIons T emost common origins of a subphrenic abscess are perfo-  ration of a peptic ulcer, perforation of the appendix, or acute infection of the  gallbladder. It is to be suspected in an unsatisfactory recovery from any of these  conditions. Intensive antibiotic therapy may mask the systemic reaction to the  infection. Chest radiographs may show a pleural ef usion and ultrasound or  computed tomographic (CT) scans should be diagnostic. In addition, the CT  scan may guide a fine-needle aspiration for culture or the placement of a cath-  eter for drainage, if the pus is thin and the cavity is unilocular. It is rare that a  surgical procedure is necessary and percutaneous transperitoneal drainage is  acceptable. In some situations surgical drainage can be undertaken.    Preo Perat Ive PreParatlon T e clinical data combined with radio-  logic studies usually indicate the location of the abscess. T e location and  extent of the abscess often can be defined by CT, which may also be used  to guide needle aspiration or catheter drainage. Subphrenic abscesses occur  much more frequently on the right side. Antibiotics, blood transfusions, and  intravenous fluids are usually necessary because of the prolonged sepsis.    anesthesIa Local anesthesia by direct infiltration of the site of the inci-  sion is preferable for the poor-risk patient. Spinal or inhalation anesthesia  also may be used, depending upon the patient’ general condition.    PosItlIon For an anterior abscess, the patient is placed supine with the  head of the table elevated. For a posterior abscess, the patient is placed on  the side with the arm on the af ected side pulled forward.    IncIslon and exPosure T eé incision is placed one fingerbreadth  below the costal margin and extended from the mid-rectus region laterally  (figure 7). T e free peritoneal cavity is not opened.    IncIslon and exPosure T esecan most often be drained with image-  guided percutaneous approach. It may be desirable to drain the subphrenic  abscess by the extraperitoneal route without rib resection whenever pos-  sible. On occasion, it may be desirable to approach the abscess through the  bed of the 12th rib (figure 9, Incision A). T e entire 12th rib is resected.  T e erector spinae are retracted toward the midline, and a deep transverse  incision is made at right angles to the vertebrae across the periosteal bed of  the resected rib, opposite the transverse process of the first lumbar vertebra  (figure 9, Incision B).    detalls of Procedure Intraoperative ultrasound can be used to  localize the abscess. T e location of the abscess cavity is approached by  the index finger of the surgeon, who separates the peritoneum from the  undersurface of the diaphragm, thus ensuring dependent drainage without  contamination of the peritoneal cavities (figure 10). Once pus has been  obtained, the abscess cavity can be entered and thoroughly evacuated, and  rubber tissue drains or mushroom catheters can be inserted. Several cul-  tures are taken routinely, and the sensitivity of the of ending organism is  determined. Some organisms, such as Staphylococcus, require isolating the  patient to prevent spread of the organism to others.    closure Drains are inserted into the abscess cavity in numbers indi-  cated by the size of the abscess. T ere is no further closure.    Posto PeratlIve care T e abscess cavity is carefully irrigated with  normal saline each day, and the capacity of the cavity measured from time  to time. T e external opening 1s maintained, and the drains or tubes are  removed sequentially as the cavity is obliterated. Vigorous pulmonary and  nutritional support is given, and antibiotics are continued until sepsis is over.   If the chest is entered, closure of the opening with placement of a tempo-  rary chest tube is usually necessary. m    IndIcatlIons Gastrojeyunostomy is indicated for certain patients with  duodenal ulcer complicated by pyloric obstruction. It 1s indicated also if  technical difficulties prevent resection or make resection hazardous; if the  patient is such a poor operative risk that only the safest surgical procedure  should be carried out; or if a vagus nerve resection has been performed. It  is occasionally indicated for the relief of pyloric obstruction in the presence  of nonresectable malignancies of the stomach, duodenum, or head of the  pancreas.    Preo Perat Ive PreParatlIon T e preoperative preparation must be  varied, depending upon the duration and severity of the pyloric obstruc-  tion, the degree of secondary anemia, and the protein depletion. Obviously,  electrolyte replacement and fluid resuscitation should be completed. Naso-  gastric suction should be implemented to allow an empty stomach where  complete obstruction has occurred and to prevent aspiration with induc-  tion of anesthesia. Preoperative antibiotics should be given. Laparoscopy  in these high-risk patients should be considered or at least a laparoscopic-  assisted procedure allowing identification of the proximal jejunum and an  extracorporeal anastomosis.    anestheslIa General anesthesia combined with endotracheal intuba-  tion is usually satisfactory.    PosItlIon T e patient is placed in a comfortable supine position with the  feet at least a foot lower than the head. In patients with an unusually high  stomach, a more upright position may be of assistance. T e optimum posi-  tion can be obtained after the abdomen is opened and the exact location of  the stomach is determined.    IncIslonandexPosure Asarule, midline epigastric incision 1s made.  T e incision is extended upward to the xiphoid or to the costal margin and  downward to the umbilicus. With the abdomen opened, a self-retaining  retractor may be utilized; but since most of the structures involved in this  operation are mobile, it is usually unnecessary to use any great amount of  traction for adequate exposure.    detalls of Procedure T e stomach and duodenum are visualized  and palpated to determine the type and extent of the pathologic lesion  present. A short loop of jesunum is utilized for gastrojeyunostomy, with the  proximal portion anchored to the lesser curvature. T e stoma is made on  the posterior gastric wall and extends from the lesser to the greater curva-  ture, about two fingers in length. It 1s located at the most dependent part of  the stomach (figure la).    When the gastroenterostomy is performed with vagotomy in the treat-  ment of duodenal ulcer, the location and size of the stoma are very impor-  tant. In order to ensure adequate drainage of the paralyzed antrum and  keep postoperative side ef ects to a minimum, a small stoma parallel to  the greater curvature and near the pylorus is indicated (figure lb). T e  jeyunum should be anchored for several centimeters to the gastric wall on  either side of the stoma. T is permits circular uncut muscles going away  from the stoma to contract and improve gastric emptying. Special ef ort is  required as arule to ensure placement of the stoma within 3 to 5cm of the  pylorus because of the inflammation and fixation of the pylorus associated  with duodenal ulceration. Accordingly, it may be impractical to perform an  anastomosis on the greater curvature as shown in figure Ib.   T elocation ofthe stoma is first outlined on the anterior gastric wall with  Babcock forceps. T e greater omentum may be brought outside the wound  so that the contour of the stomach is not distorted, and the most depen-  dent portion of the greater curvature may be more accurately determined  (figure 2). T e Babcock forceps are left in place as the greater omentum is  reflected upward over the stomach and the inferior aspect of the mesocolon  is visualized (figure 3). T e transverse colon is held firmly by an assistant  as the surgeon invaginates the Babcock forceps on the anterior gastric wall.  T is produces a bulge in the mesentery of the colon at the point through  which the stomach is to be drawn (figure 3). T e mesocolon is carefully  incised to the left of the middle colic vessels and near the ligament of Treitz,  great care being taken to avoid any of the large vessels in the arcade. Four to  six guide sutures (sutures a, b, c, d, e, and f) are placed in the margins of the  incised mesocolon to be utilized after the anastomosis to the stomach at the  proper level. T e presenting posterior wall of the stomach is grasped with a  Babcock forceps (figure 4a and b) adjacent to the lesser and greater curva-  tures, and opposite the points of counter pressure from the similarly placed  forceps on the anterior gastric wall (figure 4). A portion of the gastric wall  is pulled through the opening. In many instances, the inflammatory reac-  tion associated with the duodenal ulcer may anchor the posterior surface  of the antrum to the capsule of the pancreas. Sharp and blunt dissection  may be required to mobilize the stomach in order to ensure placement of  the stoma sufficiently near the pylorus. Some surgeons prefer to anchor the  mesocolon to the stomach at this time. T e forceps on the greater curvature  is swung toward the operator on the patient’ right side, while the forceps  on the lesser curvature is rotated to a position opposite the first assistant.   T e ligament of Treitz is identified, and a loop of jejunum 10 to 15cm dis-  tal to this fixed point is delivered into the wound. T e jejunum at this point is  held with Babcock forceps and stay sutures placed (figure 5). T e orienta-  tion of the bowel is shown in figure 6. T e technique of the anastomosis is  shown in the continuing figures 7 through 22 of this Chapter.    detalls of Procedure T e large intestine and omen-  tum are returned within the abdomen above the stomach. T e clamps and  the anastomotic site usually can be delivered outside the peritoneal cavity,  which should be entirely protected with gauze. Retraction on the edges of the  abdominal wound is discontinued while the anastomosis 1s being performed.  T is mobilization is usually impossible when the stoma must be made within  3 to 5 cm of the pylorus following vagotomy. Under these circumstances,  the anastomosis must be made within the peritoneal cavity, lest the stoma  be made too far to the left, with recurrent ulcer difficulties due to hormone  stimulation from the distended antrum inducing gastric hypersecretion.   Stay sutures are placed to facilitate exposure. Scudder clamps, which are  nontraumatic, may be placed on the af erent and ef erent limbs to prevent  to minimize contamination. T e posterior serosal sutures are now begun  by placing a mattress suture of 000 silk at either angle (figure 7). T e sur-  geon depresses the presenting portions of the stomach and jejunum with  the index and middle fingers as the posterior row of interrupted mattress  sutures in the serosa (figure 8). Alternate bites of jepunum and stomach  are taken; these include the submucosa but do not enter the lumen of the  bowel. Each suture is taken close to the preceding one to ensure a complete  closure. It is best to tie them after all have been placed.   An incision is made in the stomach. T e serosal incision may be made  with a knife (figure 9) but the majority of surgeons use electrocautery.  If this incision is too far from the serosal layer, too large a cuf of inverted  bowel may result. In making these incisions, the operator should be careful  to cut the bowel wall perpendicular to its surface, since there is always a  tendency to incise the intestine obliquely, thereby leaving an irregular and  unequalized mucosal layer for the next suture line (figure 10). T e inci-  sion in the jeysunum is made slightly shorter than that made in the stomach  (figure Il). With the stomach and intestine opened and cleaned, a continu-  ous absorbable suture is started in the midportion of the posterior mucosal  layers (figure 12). Swedged on curved needles are most commonly used.  As the operator sews away from himself or herself, he or she uses a simple  over-and-over suture or a lock stitch, which pulls together the mucosal lay-  ers (figure 13). Since this suture is also used to control the blood supply, it  must be kept under a tension sufficient for accurate approximation and pre-  vention of hemorrhage, yet not completely strangulating the blood supply  and hindering healing. T 1s 1s a critical step. Interrupted sutures are placed  to secure any bleeding points that have not been controlled by the continu-  ous suture. When the operator reaches the angle of the wound, a Connell  suture, which allows inversion of the structures as they are sewn, is substi-  tuted (figure 14). In figure 14, for example, the needle has just entered  the gastric side. It comes out on the gastric side 2 or 3mm from its point of  entrance (figure 15). It is then crossed over, inserted through the jejunal  wall from outside as in figure 16, and comes back out through the jejunal    wall before being reinserted through the gastric wall (figur e 17). After this  angle has been closed, the other end, B, of the continuous suture is used to  close the opposite angle in a similar fashion (figure 18). T e continuous  sutures, A and B, finally meet along the anterior surface. T e final bite of  each suture brings it to the inner wall of the stomach and jejunum (figure 19).  T e two ends are tied together with the final knot on the inside. If slight  oozing persists, additional interrupted sutures may be taken to supplement  the anterior mucosal layer.   Approximation of the anterior serosal layer is carried out with inter-  rupted OO0Osilk sutures (figure 20). T ese are placed approximately 6 to  8 mm apart. Additional interrupted sutures of fine silk are placed at the  angles of the anastomosis for reinforcement so that any strain at this point  avoids the original suture line (figure 21). T e patency and size of the  stoma should be determined by palpation. A secure anastomosis is desir-  able with a stoma approximately the size of the end of the thumb or two  fingers.   T e stomach is anchored to the mesocolon, with sutures b, c, and d  (figure 21) adjacent to the anastomosis in order to close the opening and  thus prevent a potential internal hernia. T is also prevents any torsion of  the jejunum near the anastomosis, which might result if the stoma retracts  above the mesocolon (figure 22).   Occasionally, in the presence of extensive inflammation about the pylo-  rus, marked obesity, or extensive malignancy, it may be impossible to mobi-  lize the posterior gastric wall sufficiently for an anastomosis that allows  adequate drainage of the antrum. Under these circumstances, anterior  gastrostomy or enterostomy should be considered following vagotomy to  ensure adequate drainage of the antrum or proximal drainage of an inoper-  able gastric malignancy. In order to avoid the possibility of poor emptying  following anterior gastrojejunostomy, the thick omentum should be divided  to permit the upper jejunum to be easily brought up over the transverse  colon. Some prefer to clear the greater curvature near the pylorus for 5 to  8 cm and place the gastrojejunal stoma in this area. T e antecolic ef erent  jejunal loop should be anchored to the anterior gastric wall for approximately  3cm beyond the anastomosis to provide uncut circular muscle contractions  to assist in gastric emptying. A Stamm-type gastrostomy should be consid-  ered to ensure patient comfort and provide an efficient and readily available  method of gastric decompression until gastric emptying is satisfactory.    Posto PeratIvecare T euse of fluids, glucose, vitamins, and paren-  teral alimentation depends upon daily clinical and laboratory evaluation.  Water in sips is given within 24 hours, and the fluid and food intake is  increased gradually thereafter. Stx small feedings per day are gradually  replaced by a full diet as tolerated. m    IndIcatlIons T ese procedures may be used when the vagus innervation  of the stomach has been interrupted either by truncal vagotomy, selective  vagotomy, or division of the vagus nerves associated with esophagogastric  resection and re-establishment of esophagogastric continuity. T e pylo-  roplasty ensures drainage of the gastric antrum following vagotomy and,  therefore, partially eliminates the antral phase of gastric secretion. It does  not alter the continuity of the gastrointestinal tract and decreases the pos-  sibility of marginal ulceration occasionally seen after gastrojeyunostomy.  Pyloroplasty carries a low surgical morbidity and mortality rate because of  its technical simplicity. Two types of pyloroplasty are commonly used: the  Heineke—Mikulicz pyloroplasty (figure a) and the Finney pyloroplasty  (figure b). Pyloroplasty should be avoided in the presence of a marked  inflammatory reaction or severe scarring and deformity on the duodenal  side of the gastric outlet. Under these circumstances, the Jaboulay pro-  cedure (figure c) should be considered or a gastroenterostomy located  within 3 cm of the pylorus on the greater curvature. Gastrin levels should  be determined. T e Jaboulay reconstruction should be considered when  a long incision is made in the anterior wall of the duodenum during the  search for very small mucosal gastrinomas.    He Ineke—Mikul Icz PyloroPlasty T epylorusis identified with the  pyloric vein as the landmark. A Kocher maneuver (Chapter 26, page 83) is  then carried out to mobilize the duodenum for good exposure and relaxation  of tension on the subsequent transverse suture line. Traction sutures of 00  silk are placed and tied at the superior and inferior margins of the pyloric  ring for anatomic orientation. Ef orts should be made to include the pyloric  vein in these sutures in order to partially control the subsequent bleeding.  A longitudinal incision is made approximately 2 to 3cm on each side of the  pyloric ring through all layers of the anterior wall (figur e 1). In the presence  of marked deformity, it may be advisable to incise the midportion of the duo-  denum and then, with a hemostat directed up through the constricted pyloric  canal as a guide, make the incision in the midportion of the pylorus, across  the midportion of the anterior duodenal wall, and across the midpoint of the  pyloric wall into the gastric side. Bleeding 1s controlled with electrocautery.   Traction on the angle sutures draws the longitudinal incision apart until  it becomes first diamond shaped (figure 1) and then transverse (figure 2).  Active bleeders tend to occur in the divided duodenal wall and in the  region of the divided pyloric sphincter. Inverting sutures of interrupted silk  are passed through all layers to approximate the mucosa. Some prefer a  one-layer closure (figure 2) in order to minimize the encroachment on the  pyloric lumen resulting from the inversion that follows a two-layer closure.  T e one-layer, the Gambee suture, is shown in cross section. T 1s is placed  in four passes, with the second and third bites involving only the gastric or  duodenal mucosa (figure 3). T e result is complete inversion with good  serosa-to-serosa approximation. After the closure is completed, the thumb  and index finger are used to palpate the newly formed lumen by invagina-  tion of the gastric and duodenal walls on each side of the transverse closure.  A temporary gastrostomy may be performed (Chapter 17).    portions of the duodenum by use of an extensive Kocher maneuver are  essential (Chapter 26, page 83). A traction suture is placed in the superior  margin of the mid pylorus, and a second suture joins a point approximately  5 cm proximal to the pyloric ring on the greater curvature of the stomach  to a point 5 cm distal to the pyloric ring on the duodenal wall (figure b).  T e walls of the stomach and duodenum are sutured together with inter-  rupted 00 or 000 silk as in the start of the usual two layer gastrointestinal  anastomosis. T ese sutures should be placed as near the greater curvature  margins of the stomach and the inner margin of the duodenum as possible  to ensure adequate room for subsequent closure. A U-shaped incision is  then made into the stomach from a point just above the traction suture,  around through the pylorus, and down a similar distance on the duodenal  wall adjacent to the suture line. If an ulcer is present on the anterior wall, it  may be excised. Electrocautery is used to control bleeding. A wedge of the  pyloric sphincter may be removed from either side to facilitate the mucosal  closure. T e posterior mucosal septum between the stomach and duode-  num is united with a running absorbable suture in a standard fashion for  a side to side anastomosis. T ese sutures run from the superior aspect and  include all layers of the septum (figure 4). T e anterior mucosal layer is  approximated with inverting interrupted sutures of 000 silk.   As seen in figure 5,a second layer of sutures starts superiorly and brings  together the seromuscular layers of the anterior walls of the stomach and  duodenum. A portion of the omentum may be sutured over the anastomo-  sis. A temporary gastrostomy may be performed (Chapter 17) or constant  nasogastric suction maintained until the stomach empties satisfactorily.    Jaboulay Gastroduodenosto My It is advisable to carry out  a very extensive Kocher maneuver (Chapter 26, page 83) with complete  mobilization of the second and third parts of the duodenum. When this  procedure is carried out, it 1s wise to visualize the middle colic vessels,  which sometimes tend to swing down over the duodenum and appear  rather unexpectedly during the dissection. It is also advisable to attempt a  limited mobilization of the inner surface of the duodenum without interfer-  ence with its blood supply. T e gastric wall, however, adjacent to the pylo-  rus and downward for 6 to 8 cm may be freed of its blood supply and tested  for mobility over to the duodenal wall. A suture is taken between the gastric  wall and duodenum as near the pylorus as practical, and a second suture is  taken between the gastric wall and the second part of the duodenum as near  the inner duodenal border as possible to provide for approximation of 6 to  8 cm of the gastric wall and duodenum (figure c).   T e procedure varies little from that described for Finney Pyloroplasty.  Sutures of 00 interrupted silk are used on the serosa. An incision is made  in the gastric wall as well as in the duodenal wall adjacent to the serosal  suture line. T e pylorus 1s left intact (figure 6). All active bleeding points  on both the gastric and duodenal sides should be controlled. T e mucosa  is approximated with either interrupted sutures of 000 silk or a continuous  absorbable suture layer. Interrupted sutures of 00 or 000 silk are placed to  approximate the seromuscular coat as a second layer (figure 7). T e infe-  rior angle between the second part of the duodenum and greater curvature  of the stomach may require several additional interrupted sutures of 00 silk  to assure complete sealing of the angle. m=    Bilateral resection of segments of the vagus nerves in the region of the lower  esophagus is a key component in treating intractable duodenal or gastroje-  junal ulcers, refractory to antisecretory medicine or when intervening situ-  ation is not optimized. T e motor paralysis and resultant gastric retention  that may follow truncal vagotomy alone make it mandatory that a concom-  itant gastric resection or drainage procedure, such as pyloroplasty or an  antrally placed gastroenterostomy, be performed. Gastrojejunal or stomal  ulcers following a previous gastrectomy or gastrojejunostomy show a favor-  able response to vagotomy. T e use of vagotomy to control the cephalic  phase of secretion is preferred when it is desirable to retain as much gastric  capacity as possible because of the preoperative nutritional status of the  patient with duodenal ulcer. In those individuals below their ideal weight  preoperatively, controlling the acid factor by vagotomy followed by pylo-  roplasty, posterior gastroenterostomy, or hemigastrectomy should be seri-  ously considered. In many patients laparoscopy provides excellent exposure  of the vagal trunks and mobilization of the distal esophagus can be straight-  forward. In patients with scarring or previous operation consideration  could be given to a transthoracic thoracoscopic approach via the left chest  to the GE junction. T ere are two vagal trunks—the anterior or left vagus  nerve, which lies along the anterior wall of the esophagus, and the poste-  rior or right vagus nerve, which is sometimes overlooked since it is more  easily separated from the esophagus. T e vagus nerves may be divided 5 to  7 cm above the esophageal junction (truncal vagotomy), divided below the  celiac and hepatic branches (selective vagotomy), or divided so that only  the branches to the upper two-thirds of the stomach are interrupted, while  the nerves of Latarjet, innervating the antrum or lower one-third, as well as  the celiac and hepatic branches, are retained (proximal gastric vagotomy).    Truncal VagoTomy A good exposure of the lower end of the esopha-  gus is essential and sometimes requires removal of the xiphoid as well as  mobilization of the left lobe of the liver. T e vagal nerves should be iden-  tified and divided as far from the esophagogastric junction as possible  (figure 1). Sections of these trunks should be sent to the pathologist for  microscopic evidence that at least two vagus nerves have been divided.  Whether silver clips or ligatures are applied to both ends of each nerve is  the choice of the individual surgeon. It may be advisable to ligate the pos-  terior nerve to control possible oozing that may take place in the mediasti-  num. T e esophagus should be carefully inspected, and the area behind the  esophagus, in particular, should be searched as the esophagus 1s retracted  upward to make sure that the posterior vagus nerve 1s not overlooked. In  most instances, the cephalic phase of secretion will not be controlled if  vagotomy has been incomplete. Some prefer to combine the vagotomy with  a hemigastrectomy in order to control the gastric phase of secretion as well  as the cephalic phase. Drainage of the antrum is essential by pyloroplasty,  gastroenterostomy, or gastroduodenostomy (see Chapters 20-21). T e  increased incidence of recurrent ulceration following vagotomy and antral  drainage by pyloroplasty or gastroenterostomy must be weighed against a  somewhat higher mortality following vagotomy and hemigastrectomy.    Selec TiVe Vago Tomy T is procedure has been suggested as a means  of decreasing the incidence of dumping by maintaining the vagal innerva-  tion of the liver and small intestine. It is not widely utilized because of the  success of antisecretory medicines in most patients and the difficult techn1-  cal aspects. T e vagus nerves are carefully isolated from the esophagus and  divided beyond the point where they give off branches to the liver and to  the celiac ganglion (figure 2). It is necessary to visualize clearly the lower  end of the esophagus and to follow the anterior nerve down over the esoph-  agogastric junction with identification of the hepatic branch. T e nerve is  divided beyond the hepatic branch, as shown in figure 2. T e posterior  vagus nerve is likewise very carefully identified as it courses down over the  esophagogastric junction, and the branch going to the celiac ganglion is    identified. T e nerve is divided beyond that point in order to make certain  that the vagus nerve supply to the small intestine has not been interrupted.  Following this, some type of decompression procedure or resection is done.    Proximal gaSTric Vago Tomy T isprocedure, also known as highly  selective vagotomy, selective proximal vagotomy, or parietal cell vagotomy,  is illustrated in figure 3. It attempts to control the cephalic phase of secre-  tion while maintaining the celiac branch, the hepatic branch, and the ante-  rior and posterior nerves of Latarjet to the distal antrum (figure 3). In  this procedure, the vagal denervation is confined to the upper two-thirds  of the stomach, while innervation 1s left intact to the lower third as well as  to the biliary tract and small intestine. With superselective vagotomy it 1s  anticipated that a drainage procedure will not be required since the pyloric  sphincter retains its normal function. As a result, the incidence of disagree-  able side effects associated with dumping should be decreased. T is proce-  dure is not widely utilized as well, mostly because of the high recurrence  rate in patients with ulcer disease refractory to medical treatment.   It has been pointed out that the nerves of Latarjet send out branches  in a crow’-foot pattern over the terminal 6 or 7 cm of the antrum. All  other branches of the vagus nerves on either side of the lesser curvature are  divided up to and around the esophagus (figure 3). T 1s may be a time-  consuming and difficult technical procedure, particularly when the expo-  sure is limited and the patient obese. Some prefer to identify the anterior  and posterior vagus nerves at the lower end of the esophagus and place  them under traction with carefully placed sutures or nerve hooks that serve  as retractors, thus ensuring that the vagal nerve trunks will not be damaged  and at the same time helping define the branches going to the stomach.  T e dissection is usually started about 6 cm from the pylorus on the ante-  rior wall of the stomach (figure 4a). Small hemostats are used in pairs to  clamp carefully and divide the blood vessels and vagal branches as the dis-  section progresses up the anterior surface of the gastric wall along the lesser  curvature (figure 4b).   Special care must be taken as the dissection reaches the area where the  left gastric artery reaches the lesser curvature of the stomach. T e anterior  nerve of Latarjet must be identified frequently as the dissection approaches  the esophagogastric junction. T e peritoneum over the lower end of the  esophagus is divided carefully to permit identification of the vagal branches  as the dissection is carried around the anterior portion of the esophago-  gastric junction. Finger dissection may be used to push gently both the  anterior as well as the posterior vagus nerves away from the esophageal  wall. After the finger has encircled the esophagus, a rubber tissue drain or  a rubber catheter is introduced around the esophagus to provide traction.  Upward traction on the esophagus provides easier identification of the top  branches of the posterior nerve of Latarjet as they course over to the lesser  curvature to provide innervation to the posterior gastric wall (figure 5).  T e lower 5 cm of the esophagus should be completely cleared to avoid  overlooking small fibers. T e posterior branches are carefully identified and  divided between pairs of small curved hemostats, similar to the procedure  utilized on the anterior wall. A rubber tissue drain can be passed around  the mobilized lesser omentum, including the nerves of Latarjet, to provide  better exposure of the divided lesser curvature. A final search is made for  any overlooked vagal branches, incomplete hemostasis, or possible injury to  the nerves of Latarjet. Some prefer to peritonealize the lesser curvature by  approximating the anterior and posterior gastric walls with a series of inter-  rupted sutures. T is approximation ensures control of any small bleeding  points and provides insurance against possible necrosis with perforation  along the denuded lesser curvature. Since the innervation to the antrum 1s  retained, it is unnecessary to provide antral drainage by either pyloroplasty  or gastroenterostomy, provided the duodenal outlet is not obstructed by  scarring or a marked inf ammatory reaction. m    IndIcatlIons T e long-term results of vagotomy are closely related to  the completeness of the vagotomy and to efficient drainage or resection of  the antrum (see Chapter 22).    Preo Perat Ive PreParatlon A careful evaluation of the adequacy  and extent of the medical management is made. Proton pump inhibitors  are effective in most patients and smoking cessation and Helicobacter Pylori  eradication are important steps in medical management prior to operation.  Obtaining fasting serum gastrin levels may be indicated. Persistent ulcer  despite appropriate therapy may indicate the need for surgery. T e laparo-  scopic approach is straightforward and should be considered.    anestheslIa General anesthesia with muscle relaxation is necessary. T e  insertion of an endotracheal tube provides smoother operating conditions  for the surgeon and easy control of the airway for the anesthesiologist. An  orogastric or nasogastric tube should be inserted to empty the stomach and  allow palpation for the esophagus.    PoslItIon T e patient is placed flat on the operating table, with the foot  of the table lowered to permit the contents of the abdomen to gravitate  toward the pelvis.    IncIslon and exPosure A high midline incision is extended up over  the xiphoid and down to the region of the umbilicus. In some patients the  exposure 1s greatly enhanced by removal of a long xiphoid process. A thor-  ough exploration of the abdomen is carried out, including visualization of  the site of the ulcer. T e location of the ulcer, especially if it is near the com-  mon duct, the extent of the inflammatory reaction, and the patient’ general  condition should all be taken into consideration in evaluating the risk of gas-  tric resection in comparison to a more conservative drainage procedure. T e  anatomy of the vagus nerve is shown in figure l.   It may be necessary to mobilize the left lobe of the liver, alternatively a  mechanical retractor (padded by a gauze sponge) can retract the left lobe  superiorly. Mobilization is especially useful in obese patients where good  exposure enhances the probability of complete vagotomy. If the operator  stands on the right side of the patient, it is usually easier to grasp the left lobe  of the liver with the right hand and with the index fnger to def ne the limits  of the thin, relatively avascular left triangular ligament of the left lobe of the  liver. In many instances the tip of the left lobe extends quite far to the left    (figure 2). By downward traction on the left lobe of the liver, and with the  index f nger beneath the triangular ligament to def ne its limits and to protect  the underlying structures, the triangular ligament is divided with a long elec-  trocautery probe or curved scissors. T e assistant stands on the patient’ left  side and can usually do this more easily than the surgeon (figure 3). T e left  lobe of the liver is then folded either downward or upward so that the region  of the esophagus is clearly exposed (figure 4). A gauze pad is placed over  the liver, and a retractor is inserted to maintain even pressure throughout the  rest of the procedure (figure 5). In many instances the exposure is adequate  without mobilization of the left lobe of the liver.    detalls of Procedure T e region of the esophagus is palpated.  T e peritoneum immediately over the esophagus is grasped with a for-  ceps, and an incision 1s made in the peritoneum at right angles to the long  axis of the esophagus (figure 5). T e incision may be extended laterally  to ensure mobilization of the fundus of the stomach. Curved scissors are  then directed gently upward to free the anterior surface of the esophagus  from the surrounding tissue. T is can be done by blunt dissection, using the  index fnger (figure 6). T e dissection should carry posteriorly and later-  ally along both crura as far as necessary to allow the posterior esophagus  to be dissected. Sometimes it is helpful to divide the left side of the crura  and the proximal attachments to the stomach. After an inch or more of the  anterior wall of the esophagus has been freed from the surrounding struc-  tures, the index fnger should be introduced beneath the esophagus from  the left side. It is frequently necessary to loosen some adhesions in this area  by sharp dissection. Usually, little difficulty is encountered in gently passing  the index fnger beneath the esophagus and its indwelling nasogastric tube  and completely freeing it from the surrounding structures. Just to the right  of the esophagus, the index fnger will usually encounter resistance from  the uppermost limit of the hepatogastric ligament (figure 7). T is portion  of the structure should be divided, since its division affords more mobili-  zation of the esophagus and tends to provide exposure of the posterior or  right vagus nerve. T e major portion of the hepatogastric ligament in this  area 1s quite avascular and thin, so that it can be perforated easily with scis-  sors or electrocautery. If electrocautery is not available then a pair of right-  angle clamps is then applied to the uppermost portion of the ligament, and  the contents of these clamps divided with long, curved scissors (figure 8).  T is exposes the region posterior to the esophagus and ensures adequate  exposure of the hiatal region.    detalls of Procedure Downward traction 1s maintained  on the esophagus while it 1s further freed from the surrounding structures  by blunt dissection with the index fnger. T e vagus nerves are not always  easily identif ed, and their location is more quickly discovered by palpation  (figure 9). As the tip of the index finger is passed over the esophagus, the  tense wirelike structure of the nerve is easily identif ed. It should be remem-  bered that one or more smaller nerves may be found, both anteriorly and  posteriorly, in addition to the large left and right vagus nerves. Additional  small f laments may be seen crossing over the surface of the esophagus 1n its  long axis. T e left vagus nerve is usually located on the anterior surface of  the esophagus, a little to the left of the midline, while the right vagus nerve  is usually located a little to the right of the midline, posteriorly (figur es 10  and 10a). T e left vagus is then grasped with a fne clamp, and is dissected  free from the adjacent structures (figure 11). T e nerve can be separated  from the esophagus easily by blunt dissection with the surgeon’ index fn-  ger. It is usually possible to free at least 6 cm of the nerve (figure 12).  T e nerve is clipped and is divided with long, curved scissors as high as  possible. It is usually necessary to ligate the gastric ends of the vagus nerve  as well. (figure 13). T e use of clips at the point where the vagus nerves  divide minimized bleeding and serves to identify the procedures on sub-  sequent roentgenograms. After the left vagus nerve has been resected, the  esophagus is rotated slightly, and the traction is directed more to the left. It  is usually not difficult to dissect free the right or posterior vagus nerve with  the index fnger or nerve hook (figure 14). In some instances it has been  found that the nerve has been separated from the esophagus at the time  it was initially freed from the surrounding structures. T e nerve, in such  instances, appears to be resting against the posterior wall of the esophageal  hiatus. T e tendency to displace the right vagus nerve posteriorly during  the blind process of freeing the esophagus no doubt accounts for the fact  that this large nerve may be overlooked while all f laments about the esoph-  agus are meticulously divided. T is is the nerve most commonly found to  be intact at the time of secondary exploration for a clinical failure of the  vagotomy. A careful search should be made for additional nerves, since it is  not uncommon to fnd more than one. A minimum of 6 cm of the right or  posterior vagus nerve should be resected (figure 15). Although the nerves  may be clearly identif ed, the surgeon should not be satisf ed until another  careful search has been made completely around the esophagus. By traction    on the esophagus and by direct palpation, any constricting band should be  freed and resected, and a careful inspection should be made throughout  the circumference of the esophagus. T e operator will fnd that many of  the little f laments that he dissects, in the belief that they are nerves, will  prove to be small blood vessels that will require ligation. A fnal survey  should always be made to be absolutely certain that the large right vagus  nerve has not been displaced posteriorly, thus escaping division. A frozen  section examination may be obtained to verify that both nerves have been  removed. Traction should be released and the esophagus allowed to return  to its normal position. T e area should be carefully inspected for bleeding.  No effort is made to reapproximate the peritoneal cuff over the esophagus  to the cuff of peritoneum at the junction of the esophagus with the stom-  ach. Finally, the esophagus is retracted upward and to the left by a narrow  S retractor in order to expose the crus of the diaphragm. Two to three of  nonabsorbable sutures may be placed sut to approximate the crus of the  diaphragm as in the repair of a hiatus hernia if the hiatus appears patulous  (figures 16 and 17). Sufficient space about the esophagus must be retained  to admit one fnger or the passage of a 4 French or larger esophageal dila-  tor into the stomach. All packs are removed from the abdomen, and the  left lobe of the liver is returned to its normal position. It is not necessary to  reapproximate the triangular ligament of the left lobe.   Vagotomy must always be accompanied either by a gastric resection or  drainage of the antrum by posterior gastroenterostomy or division of the  pylorus by pyloroplasty. Since gastric emptying may be unduly delayed  following vagotomy, efficient gastric drainage by gastrostomy should be  considered.    Posto Perat Ive care Gastric suction is maintained until it has been  determined that the stomach is emptying satisfactorily. If evidence of gas-  tric dilatation develops, constant gastric suction 1s instituted. Occasionally,  a moderate diarrhea will develop, which may be temporarily troublesome.  T e general care is that of any major upper abdominal procedure. Inability  to swallow solid food because of temporary cardiospasm may occur for a  few days in the early postoperative period. Six small feedings consistent  with an ulcer diet should be recommended in order to combat the disten-  tion that may occur with an atonic stomach. T e return to an unrestricted  diet is determined by the patient’ progress. m=    IndIcatlIons T e Billroth I procedure for gastroduodenostomy is the  most physiologic type of gastric resection, since it restores normal continu-  ity. Although long preferred by some in the treatment of gastric ulcer or antral  carcinoma, its use for duodenal ulcer has been less popular. Control of acid  secretion by vagotomy and antrectomy has permitted retention of approxi-  mately 50% of the stomach while ensuring the lowest ulcer recurrence rate of  all procedures (figure 1). T is allows an easy anastomosis without tension,  providing both stomach and duodenum have been thoroughly mobilized.  Furthermore, the poorly nourished patient has an adequate gastric capacity  for maintaining a proper nutritional status postoperatively. Purposeful con-  striction of the gastric outlet to the size of the pylorus tends to delay gastric  emptying and decrease postgastrectomy complaints.    PoslItIon T e patient is laid supine on the flat table, the legs being  slightly lower than the head. If the stomach is high, a more erect position  is preferable.    IncIslon and exPosure A midline incision is usually made. If the  distance between the xiphoid and the umbilicus is relatively short, or if the  xiphoid is quite long and pronounced, the xiphoid is excised. Sufficient  room must be provided to extend the incision up over the surface of the  liver, because vagotomy is routinely performed with hemigastrectomy and  the Billroth I type of anastomosis, especially in the presence of duodenal  ulcer.    detalls of Procedure T e Billroth I procedure requires extensive  mobilization of the gastric pouch as well as the duodenum. T 1s mobiliza-  tion should include an extensive Kocher maneuver for mobilization of the  duodenum. In addition, the greater omentum should be detached from the  transverse colon, including the region of the flexures. In many instances  the splenorenal ligament is divided, as well as the attachments between the  fundus of the stomach and the diaphragm. Additional mobility is gained  following the division of the vagus nerves and the uppermost portion of the  gastrohepatic ligament. T e stomach is mobilized so that it can be readily  divided at its midpoint. T e halfway point can be estimated by selecting  a point on the greater curvature where the left gastroepiploic artery most  nearly approximates the greater curvature wall (figure 1). T e stomach on  the lesser curvature is divided just distal to the third prominent vein on the  lesser curvature.   Extensive mobilization of the duodenum is essential in the performance  of the Billroth I procedure. Should there be a marked inflammatory reac-  tion, especially in the region of the common duct, a more conservative pro-  cedure, such as a pyloroplasty or gastroenterostomy and vagotomy, should  be considered. If it appears that the duodenum, especially in the region of  the ulcer, can be well mobilized, the peritoneum is incised along the lateral  border of the duodenum and the Kocher maneuver is carried out. Usually  it is unnecessary to ligate any bleeding points in this peritoneal reflection.  With blunt dissection the peritoneum can be swept away from the duo-  denal surface as the duodenum 1s grasped in the left hand and reflected  medially (figure 2). It is important to remember that the middle colic ves-  sels tend to course over the second part of the duodenum and are many  times encountered rather suddenly and unexpectedly. For this reason the  hepatic flexure of the colon should be directed downward and medially  and the middle colic vessels identified early (figure 2). As the posterior  wall of the duodenum and head of the pancreas are exposed, the inferior  vena cava readily comes into view. T e firm, white, avascular ligamentous  attachments between the second and third parts of the duodenum and  the posterior parietal wall are divided with curved scissors, down through  and almost including the region of the ligament of Treitz (figure 2). T 1s    extensive mobilization is carried downward in order to ensure a very thor-  ough mobilization of the duodenum. Following this, the omentum is sep-  arated from the colon, as described in Chapter 27 In obese patients it is  usually much easier to start the mobilization by dividing the attachment  between the splenic flexure of the colon and the parietes (figure 3). An  incision is made along the superior surface of the splenic flexure of the  colon as the next step in freeing up the omentum. T is should be done in  an avascular cleavage plane. T e¢ lesser sac is entered from the left side. Care  should be taken not to apply undue traction upon the tissues extending  up to the spleen, since the splenic capsule may be torn, and troublesome  bleeding, even to the point of requiring splenectomy, may be encountered.  T e omentum is then dissected free throughout the course of the transverse  colon.   A truncal vagotomy 1s carried out as described in Chapter 17. At this point  considerable distance can be gained if the peritoneum attaching the fundus  of the stomach to the base of the diaphragm is divided up to and around the  superior aspect of the spleen. If the exposure appears difficult, it is advisable  for the surgeon to retract the spleen downward with his right hand and,  using long curved scissors in his left hand, divide the avascular splenorenal  ligament (Chapter 90, figur es Sand 6). It must be admitted that sometimes  troublesome bleeding does occur, which requires an incidental splenectomy,  but in general great mobilization of the stomach is accomplished by this  maneuver. Any bleeding from the splenic capsule should be controlled by  conservative measures to minimize the need for splenectomy.   So far, the surgeon is not committed to any particular type of gastric  resection but has ensured an extensive mobilization of the stomach and  duodenum. T e omentum should be reflected upward and the posterior  wall of the stomach dissected free from the capsule of the pancreas, should  any adhesions be found in this area. In the presence of a gastric ulcer, pen-  etration through to the capsule of the pancreas may be encountered. T ese  adhesions can be pinched of between the thumb and index finger of the sur-  geon and the ulcer crater allowed to remain on the capsule of the pancreas.  A biopsy for frozen section study should be taken of any gastric ulcer since  malignancy must be ruled out. T e colon is returned to the peritoneal cavity.  T e right gastric and gastroepiploic arteries are doubly ligated (Chapter 26,  figures 2 to 16), and the duodenum distal to the ulcer divided.   At least lor 1.5 cm of the superior as well as the inferior margins of the  duodenum must be thoroughly cleared of fat and blood vessels at the point  of resection of the stomach is decided upon (figure 4).T eduodenum can  be divided with a linear cutting or closed with a noncutting stapler.   In many instances, especially in the obese patient, it 1s advisable to fur-  ther mobilize the stomach by dividing the thickened, lowermost portion of  the gastrosplenic ligament without dividing the left gastroepiploic vessels.  Considerable mobilization of the greater curvature of the stomach without  traction on the spleen can be obtained if time is taken to divide carefully  the extra heavy layer of adipose tissue that is commonly present in this  area. Following this further mobilization of the greater curvature, a point  is selected where the left gastroepiploic vessel appears to come nearer the  gastric wall. T is is the point in the greater curvature selected for the anas-  tomosis, and the omentum is divided up to this point with freeing of the  serosa of fat and vessels for the distance of the surgeon’ finger (figure 4).  Traction sutures are applied to mark the proposed site of anastomosis. A  site on the lesser curvature is selected just distal to the third prominent vein  on the lesser curvature (figure 1). Again, two traction sutures are applied,  separated by the width of the surgeon’ finger. T is distance of about a cen-  timeter on both curvatures assures a good serosal surface for closure of the  angles.   It makes little dif erence how the stomach is divided, although there is  some advantage to using a linear cutting or noncutting stapling instrument  (figure 4). Before the stomach is divided, a row of interrupted 000 silk  sutures may be placed almost through the entire gastric wall in order to (1)  control the bleeding from the subsequent cut surface of the gastric wall, (2)  fix the mucosa to the seromuscular coat, and (3) pucker and constrict the end  of the stomach to create a pseudopylorus (figure 5).    detalls of Procedure T e staple line can be oversewn  omitting the point of anastomosis along the lesser curvature. T is opening  should be approximately 2.5to 3cm wide (figure 6).T ese sutures are then  cut in anticipation of a direct end-to-end anastomosis with the duodenum  (figure 7). Ifthe margins of the lesser and greater curvatures of the stom-  ach as well as the superior and inferior margins of the duodenum have  been properly prepared, it is relatively easy to insert angle sutures of 00 silk.  Successful closure of the angles depends upon starting the suture on the  anterior gastric as well as the anterior duodenal wall rather than more pos-  teriorly. Interrupted sutures of 00 silk are then taken to close the stomach  and duodenum together. Slightly bigger bites are necessary on the gastric  side as a rule rather than on the duodenal side, depending upon the dis-  crepancy in size between the two openings (figure 8). T e sutures should  be tied, starting at the lesser curvature and progressing downward to the  greater curvature. T e angle sutures are retained while additional 000 silk  or fine absorbable synthetic sutures are placed to approximate the mucosa  (figure 9, a—a‘ and b—b’). Some prefer a continuous synthetic absorb-  able suture to approximate the mucosa. T e anterior mucosal layer is closed  with a series of interrupted sutures of 000 silk or a continuous synthetic  absorbable suture. T e seromuscular coat is then approximated to the duo-  denal wall with a layer of interrupted sutures (figure 10). It has been found  that a cuf of gastric wall can be brought over the duodenum, resulting in a    “pseudopylorus,’ if two bites are taken on the gastric side and one bite on  the duodenal side. When this suture is tied (figure 10), the gastric wall is  pulled over the initial mucosal suture line.   T e vascular pedicles on the gastric side are anchored to the ligated right  gastric pedicle along the top surface of the duodenum as well as the ligated  right gastroepiploic artery pedicle (figure 10, a and b). A and Bare then  tied together to seal the greater curvature angle (figure Il). A similar type  of approximation is ef ected along the superior surface in order to seal the  angle and remove all tension from the anastomosis (figure 11). T e stoma  should admit one finger relatively easily. T ere should be no tension what-  soever on the suture line.   T e upper quadrant is inspected for oozing and thoroughly irrigated  with saline.    Posto PeratIve care Intravenous administration of a balanced elec-  trolyte solution is continued until bowel function has returned and an oral  diet is tolerated. A nasogastric tube may be used. When bowel activity has  resumed, clear liquids are given by mouth. If there is no evidence of reten-  tion, a progressive feeding regimen is begun. T is consists of five or six  small feedings per day of soft food, moderately restricted in volume, high in  protein, and relatively low in carbohydrate. Eventually, the only limitations  to the individual’ diet are those imposed by his or her own intolerance. m    IndIcatlIons T e Billroth I gastric resection along with truncal vagot-  omy is frequently performed for intractable duodenal ulcer or benign  gastric ulcer. T e procedure may be performed when hemigastrectomy is  carried out for a variety of other reasons. It is hoped that this reconstruction  to anormal configuration will result postoperatively in few symptoms and  improved nutrition.    Preo Perat Ive PreParat lon T estomach isaspirated preoperatively,  and nasogastric suction is maintained. Antibiotics are given to patients  with achlorhydria, since they may have significant bacterial colonization of  the duodenum or stomach.    anestheslIa Routine general anesthesia is given via a cuffed endotra-  cheal tube.    PosItlIon T e patient is placed supine on the table in a modest reverse  Trendelenburg position.    detalls of Procedure When there is evidence of malignancy, the  stomach should be resected with the width of the hand (75-10 cm) beyond  the upper margins of the tumor. When the lesion is near the pylorus, at least  2.5cm of the duodenum should be resected, along with the omentum and  any lymph nodes about the right gastroepiploic veins.   T e Billroth I procedure for control of peptic ulcer should include vagot-  omy (Chapters 22 and 23) as well as hemigastrectomy. T e stomach 1s tran-  sected at the third vein on the lesser curvature and on the greater curvature  where the gastroepiploic arterial blood supply is nearest the greater curva-  ture (Chapter 26, figure 1). T ese anatomic landmarks ensure a complete  antrectomy with control of the hormonal phase of gastric secretion.   As shown in Chapter 26, the duodenum and stomach are mobilized. A  modified Furniss clamp is placed across the duodenum at the appropri-  ate level, and a purse-string suture of monofilament polypropylene on a    straight needle is introduced (figure 1). T 1s automatically creates a purse  string on the duodenal stump. T e duodenum 1s divided and the previously  selected site for division of the stomach should be cleared of fat in order to  ensure good approximation of the anterior and posterior walls of the stom-  ach by the noncutting linear stapler. T e longer staples are usually needed  for the thick walls of the stomach. Any bleeding points are controlled with  additional sutures.   A gastrotomy is made with a cutting linear stapler (figure 1) or elec-  trocautery for the intragastric introduction of the circular stapler instru-  ment through the anterior gastric wall at right angles to and about 3 to 5cm  proximal to the staple line closure of the distal stomach (figure 2).   T e closed end of the stomach is reflected to the lef , and the posterior  gastric wall is grasped with a Babcock forceps 3 to 5 cm from the mid-  portion of the staple line closing the distal stomach. T e circular stapler  of the appropriate size is entered into the stomach with its detachable  pointed plastic trocar exiting the back wall of the stomach. T e plastic trocar  is removed and replaced with the metal anvil cap (figure 2). T e cap is  screwed onto the tip of the center rod and it is inserted into the duodenum  (figure 3). T e monofilament polypropylene purse string around the end  of the duodenum 1s snugged and securely tied (figure 4). T e wing nut on  the near end of the circular stapler handle is turned until the stomach and  the duodenum are firmly approximated. T e safe zone indicator is checked  to be certain that the thickness of the combined stomach and duodenum  are within correct range of the staples. T e safety is released, and the outside  handles are squeezed. A double staggered, circular tow of staples is created,  and an internal circular knife cuts the bowel walls within the staple lines  simultaneously. T e wing nut is loosened so that the anvils open, and the  stapling instrument is gently removed (figure 5). T e doughnuts of tissue  are carefully inspected to be certain there is no defect or discontinuity in  the anastomosis. Several additional interrupted sutures may be placed to  reinforce the anastomosis. T e outer-wall gastrotomy opening is closed with  a mucosa-to-mucosa noncutting linear stapler (figure 6).    detalls of Procedure Alternatively, some prefer to  introduce the circular stapler into the open distal end of the stomach prior to  its removal (figur e 7) and direct the rod through the center of a previously  placed purse-string suture in the posterior gastric wall approximately 3 cm  from the proposed line of resection. T e duodenal opening is checked with  a sizing instrument; the 28-mm circular stapler 1s most commonly used.  T ecap is applied to the rod, and it is introduced into the open end of the  transected duodenum (figure 8). T emonofilament polypropylene purse-  string suture around the duodenal wall is tied tightly (figure 9).T eanvil  and cap are approximated and the instrument is fired. T e stapler is opened  and then gently rocked back and forth and the line of staples stabilized with  one hand as the tilted head of the instrument is slowly removed. Additional  interrupted sutures may be indicated about the staple line (figure 10).T e    posterior wall of the stomach may be opened longitudinally for a short dis-  tance to obtain better visualization of the suture line. T ereaf er, the non-  cutting linear stapler (TA 90) with the longer gastric staples is applied to  transect the avascular distal antrum of the stomach (figure 11). T is may  be the preferred method, since the anterior-wall suture line created by the  gastrotomy for introduction of the stapler is avoided (figure 12).    closure Asmall nasogastric (NG) tube may be inserted for decompres-  sion and later feedings. T e incision is closed in a routine manner.    Posto PeratIve care Daily weight, fluid, and electrolyte measurements  are recorded until the patient is taking adequate fluids and nutrition by mouth.  Clear liquids may be permitted on the first postoperative day. Oral intake  should be restricted if there is a feeling of fullness or if vomiting occurs. =    IndIcatlIons Subtotal gastrectomy is indicated in the presence of  malignancy; in the presence of gastric ulcer that persists despite intensive  medical therapy; and sometimes in the presence of pernicious anemia,  suspicious cells by gastric cytology, or equivocal evidence for and against  malignancy by repeated gastroscopic observation with direct biopsy. It may  be utilized to control acid secretion in cases of intractable duodenal ulcer. A  more conservative procedure should be considered in underweight patients  with duodenal ulcer, especially females. Likewise, block excision of a gastric  ulcer with multicentric frozen section studies should be made for proof of  malignancy before performing a radical resection on the assumption the  lesion may be malignant.    Preo PeratIve PreParatlon T e preoperative preparation will be  determined largely by the type of lesion presented and by the complication  it produces. Sufficient time should be taken to improve the patient’s nutri-  tion if possible, especially if there has been considerable weight loss in a  patient with obstruction. T e fluid and electrolyte normalization should be  treated with intravenous fluids and electrolytes as necessary. T e increased  incidence of pulmonary complications associated with upper abdominal  surgery makes it imperative that elective gastric surgery be carried out only  in the absence of respiratory infection, and active pulmonary physiother-  apy with possible bronchodilators, expectorants, and incentive spirometry  should be started in all patients but especially those with chronic lung dis-  ease. Preoperative antibiotics should be given.    anestheslIa General anesthesia with endotracheal intubation should be  used. Excellent muscular relaxation without deep general anesthesia can  be attained by utilizing muscle relaxants. Epidural catheter placement may  be considered for analgesia and after surgery.    PoslItIon Asarule, the patient is laid supine on a flat table, the feet being  slightly lower than the head. If the stomach is high, a more erect position  is preferable.    IncIslon and exPosure A midline incision extending from the  xiphoid to the umbilicus may be used. Additional exposure can be obtained  by excising the xiphoid using electrocautery. Placement of a self-retaining  retractor or a broad-bladed, fairly deep retractor placed against the liver  down to the gastrohepatic ligament will aid in visualization.    detalls of Procedure T e surgeon should focus his or her atten-  tion on the arterial blood supply (figure 1). Although the stomach will  retain viability despite extensive interference with its blood supply, the duo-  denum lacks such a liberal anastomotic blood supply, and great care must  be exercised in the latter instance to prevent postoperative necrosis in the  duodenal stump. T e blood supply to the lesser curvature of the stomach  can be totally interrupted, and the retained fundus will be nourished by  the small vessels in the gastrosplenic ligament in the region of the fun-  dus. Importantly, if it is desirable to mobilize the stomach into the chest,  its viability can be retained if only the right gastric artery 1s left intact. In  such instances, however, the gastrocolic ligament should be divided some  distance from the greater curvature to prevent interference with the right  and the left gastroepiploic vessels.   T e blood supply may also be used as landmarks in designating the  extent of the gastric resection. Approximately 50% of the stomach is resected  where the line of division extends from the region of the third large vein on  the lesser curvature down from the esophagus to a point on the greater  curvature where the left gastroepiploic vessels most nearly approach the    gastric wall. Approximately 75% resection can be assumed when the line of  resection includes most of the lesser curvature with extra gastric ligation of  both the left gastric and left gastroepiploic vessel.   T esurgeon likewise should be familiar with the major lymphatic drain-  age of the stomach in determining the presence or absence of metastasis  if malignancy is suspected. Under such circumstances it is advisable to  keep the dissection as far away as possible from both curvatures in order  to retain all involved lymph nodes with the specimen. T ere is a tendency  for metastases to involve distant lymph nodes of the lesser curvature (a)  and the lymph nodes beneath the pylorus (b) as well as those of the greater  omentum (c) (figure 1).   In general, it is desirable to move the greater omentum, most of the  lesser curve to the esophagus, and about 2.5 cm of the duodenum (includ-  ing subpyloric lymph nodes), and the greater curvature. It is rarely neces-  sary to remove the spleen unless there is direct extension of a gastric cancer  into the spleen. Extended radical dissection of the preaortic (Figure | d  and Chapter 31 figures 2, 4 and 11) and portal area lymph nodes (not in  the Chapter) has been shown to be beneficial in the Japanese experience;  however, the utility of these dissections remains controversial.   Prior to operation, external (CT, MRI, PET) imaging and internal endo-  scopic transluminal ultrasound evaluations may show an inoperable exten-  sion of the malignancy. In addition, many potential candidates for a cancer  resection are first evaluated with diagnostic laparoscopy (see Chapter 13  page 44, 45) and biopsy, as up to 40% of patients may have occult distant  spread. Such findings preclude curative resection but not necessarily a gas-  tric procedure for relief of obstruction and bleeding.   If the exploratory peritoneoscopy does not reveal contraindications to  resection, the abdomen is opened and a careful regional inspection with palpa-  tion is performed. It must also be determined whether there have been direct  extension and fixation to adjacent structures, such as the pancreas, liver, or  spleen. Additional information may be obtained as to the extent and fixation  of the tumor mass by exploring the lesser omental cavity through an opening  made in the relatively avascular gastrohepatic ligament (figure 2). Evidence  of fixation of the posterior gastric wall with the pancreas or involvement of  the tissues about the middle colic vessels should be sought. However, in the  absence of visible or palpable distance metastases, it may be feasible to excise  the stomach, en masse, along with the spleen and portions of the left lobe of  the liver, or tail and body of the pancreas, if the involvement is by direct exten-  sion of the tumor. If there is widespread metastatic involvement with impend-  ing pyloric obstruction, it may be wiser to avoid radical surgery and to carry  out the simple procedure of anterior or posterior gastrojejunostomy.   After evaluation indicates that a subtotal gastrectomy 1s practicable,  it has been found that preliminary mobilization of the duodenum by  the Kocher maneuver may facilitate some of the subsequent steps neces-  sary in the procedure (figures 3 to 5). The duodenum is grasped with  Babcock forceps in the region of the pylorus, and traction is sustained  downward (figure 3). Any avascular adhesive bands that appear to  be fixing the duodenum in the region of the hepatoduodenal ligament  should be severed. The common duct is exposed so that it can be identi-  fied easily from time to time as the duodenum is divided and the stump  is inverted (figure 6).   After the duodenum and region of the pylorus have been mobilized by  freeing all the avascular attachments, the index finger of the right hand is  passed through an avascular portion of the gastrohepatic ligament above  the pylorus to facilitate the introduction of a Penrose drain or gauze tape,  which is brought up through an avascular space along the greater curvature  and is used for traction (figure 7).    detalls of Procedure T e gastrocolic ligament is  divided near the epiploic vessels along the greater curvature, if there is no  evidence of malignancy. T e stomach is retracted upward, and the surgeon’  left hand is introduced behind the stomach to avoid the possibility of dam-  aging the middle colic vessels when the gastrocolic ligament 1s divided,  since these vessels may be very near (figure 8). Furthermore, by spread-  ing the fingers apart beneath the gastrocolic ligament along the greater  curvature, it is easier to identify the individual vessels so that they can be  more accurately clamped and divided between pairs of small curved clamps  (figure 9). T e dissection is carried around to the region of the gastro-  splenic ligament, and a portion of this structure may also be removed,  depending upon the amount of stomach to be resected. It is necessary to  free the greater curvature to this extent to accomplish a 75% to 80% resec-  tion of the stomach. T is usually demands the sacrifice of the left gastroepi-  ploic artery and one or two of the short gastric arteries in the gastrosplenic  ligament. T e nutrition of the remaining fundus of the stomach depends  upon the remaining short gastric arteries (figure 10) when the left gastric  artery has been ligated at its base. When hemigastrectomy is planned, the  greater curvature is divided in the area where the left gastroepiploic artery  most nearly approximates the gastric wall. On the lesser curvature the third  large vein on the anterior gastric wall is used as the approximate point of  division to ensure a hemigastrectomy (figure 1).   In the obese patient the gastrosplenic ligament may be quite thickened  and the identification of the vessels for ligation more difficult than elsewhere.  However, fewer vessels require ligation if the omentum is removed, as in  Chapter 27, rather than repeatedly clamping and tying the blood vessels in  the gastrocolic ligament near the greater curvature. T e division of the usual  attachments of the omentum to the lateral abdominal wall about the splenic  flexure of the colon will further mobilize the greater curvature of the stom-  ach. Undue traction on the stomach or omentum may result in troublesome  bleeding from the spleen, especially if the small strands of tissue extending up  to the anterior margin are torn along with some of the splenic capsule. Under  such circumstances splenectomy may be safer than depending on a hemo-  static sponge or splenorrhaphy to control the troublesome and persistent  bleeding. However, every ef ort should be made to repair the torn capsule,  either by the use of coagulant or by the use of sutures, which may include the  omentum when tied, in order to conserve the spleen, especially in younger  patients. Alternatively, topical hemostatic agents can be applied and packed  of for a period of time to establish excellent control. T e greater curvature  can be further mobilized into the field of operation if the relatively avascu-  lar splenocolic ligament is divided (Chapter 90 figures 5-7). Indeed, the  spleen may be quite extensively mobilized by dividing the splenorenal liga-  ment laterally, permitting it, along with the fundus of the stomach, to be pre-  sented into the field of operation. T is procedure ensures an easier exposure    for the gastrojejunal anastomosis following a very high gastric resection.  Any bleeding points in the splenic bed should be carefully controlled with  electrocautery.   At this time it is desirable to prepare the greater curvature for subse-  quent anastomosis. T e serosa should be dissected free of fat for approx1-  mately the width of the index finger. A transfixing silk suture is placed in  the greater curvature in this area to serve as a guide suture at the time the  clamps or staplers are finally applied for division of the stomach (figure 1],  page 85 and figure 30, page 89 in this Chapter). In addition, such a trans-  fixing suture tends to prevent damage to the adjacent blood supply from  subsequent manipulation of the stomach while preparing it for anastomosis  (figure ll).   Upward retraction of the stomach is maintained as the gastrocolic liga-  ment is divided up to the region of the pylorus. If there is a possibility of  malignancy within the area, care should be taken to stay about 3 to 5cm  from the pylorus in order to include the subpyloric nodes with the speci-  men. At the same time large, blind bites with hemostats in the neighbor-  hood of the inferior portion of the duodenum should be avoided because  of possible damage to the pancreaticoduodenal artery. It should be remem-  bered that since the duodenum does not have a rich anastomotic blood  supply but is supplied from end arteries, it is necessary to guard its blood  supply carefully. T e right gastroepiploic vessels should be carefully iso-  lated from the surrounding fat and securely ligated (figure 12).   After the blood supply of the greater curvature of the stomach has been  divided and tied, the vascular supply and ligamentous attachments to the  superior portion of the first part of the duodenum can be divided. Freeing  the pylorus and the upper portion of the duodenum may be one of the  most difficult steps in the operation, especially in the presence of a large,  penetrating ulcer. One cannot state beforehand whether the attack should  begin at the upper or lower border of the duodenum. In the presence of  gastric malignancy extending to the pylorus, it is essential to remove at least  3cm of the duodenum because of the possibility of infiltration of carcinoma  for some distance within the wall of the duodenum itself. In addition, a  more extensive lymph node dissection is accomplished of the area beneath  the pylorus and the periportal area along with an omentectomy (see  Chapter 27). T e most medial portion of the hepatoduodenal ligament,  which includes the right gastric artery, is divided. It is better to take small  bites in this area with a small curved hemostat and re-apply the clamps  repeatedly than to attempt mass ligation (figure 13). T e location of the  common duct and adjacent vessels within the hepatoduodenal ligament  should be accurately identified before these clamps are applied. T e mobi-  lization of the duodenum is facilitated by the division and ligation of the  contents of these clamps. T e vascular pedicles from the duodenal side of  the anastomosis are clearly defined.    detalls of Procedure Transfixing silk traction sutures  are applied to the superior and inferior borders of the duodenum adjacent  to its retained blood supply (figure 14). T ese traction sutures are helpful  when passing a linear stapler or the narrow crushing large vascular clamp  is applied to the duodenum. T e duodenal stump can be closed with a  cutting linear stapler, noncutting linear stapler or as shown with sutures  in a single or double layer. After the blood supply about the pylorus has  been divided and tied, the stomach is held upward in order to free any  adhesions between the first portion of the duodenum and the pancreas  (figure 14). At this time the transverse colon can be returned to the abdo-  men and retracted out of the operating field.   A thin-bladed, noncrushing clamp of the vascular type (Potts) can then  be applied across the duodenum at the prepared level or it can be stapled  with a linear cutting or noncutting stapler (figure 15). A large clamp is  applied to the gastric side to prevent spilling when necessary. T ere should  be at least 1 cm of cleansed serosal surface at either border of the duode-  num, between the noncrushing clamp and the traction sutures when this  technique is used. T is amount of prepared duodenal wall is necessary to  ensure a safe subsequent closure of the duodenal stump. If the adjacent  ligature does not permit 1cm of cleared serosa between it and the margin  of the clamp, small served clamps should be applied to the interfering vas-  cular attachments, and such attachments should be divided and ligated.  T e duodenum is divided with a knife, and the stomach is retracted to  one side. T e duodenal stump is then retracted laterally in order to deter-  mine whether a sufficient amount of the serosa of the posterior wall has  been cleared away to permit a safe closure of the duodenal stump. At least  lcm distal to the clamp, the duodenum should be freed from the pancreas  in order that subsequent sutures in the serosa may be placed under full  vision. Individual clamping and subsequent ligation of the small vascular  attachments must be carried out without damaging the gastroduodenal  artery (figure 16). T e placement of deep sutures to control bleeding    should be rigorously avoided in this area because of the potential danger  of pancreatitis.   T ere are many ways of closing the duodenal stump. However, it should  be remembered that a very firm closure is necessary, since blowing-out of the  duodenal stump is not an uncommon fatal complication of gastric surgery  which may be caused by failure to clear a sufficient amount of duodenum,  especially along the upper border but more often is related to technical difficul-  ties from inflammation caused by chronic ulcer disease. T e tendency of the  ‘cloverleaf” deformity associated with the ulcer to produce a diverticulum-  like extension beyond the superior margin must be corrected in many  instances to ensure a closure of the stump in this area. Failure to free up and  excise this deformity tends to make inversion of the mucosal layer very dif-  ficult. T e superior margin as well as the inferior margin of the duodenum  adjacent to the clamp may be grasped with Babcock forceps preliminary to  removal of the noncrushing clamp (figure 17). As the noncrushing clamp  is removed, the bleeding margin of the duodenal stump is grasped with  two or three Babcock or Allis forceps (figure 18). T e duodenum is then  closed with interrupted 0000 silk sutures or a continuous absorbable suture  (figure 19). T e mucosal suture line should then be inverted by applying a  row of interrupted mattress sutures of 00 silk, which tends to pull the ante-  rior wall downward toward the pancreas (figure 20). A cleaned serosal  surface should be available at both the superior and inferior margins when  this layer of interrupted serosal sutures is finally inverted.   As a final safety measure to reinforce the closure, interrupted sutures  may be taken in the anterior wall of the duodenum and, superficially, in  the capsule of the pancreas, especially in situations where a posterior ulcer  has caused inflammation (figures 21 and 22). While the duodenal stump  is being closed, the common duct should be visualized and its relationship  determined from time to time, so that there is no possibility of its acciden-  tal angulation, injury, or obstruction as a result of inverting the duodenal    detalls of Procedure One of the important steps in  gastric resection is the preparation of the lesser curvature. Frequently, the  gastrohepatic ligament is quite thin and avascular at some distance from  the lesser curvature. It is divided between pairs of small curved forceps  (figure 23). In the presence of malignancy the division of the gastrohe-  patic ligament should be as near the liver as possible and carried up almost  to the esophagus to make certain that all involved nodes along the lesser  curvature are removed. T e uppermost portion of the gastrohepatic liga-  ment may be clamped before division, since it may contain a sizable artery  that requires ligation. T e division of the gastrohepatic ligament does not  involve a division of the left gastric artery, which comes up from the celiac  axis directly to the stomach (figures 24 and 25). Whether the left gastric  artery is ligated depends upon how extensive a resection is indicated. A  radical gastric resection is usually interpreted as one in which the left gas-  tric artery has been ligated and the stomach divided at this level or higher.  Attempts at mass ligation, especially in the obese, of the fat and blood  vessels along the lesser curvature are dangerous and do not ensure a lesser  curvature properly prepared for closure or anastomosis, as the case may  be. T e left gastric vessels divide as they reach the stomach, extending  paired branches to either side of the curvature to enter the gastric wall  (figure 24). An ef ort should be made to surround an individual vessel  before its division and ligation (figure 25). T e main vessels on either  side of the curvature should be ligated as well as the individual tributar-  ies that run down over the gastric wall (figures 26 and 27). In a thin  patient, a mass ligation may be carried out without difficulty by passing a  small curved clamp from front to back, being careful to avoid the blood  vessels extending downward over both anterior and posterior surfaces  of the stomach. Following this, a transfixing suture, A (figure 27), 1s  placed to approximate the serosa of the anterior gastric wall to the serosa  of the posterior gastric wall, so that when it is tied, a firm peritonealized  surface is provided for the important subsequent sutures to be placed in  this area. T e lesser curvature should be freed of attached fat for several  centimeters, and the larger blood vessels should be clamped and tied on  the gastric wall. A smooth serosal surface is essential for a safe anasto-    mosis (figure 27). Further celiac and preaortic lymph node dissections  for malignancy may be done now or after high division of the left gastric  artery (figure 28). Proximal vessel division and vascular control can also  be obtained with linear cutting or noncutting staplers with appropriate  vascular staple lengths.   When a very high resection is indicated, especially in the presence of  malignancy, it is desirable to divide the left gastric artery as far away from  the lesser curvature as possible (figur e 29). Care should be taken to isolate  the surrounding tissue from the pillar that includes the left gastric vessels.  Since these are large vessels, they are doubly clamped on the proximal side  and transfixing sutures are used. It is frequently much simpler to ligate the  left gastric artery near its point of origin rather than to attempt to ligate its  individual branches as they divide along the lesser curvature. When the  left gastric artery has been ligated, it is essential that the lesser curvature  be prepared for anastomosis relatively near the gastroesophageal junction  (figure 29). It is possible to mobilize the small gastric pouch into the field  by dividing the vagus nerves and incising the peritoneal attachments to  the fundus as well as to the splenorenal ligament. T e blood supply to the  remaining stomach will be adequate through the short gastric vessels and  in some patients a posterior gastric artery that originates from the splenic  artery. Such mobilization facilitates the anastomosis when the exposure is  otherwise difficult.   Regardless of the method used, it 1s important that the serosa be prop-  erly cleared for about the width of the index finger adjacent to the traction  sutures, A and B, and either curvature (figur e 30). One or more additional  sutures are usually required to adequately approximate the serosal surfaces  along the lesser curvature. T e stomach is now ready for the application of  a stapling instrument preparatory to division of the stomach. It 1s impor-  tant to stabilize the lesser as well as the greater curvature of the stomach by  means of either Allis or Babcock forceps, lest the gastric wall be distorted  as the crushing or sewing clamps are applied across the areas of both cur-  vatures that have been previously prepared (figure 30). Various methods  of reconstruction may then employed as shown in Chapters 28, 29 and 30,  however Roux-en-y gastrojeyunostomy (Chapter 33) is preferred. m    Details of ProceDure In cases of malignancy of the stomach, it is  desirable to resect the greater omentum, because it allows for improved  removal of lymph nodes along the greater curvature of the stomach and  because of the possibility of metastatic implants in this structure. Removing  the omentum is not difficult and can commonly be effected with less tech-  nical effort than dividing the gastrocolic ligament adjacent to the greater  curvature of the stomach (see Chapter 26, figures 8 to 10). For this rea-  son, some prefer to use this procedure rather routinely, regardless of the  indication for subtotal gastrectomy. T e transverse colon is brought out of  the wound, and the omentum is held sharply upward by the operator and  assistants (figure 1). Using scissors of the Metzenbaum type, dissection is  started at the right side, adjacent to the posterior taenia of the colon. In many  instances the peritoneal attachment can more easily be divided with a scalpel  or electrocautery than with scissors. A thin and relatively avascular peritoneal  layer can be seen, which can be rapidly divided (figures | to 3). Upward  traction is maintained on the omentum as blunt gauze dissection 1s utilized  to sweep the colon downward, freeing it from the omentum (figure 2).  As the dissection progresses, a few small blood vessels in the region of the   anterior taenia of the colon may require division and ligation. Finally,  the thin, avascular peritoneal layer can be seen above the colon. T 1s is  incised, giving direct entrance into the lesser omental sac (figur es 4 and 5).  In the obese individual it may be easier to divide the attachments of the    omentum to the lateral abdominal wall just below the spleen as a prelimi-  nary step. Ifthe upper margin of the splenic flexure can be visualized clearly,  the splenocolic ligament is divided and the lesser sac entered from the lef  side rather than from above the transverse colon, as shown in figure 6.  T e surgeon should be on guard constantly to avoid injuring the splenic  capsule of the middle colic vessels, since the mesentery of the transverse  colon may be intimately attached to the gastrocolic ligament, especially on  the right side. As the dissection progresses toward the lef , the gastrocolic  omentum is divided, and the greater curvature of the stomach 1s separated  from its blood supply to the desired level (figure 6). In some instances it  may be easier to ligate the splenic artery and vein along the superior sur-  face of the pancreas and remove the spleen, especially if there is a malig-  nant growth in this location. It should be remembered that if the lef gastric  artery has been ligated proximal to its bifurcation, and the spleen has been  removed, the blood supply to the stomach has been so compromised that  the surgeon is committed to total gastrectomy.   In the presence of malignancy the omentum over the head of the pan-  creas 1s removed, as well as the subpyloric lymph nodes (figur e 7). Small,  curved clamps should be utilized as the wall of the duodenum is approached,  and the middle colic vessels, which may be adherent to the gastrocolic liga-  ment in this location, should be carefully visualized and avoided before the  clamps are applied. Unless care is exercised, troublesome hemorrhage and  a compromised blood supply to the colon may result. m    IndIcatIons T e Polya procedure, or a modification of it, is one of the  safest and most widely used repairs after extensive gastric resections have  been performed, whether for ulcer or cancer.    detalls of Procedure T e schematic drawing (figure 1) shows the  position of the viscera after this operation is completed, which in principle  consists of uniting the jejunum to the open end of the stomach. T e jejunum  may be anastomosed either behind or in front of the colon. In the retrocolic  anastomosis, a loop of jejunum is brought through a rent in the mesentery of  the colon to the left of the middle colic vessels and near the ligament of Treitz  (figure 2). In the antecolic anastomosis, a longer loop must be used 1n order  to pass in front of the colon freed of fatty omentum. If the resection has been  done for ulcer to control the acid factor, it 1s important that the afferent jeyu-  nal loop be made reasonably short, since long loops are more prone to subse-  quent marginal ulceration. T ejeyunum is grasped with Babcock forceps and  brought up through the opening made in the mesocolon, with the proximal  portion in juxtaposition to the lesser curvature of the stomach (figure 2).  With the Polya technique the gastrojejunostomy uses the entire length of the  stomach and jeyunum for the anastomosis. T e Hofmeister technique shown  in Chapter 29 is an alternative in which only a portion of the gastric length is  used for the anastomosis (Chapter 29, figure 1). T e jejunal loop is approxi-  mated to the posterior surface of the stomach adjacent to the staple line by a  layer of closely placed, interrupted 00 silk mattress sutures (figure 3). T is  posterior row should include both the greater curvature and the lesser cur-  vature of the stomach. Otherwise, subsequent closure of the angles may be  insecure. T e ends of the sutures are cut, except those at the lesser and greater  curvatures, B and A, which are retained for purposes of traction (figure 4).  T e border of the stomach is cut away with scissors or electrocautery. An  opening is made lengthwise in the jejunum, approximating in size the open-  ing in the stomach. T e fingers hold the jejunum down fat, and the incision  is made close to the suture line (figur e 5).   T e mucous membranes of the stomach and jejunum are approximated  by a continuous mucosal absorbable synthetic suture as the opposing  surfaces are approximated by Allis clamps applied to either angle (figure 6).    A continuous suture is started in the middle and is carried toward either  angle as a running suture or as an interlocking continuous suture, if pre-  ferred. T e corners are inverted with a Connell-type suture that is con-  tinued anteriorly, and the final knot is tied on the inside of the midline  (figure 7). Some prefer to approximate the mucosa with multiple inter-  rupted 000 silk sutures. T e anterior layer is closed with the knots on the  inside by using an interrupted Connell-type suture. T e anterior serosal  layers are then approximated with interrupted 00 silk sutures (figure 8).  Finally, at the upper and lower angles of the new stoma, additional sutures  are placed so that any strain exerted on the stoma 1s met by these addi-  tional reinforcing serosal sutures and not by the sutures of the anastomosis  (figure 9). In the retrocolic anastomosis the new stoma is anchored to the  mesocolon with interrupted sutures, care being taken to avoid blood vessels  in the mesocolon and prevent the small bowel from herniating through the  mesocolon (figure 10).   Pulmonary complications are common; therefore the patient is encour-  aged to cough and sit upright. If the patients’ condition warrants, he or she  may be out of bed on the first day after operation. Water in sips 1s allowed  24 hours after operation. Constant gastric suction is maintained during the  procedure and for a few days after operation. It may be discontinued when  clinical signs of GI function return. After the nasal tube is removed, the  patient may be placed on a postgastrectomy diet regimen that progresses  gradually from bland liquids to six small feedings per day. Beverages con-  taining caffeine, excessive sugar, or carbonation should be avoided. An  additional daily intake of fats should be encouraged for those patients well  below their ideal body weight. Frequent evaluation of the patient’s dietary  intake and weight trends is strongly advised during the first year after sur-  gery and at longer intervals thereafter for at least 5 years. m    Details of ProceDure T e schematic drawing shows the position  of the viscera after this operation is completed, along with the alternative  antecolic placement of the jejunal loop. In principle, this technique consists  of closing about one-half of the gastric outlet adjacent to the lesser cur-  vature and performing a gastrojejunal anastomosis adjacent to the greater  curvature, with approximation of the jejunum to the entire end of the gas-  tric remnant (figure 1). Alternatively a Roux-en-Y reconstruction should  be considered in some cases to avoid significant bile reflux that can occur  with a small gastric pouch. T 1s operation is favored when very high resec-  tions are indicated, because it provides a safer closure of the lesser curva-  ture. It may also retard sudden overdistention of the jejunum after eating.  T e jejunum may be brought up either anterior to the colon or through an  opening in the mesocolon to the left of the middle colic vessels (Chapter 28,  figure 2).   T ere are many ways of closing the opening of the stomach adjacent to  the lesser curvature. Linear cutting or noncutting staplers are most com-  monly used as the staple line can be cut of at the site of the anastomosis.  T e older but ef ective Payr clamp is shown (figure 2), as it provides a  protruding cuf of gastric wall in situations where stapling instruments are  not available.   T e Staple line adjacent to the greater curvature is grasped with Babcock  forceps to ensure a stoma approximately two fingers wide. A continuous  absorbable synthetic material on a curved needle is started in the mucosa,  which protrudes beyond the clamp in the region of the lesser curvature, and  is carried downward toward the greater curvature until the Babcock forceps  defining the upper end of the stoma is encountered (figur e 3). Some prefer  to approximate the mucosa with interrupted 000 silk sutures. T e crush-  ing clamp is then removed, and an enterostomy clamp is applied to the  gastric wall. A layer of interrupted mattress sutures of 00 silk is placed to  invert either the mucosal suture line or the stapled gastric wall (figure 4).  It should be carefully ascertained that a good serosal surface approximation  has been ef ected at the very top of the lesser curvature. T e sutures are not  cut but may be retained and subsequently utilized to anchor the jejunum to  the anterior gastric wall along the closed end of the gastric pouch.   A loop of jejunum adjacent to the ligament of Treitz is brought up ante-  rior to the colon or posteriorly through the mesocolon in order to approxi-  mate it to the remaining stomach. T e jejunal loop should be as short as    possible but must reach the line of anastomosis without tension when the  anastomosis 1s completed. An enterostomy clamp is applied to the portion  of jejunum to be used in making the anastomosis. T e proximal portion of  the jejunum is anchored to the lesser curvature of the stomach. An enteros-  tomy clamp is maintained on the gastric remnant unless this is impossible  because of its high location. Under these circumstances it is necessary to  make the anastomosis without applying clamps to the stomach.   T e posterior serosal layer of interrupted mattress sutures of 00 silk  anchors the jejunum to the entire remaining end ofthe stomach. T isisdone  to avoid undue angulation of the jejunum; it removes strain from the site of  the stoma and reinforces the closed upper half of the stomach posteriorly  (figure 5). Following this, the crushed or stapled gastric wall still retained  in the Babcock forceps is excised with scissors, and any active bleeding  points are tied (figure 6). T e contents of the stomach are aspirated by  suction unless it has been possible to apply an enterostomy clamp on the  gastric side. T e mucosa of the stomach and the jejunum toward the greater  curvature are approximated by a continuous fine double ended absorbable  suture on an atraumatic needle (figure 7). Some prefer interrupted sutures  of 000 silk. A Connell-type stitch is used to invert the angles and the ante-  rior mucosal layer (figure 8). A layer of interrupted mattress sutures is  continued anteriorly from the closed portion to the margin at the greater  curvature. Both the angles of the lesser and greater curvatures are reinforced  with additional interrupted sutures. T e long tails retained from closing the  upper portion of the stomach are rethreaded on a spring-eye French needle  (if still available to the surgeon). Otherwise, new nonabsorbable sutures  are placed (figure 9). T ese sutures are utilized to anchor the jeyunum to  the anterior gastric wall and buttress the closed end of the stomach anter1-  orly, as was previously done on the posterior surface. T e stoma is tested for  patency as well as for the degree of tension placed on the mesentery of the  jejunum. T e transverse colon is adjusted behind the jejunal loops going to  and from the anastomosis. If a retrocolic anastomosis has been performed,  the margins of the mesocolon are anchored to the stomach about the anas-  tomosis (Chapter 28, figure 10).    closure T e wound is closed in the routine manner. Retention sutures  should be used in emaciated or cachectic patients.    IndIcatIons T e Billroth II gastric resection is one of the most com-  monly performed procedures for malignancy of the stomach or for the  control of gastric hypersecretion in the treatment of ulcer. T e extent of the  resection varies, with a two-thirds to three-fourths resection being the most  common. When the left gastric vessels are ligated, 75% or more of the stom-  ach is resected with the major blood supply coming from the gastrosplenic  circulation. In the presence of carcinoma involving the body of the stom-  ach, all the lymph nodes along the lesser curvature up to the esophagus  are resected. T e greater omentum is also removed, along with any lymph  nodes about the right gastroepiploic vessels. When a malignancy is near  the pylorus, 2 to 3 cm at least of the duodenum distal to the pylorus should  be resected (see discussion in Chapter 26). Sometimes only a rim of gas-  tric mucosa remains attached to the esophagus, which may require recon-  struction with sutures rather than with the stapler. Consideration should be  made for laparoscopic resection in cases without a contraindication such as  extensive previous operations or large bulky tumors.    PosItlIon T e patient is placed supine on the table in a modest reverse  Trendelenburg position.    o Perat Ive PreParatlon T eskin of the lower chest and upper abdo-  men is shaved and prepared in a routine manner with antiseptic solutions.  Preoperative antibiotics are administered.    IncIslon and exPosure Anupper midline incision is made. If a high  resection is indicated, the xiphoid process is resected and the left lobe of  the liver may be freed and folded toward the right side after dividing the  triangular ligament.    detalls of Procedure T eentire omentum is usually freed from the  transverse colon, including both flexures in the presence of malignancy  (see Chapter 27, Omentectomy). It is technically easy to remove the greater  omentum by the technique shown in Chapter 27, figures | to 5.T e supe-  rior and inferior borders of the duodenum are partially freed to permit  mobilization and ligation of the duodenal opening by a non-cutting lin-  ear stapler or a cutting linear stapler if there is adequate length. A Kocher  clamp is applied across the pyloric end of the stomach or duodenum just  beyond the point where the staple line is divided with a knife if using a  non-cutting linear stapler (figure 1). T e duodenum should be disturbed  as little as possible when a posterior penetrating ulcer is known to be pres-  ent, lest perforation into the ulcer crater occur with subsequent leakage.   T e lesser and greater curvatures at the level selected for resection are  freed of fat in preparation for the placement of the linear stapler in a similar    fashion, using staples of adequate length for a thickened or edematous  stomach (figure 1). T e nasogastric tube is retracted before the stapler is  applied. Straight Kocher clamps are applied on the specimen side from either  curvature, and the stomach is divided with a scalpel applied against the sta-  pler if a non-cutting stapler is used. Additional sutures may be required to  control bleeding in the staple line. T e extent of stomach removed and the  performance of vagotomy are both related to the indications for the resection.   T ejeyunum just beyond the ligament of Treitz is selected for the anas-  tomosis. It must be sufficiently long to easily reach the gastric pouch, but  extra-long loops are avoided. While the loop of jejunum may be brought up  through an opening made in the avascular portion of the transverse meso-  colon to the left of the middle colic vessels (retrocolic position), many bring  the loop of jejunum up over the transverse colon (antecolic position). A  thick, fat omentum should either be resected or split to permit the shortest  loop of bowel to be used.   T ere are various options for performing the anastomosis between the  gastric pouch and the jejunum. T e anastomosis may span the full width of  the stomach, with the stoma made either anterior or posterior to the suture  line closing the stomach. Usually the proximal jejunum is anchored to the  lesser curvature (figure 2). An anastomosis to the posterior gastric wall is  commonly made as illustrated. T e jejunum is anchored to the full width  of the posterior gastric wall, perhaps 3 cm proximal to the line of staples  occluding the stomach. Babcock forceps or sutures can be used to fx the  jejunum in place parallel to the gastric wall. Stab wounds are made either  with a scalpel or cautery on the greater curvature end and the distal end of  the jejunum limb to permit the introduction of the cutting linear stapler  blades (figure 2). T e size of the anastomosis is governed by the depth to  which the blades are inserted (figure 3). When the cutting linear stapler  is removed, the staple lines are inspected for bleeding, which may require  a few sutures for control. Finally, the stab wounds are approximated with  traction sutures (figure 4) or Allis clamps and stapled shut with the non-  cutting stapler (figure 5). Additional interrupted sutures are added when  bleeding is present, and the jejunum may be anchored to the lesser curve to  remove any possible tension on the suture lines. T e patency of the stoma  is tested by fnger palpation (figure 6). T e nasogastric catheter is then  passed for some distance into the distal jejunum to provide early decom-  pression followed within a day or two by the administration of liquid diet  upon resumption of peristaltic activity of the gastrointestinal tract.    Posto Perat Ive care Fluid and electrolyte balances are maintained  and the blood volume is restored. Liquids in small amounts are permit-  ted within 24 hours. Early ambulation is encouraged. T e stomach tube is  removed as soon as there is clinical evidence of gastric emptying. =    IndIcatlIons Total gastrectomy may be indicated in treating extensive  stomach malignancies. T is radical procedure is not performed when car-  cinoma with distant metastasis to the liver or pouch of Douglas or seeding  throughout the peritoneal cavity is present. It may be performed in asso-  ciation with the extirpation of adjacent organs including the spleen, body  and tail of the pancreas, or a portion of the transverse colon. It is also the  procedure of choice in controlling the intractable ulcer diathesis associated  with non-beta islet cell tumors of the pancreas when pancreatic tumor or  metastases remain that cannot be controlled medically.    Preo PeratIve PreParatlon Electrolyte replacement and _ fluid  resuscitation should be complete. If colonic involvement is anticipated, the  colon should be emptied with appropriate mechanical preparation. Blood  should be readily available for transfusion.    PoslItlIon T e patient is placed in a comfortable supine position on the  table with the feet slightly lower than the head.    o PeratIve PreParatlon T earea ofthe chest from above the nipple  downward to the symphysis is shaved. T e skin over the sternum, lower  chest wall, and entire abdomen is cleansed with the appropriate antiseptic  solution. Preparation should extend sufficiently high and to the left on the  chest for a midsternal or left thoracoabdominal incision if necessary.    IncIslon and exPosure A diagnostic laparoscopy is often performed  first to rule out inoperable spread of a malignancy (Chapter 13). If this view  is clear, then a limited incision is made in the midline (figure 1, a—a))  between the xiphoid and umbilicus. T e initial opening is only to permit  inspection of the stomach and liver and to introduce the hand for general  exploration of the abdomen. Because of the high incidence of metastases,  a more liberal incision extending up to the region of the xiphoid and down  to the umbilicus, or beyond it on the left side, is not made until it has been  determined that there is no contraindication to total or subtotal gastrec-  tomy (figure 1). Additional exposure is allowed by removal of the xiphoid.  Active bleeding points in the xiphocostal angle are transfixed with 00 silk  sutures, and bone wax may be applied to the end of the sternum. Some    prefer to split the lower sternum in the midline and extend the incision to  the left into the fourth intercostal space. Adequate exposure is mandatory  for a safe anastomosis between the esophagus and jejunum.    detalls of Procedure Total gastrectomy should be considered for  malignancy high on the lesser curvature if there is no metastasis to the liver  or seeding over the general peritoneal cavity, particularly in the pouch of  Douglas (figure 2). Before the surgeon is committed to a total gastrectomy,  he or she must have a clear view of the posterior aspect of the stomach to  determine whether the growth has extended into the adjacent structures  including the pancreas, mesocolon, or major vessels (figure 3). T 1s can  be assessed by reflecting the greater omentum upward, withdrawing the  transverse colon from the peritoneal cavity, and searching the transverse  mesocolon for evidence of invasion. By palpation the surgeon should deter-  mine that there is free mobility of the growth without involvement of fixa-  tion to the underlying pancreas or major vessels, especially in the region of  the left gastric vessels (figure 4).   T e entire transverse colon, including the hepatic and splenic flexures,  should be freed from the omentum and retracted downward. As the omen-  tum is retracted cephalad and the transverse colon caudad, the venous  branch between the right gastroepiploic and middle colic veins is visual-  ized and ligated to avoid troublesome bleeding. T e greater omentum in  the region of the head of the pancreas and the hepatic flexure of the colon  is freed so that it can be entirely mobilized from the underlying head of the  pancreas and duodenum.   Following the exploration of the lesser sac, the surgeon further mobi-  lizes the stomach. If the tumor appears to be localized, even if it is large and  involves the tail of the pancreas, colon, and kidney, a very radical extirpa-  tion may be carried out. Resection of the left lobe of the liver may occasion-  ally be necessary.   To ensure complete removal of the neoplasm, at least 2.5-3 cm of duo-  denum distal to the pyloric veins should be resected (figure 2). Since it is  not uncommon to have metastasis to the infrapyloric lymph nodes, they  should be included in the resection. T is is accomplished by doubly ligating  the right gastroepiploic vessels as far away from the interior surface of the  duodenum as possible (figure 5).    detalls of Procedure T e right gastric vessels along the  superior margin of the first part of the duodenum are isolated and doubly  ligated some distance from the duodenal wall (figur e 6). Palpation for poten-  tially involved lymph nodes in the portal area is performed. If dissection is to  be done, the surgeon must carefully identify and preserve the common hepatic  and gastroduodenal arteries as well as the portal vein and common bile duct.  T e gastrohepatic ligament is divided as near the liver as possible up to the  thickened portion, which contains a branch of the inferior phrenic artery.   T e duodenum is divided with noncrushing straight forceps on the duo-  denal side and a crushing clamp, such as a Kocher, on the gastric side, or  it may be divided with a linear cutting or non-cutting stapler (figure 7).  When clamps are used, the duodenum is divided with a scalpel. A sufficient  amount of the posterior wall of the duodenum should be freed from the  adjacent pancreas, especially inferiorly, where a few vessels may enter the  wall of the duodenum (figure 8). Even if it is extensively mobile, the duo-  denal stump should not be anastomosed to the esophagus because of subse-  quent esophagitis from the regurgitation of duodenal juices. If not stapled,  the duodenal stump can be closed with sutures in a single or double layer. If  stapled some surgeons prefer to oversew the staple line on the duodenum.    T eregion of the esophagus and fundus is next exposed and mobilized  medially. T e avascular suspensory ligament supporting the left lobe of the  liver is divided, and the surgeon grasps the left lobe with the right hand  and defines the limits of the avascular suspensory ligament from under-  neath by upward pressure with the index finger (figure 9). Occasion-  ally, a suture will be required to control oozing from the very tip of the  mobilized left lobe of the liver. T e left lobe should be carefully palpated  for evidence of metastatic nodules deep within the substance of the liver.  T e mobilized left lobe of the liver is folded upward and covered with a  moist pack, over which a large S retractor is placed. At this time the need  for upward extension of the incision, or removal of the xiphoid process  should be considered. T e uppermost portion of the gastrohepatic liga-  ment, which includes a branch of the inferior phrenic vessel, is isolated  by blunt dissection. Two right-angle clamps are applied to the thickened  tissues as near the liver as possible. T e tissues between the clamps are  divided and the contents of the clamps ligated with transfixing sutures  of 00 silk (figure 10). T e incision in the peritoneum over the esopha-  gus and between the fundus of the stomach and base of the diaphragm is  outlined in figure 10.    detalls of Procedure T e peritoneum over the esoph-  agus is divided and all bleeding points are carefully ligated. Several small  vessels may require ligation when the peritoneum between the gastric fun-  dus and base of the diaphragm is separated. T e lower esophagus is freed  by finger dissection similar to the technique of vagotomy (Chapter 23). T e  vagus nerves are divided to further mobilize the esophagus into the peri-  toneal cavity. By blunt and sharp dissection, the left gastric vessels are 1so-  lated from adjacent tissues (figure 11). T ese vessels should be encircled  with the surgeon’ index finger and carefully palpated for evidence of meta-  static lymph nodes. A pair of clamps, such as curved half-lengths, should  be applied as close as possible to the point of origin of the left gastric artery,  and a third clamp applied nearer the gastric wall. T e contents of these  clamps are first ligated and then transfixed distally. Alternatively, these ves-  sels may be ligated using a vascular cutting linear stapler. Likewise, the left  gastric vessels on the lesser curvature should be ligated to enhance the sub-  sequent exposure of the esophagogastric junction. Depending on the loca-  tion of the tumor and the findings on palpation, the surgeon may decide  upon further celiac and preaortic lymph node dissection.   When the tumor is near the greater curvature in the midportion of the  stomach, it may be desirable to remove the spleen and tail of the pancreas  to assure an en bloc dissection of the immediate regional lymphatic drain-  age zone. T e location and extent of the tumor, as well as the presence or  absence of adhesions or tears in the capsule, determine whether the spleen  should be removed. If the spleen is to remain, the gastroplenic ligament is  divided as described for splenectomy (Chapter 90). T e left gastroepiploic  vessel is doubly tied. T e greater curvature is freed up to the esophagus.  Several vessels are usually encountered entering the posterior wall of the  fundus near the greater curvature.   T e anesthetist should aspirate the gastric contents from time to time to  prevent possible regurgitation from the stomach as it 1s retracted upward,  as well as peritoneal soiling when the esophagus is divided.   The duodenum is closed in two layers (see Chapter 26, figure 19).  The walls of the duodenum are closed with a first layer of interrupted  000 silk sutures. These are invaginated with a second layer of 000 silk  mattress sutures. Alternatively, the duodenum may be closed with a sta-  pling device.   One of the numerous methods that have been devised for reconstructing  gastrointestinal continuity following total gastrectomy is selected.    T e surgeon should keep in mind certain anatomic differences of the  esophagus, which make its management more difficult than that of the  rest of the gastrointestinal tract. First, since the esophagus is not covered  by serosa, the longitudinal and circular muscle layers tend to tear when  sutured. Second, the esophagus, while at first appearing to extend well  down into the abdominal cavity, may retract into the thorax when divided  from the stomach, leaving the surgeon hard-pressed for adequate length.  It should be mentioned, however, that if the exposure is inadequate, the  surgeon should not hesitate to remove more of the xiphoid or to split the  sternum with potential extension into the left fourth intercostal space.  Adequate and free exposure must be obtained to secure a safe anastomosis.   T e wall of the esophagus can be lightly anchored to the crus of the dia-  phragm on both sides, as well as anteriorly and posteriorly (figur e 12), to pre-  vent rotation of the esophagus or upward retraction. T ese sutures must not  enter the lumen of the esophagus. Two or three 0 silk sutures are placed pos-  terior to the esophagus to approximate the crus of the diaphragm (figure 12).   Many methods have been devised for facilitating the esophagojejunal  anastomosis. Some prefer to leave the stomach attached as a retractor until  the posterior layers have been completed. T e posterior wall of the esophagus  may be divided and the posterior layers closed before the stomach 1s removed  by dividing the anterior esophageal wall. In another method a noncrushing  vascular clamp of the modified Pace—Potts type can be applied to the esopha-  gus. Because the esophageal wall tends to tear easily, it is helpful to give sub-  stance to the wall of the esophagus and prevent fraying of the muscle layers  by fixing the mucosa to the muscle coats proximal to the point of division.  A series of encircling mattress sutures of 0000 silk can be inserted and tied,  using a surgeon’ knot (figure 13). T ese sutures include the full thickness of  the esophagus (figure 14). T e angle sutures, A and B, are used to prevent  rotation of the esophagus when it is anchored to the jejunum (figure 14).   T e esophagus is then divided between this suture line and the gastric  wall itself (figure 15). Soiling should be prevented by suction on the naso-  gastric tube as it 1s withdrawn up into the lower esophagus and a clamp 1s  placed across the esophagus on the gastric side. In the presence of a very  high tumor that reaches the gastroesophageal junction, several centime-  ters of esophagus should be resected above the tumor. If 2.5 cm or more of  esophagus does not protrude beyond the crus of the diaphragm, the lower  mediastinum should be exposed in order to ensure a secure anastomosis    detalls of Procedure T e next step consists of mobi-  lizing a long loop of jejunum, redundant enough so that it extends easily  to the open esophagus. T e jejunal loop is brought up through an opening  in the mesocolon just to the left of the middle colic vessels. T e region about  the ligament of Treitz may need to be mobilized to ensure that the jejunum  will reach to the diaphragm for easy approximation with the esophagus.  T e surgeon should be sure that the mesentery is truly adequate for the  completion of all the layers of the anastomosis.   Various methods have been used to assure better postoperative nutrition  and fewer symptoms following the complete removal of the stomach. A  large loop of jeyunum with an enteroenterostomy has been commonly used.  However, bile reflux and ensuing alkaline esophagitis may be lessened by  the Roux-en-Y reconstruction. Interposition of jejunal segments between  the esophagus and duodenum, including reversed short segments, has not  been found to be very satisfactory, and hence is uncommonly used.   Roux-en-Y reconstruction begins with division of the jejunum  approximately 30 cm beyond the ligament of Treitz. With the jejunum  held outside the abdomen, the arcades of blood vessels can be clearly  defined by transillumination (figure 16). Two or more arcades of blood  vessels are divided and a short segment of devascularized intestine may  need to be resected (figure 17). T e arm of the distal segment of jeju-  num is passed through the opening in the mesocolon to the left of the  middle colic vessels. Additional mesentery is divided if the end segment  of the jejunum does not easily extend up to and parallel with the crus    of the diaphragm behind the esophagus. When the adequate length has  been assured, the decision is made whether to perform an end-to-end  anastomosis or an end-to-side anastomosis with the esophagus. If the  end-to-side anastomosis is selected, the end of the jejunum 1s closed with  two layers of 000 silk sutures or stapled (figures 18 and 19). T e end of  the jejunum is then pulled through the opening made in the mesocolon  to the left of the middle colic vessels (figur e 20). Care must be taken to  avoid angulating or twisting the mesentery of the jejunum as it is pulled  through. T e jejunal wall is anchored about the margins of the hole in  the mesocolon. All openings in the mesocolon should be occluded to  avoid the possibility of an internal hernia. T e opening created beneath  the free margin of the mesentery and the posterior parietes should be  obliterated by interrupted sutures placed superficially, avoiding injury  to blood vessels.   T e length of jejunum should again be tested to make certain that the  mesenteric border can be approximated easily for 5 to 6 cm or more to  the base of the diaphragm behind the esophagus (figure 21). Additional  mobilization of the jejunal limb for a distance of 4 or 5cm may be secured  by making relaxing incisions in the posterior parietal peritoneum around  the base of the mesentery. Additional distance may be gained by very care-  fully incising the peritoneum both above and below the vascular arcade  along with a few short radial incisions toward the mesenteric border. T e  closed end of the jejunum is shown directed to the right, but more com-  monly it is directed toward the left.    detalls of Procedure Arowofinterrupted 00 silk sutures  is placed to approximate the jesunum to the diaphragm on either side of the  esophagus, as well as directly behind it (figur e 22). It is necessary to empha-  size that the arm of jejunum is anchored to the diaphragm to remove tension  from the subsequent anastomosis of the esophagus. After these anchor sutures  are tied, angle sutures are placed in either side of the esophagus and jejunum  (figure 23,c,d). T e esophageal wall should be anchored to the upper side  of the jesunum. An effort should be made to keep the interrupted sutures close  to the mesenteric side of the jejunum, since there is a tendency to use all the  presenting surface of the jeyunum in the subsequent layers of closure. T ree or  four additional interrupted 00 silk mattress sutures, which include a bite of the  esophageal wall with the serosa of the bowel, are required to complete the clo-  sure between the angle sutures, C and D (figur e 24). A small opening is then  made into the adjacent bowel wall with the jejunum under traction so that    during the procedure there is no redundancy of the mucosa from too large an  incision. T ere isa tendency to make too large an opening in the jeyunum with  prolapse and irregularity of the mucosa, making an accurate anastomosis with  the mucosa of the esophagus rather difficult. A layer of interrupted 0000  silk sutures is used to close the mucosal layer, starting at either end of the  jejunal incision with angle sutures (figure 25, e, f). T e posterior muco-  sal layer is closed with a row of interrupted 0000 silk sutures (figure 26).  T e Levin tube may be directed downward into the jejunum (figure 27).  T e presence of the tube within the lumen tends to facilitate the placement  of the interrupted Connell-type sutures closing the anterior mucosal layer  (figure 27). An additional layer will be added as carried out posteriorly.  T erefore, when the jejunum is anchored to the diaphragm, the wall of the  esophagus, and the mucosa of the esophagus, a three-layered closure is pro-    detalls of Procedure T e second layer of interrupted  000 silk sutures is completed anteriorly (figur e 29). Next, the peritoneum,  which has been initially incised to divide the vagus nerve and mobilize the  esophagus, is brought down to cover the anastomosis and anchored with  interrupted 000 silk sutures to the jeyunum (figure 30). T is ensures a  third layer of support that extends all the way anteriorly around the esoph-  ageal anastomosis and takes any tension off the delicate line of anastomosis  (figure 31). T ecatheter can be extended well down the jejunum through  the opening in the mesocolon to prevent angulation of the bowel. A num-  ber of superficially placed fine sutures are taken to anchor the edge of the  mesentery to the posterior parietes to prevent angulation and interference  with the blood supply (figure 31). T ese sutures should not include pan-  creatic tissues or vessels in the margin of the jejunal mesentery. T e color  of the arm of the jejunum should be checked from time to time to make  sure the blood supply is adequate. T e open end of the proximal jejunum  (figure 32, Yon figure 16, 17 and 21 page 105) is then anastomosed at an  appropriate point in the jejunum (figure 32, X on figure 16, 17 and 20  page 105) with two layers of 0000 silk, or a side-to-side linear stapled tech-  nique. T e opening into the mesentery beneath the anastomosis is closed  with interrupted sutures to prevent any subsequent herniation. figur e 32a  is a diagram of the completed Roux-en-Y anastomosis. Some surgeons use  closed suction external drains placed in proximity to the duodenal stump  and the esophagojejyunostomy.    Posto PeratIve care Suction is maintained through the nasojejunal  tube, which has been threaded through and beyond the anastomosis. T e    patient is ambulated on the first postoperative day, and a gradual increase in  activity is encouraged. Clear liquids may be given in limited amounts after  24 hours. Oral feedings are begun once the integrity of the anastomosis is  established with a fluoroscopic water-soluble contrast study. T ese patients,  of course, will need frequent small feedings, and adequate caloric intake  may bea problem. T is calls for careful collaboration between patient, sur-  geon, and dietitian. In addition, long-term supplemental vitamin By will be  necessary, and oral iron and vitamins may be indicated for life.   Initially, scheduled reevaluations at intervals of 6 to 12 months are  advisable to assess caloric intake. Stenosis of the suture line may require  dilatations.   Total gastrectomy is rarely performed to control the hormonal effects of  a gastrinoma. It is usually reserved for gastric acid hypersecretion refrac-  tory to medical treatment or patients with complications such as gastrocolic  fistula. If the patient does have a gastrinoma, then serum gastrin levels are  taken to evaluate the presence and progress of residual tumor or metasta-  sis. Blood calcium levels are also advised to document hyperparathyroidism  that may be present in multiple endocrine neoplasia type I. If hypercalcemia  is present, the possibility of multiple endocrine neoplasia should be inves-  tigated in all members of the patient’ family. Long-term follow-up studies  should include determination of serial serum gastrin, calctum, parathor-  mone, prolactin, cortisol, and catecholamine levels. Evidence of recurrent  hyper-parathyroidism is not uncommon. Normal fasting serum gastrin lev-  els may become elevated if residual gastrin-producing tumor is present. T e  presence of one endocrine tumor is an indication to search for others over  the years of follow-up observation. m=    IndIcatlIons T e indications and preoperative preparations are spe-  cific and are reviewed in Chapter 31, where the commonly used methods  of reconstruction are shown with hand-sewn anastomoses. Many surgeons,  however, prefer to use staples, because they simplify the anastomoses and  lessen the total time of this operation.    PosIt Ion Exposure is enhanced if the patient is placed in a reversed  Trendelenburg position.    o Perat Ive PreParatlon T eskin over the lower thorax as well as the  abdomen is shaved and cleansed with the appropriate antiseptic solution.    IncIslon and exPosure A_ diagnostic laparoscopy is often per-  formed first to rule out inoperable spread of a malignancy. If this is clear,  then a midline incision starting over the xiphoid and extending down to  the umbilicus is made initially. T is permits abdominal exploration and  enables the surgeon to make a decision for or against proceeding with total  gastrectomy. T e incision is usually extended to the left and below the  umbilicus if the decision is made to proceed with total gastrectomy. In the  absence of metastases to the liver, peritoneum, omentum, and pelvis, the  greater omentum is completely freed from the transverse colon. T 1s per-  mits evaluation of the posterior wall of the stomach as well as an evaluation  for metastases about the left gastric vessels and attachments to the pancreas.  Excision of the xiphoid provides a better exposure of the esophagogastric  junction, along with medial mobilization of the left lobe of the liver follow-  ing the division of the suspensory ligament to this lobe. An outline ofa final  reconstruction is shown in figure I.    detalls of Procedure As in Chapter 31, the region of the duode-  num is first mobilized by the Kocher maneuver, and the blood supply  about the pylorus ligated to prepare only the duodenal wall for the appli-  cation of the stapler. T e right gastroepigastric vessels are doubly ligated  as far away from the duodenal wall as possible to ensure the inclusion of  any possible lymph node metastases. T e right gastric blood supply to  the superior surface of the duodenum should also be divided and ligated  to ensure the removal of 2.5 to 3 cm of duodenum distal to the pyloric  vein, if the procedure is being performed for gastric carcinoma. T e  duodenum is closed with a non-cutting linear stapler. T e duodenum is  divided between the stapler and the Kocher clamp on the pyloric end of  the duodenum. Alternatively the duodenum may be divided with a lin-  ear stapler. T e entire stomach, along with the omentum and the gastric  hepatic ligament, is then mobilized as shown in Chapter 31. T e gastric    vessels are divided and ligated in the presence of cancer of the fundus of the  stomach. T e spleen may also be resected, but this is indicated only if the  spleen is involved with local spread of the tumor.   A good clear exposure of the lower esophagus is essential, along with  the margins of the esophageal hiatus. Since the esophagus tends to retract  upward when divided, it is helpful if the esophagus is pulled gently down-  ward after vagotomy and anchored to the margins of the hiatus with four  or five interrupted sutures that include only a modest bite of the esophageal  wall (figure 2). T is ensures 5 or 8 cm of nonretractable esophagus below  the hiatal opening. T e crus of the diaphragm should be approximated  posterior to the esophagus, allowing a reasonable-sized opening.   T e nasogastric tube is retracted, and the modified Furniss clamp  is applied to the esophagus above the gastric junction (figure 2). T e  esophagus is divided against the clamp after a monofilament polypropyl-  ene suture on a straight needle has been inserted. T is resection line must  be close to the clamp to ensure a safe and secure closure by the stapler. It 1s  also acceptable to divide the esophagus and place a purse-string freehand.  T ejeyunum about 30 cm below the ligament of Treitz is exposed, and the  blood supply in the mesentery studied to ensure a good blood supply to the  mobilized arm of jeyunum, which should be 50 to 60 cm long. T e division  of the jejunum and mesenteric blood vessels is demonstrated in figures 16  and 171n Chapter 31.   T e divided jejunum is brought up through an opening in the avascu-  lar area to the left of the middle colic vessel. Special attention is required  to avoid twisting the section of jejunum or in any way interfering with its  blood supply. T e jejunum is anchored to the margin of the opening, which  must be closed to avoid internal herniation. T e limb must extend easily up  to the end of the esophagus as well as 5 to 8 cm beyond to provide entrance  for the stapler to effect the esophagojejunal anastomosis (figure 3).   T e blood supply to the end of the jejunal limb is reconfirmed to be  strong and adequate. T e esophageal size is measured (figure 4) with a  calibrated sizing instrument. Some prefer to dilate the end of the esophagus  by inserting a Foley catheter (size 16 French) into the lower esophagus and  injecting 7 to 10 cm of saline, which gently dilates the end of the esopha-  gus for the easier introduction of the anvil of the stapler. T 1s may permit  the introduction of a larger stapler. T e appropriately sized circular stapler  instrument is passed through the open end of the jejunum and directed  toward the antimesenteric surface. T e sharp plastic trocar on the end of  the circular stapler instrument is passed through the antimesenteric sur-  face of the small intestine. T e tilting anvil is inserted through the opening  made by the trocar and attached to the main portion of the circular stapler  instrument. T e tilted circular stapler cap is then carefully introduced into  the esophagus (figure 5).    detalls of Procedure T e security of the esophageal  purse string should be evaluated before the handle and cartridge are  approximated (figure 6). After verifying that the combined thickness of  the esophagus and jejunum is within the safe range of the staples, the cir-  cular stapler instrument is fired. Superficial interrupted sutures about the  anastomosis are added after the instrument has been opened, gently rotated,  and withdrawn. T e nasogastric tube is passed beyond the anastomosis.   T e open end of the jejunal limb is prepared for a stapled closure  (figure 7). Once again, the non-cutting linear stapler should be applied to  serosa and at an angle to ensure an adequate blood supply to the antimes-  enteric border. Some prefer to place several sutures to anchor the arm of the  jeyunum posteriorly. T is removes tension from the suture line and ensures  against possible rotation.   T e reestablishment of the gastrointestinal tract continuity beyond the  ligament of Treitz can be accomplished in many ways. T e afferent limb 1s con-  nected to the Roux-en-Y jejunal loop approximately 25 cm from the ligament  of Treitz and about 40 cm from the esophagojejunal anastomosis. A side-to-  side anastomosis is performed, using a cutting linear stapler introduced into  the antimesenteric sides of the jejunum (figure 8). T is anastomosis can be  accomplished like the enteroenterostomy of a Roux-en-Y. T e mucosal stab  wounds are then closed with a non-cutting linear stapler (figure 9).    T e construction of a pouch below the esophagojeyunal anastomo-  sis does not seem to have a significantly beneficial effect on long-term  nutrition.   T etwo jejunal limb mesenteries are approximated to eliminate potential  internal hernia. T e adequacy of the blood supply of each limb is verified,  especially at the critical point near the anastomosis.    Posto PeratlIve care Fluid and electrolyte balance are maintained  during the initial postoperative period. Early ambulation is encouraged.  Clear liquids are given in limited amounts after 24 hours. Oral feed-  ings are begun once the integrity of the anastomosis is established with  a fuoroscopic water-soluble contrast study. T e patient is instructed in  the value of six small feedings per day initially and is gradually advanced  to three regular meals. T e patient and family require reassurance that  long-term problems concerning eating should be minimal. T e weight  should slowly increase, unless a diagnosis of extensive malignancy has  been verified. Vitamin By injections must be given monthly along with a  monthly dietary survey and nutritional evaluation. T ese monthly visits  with reassurance can be helpful to the patient in returning the caloric  intake toward normal during the first year after operation (see also dis-  cussion at Chapter 31). m=    IndIcatlIons T e diversion of bile away from the gastric outlet that has  been altered by pyloroplasty or some type of gastric resection may be ind1-  cated in an occasional patient with persistent and severe symptomatic bile  gastritis.    Preo Perat Ive PreParatlIon A firm diagnosis of postoperative reflux  gastritis should be established. Endoscopic studies should demonstrate  gross as well as microscopic evidence of severe gastritis of greater inten-  sity than is routinely observed from the regurgitation of duodenal contents  through an altered gastric outlet. A gastric analysis is performed in a search  for evidence of previous complete vagotomy. Bartum studies and serum  gastrin determination are routinely performed. In addition to a firm clini-  cal diagnosis of postoperative reflux bile gastritis, there should be evidence  of persistent symptoms despite long-term intensive medical therapy. T e  operative procedure is designed to completely divert the duodenal contents  away from the gastric outlet. Ulceration will occur unless the gastric acidity  is controlled by a complete vagotomy combined with antrectomy.  Constant gastric suction by a nasogastric tube is maintained.    PosItlIon T e patient is placed in a supine position with the feet lower  than the head.    IncIslon and exPosure T e incision is made through the old scar  of the previous gastric procedure. T e incision should extend up over the  xiphoid since exploration of the esophagogastric junction may be required  to determine the adequacy of a previous vagotomy. Care is taken to avoid  accidental opening of loops of intestine that may be adherent to the  peritoneum.   Even when a previous vagotomy has been performed, it is advisable to  search for overlooked vagal fibers, especially the posterior vagus nerves,  unless firm adhesions between the undersurface of the left lobe of the liver  and upper stomach make such a search too hazardous.    T esite of the previous anastomosis is freed up to permit careful inspec-  tion and palpation for evidence of ulceration or stenosis, or evidence of a  previous unphysiologic procedure such as a long loop, angulation, or par-  tial obstruction of the jejunostomy. A patulous gastroduodenostomy may  be found (figure 1).   T e extent of the previous resection must be determined to be certain  that the antrum has been resected. A complete vagotomy as well as antrec-  tomy is mandatory as a safeguard against recurrent ulceration.    detalls of Procedure When a Billroth I procedure is to be con-  verted, it is essential to carefully isolate the anastomosis both anteriorly  and posteriorly before applying straight Kocher clamps to either side of the  anastomosis (figure 2). Because a Kocher mobilization and medial rota-  tion of the duodenum were previously made to ensure absence of tension  in the suture line, it is important to sacrifice as little duodenum as pos-  sible (figure 2). Unexpected injury to the accessory pancreatic duct or the  common duct may occur if further mobilization of the first portion of the  duodenum 1s carried out.   T e end of the duodenum is closed with a row of interrupted sutures  (figure 3), although many surgeons prefer to close the duodenum with  a double row of staples. T is suture line is then reinforced with a second  layer of interrupted silk sutures that bring the anterior duodenal wall down  to the pancreatic capsule. T e transverse colon is reflected upward, and  the upper jejunum from the ligament of Treitz downward for at least 40 to  50 cm is freed from any adhesions that may have followed previous opera-  tions. An arm of jeyunum (figure 4) is mobilized as shown in Chapter 31,  figures lo—20. T e end of the jejunum is closed with a double layer of  sutures. T is suture line is inverted by a second layer of interrupted 00 silk  sutures to evert the mucosal layer (figure 6); the angles should be securely  approximated. A retrocolic rather than an antecolic anastomosis is usually  made (figure 4) as the active limb 1s brought through an opening in the  mesocolon to the left of the middle colic vessels. T e open end of the Roux-  en-Y loop is closed in two layers. T e first is a running absorbable suture  (figure 5). Alternatively, this may have been stapled if the jeyunum was  divided with a cutting linear stapler instrument. A second layer of invert-  ing interrupted silk mattress sutures may be placed figure 6.    detalls of Procedure It is advisable to resect additional  stomach to be certain that all of the antrum has been removed. A noncrushing  clamp is applied across the gastric pouch to control bleeding and prevent gross  soiling, as well as to fix the gastric wall for the placement of sutures (figur e 7).  A two-layer anastomosis, end of stomach to side of jeyunum, is made with  the full width of the gastric outlet (figure 8).T eend ofthe jesunum should  not extend more than 2 cm beyond the anastomosis (figure 9). All open-  ings in the mesocolon are closed with interrupted sutures to avoid a possible  internal hernia and avoid a twist or angulation of the arm of jeyunum.   A jejunojejunal anastomosis is done at least 40 cm from the gastrojeju-  nal anastomosis (figure 10). A two-layer anastomosis is performed, and  all openings in the mesenteries are closed to avoid any chance of herniation    or obstruction about the anastomosis (figure ll). A long Levin tube is  directed through the anastomosis and may be directed around into the  duodenum to ensure decompression of the duodenal stump. After a thor-  ough search for needles, instruments, and sponges, and af rming a correct  count, the abdomen is closed.    Posto Perat Ive care Fluid and electrolyte balance are maintained.  Clear liquids are initiated on the first postoperative day, followed by gradual  advancement of oral intake. Ultimately, six small feedings a day are permit-  ted since slow gastric emptying is often a problem. Careful medical super vi-  sion 1s required to ensure a good result. =    IndIcatlIons Fundoplication may be considered in certain patients  with symptomatic reflux gastritis associated with esophagitis or refractory  to maximal medical therapy. Esophagitis with stricture and paraesopha-  geal hernia are other common indications. A preliminary trial of repeated  dilatations should be instituted when there is evidence of a stricture of the  lower end of the esophagus prior to fundoplication.   Substernal pain, especially in the recumbent position, difficulty in swal-  lowing, and recurrent bouts of aspiration pneumonia are commonly asso-  ciated with gastroesophageal reflux. Esophagoscopy should be performed  to assess for presence of hiatal hernia, esophagitis, esophageal stricture or  mass, and Barrett’ esophagus. Esophageal motility must be assessed by  either manometry or video barium esophagram demonstrating normal  motility. In the absence of erosive esophagitis, 24-hour pH monitoring  should be performed to provide objective evidence of acid reflux.   Surgical procedures are designed to prevent acid peptic reflux and to  restore normal sphincteric function. When reflux esophagitis is associated  with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and  pyloroplasty should be considered.    Preo PeratIve PreParat lon Pulmonary function studies are indi-  cated in patients with a history of aspiration pneumonia. Antacid therapy  is maintained. Systemic antibiotics may be given. Nasogastric intubation  should be instituted.    PosItlIon T e patient is placed in a comfortable supine position on the  table with the feet slightly lower than the head.    oPeratIve PreParatlon T e area from the nipples downward to  the symphysis is shaved. T e skin over the sternum, lower chest wall, and  the entire abdomen is cleaned with the appropriate antiseptic solutions.    IncIslon and exPosure A liberal incision starting over the xiphoid  and extending down the midline to the umbilicus is made (figure 1).  When the xiphoid is elongated, it is removed to enhance the exposure of  the esophagogastric junction. Active arterial bleeding in either xiphocostal  angle is controlled with a transfixing suture of 00 silk.    detalls of Procedure T e peritoneum is opened and the abdomen  explored with special attention given to the gallbladder, duodenal bulb, and  the size of the esophageal hiatus. A considerable portion of the stomach  may be up in the chest as a result of the enlarged hiatus opening.   It is important to develop good exposure of the margins of the esopha-  geal hiatus. T e exposure is improved by dividing the relatively avascular  triangular ligament of the left lobe of the liver and rotating it toward the  midline (figure 2). It is retracted medially by a large S retractor applied to  a moist pad placed over the mobilized left lobe (figure 3).   T e peritoneum over the esophagus 1s incised and the esophagus mobi-  lized with the index finger of the right hand (Chapter 23, figure 7). T e  vagus nerves are not divided unless the operative, laboratory, roentgeno-  graphic, and clinical studies verified gastric hypersecretion with evidence  of duodenal deformity and a concurrent drainage procedure such as a  pyloroplasty is also planned. It is important to divide and ligate the upper-  most portion of the gastrohepatic ligament in order to provide exposure for  the fundoplication. T e uppermost portion of the gastrohepatic ligament  is grasped by a long pair of right-angle clamps (figure 3). T e contents  between the clamps are divided, and each side 1s tied with 00 silk to ensure  adequate control of the left phrenic artery (figure 3). T 1s may include the  hepatic branch of the vagus nerve. T ecuf of peritoneum at the esophago-  gastric junction may include considerable extra tissue due to trauma from  the hiatus hernia. Additional sutures may be required to control bleeding in  this area. Such sutures must not include the vagus nerves unless vagotomy  is indicated by an associated duodenal ulcer and measured high acid val-  ues. T e peritoneum to the left of the esophagogastric junction should be  divided meticulously with great care to avoid tearing of the splenic capsule.   Downward traction with a rubber tissue (Penrose) drain about the  esophagus is maintained to completely reduce the funds of the stomach  into the peritoneal cavity. A small S retractor is introduced posterior to the  esophagus to provide exposure to the hiatus (figure 4). T e margins of the  hiatus are grasped with long Babcock forceps to facilitate the placement of  two or three interrupted sutures of 0 silk for closure of the hiatus posterior  to the esophagus (figure 4). T e hiatus is narrowed to the point where the  index finger can be inserted easily alongside the esophagus. Alternatively,  many surgeons prefer to size the opening with passage of a large esophageal  dilator usually ranging between 56 and 60 French.    detalls of Procedure T e efectiveness of the proce-  dure depends upon the adequacy of the fundoplication. It 1s important to  completely mobilize the fundus of the stomach by ligating the gastrosplenic  (short gastric) vessels and posterior draining veins of the gastric fundus  (figure 5). T is must be done carefully to avoid splenic injury. Some  prefer to ligate the vessel on the gastric side by a transfixing suture that  includes a portion of the gastric wall, alternatively a ultrasonic or bipo-  lar ligating device may be used. A rubber tissue (Penrose) drain is placed  around the esophagus to provide downward traction (figure 6). A large  (56—60 French) Maloney dilator is inserted into the esophagus before the  procedure to prevent undue compression of the esophageal lumen and  to ensure performance of a loose fundoplication. T e right hand is intro-  duced behind the fundus of the stomach to test the adequacy of the gastric  mobilization (figure 6). It is absolutely essential that sufficient fundus be  freed up to permit an easy wrap around the lower esophagus. As down-  ward traction is maintained on the esophagus with the rubber drain, the  right hand holds the gastric wall around the esophagus. One or more long  Babcock forceps are applied to the gastric wall on either side of the esopha-  gus (figure 7). Traction on both sets of forceps makes it unnecessary for  the hand of the surgeon to be in the wound. T e anterior and posterior gas-    tric walls are approximated with interrupted sutures of 00 silk (figure 7).  T ree interrupted sutures are adequate along a 2- to 3-cm distance. Each  suture should include a superficial bite in the esophageal wall and the  gastric wall as insurance against the fundoplication “slipping” downward  around the gastric cardia (figur e 8). In addition, many place an anchoring  suture between the gastric wrap and the crus or lateral esophageal wall. T is  also prevents downward migration of the fundoplication. T e large dila-  tor in the esophagus prevents undue constriction of the esophagus. After  the traction rubber drain and esophageal dilator are removed, the surgeon  introduces the index finger or thumb upward under the plicated gastric  wall. Neither undue constriction must exist nor further mobilization of the  greater curvature of the fundus be provided. T e area of the esophagus is  finally inspected to be certain that the vagus nerves have not been injured.  A pyloroplasty should be considered if the vagotomy is performed.    Posto PeratIvecare Clear liquids are given in limited amounts on  the first postoperative day, followed by a thick liquid diet for the first  several days. Gradual return to a full diet occurs over a several week  period. mg    IndIcatlIons Symptomatic gastroesophageal reflux disease is the most  common indication for laparoscopic fundoplication using the floppy  360-degree Nissen technique. T e clinical presentation and diagnostic  workup are described in detail in Chapter 34. Repeated episodes of aspira-  tion pneumonia or asthma triggered by reflux are significant indications.  Intolerance to medical management with proton pump inhibitors, noncom-  pliance with recommended medication regimens, and the cost of lifelong  medications represent additional indications for this procedure.    Preo Perat Ive PreParat Ion A full general medical evaluation 1s per-  formed and the usual preanesthesia testing is obtained. Esophageal func-  tion studies such as manometry or video esophagography are necessary in  order to plan for a full or partial fundoplication and to detect underlying  dysmotility not related to reflux. Special emphasis is placed upon the pulmo-  nary workup. Pulmonary function studies are needed in high-risk patients,  especially if recurrent episodes of aspiration pneumonia or asthma have  occurred. Antacids, acid blockers, and proton pump inhibitors are contin-  ued. Perioperative antibiotic coverage is optional.    anesthesIa General anesthesia with endotracheal intubation is used.  An orogastric (OG) tube is placed for gastric decompression.    PosItIon T e patient is placed in the supine split-legged or low lithot-  omy position with the arms out on arm boards or tucked in at the sides  (figure l). T e legs are spread sufficiently for the surgeon to be positioned,  but the thighs are only partially elevated. Elastic stockings or pneumatic  sequential compression stockings are put on the lower legs. T e patient is  placed in a reverse Trendelenburg position, with at least 30 degrees of eleva-  tion to the head of the table.    IncIslon and exPosure A combination of 5- and 10-mm ports are  placed as shown (figure 1). Following Veress needle access and perito-  neal insufflation, a 5- or 10-mm camera port is placed just to the lef of  the midline, 15 cm caudal to the xiphoid process using a closed technique.  Alternatively, an open Hasson technique may be used (Chapter 11). All four  quadrants of the abdomen are explored visually. Placement of each of the  other selected port sites begins with skin infiltration using a local anes-  thetic. T e local needle can then be passed perpendicularly through the  abdominal wall and its entry site verified. A 10-mm port is placed in the  lef midsubcostal position. Five-mm ports are placed in the epigastri1um    just to the right of the midline and through the falciform ligament, and in  the far lef subcostal positions. In order to expose the esophageal hiatus, a  self-retaining liver retractor may be placed in the subxiphoid position, or  alternatively, via a right subcostal port (figure 2).    detalls of Procedure T e surgeon uses the right and lef subcostal  ports for the operating instruments (figure 1).T e assistant guides the vid-  eoscope while providing additional traction and exposure with an instru-  ment passed through the lef lateral subcostal port. Ifthere is a hiatal hernia,  it is gently reduced and the assistant provides retraction on the gastroesoph-  ageal fat pad. T e dissection begins with the division of the pars flaccida of  the lesser omentum using ultrasonic dissection (figur e 3). In thin patients,  this is a minimal structure that is easily entered and contains few vessels.  However, in overweight patients, the gastrohepatic ligament has significant  fatty substance that requires a careful dissection. Exposure for the surgeon  may be improved with a careful grasping and elevation of the cut hepatic  edge of the ligament. Careful dissection is essential, as some patients may  have an aberrant lef hepatic artery in this region (figure 4). T is vessel  must be identified and preserved. T e peritoneum over the lef crus muscle  is carefully dissected and divided until the crus muscle bundle is clearly  seen (figure 5). T e phrenoesophageal ligament is divided with the ultra-  sonic dissector to complete the anterior peritoneal dissection (figure 5).  With traction on the lesser curve of the stomach, the peritoneum over  the right crus muscle is entered. T 1s crus is cleaned posteriorly. T e hia-  tal defect will appear behind the esophagus and the posterior “V” or fan-  shaped fusion of the lef and right crus will become apparent.   T e mobilization of the fundus begins with the surgeon grasping the  greater curvature of the stomach with an atraumatic clamp that retracts the  stomach anteriorly and to the patient’ right (figure 6).T eassistant grasps  the lateral gastrosplenic ligament and retracts this ligament and spleen to  the patient’ lef .T e area of the gastrosplenic ligament is clearly visualized  (figure 6). A suitable zone 1s chosen and opened with blunt dissection.  T e ultrasonic dissector begins sequential division of the short gastric ves-  sels about 1cm out from the stomach so as to minimize thermal injury  (figure 6). T e tissue grasped by the ultrasonic dissector must be clearly  visualized, especially in its tip, so as not to partially transect the next short  gastric vessel. A partially cut vessel results in bleeding that is difficult to  isolate and control without conversion to an open abdominal operation. A  better visualization of the lesser sac space and the path of the gastrosplenic  ligament can be obtained if the stomach 1s sequentially grasped along its  posterior wall beneath the cut short gastrics (figure 6).    detalls of Procedure T is ultrasonic dissection con-  tinues to divide the short gastrics superiorly until the spleen is free and  the lef crus of the diaphragm is visualized completing the circumferen-  tial esophageal dissection (figure 7). Posterior peritoneal adhesions to the  back of the stomach may need division and posterior draining veins should  be divided with the ultrasonic dissector to ensure adequate mobility of the  fundus. Care must be taken in this region to avoid the lef gastric artery.   With the circumferential esophageal dissection achieved (figure 8) a  Penrose drain may be placed around the distal esophagus to facilitate cau-  dal retraction (figure 9). Alternatively, the gastroesophageal fat pad may  be used to facilitate this retraction. T e distal esophagus is mobilized within  the mediastinum using blunt dissection to provide a minimum of 3 cm of  tension free esophageal length below the diaphragm.   T e esophagus is then mobilized further with careful preservation of the  lef anterior and right posterior vagus nerves. Two to three centimeters of  the esophagus should extend into the abdomen without traction. T 1s dis-  section is performed using gentle elevation and lateral retraction of the gas-  troesophageal junction with the shaf of an instrument. Dissection should  not proceed blindly into the hiatus or above the superior or cephalad top of  each crus, as a pleural opening may be created. T is usually does not pres-  ent a significant problem, as the positive-pressure endotracheal ventilation  has greater pressure than the CO, inflation pressure within the abdomen.   With experience, most surgeons can estimate the extent of the hiatal  opening that needs to be closed. In general, two sutures are required to  join the two crus muscles posteriorly. T is may be accomplished using  intracorporeal sutures, (figure 9) or a 10-mm endoscopic suturing instru-  ment containing a 0 non-absorbable braided suture. T e suture is passed  through the lef crus, then the right crus from the patient’ lef to right  (figure 10). A second suture in the crus is usually sufficient.    T e floppy 360-degree wrap is created af er first determining that there  is sufficient gastric mobility. T e upper greater curvature of the stomach is  passed behind the esophagus. A pair of instruments grasp the stomach in  the proposed wrap areas and a “shoeshine’-like maneuver from side to side  is performed (figure 11). It is verified that there is more than enough gas-  tric mobility to create a tension-free loose wrap over a several-centimeter  zone. T 1s maneuver may reveal the need for further division of short gas-  tric vessels along the lower aspect of the greater curvature of the stomach.  T e orogastric tube is withdrawn and the anesthesiologist passes a 56- to  60-French esophageal dilator (figure 12). It is essential that the tapered  tip of this dilator is passed fully into the stomach so as not to undersize the  esophagus. With the dilator in place, the adequacy of the hiatal opening is  verified by examining the posterior approximation of the right and lef crus.  In addition, the right and lef gastric wraps are tested for sufficient length  to cover a zone of 2 to 3 cm of intra-abdominal esophagus (figure 12).  Construction of the wrap requires three sutures that begin at the cephalad  extent of the fundoplication (figure 13). Each suture is placed as a triple  bite (figure 14a), the midportion of which includes a seromuscular  partial-thickness component of the esophagus. A final suture anchors the  wrap to the right crus (figure 14) or lateral esophageal wall to prevent  distal migration of the wrap around the gastric cardia.    closure T e fascia of the 10-mm port sites are sutured with one or two  delayed absorbable 00 sutures. T e skin is approximated with fine absorbable  subcuticular sutures. Adhesive skin strips and dry sterile dressings are placed.    Posto Perat Ive care Gastric decompression with a nasogastric tube  is usually not required. Clear liquids are given as tolerated and the diet is  advanced to sof , easily chewed foods. Some patients may experience tran-  sient dysphagia, which can be controlled with dietary changes. m    IndIcatlIons T e manifestations of achalasia include chest pain, dys-  phagia, and in late situations malnutrition. Most patients have been treated  for some length of time for the presumptive diagnosis of gastroesophageal  reflux disease, however upon objective evaluation, the classic findings of  aperistalsis of the esophagus and nonrelaxation of the lower esophageal  sphincter are realized. Radiographic evidence may demonstrate long-  standing disease and in some situations a dilated and distended esophagus.   T e treatment of achalasia can be multidisciplinary. Endoscopic surveil-  lance and exclusion of malignancy or mechanical obstruction is important.  Injection of botulin toxin into the lower esophageal sphincter has shown  to provide relief, although this relief is temporary and may further compli-  cate later definitive therapy. Botox injection for the treatment of achalasia  should only be considered as a temporizing measure or as palliative therapy  in selected patients. Pneumatic dilatation of the lower esophageal sphincter  with a 3- or 4-cm balloon can be considered. T is should be done under  fluoroscopic guidance and reports have demonstrated reasonable success  rates, especially when combined with salvage therapy or recurrent dila-  tion. Despite these successes, surgical intervention remains as the first-line  therapy for most patients and is associated with good outcomes. Peroral  endoscopic myotomy is an emerging therapy that allows for division of  the circular muscle fibers alone via a transoral-transmucosal route and 1s  under evaluation.    Preo PeratIve PreParatlIon Patients should be screened for other  medical conditions, careful attention should be paid to the risk of pulmo-  nary disease as chronic aspiration maybe a significant factor. Malnutrition  likewise should be addressed. When a dilated esophagus is seen or a chronic  disease 1s suspected, then careful preparation of the esophagus should be  undertaken. Many patients will require a liquid only diet for several days  prior to surgery to allow most of the solid contents of the esophagus to be  gone at the time of induction of anesthesia and operative intervention. In  planning the operative approach, the two standard approaches have been  the left chest or through the abdomen. After extensive experience with lap-  aroscopic exposure and laparoscopic manipulation of the gastroesophageal  junction the preferred method is now a transabdominal laparoscopic Heller  myotomy.    anesthesIa Patients are given a general anesthetic with careful atten-  tion to prevent aspiration upon induction.    PosIt Ion Patients are placed in a supine position and can be in a leg  split position with the arms extended, the operating surgeon can then stand  between the patients’ leg with an assistance on each side.    detalls of the Procedure A variable trocar positioning can be uti-  lized, however standard approach would include a midline periumbilical  camera trocar with four additional trocars placed in the hypochondrium  for #1 retraction of the liver, #2 and #3 for operative manipulation, and port  #4 is usually added after placement of the others (not shown in figure) for    retraction of the stomach (figure 1). After retraction of the left lobe of  the liver anteriorly, the esophagus is approached through the gastrohepatic  ligament (figure 2). T e dissection of the right crura (figure 3b), is fol-  lowed by the left and then circumferential dissection of the gastroesopha-  geal junction is performed with mobilization of the distal esophagus into  the abdomen. figure 3a shows the anatomy of the vagus nerves which  should be identified and preserved throughout the dissection. T e place-  ment of an atraumatic Penrose drain around the GE junction allows for  gentle inferior traction aiding the mobilization of the proximal esophagus.  T e dissection should be carried into the mediastinum as high as practi-  cally possible, however rarely is further opening of the hiatus necessary.  Some mobilization of the proximal stomach maybe necessary although  division of the short gastric vessels is rarely needed.   After complete dissection, the fat pad overlying the gastroesophageal  junction should be divided using careful electrocautery or ultrasonic dis-  section to allow complete visualization of the GE junction. T e anterior and  posterior vagus nerves should be identified and preserved throughout the  course of the dissection. When approached laparoscopically, the myotomy  can be made on the anterior or right anterolateral aspect of the esophagus  parallel to the anterior vagus, preventing injury (figure 4a). T 1s section  is started approximately 2 cm above the GE junction using a combination of  blunt and judicious use of energy to identify first the longitudinal muscles,  and then the circular muscles. Once the submucosal plane is entered, blunt  dissection allows careful separation of the submucosa from the circular  coat of fibers which then can be divided, first in a proximal fashion 6 to  8 cm above the gastroesophageal junction and then distally onto the stomach  approximately 2 to 3cm (figure 4b). Caution should be used at the distal  extent as the gastric mucosa can become adherent to the muscular fibers at  this juncture. Following the careful myotomy, the area should be carefully  inspected for injuries to the submucosa. Intraoperative endoscopy can be  utilized to insuf ate and check for leaks as well as to identify the Z line to  ensure that the myotomy has been carried down well onto the stomach.   Partial fundoplication is a routine part of laparoscopic esophageal  myotomy. A posterior Toupet fundoplication can be created by placing the  redundant portion of the proximal stomach posterior to the esophagus, fix-  ing it to the posterior crura, and then to the right side and left side of the  cut myotomy (figure 5). Alternatively, a Dor fundoplication or an anterior  fundoplication can be created by taking a redundant portion of the fundus  of the stomach and placing it anterior to the esophagus, placing sutures  first on the left side of the cut myotomy (figure 6a). T en the redundant  portion of the stomach is placed over the myotomy anteriorly and secured  by placing sutures on the right lateral aspect of the esophagus (figure 6b).  Trocar sites greater than 5 mL should be sutured in the fascia and the skin  closed in a routine fashion.    Posto PeratIvecare Most patients can be started on a full liquid diet  on the evening of surgery. Early mobilization is encouraged, however heavy  lifting and straining should be avoided. Patients should be advised that  their dysphagia may improve slowly over the first few weeks following sur-  gery as postoperative edema resolves. Surveillance endoscopy is important  over the course of the patient’s life or screening for malignancies. m    IndIcatlIons Selection of patients for bariatric procedures is based on  evidence-based guidelines. Patients must have failed dietary therapy and  have a body mass index (BMI) greater than 40 kg/m? without associated  medical conditions or a BMI greater than 35 kg/m? with associated medical  condition(s). In addition, practical considerations for the patient to be a  candidate for the procedure include psychiatric stability, a motivated atti-  tude, and comprehension of the nature of the procedure and the changes in  eating that will follow the procedure.    Preo Perat Ive PreParatlIon A team approach is necessary for the  optimal care of the patient with morbid obesity. Prior to the initial clinic  visit, the patient must provide evidence of a medically supervised diet,  counseling and referral from a primary care physician, and completion of a  reading assignment to include a comprehensive review of bariatric surgery  including the types of procedures, expected results, and possible compli-  cations or attendance at a seminar regarding the same. At the initial visit  the patient 1s expected to attend a group session on bariatric surgery and a  presentation by the nutritionalist on dietary issues preoperatively and post-  operatively. In addition, the patient has individual assessment and coun-  seling with the surgical team and the dietician. Subsequent evaluations  may include, as indicated, a full psychological evaluation, specialty medi-  cal evaluation, ultrasound of the gallbladder, and a pulmonary evaluation  including baseline arterial blood gases. Finally, preoperative assessment by  anesthesiology is warranted.    anesthesla General endotracheal tube anesthesia is required for the  procedure. T e anesthesiologist should be prepared for the potential of a  difficult intubation including the availability of flexible bronchoscopy to  assist placement of the endotracheal tube.    PosIt lon T epatient is transferred to the operating room table with a lat-  eral transfer device. T e patient is placed in the supine position and secured  to the operating room table with Velcro leg straps and a spindle sheet for the  pelvis. T e arms are placed on arm boards, and sometimes the left arm is  tucked at the side. Additional securing of the patient to the table with tape  may be appropriate. figure la shows the room setup.    oPeratIve PreParatlIon Preoperative antibiotics are administered  and venous thromboembolism prophylaxis is employed. Hair on the  abdominal wall is removed with a clipper. A Foley catheter is placed and an  orogastric tube is positioned.    IncIslon and detalls of the o PeratlIon T e abdomen is pre-  pared and draped in the standard surgical fashion. A small transverse skin  incision 1s made in the left upper quadrant through which a Veress needle  is inserted and pneumoperitoneum is established to a maximum pressure  of 15mm Hg. T e Veress needle is withdrawn and a 12-mm port is placed.  A 10-mm 30-degree laparoscope is inserted into the abdominal cavity and  the peritoneal cavity and viscera inspected to ensure that there is no evi-  dence of port insertion injury. Next, a supraumbilical 10-mm port, a right  upper quadrant 15-mm port, and right and left upper quadrant 5-mm ports  are placed under direct visualization (figure lb). T e greater omentum is  elevated, exposing the transverse colon and ligament of Treitz (figure 2a).   In some centers, staple lines are reinforced with absorbable material  such as polyglycolic/trimethylene carbonate copolymer fiber. T e staple  lines that may benefit from reinforcement are so indicated. T e jeyunum  is divided approximately 30 cm from the ligament of Treitz with an endo-  scopic stapler (figure 2b). T e small bowel mesentery is divided with an  endoscopic linear stapler with reinforcement to provide extra length to the  Roux limb. It may be helpful to mark the proximal portion of the efferent  limb of the Roux loop of the jejunum with a blue Penrose drain in order to  avoid confusing the divided ends of the jejunum. T 1s will be later anasto-  mosed to the gastric pouch. T e efferent Roux limb is then measured 150 cm  from the division of the bowel (figure 2b), at which point a side-to-side  jeyunojejunostomy is performed between the distal Roux limb and the bilio-  pancreatic limb (figure 3). T etwo small bowel segments are aligned along  their antimesenteric surface with a 2-0 Polysorb suture. Two small enteroto-  mies are made on the antimesenteric surface with an ultrasonic device. A  side-to-side jeysunojeyunostomy is performed with an endoscopic linear sta-  pler.T e enterotomy is closed transversely with an endoscopic linear stapler.    A 2-0 nonabsorbable antitorsion suture is placed. T e mesenteric defect at  the jeyunojeyunostomy is closed with a running 2-0 nonabsorbable suture.  T e Roux limb is then traced back proximally to verify appropriate orienta-  tion. T e greater omentum is divided with the ultrasonics device, taking  care to avoid injury to the underlying transverse colon (figure 2a). T 1s  provides space for passage of the Roux limb in an antecolic fashion to the  gastric pouch.   T e patient is placed in the reverse Trendelenburg position and the oro-  gastric tube is removed. A liver retractor is inserted in one of the proximal  ports. T e left lateral segment of the liver is retracted anteriorly exposing  the gastroesophageal junction. T e pars flaccida is divided bluntly providing  exposure to the lesser sac. T e lesser omentum is divided with an endo-  scopic linear stapler with reinforcement to the lesser curvature approxi-  mately 4 cm from the gastroesophageal junction. Once this is completed, a  distal gastrotomy is made with the ultrasonics device (figure 4). A25-mm  circular stapler is usually employed for the gastrojejunostomy. T is may be  reinforced. T e anvil of the stapler is inserted into the stomach through the  distal gastrotomy. A second small gastrotomy is made along the lesser cur-  vature approximately 4 cm distal to the gastroesophageal junction using an  articulating dissector and an ultrasonics device (figure 5). T e tip of the  anvil is delivered through the proximal gastrotomy (figure 6). T e distal  gastrotomy is then closed with an endoscopic stapler.   Attention is then turned toward creation of a 30-mL gastric pouch  (figure 6). T e first staple line is made transversely, closely approximating  the anvil with a reinforced endoscopic linear stapler (3.8-mm staple). T e  next several staple lines are made longitudinally toward the angle of His  with a reinforced endoscopic linear stapler. Complete division of the stom-  ach is verified by laparoscopic visualization. Next, the proximal efferent  Roux limb is brought in an antecolic fashion to the gastric pouch. If placed,  the blue Penrose drain is removed and the proximal 3 cm of the mesentery  is divided with an endo-GIA gray stapler. T e jejunal staple line is opened  with the ultrasonic device. T e 25-mm circular stapler is inserted into the  enterotomy of the Roux limb (figure 7). T e spike of the circular stapler is  advanced through the antimesenteric surface of the jejunum. T e anvil of  the gastric pouch is connected to the stapler (figure 7). A stapled gastroje-  junostomy is performed (figure 8). T e jejunal enterotomy is closed with  an endoscopic linear stapler resecting the distal 3 cm of the Roux limb that  is passed from the field. A 2-0 absorbable antitension suture is placed at the  gastrojeyunal anastomosis.   Next, an intraoperative upper endoscopy is performed to determine  patency of the gastrojejunal anastomosis and the presence of intraluminal  bleeding. If bleeding is encountered, it may be controlled with a reinforcing  suture. T e gastric pouch is insuf ated under saline. No bubbles should be  identified, indicating absence of an anastomotic leak. If bubbles are seen,  the staple line should be oversewn.    closure T e liver retractor is removed. T e fascia of the 12-mm port site  is closed with two interrupted 0 absorbable sutures. It may be helpful to use  a Carter-T omason port closure device for this purpose. T e remainder of  the ports are withdrawn under direct visualization and inspected for evi-  dence of bleeding. T e camera is withdrawn and the abdomen is deflated.  T e subcutaneous tissues are irrigated with saline solution and all skin inci-  sions are closed with 4-0 absorbable subcuticular sutures. T e skin is cleaned  and dried. Steri-Strips are applied.    Posto PeratIve care Appropriate fluid resuscitation is required  and urine output monitored with a Foley catheter for the first 24 hours.  A nasogastric tube is not necessary. A contrast study may be obtained on  postoperative day 1 to determine the presence or absence of a leak from  the gastrojeyjunostomy or obstruction. If there is no leak or obstruction,  or in the absence of a contrast study, if the patient exhibits no tachycardia  or temperature greater than 100°E then a trial of water with advancement  to liquids as tolerated may be started. T e timing of discharge is usually  2 to 3 days but may be influenced by many factors. T e patient is seen within  30 days to assess oral intake and wound healing. Patients with diabetes may  experience decreasing insulin requirements and even hypoglycemic epi-  sodes that precede significant weight loss. Long-term follow-up is required  in all patients. m    IndIcatIons T e vertical sleeve gastrectomy is an accepted primary or  staged bariatric procedure with indications that follow current NIH guide-  lines. Body mass index (BMI) of greater than 40 kg/m2, or greater than 35 kg/m?  with significant comorbid conditions related to obesity, as well as, failure of  conservative medical management needs to be documented. Other common  requirements include medical, dietary, and psychological evaluations, and a  history of past attempts at medical weight management. Informed consent  should include a dietary and behavior modification educational program to  ensure patients are aware of how the operation will impact their ability to  eat and provide strategies for lifetime success. Sleeve gastrectomy may be  chosen over other bariatric procedures for its minimal malabsorption due  to normal gastrointestinal continuity, including access to the duodenum, its  lower risk of marginal ulceration, and patient preference. Relative contrain-  dications include severe gastroesophageal reflux disease.    Preo PeratIve PreParatlon As with all morbidly obese patients  comorbidities should be evaluated and optimized before surgical interven-  tion. T is may include screening for and treating obstructive sleep apnea,  an appropriate cardiac and pulmonary functional evaluation, airway eval-  uation, and optimizing glucose control in diabetics. It 1s suggested that  these patients have an upper endoscopy to evaluate anatomy and diagnose  functional or pathologic changes before resection. All patients receive  preoperative antibiotics and prophylaxis for deep vein thrombosis (DVT)  per institutional guidelines. In addition, there is some evidence that having  patients on a “liver shrink” (low calorie, low fat) diet preoperatively can  help make the operation technically easier by decreasing the volume of the  liver and improving compliance of a thick abdominal wall.    anestheslIa T e operation is performed with general endotracheal anesthe-  sia. Difficulties are related to morbid obesity and may include a difficult airway,  difficult venous access and challenges with monitoring, and positioning the  patient due to their large body habitus. Communication with anesthesia 1s essen-  tial to the safe performance of this operation especially related to orogastric tube  management, Bougie placement, fluid management, and medications to prevent  postoperative nausea and emesis. Postextubation pathways should be in place  related to obstructive sleep apnea (Continuous Positive Airway Pressure-CPAP  and Bilevel Continuous Airway Pressure-BiPAP use) and pain management.    PosIt Ion T e operation is typically performed with the patient supine  or in modified lithotomy with a split leg table (figure la). Morbidly obese  patients should be secured well to the table to avoid movement when in steep  reverse Trendelenburg, as well as, have pressure points well padded to avoid  injury and risk of rhabdomyolysis. Knowledge of table capacities, foot rests,  and table extenders are helpful and should be available in the operating room.    o PeratIve PreParatlon Patients should receive preoperative antibi-  otics dose appropriate for their body weight per institutional guidelines,  timely DVT prophylaxis and correct-sized sequential compression devices  placed on their lower extremities. A urinary catheter may sometimes be  placed. An orogastric tube should be placed by anesthesia before initial tro-  car access. Bougies, staplers, extra-long instrumentation, and energy device  preferences should be available as needed.    IncIslon and exPosure Typical access to the abdomen 1s achieved  by the method the surgeon is most comfortable performing, however due  to the thickness of the abdominal wall, left upper quadrant access with a  Veress needle or optical viewing trocar has been shown to be safe. Trocar  position is chosen to allow dissection and manipulation of both the inferior  aspect of the stomach and the gastroesophageal junction at the angle of His  (figure lb). T e imitial 5-mm trocar is placed in the abdomen around the  left, midclavicular line, a hands-width below the costal margin. T e abdo-  men is explored with a 5-mm, 30-degree laparoscope and additional 5-mm  periumbilical and 5-mm left-lateral trocars are placed relative to the posi-  tion of the initial trocar and distance to the stomach. A 15-mm trocar is  placed to the right of the supraumbilical trocar (figure |b). As the staplers  are placed through this port its position should be such that the stapler  insertion can be close to parallel to the lesser curve of the stomach. A sub-  xiphoid trocar is placed for liver retraction and a flexible liver retractor may  be secured to the bed on the patient’ right (figure 3). T e operation is best  performed with the patient in some degree of reverse Trendelenburg.    detalls of the Procedure A vertical sleeve gastrectomy involves a  greater curve resection to fashion a longitudinal gastric tube that produces a  restrictive bariatric procedure. To perform this procedure the greater curve must  be dissected free of all its attachments from a point 5cm proximal to the pylorus    to the angle of His and left crura. To begin the operation the camera is placed in  the midclavicular, left upper quadrant port site and held by the assistant on the  patient’ left side who also uses the left-lateral port to assist. T e surgeon stands  on the patient’ right and uses an atraumatic grasper and energy device in the  15-mm and 5-mm right-sided ports. Typical dissection begins along the greater  curve near the angularis in an area where it 1s easier to gain access to the lesser  sac. T e gastroepiploic vessels are divided close to the stomach and this is con-  tinued up toward the short gastric vessels (figur e 2). Division of the vessels can  be performed using bipolar or ultrasonic dissectors. Extra care must be taken as  you approach the superior pole of the spleen where the stomach may be in close  approximation to the spleen to avoid thermal injury to the stomach or cause  bleeding (figure 3). At this point the energy device may be moved to the left  lateral most port to facilitate dissection. T e dissection continues to completely  mobilize the angle of His until the left crura is identified. Dissection and divi-  sion of the most proximal and posterior short gastric vessel is often necessary.  When this dissection is complete the hiatus should be examined for evidence  of a hernia. If one is found the sac and stomach should be reduced and the  crura repaired. Once proximal dissection is completed, attention is then taken  distally to divide the greater curve attachments to approximately 5cm proximal  to the pylorus (figur e 4). Once the greater curve is completely dissected free of  attachments and hemostasis 1s achieved, attention is taken to ensure the stom-  ach is mobilized posteriorly. Only attachments on the most medial aspect of  the posterior wall of the lesser curve should be left behind in order to allow the  staplers to be safely fired and be able to divide the stomach completely.   T e orogastric tube is removed and a nontapered Bougie is placed into the  stomach under laparoscopic vision and directed along the lesser curve toward  the pylorus below the divided attachments (figure 5). Sequential firings of a  stapler are used to divide the stomach along the Bougie. T e initial firing begins  at a point approximately 5 cm proximal to the pylorus and should be fired at  angle that is close to parallel with the proximal lesser curve (figure 5). With  each subsequent firing, care should be taken to ensure the stapler is in close  proximity to the Bougie but avoids excessive tension on the tissue. In addi-  tion, care should be taken to have nearly equal lengths of anterior and posterior  stomach in the sleeve to avoid “spiraling” the sleeve, which can lead to future  complications. As the division approaches the angle of His many surgeons will  angle the stapler around the esophageal fat pad and preserve it. Once the greater  curve is completely amputated (figur e 6) the stomach 1s removed through the  15-mm port site with or without a specimen retrieval bag.   T e Bougie is removed and the sleeve should be examined intraopera-  tively for length and caliber, integrity of the staple line, hemostasis, and to  identify areas of potential narrowing from technical errors. T is may all be  done with careful upper endoscopy.   Technical variations of the procedure include varying stapler sizes that  best match staple height to the thickness of the tissue, adding buttress mate-  rial to some or all of the stapler firings, oversewing of the staple lines, and  Bougie size. Bougie size may be varied to optimize weight loss versus preven-  tion of complications such as leaks of the staple line. Bougie sizes between  32-Fr and 36-Fr have been thought to induce the best weight loss however,  sizes under 40-Fr have correlated to higher leak rates.    closure T e I> and 10-mm port sites are closed with #1 absorbable  suture and is facilitated by use of a port closure device. After the fascia is  closed the subcutaneous tissues are well irrigated before skin closure. T e  5-mm port sites require skin closure only.    Posto Perat Ive care Typical hospital stay after a vertical sleeve gas-  trectomy is | to 2 days and depends upon the patient’ ability to tolerate  enough liquids to maintain hydration, tolerate their medications with con-  trol of their medical problems, ambulate and not have signs or symptoms  of potential complications. Orogastric tubes may be used but are not nec-  essary. Diet is advanced to liquids on postoperative day | and a liquid/full  liquid diet is typically continued for a month. Medication by mouth should  be minimized and necessary pills that are not very small may be crushed or  converted to liquid form. Nausea, reflux symptoms, and discomfort when  eating can be more common after sleeve gastrectomy than other bariatric  procedures and the patient should be educated and treated appropriately.  Prophylactic regimens beginning in the operating room can be ef ective.   Centers performing bariatric procedures employ pathways for man-  aging and monitoring sleep apnea, DVT prophylaxis, pain management,  early ambulation, and complication identification. Tachycardia continues  to be the most consistent sign suggestive of a complication and may include  bleeding, leak, or other cardiopulmonary complications. Lifetime follow-  up of these patients is recommended. m    IndIcatlIons A surgeon may select the use of a gastric band to restrict  the gastric size. T e same selection criteria used for the Roux-en-Y gastric    o Perat Ive PreParat Ion Prophylactic antibiotics and venous throm-  boembolism prophylaxis are employed. A Foley catheter is not inserted into  the bladder because of the short duration of the procedure.    PoslItIlonIng T e patient is positioned in a modified lithotomy position.  T e surgeon is positioned between the legs and the assistant to the patient’  left. T e room setup is shown in figure I.    IncIslon and detalls of the o Peratlon T e port placement is  similar to that of a Roux-en-Y gastric bypass, with the exception of a left sub-  costal 15-mm port that is used to introduce the gastric band (figur e 2). Fewer  ports may be used in some patients. T e patient is placed in the reverse  Trendelenburg position. T e GE junction is exposed by retracting the liver  proximally (figure 3). Blunt dissection 1s used to create a retrogastric tun-  nel as shown in figure 4. Retraction of the stomach inferiorly facilitates  exposure of the greater curve side of the GE junction. T e retrogastric dis-  section is minimal and the goal should be to create a narrow tunnel that will  act to prevent slippage of the device. T e tunnel is created superior to the  left gastric artery. T e orogastric tube placed by anesthesia is removed and    a calibration balloon inserted and inf ated with 15 mL of saline. T e band  is placed into the abdomen using an insertion device (figures 5 and 6).  It is placed through a 15-mm port or passed directly through the abdomi-  nal wall (figure 6). An atraumatic grasper is used to advance the gastric  band from the opening along the greater curvature near the angle of His to  the previously made opening in the soft tissue along the lesser curvature  (figure 7). T e band is placed around the stomach just below the intra-  gastric balloon (figure 8). T e balloon is def ated and the band is buckled  close (figure 9). T e orogastric sizing balloon is removed. T e final posi-  tion of the band is shown in figure 9. Several interrupted nonabsorbable  sutures (2-0) are used to imbricate the stomach over the band in order to  prevent slippage (figure 10). T e distal tubing is retrieved through a left  paramedian incision at the 15-mm port site (figure 2). A subcutaneous  pocket is made for the port used to adjust the band. T e port is tacked to  the anterior rectus sheath with four 0 nonabsorbable sutures (figure 11).    closure Closure follows the same procedures outlined for the laparo-  scopic Roux-en-Y gastric bypass.    Posto PeratIve care T e patient is permitted clear liquids the night  of surgery and advanced to an initial diet on postoperative day 1. T e  patient is discharged within 23 hours of surgery if the initial diet is toler-  ated. A contrast study to determine band position 1s not necessary prior to  discharge. Adjustment of the band is not performed for 6 weeks. T e initial  adjustment is performed under fuoroscopic guidance. m    IndIcatlons Transhiatal esophagectomy with cervical esophagogas-  trostomy is indicated for most conditions that require esophageal resec-  tion and reconstruction. Common indications include carcinoma of the  esophagus or gastroesophageal junction, end-stage achalasia, and severe  esophageal strictures refractory to endoscopic dilation. T 1s approach may  be utilized for primary resection of early stage cancers or Barrett’s esopha-  gus with multifocal high-grade dysplasia as well as following neoadjuvant  chemoradiation for locally advanced cancers.   Transhiatal esophagectomy is contraindicated in patients with upper or  middle third esophageal cancers with concern for tracheobronchial inva-  sion based on imaging studies or bronchoscopy. In patients with a history  of previous esophageal surgery, including fundoplication, esophagomyot-  omy or repair of esophageal perforation, the surgeon must be prepared to  convert to a transthoracic approach as transabdominal esophageal mobili-  zation may prove difficult or impossible in these settings. Finally, in cases  where carcinoma involves the gastric cardia and may require a significant  gastric resection, the colon should be evaluated preoperatively and pre-  pared for use in esophageal reconstruction.    Preo Perat Ive PreParatlIon T e preoperative workup for patients  with esophageal and GE junction cancers includes a thorough history and  physical examination, esophagogastroduodenoscopy with biopsy for diag-  nosis. Esophageal nodules may be adequately staged by endoscopic muco-  sal resection, whereas larger tumors require endoscopic ultrasound and  PET-CT imaging for complete clinical staging. Bronchoscopy should be  considered for patients with squamous cell carcinomas, lesions involving  the proximal third of the thoracic esophagus, and respiratory symptoms  such as cough or hemoptysis.   Before proceeding with esophageal resection, the patient’ medical con-  dition and nutritional status should be considered carefully as patients  with poor nutritional status and multiple comorbid medical conditions are  subject to increased perioperative complications. T orough cardiovascular  and respiratory evaluations are particularly important and objective testing  such as cardiac stress tests, echocardiography, and pulmonary function tests  should be obtained liberally if there are concerns. Smoking cessation and  a daily walking program should be strongly encouraged as these lifestyle  modifications significantly reduce pulmonary complications, and enteral  tube feedings via nasogastric or jejunal feeding tubes should be considered  in patients with significant weight loss or other signs of severe malnutrition.   Patients should be administered a mechanical bowel preparation on  the evening prior to surgery in the rare event that esophageal reconstruc-  tion with a colon interposition is necessary. Appropriate prophylactic antibiotics    are administered intravenously prior to incision. Sequential compres-  sion devices and subcutaneous heparin are used for deep vein thrombosis  prophylaxis.    anestheslIa T e procedure is performed under general endotracheal  anesthesia. Adequate peripheral intravenous access and a radial artery  catheter are placed to allow for adequate fluid administration and blood  pressure monitoring during the procedure.    PosltlIon T e patient is placed in the supine position with the arms  tucked at the sides. A nasogastric tube 1s placed to decompress the stomach  and aid in identification of the esophagus during mediastinal mobilization.  A roll is placed behind the shoulders to facilitate neck extension, and the  head is turned to the right and supported on a sof head ring. T e neck,  anterior chest, and abdomen are prepped and draped from the mandible  to pubis.    overview of the o Peratlon figure | shows the incisions in the  midline abdomen and the lef cervical area. figure 2 shows the relevant  anatomy and arterial supply of the stomach and the anticipated line of tran-  section form removal of the proximal stomach and esophagus.    abdomInal Portlon of theo Peratlon T e initial portion of the  operation is performed through a midline laparotomy extending from the  xiphoid to the umbilicus. T e abdomen is inspected for metastatic disease  and other pathology. Suspicious lesions outside the field of resection should  be biopsied and sent for frozen section analysis. A self-retaining retractor  aids in exposure of the upper abdomen and mediastinum. T e round and  falciform ligaments are divided; and the lef lobe of the liver is dissected free  from its diaphragmatic attachments and retracted to the right to expose the  esophageal hiatus.    detalls of Procedure Following the assessment of the stomach  as a Suitable conduit for esophageal replacement, the lesser sac is entered  by incising the gastrocolic ligament at the level of the inferior pole of the  spleen. T e gastrocolic ligament is sequentially divided with energy (bipolar  or ultrasonic), or between clamps and ligated (figure 3). Care is taken to  preserve the right gastroepiploic artery which is traced to its origin, and the  pancreaticogastric attachments are divided using electrocautery. T e gastro-  splenic ligament is sequentially divided with energy (bipolar or ultrasonic),  or between clamps and ligated and the posterior gastric attachments are  divided to completely mobilize the gastric fundus (figure 4).    detalls of Procedure T e pars flaccida of the lesser  omentum is divided to expose the right crus and the phrenoesophageal  ligament is divided, taking care not to injure the esophagus or GE junc-  tion (figure 5). T ecrura are dissected and the distal esophagus is mobi-  lized and encircled with a Penrose drain (figure 6). In order to allow free  movement of the pylorus to the level of the esophageal hiatus without ten-  sion, the hepatic flexure of the colon is mobilized and retracted inferiorly    and the duodenum is mobilized from its retroperitoneal attachments by  performing a Kocher maneuver (figure 7). T e dotted lines in figure 7  show the course of the division of the gastrohepatic omentum and the gas-  trocolic omentum. T elef gastric artery and a coronary vein are identified  and divided near their origin using a linear cutting stapler, with care taken  to maintain as much lymph node-bearing sof tissues as possible with the    detalls of Procedure With the gastric mobilization,  Kocher maneuver, and distal esophageal dissection complete, attention is  turned to the cervical esophageal dissection. An incision is made along  the anterior border of the lef sternocleidomastoid muscle extending  from the sternal notch to just above the cricoid cartilage (figure 9).  T e platysma muscle and fascia along the anterior border of the sterno-  cleidomastoid muscle are incised and the omohyoid muscle is identified  and divided. T e omohyoid fascia is incised and the carotid sheath is  retracted laterally to allow access to the tracheoesophageal groove. T e  middle thyroid vein may be divided to facilitate this exposure. T e pre-  vertebral space is entered by blunt finger dissection (figure 10). T e    anterior strap muscles are divided and the tracheoesophageal groove is  dissected to allow anterior esophageal dissection. Care is taken to avoid  the recurrent laryngeal nerve, but no specific attempt is made to visu-  alize it. By careful finger dissection, the esophagus is circumferentially  mobilized and encircled with a Penrose drain (figure 11). Cephalad  retraction of the rubber drain allows blunt dissection of the esophagus  from the superior mediastinum.   Following completion of the cervical esophageal dissection, caudal trac-  tion 1s placed on the rubber drain around the gastroesophageal junction,  and the surgeon’ hand 1s passed into the posterior mediastinum along the  prevertebral fascia, posterior to the esophagus (figure 12).    detalls of Procedure As the blunt dissection is  extended to cephalad, a finger passed from the cervical incision can be pal-  pated, and the posterior dissection completed (figure 13). Care must be  taken to closely monitor the patient’ blood pressure throughout this portion  of the operation. T e anterior esophageal dissection is similarly performed  by inserting the hand into the posterior mediastinum along the anterior sur-  face of the esophagus with the palm facing posteriorly. Two fingers are gently  advanced cephalad, with care taken to avoid injury to the pericardium or mem-  branous trachea, until the dissection is complete in the superior mediastinum  (figure 14). Upon completion of the anterior and posterior dissection, ceph-  alad retraction from the cervical incision allows blunt mobilization of the  lateral attachments along the superior portion of the esophagus. Following    this, a hand is reinserted via the diaphragmatic hiatus to complete the lateral  dissection by pressing the esophagus against the spine and using a posterior  raking motion with the fingers.   Filmy attachments are divided bluntly, and thicker tissues and the vagal  trunks are retracted toward the esophageal hiatus and divided sharply  between the clips.   When the mediastinal dissection is complete, the nasogastric tube  is withdrawn into the proximal esophagus and the cervical esophagus is  divided using a TA stapler, with care taken to preserve adequate esophageal  length to perform a tension-free anastomosis. A rubber drain is sutured to  the specimen to maintain the posterior mediastinal tunnel as the esophagus  is delivered into the abdomen (figures |S and 16).    detalls of Procedure Vasculature along the lesser  curvature of the stomach is then divided with the linear stapling device  approximately 6 cm proximal to the pylorus to mark the extent of gastric  division for creation of the conduit. Branches of the right gastric artery will  provide some blood flow to the distal lesser curvature and should be pre-  served. T e stomach is divided from the fundus to the lesser curve using  serial firings of the GIA 80—4.5 stapler to create a gastric tube approximately  5cm wide (figure 17). T e esophagus and proximal stomach are assessed  to ensure adequate margins of resection. With the gastric staple line facing  the patient’ right side, the stomach is sutured to the Penrose drain and  pushed upward through the posterior mediastinum and grasped with sur-  geon’s lef hand or a Babcock clamp via the cervical incision (figure 18).  Approximately 4 to 5 cm of gastric tube are delivered into the cervical inci-  sion for creation of the anastomosis (figure 19).   T e cervical esophagogastrostomy may be created using a two-layer  hand-sewn or linear stapled technique. A stapled cervical esophagogastros-  tomy is created by orienting the gastric conduit along the posterior cervical  esophagus (figure 20). A longitudinal gastrotomy is created and two stay  sutures of 3-0 silk are placed (figure 20). T e esophagogastrostomy Is cre-  ated using a linear stapler (3.5mm staples) (figur e 21). Before releasing the  stapler, two 3-0 silk sutures are placed between the stomach and esophagus  on each side to buttress the anastomosis. T e resulting common opening is  closed in two layers, with an inner layer of 3-0 running absorbable suture  and an outer layer of interrupted 3-0 silk sutures. Alternatively, this can be  closed with a TA stapler as shown in figure 22.    T e nasogastric tube is advanced past the anastomosis so that its tip is  located in the distal stomach below the diaphragm. A 14-Fr feeding jeju-  nostomy tube is then placed in a limb of proximal jejunum and brought  out through a separate stab incision. We do not routinely perform a pylo-  roplasty due to the low incidence of delayed gastric emptying following  this procedure. T e abdominal and cervical incisions are closed in layers,  and a Penrose drain is placed adjacent to the anastomosis and brought out  through the inferior aspect of the cervical incision.    Posto PeratIvecare T e patient is transferred to the intensive care unit  postoperatively. Early extubation is preferred, and aggressive pulmonary to1-  let is begun immediately. A portable chest x-ray should be obtained in order  to confirm placement of life support devices and to rule out pneumo- or  hemothorax. Epidural analgesia is usually not required as adequate pain con-  trol can be achieved with intermittent opioid pain medications. T e patient  is maintained on intravenous fluids until adequate oral or enteral nutrition  is achieved, usually for several days. Intravenous beta-blockers should be  administered as prophylaxis for supraventricular arrhythmias. Typically, the  nasogastric tube is removed on postoperative day number three; a thick liq-  uid diet started on day number four; and a mechanical sof diet started on day  number five. An esophagram is obtained when there is clinical suspicion of  possible anastomotic disruption. Jeyunostomy feeds are reserved for patients  who are unable to tolerate adequate oral intake due to concern for tube feed-  ing-induced small bowel necrosis in patients who are hemodynamically and  catabolically stressed. Barring complications, patients are discharged when  they achieve adequate oral intake, typically within 7 to 10 days. m=    IndIcatlons_ Transthoracic esophagectomy is indicated for the manage-  ment of surgically resectable cancers of the esophagus and gastroesophageal  junction. An abdominal incision is utilized to mobilize the distal esopha-  gus and gastroesophageal junction, including the tumor and surround-  ing lymph nodes. T e gastric conduit is mobilized and the blood supply  is based on the right gastroepiploic artery. T e thoracic esophagus is then  approached through a right posterolateral thoracotomy through which the  specimen is resected and reconstruction is performed. Surgical resection  is indicated for early staged, nonmetastatic tumors that are not amenable  to endoscopic resection (T1). Surgery is also performed for nonmetastatic,  intermediate staged tumors (T2-T4, N1), but usually follows a course of  chemoradiation and restaging. Transthoracic esophagectomy may also be  indicated for the management of benign disease such as refractory stric-  tures, caustic injuries, or a dilated “burned esophagus” with dysphagia fol-  lowing treatment for achalasia.   T ere is some controversy regarding the optimal surgical approach for  esophageal resections. Transhiatal and minimally invasive approaches have  become popular due to the potential for decreased complications and data  indicated equivalent outcomes. T e decision to perform a transthoracic  approach is made based on patient factors, surgeon preference, and experi-  ence. Potential benefits of the thoracic approach include a more thorough  lymph node dissection and lower leak rates.    Preo PeratIve PreParatlIon T e preoperative workup for patients  with esophageal and GE junction cancers should include a thorough history  and physical examination, esophagogastroduodenoscopy for diagnosis, and  PET-CT imaging and endoscopic ultrasound for staging. Bronchoscopy  should be considered for patients with squamous cell carcinomas, lesions  involving the proximal third of the thoracic esophagus, and respiratory  symptoms such as cough or hemoptysis. T e patient’ medical condition  should be considered carefully before undertaking an esophageal resection  as these procedures are extensive and patients with medical comorbidities  may not tolerate them well. T orough cardiovascular and respiratory evalu-  ations are particularly important and objective testing such as cardiac stress  tests, echocardiography, and pulmonary function tests should be obtained  liberally if there are concerns. Patients should be administered a mechani-  cal bowel preparation on the evening prior to surgery in the rare event that  esophageal reconstruction with a colon interposition is necessary. Appro-  priate prophylactic antibiotics are administered intravenously prior to inci-  sion. Sequential compression devices and subcutaneous heparin are used  for deep vein thrombosis prophylaxis.    anestheslIa T e procedure is performed under general anesthesia. A  double-lumen endobronchial tube is utilized to allow for single lung ven-  tilation during the thoracic part of the procedure. A single lumen tube  may be placed for the initial abdominal part of the procedure and then  exchanged for a double-lumen tube by the anesthesia team before reposi-  tioning and performance of the thoracotomy. A nasogastric tube should be  placed early during the procedure to decompress the stomach and facilitate  palpation of the esophagus. T is should not be secured until completion of  the reconstruction as it will be repositioned several times during the pro-  cedure. A thoracic epidural may be helpful for postoperative pain control  and may be associated with decreased cardiorespiratory complications.    PoslItlonIng T e patient is initially placed in the supine position with  the arms out at the sides. A bean bag should be placed under the patient,  but is not deflated until repositioning after the abdominal part of the pro-  cedure has been completed. Upon completion of the abdominal part of the  procedure, the patient is repositioned in the left lateral decubitus position  with the right side up. An axillary roll is placed, the left arm is padded, and  the right arm is placed on a padded overhead arm board and secured.    detalls of Procedure (abdominal portion) After general anes-  thesia had been induced, the abdomen is prepped and draped in standard  surgical fashion. T e abdomen is then entered through a midline incision  extending from the xiphoid to below the umbilicus. For the abdominal por-  tion of the procedure, please refer to Chapter 40. A 14 FR feeding jejunos-  tomy tube is then placed in a limb of proximal jejunum in a Witzel fashion  (Chapter 47, pages 160—161). Care should be taken not to compromise the  lumen of the bowel. It is not necessary to routinely perform a pyloroplasty  for possible delayed gastric emptying as the incidence 1s less than 10% T e  fascia is then closed in the routine manner and the skin edges are reap-  proximated with staples. A dry sterile dressing is applied.    detalls of Procedure (thoracic portion) T e patient is positioned for  right thoracotomy. T e right side is chosen in order to ensure adequate proxi-  mal exposure of the esophagus. T e right chest is then prepped and draped in  standard fashion. An occlusive drape can be useful to prevent slippage of the  drapes. T e chest is then entered through a standard posterolateral thoracot-  omy incision through the sixth intercostal space. (figure 1). A rib retractor  is placed and the inferior pulmonary ligament is divided using electrocautery  (figure 2). T e esophagus is completely dissected free from its surrounding  attachments, including the adjacent lymph nodes. T e azygos vein is mobi-  lized as it passes over the proximal thoracic esophagus, and is divided with  the linear stapling device and secured with large hemoclips (figure 3). T e  nasogastric tube should be withdrawn into the proximal esophagus prior to  division. T e proximal esophagus is stapled with a TA stapling device then  divided leaving the proximal esophagus open (figure 4). T e gastric conduit  is pulled into the chest, and the stomach is divided from the fundus to the  lesser curvature using a linear stapling device (figure 4). T e specimen 1s  passed off the table and sent to pathology. T e gastric conduit staple line is  usually oversewn using interrupted 3-0 silk sutures. Esophagogastrostomy is  created in two layers using interrupted 3-0 silk sutures (figure 5). T e naso-  gastric tube should be advanced through the anastomosis prior to completion  of the anterior row, and secured firmly at the nares. T e conduit is secured to  the chest wall laterally using interrupted 3-0 silk sutures in order to prevent  torsion. Angled and straight 32-French chest tubes are placed and secured to  the skin using 0 monofilament nonabsorbable sutures. T e chest 1s then closed  using looped 0 absorbabale monofilament pericostal sutures. T e soft tissues  are closed in layers using running 0 absorbable and 2-0 absorbable sutures.  T e skin edges are reapproximated with staples and a dry sterile dressing is  applied. Chest tubes should be connected to 20 cm H,O pleurovac suction.    Posto PeratIve care T e patient is transferred to the intensive care  unit postoperatively and extubated as soon as possible. If the patient is  to remain intubated because of respiratory insuf ciency or other clinical  issues, the double lumen endotracheal tube should be replaced with a large  caliber single lumen tube. A portable chest x-ray should be obtained in order  to confirm placement of life support devices and to rule out pneumo or  hemothorax. T e patient is maintained on intravenous fluids until adequate  oral or enteral nutrition is achieved, usually for several days. Intravenous  beta-blockers should be administered as prophylaxis for supraventricular  arrhythmias. T e nasogastric tube is removed on postoperative day number  three; a clear liquid diet started on day number four; and a mechanical soft  diet started on day number five. We do not usually initiate early enteral  nutrition through the jejunostomy tube because of the concern for tube  feeding-induced small bowel necrosis in patients who are hemodynami-  cally and catabolically stressed. Jejunostomy feeds are reserved for patients  who are unable to tolerate adequate oral intake for whatever reason. Bar-  ring any complications, patients are discharged to home once they are able  to tolerate an adequate diet. Chest tubes are placed to water seal as long as  there are no air leaks, and are removed after an oral diet has been estab-  lished and prior to discharge. T e usual hospitalization is 7 to 10 days. m    IndIcatlIons Pyloromyotomy (Fredet—Ramstedt operation) is done in  infants with congenital hypertrophic pyloric stenosis.    Preo Perat Ive care T e diagnosis 1s established by the characteristic  history of projectile vomiting and the physical finding of a pyloric mass  or “olive” on abdominal examination. T is may be confirmed by an upper  gastrointestinal series but more frequently by ultrasound. T e correction of  dehydration and acid—base imbalance by adequate parenteral fluid therapy  is aS important as surgical skill in lowering the mortality rate. Although  prolonged gastric intubation is to be avoided, 6 to 12 hours of preparation  with intravenous hydration plus suction may be necessary to restore the  baby to good physiologic condition. Oral feedings are discontinued as soon  as the diagnosis 1s made, and an intravenous infusion is started in a scalp  vein. T en 10 mL/kg of 5% glucose in normal saline is administered rapidly.  T is is followed by a solution of one part 5% dextrose in normal saline to  one part 5% dextrose in water (one-half normal saline with 5% D/W) given  at the rate of 150 mL/kg per 24 hours. T e baby should be reevaluated every  8 hours with respect to state of hydration, weight, and evidence of edema.  Ordinarily, this solution is continued for 8 to 16 hours. After adequate ur1-  nary output is established, potasstum should be added to the intravenous  solutions. In the baby who is moderately or severely dehydrated, it is wise  to determine the serum electrolyte values before initiating replacement  therapy and to check the values in 8 to 12 hours.    anesthesIa Endotracheal intubation on the conscious infant is the saf-  est anesthetic technique, followed by general anesthesia.    PosItIon A temperature-controlled blanket is placed under the infant’  back to help compensate for the loss of body heat and to arch the abdomen  slightly to improve the operative exposure. To prevent heat loss through the  arms and legs, they are wrapped with sheet wadding, and the intravenous  site is carefully protected.    IncIslon and exPosure T e open approach is presented. Alterna-  tively, a laparoscopic approach may be performed. It 1s advisable for the  general surgeon to be familiar with the open approach. A gridiron incision    placed below the right costal margin, but above the inferior edge of the  liver, is used. T e incision is 3 cm long and extends laterally from the outer  edge of the rectus muscle. T e omentum or the transverse colon usually  presents in the wound and is easily identified. By gentle traction on the  omentum, the transverse colon is delivered and, in turn, traction on the  transverse colon will deliver the greater curvature of the stomach easily into  the wound. T e anterior wall of the stomach is held with a moistened gauze  sponge and, upward traction on the antral portion of the stomach, the pylo-  rus 1s delivered into the wound.    detalls of Procedure T e anterosuperior surface of the pylorus  is not very vascular and is the region selected for the pyloromyotomy  (figure 2). As the pylorus is held between the surgeon’ thumb and index  finger, a longitudinal incision of 1to 2cm long is made (figure 3). T einci-  sion 1s carried down through the serosal and muscle coats until the mucosa  is exposed, but the mucosa 1s left intact (figure 4). Great care must be  taken at the duodenal end of the incision, for here the pyloric muscle ends  abruptly, in contrast with the gastric end, and the mucosa of the duode-  num may be perforated (see danger point) (figure 1). T e cut muscle is  now spread apart with a straight or a half-length hemostat until the mucosa  pouts up to the level of the cut serosa (figures 4 and 5). Usually, hem-  orrhage can be controlled by applying a sponge wet with saline, and only  rarely is a ligature or stitch necessary to control a bleeding vessel. T e sur-  geon must ascertain that no perforation of the mucous membrane exists.    closure T e peritoneum and transversalis fascia are closed with a run-  ning suture of 0000 chromic. T e remaining fascial layers are closed with  fine interrupted sutures. T e skin margins are approximated with running  000000 nylon sutures or subcuticular absorbable sutures reinforced with  skin-adhesive strips.    Posto PeratlIve care Six hours following operation, the suction is  discontinued and the nasogastric tube is removed. At this time, 15 mL of  dextrose and water is of ered to the infant. Following this, the infant is  of ered 30 mL of an evaporated milk formula every 2 hours until the morn-  ing after operation. T ereafter, the infant is fed progressively more formula  on a 3-hour schedule. m    IndIcat Ions Intussusception occurs most commonly in infants from the  age of a few months to 2 years. Time must be taken to correct dehydration or  debility by administering parenteral fluids. A stomach tube should be passed  to deflate the stomach and to reduce the danger of aspirated vomitus to a  minimum. If the intussusception has been of considerable duration and there  is evidence of bleeding, as in the characteristic mahogany stools in infants,  blood products should be administered with the operating room alerted and  hydration established satisfactory for operation. T e child is taken to the x-ray  department, and here hydrostatic reduction by bartum enema is attempted,  utilizing a pressure of no more than 3 ft. As much as 1 hour may be spent in  this procedure as long as manipulation of the abdomen is avoided and the  exposure to fluoroscopy limited as much as possible. If the intussusception  (figure 1) is going to reduce, it will progressively do so. If this method fails,  surgery follows immediately. Ifa mass lesion or cancer is suspected in an elderly  patient, then a re-section should be performed rather than a manipulation.    anesthesIa Meperidine or morphine should be added in appropriate  doses in older infants and children. Endotracheal intubation on the conscious  infant is the safest anesthetic technique, followed by general anesthesia.    PosItIon T e patient is placed in a dorsal recumbent position. Feet and  hands are held flat to the operating table by straps or pinned wrappings.    IncIsIon and exPosure In most instances, a transverse incision  made in the right lower quadrant provides adequate exposure. T e lateral  third of the anterior rectus fascia and the adjacent aponeurosis of the exter-  nal oblique are incised transversely. T e lateral edge of the rectus muscle  may then be retracted medially and the internal oblique and transversalis  muscles divided in the direction of their f bers. If more exposure is required,  the incision in the anterior rectus fascia may be extended, and a portion or  all of the right rectus muscle may be transected.    detalls of Procedure T e major portion of the reduction is done  intra-abdominally by milking the mass back along the descending colon,  transverse colon, and ascending colon. When reduction has proceeded thus  far, the remainder can be delivered out of the abdominal cavity. T e mass  is pushed back along the descending colon by squeezing the colon distal to  the intussusception (figur e 2). Iftraction is applied, it should be extremely  gentle to avoid rupturing the bowel. T e discolored and edematous bowel at  frst may not appear to be viable, but the application of warm saline solution  may improve its tone and appearance. Unless the intestine is necrotic, it 1s  better to persist in attempts at reduction than to resort to early and unnec-  essary resection, required in less than 5% of the cases. An etiologic fac-  tor, such as an inverted Meckel’ diverticulum or intestinal polyp, is found  in only 3% or 4% of childhood cases of intussusception. It is unnecessary  to tack down the terminal ileum or to anchor the mesentery. Recurrences  are not common, and such preventive procedures only prolong the opera-  tion. Intussusception is uncommon in adults. It may occur at any level of  the small or large intestine. After the intussusception in adults has been  reduced, a search should be made for the initiating cause—that is, tumors  (especially intrinsic), adhesive bands, Meckel’ diverticulum, and so forth.  Resection is indicated if dead bowel is encountered.    closure T eabdomen is closed in the routine manner. T e skin margins  are approximated with nylon sutures or subcuticular absorbable sutures  reinforced with skin-adhesive strips.    Posto PeratiIve care Nasogastric suction is continued until peri-  staltic activity is audible or until a stool is passed. Antibiotics and colloid  replacement are not necessary in an uncomplicated intussusception but  again are most valuable adjuncts in the case requiring resection. About  5mL/kg of colloid or 5% albumin solution provides an invaluable daily sup-  portive measure for the seriously ill child who has had resection of a gan-  grenous intussusception. Recurrence in the adult should suggest a cause  overlooked initially but probably amenable to surgical correction, such as  removal of a polyp or adhesive band.    excision is a benign incidental procedure during a laparotomy for other  causes. T e majority of these diverticula cause no symptoms, but a diseased  one can successfully mimic many other intestinal diseases, any of which  would require exploratory laparotomy.   T e presence of gastric mucosa in the diverticulum can produce ulcer-  ation with massive intestinal hemorrhage with brick-red stools, inflamma-  tion, or a free perforation with peritonitis, particularly in children. Although  similar complications can occur in adults, intestinal obstruction caused by  fxation of the tip of the diverticulum or a connecting band running to the  umbilicus is not uncommon. T e diverticulum may become inverted and  form the starting point of an intussusception. Benign diverticula should be  removed as incidental procedures unless contraindicated by a potentially  complicating disease elsewhere in the abdomen. T ese congenital anoma-  lies are remnants of the embryonic omphalomesenteric duct arising from  the midgut, are found in 1% to 3% of patients, principally males, and are  located usually 20 to 35 cm above the ileocecal valve. T e terminal ileum  should be routinely examined for a Meckel’s diverticulum as part of a thor-  ough abdominal exploration.    Preo PeratIve PreParatlon Preoperative preparation is devoted  chiefly to the restoration of blood, fluids, and electrolytes. Nasogastric suc-  tion is advisable in the presence of obstruction or peritonitis, which may  require additional blood, plasma, and antibiotics.    anesthesIa General inhalation anesthesia is preferred; however, spinal  or local anesthesia may be indicated under special circumstances.    IncIslon and exPosure A midline incision is preferred because of its  maximum flexibility. However, incidental excision of a Meckel’ diverticu-  lum may be performed through any incision that exposes it.    detalls of Procedure T e segment of the terminal ileum involved  with the Meckel’ diverticulum is delivered into the wound by Babcock for-  ceps for stabilization. T e Meckel’ diverticulum may be as far as 20 to 35cm  back from the level of the ileocecal valve. If a mesodiverticulum is present,  it should be freed, divided between hemostats, and ligated as a mesoappen-  dix (figure 3). If the diverticulum has quite a wide neck, it may be excised  either by oblique or cross clamping of the base, by wedge or V-shaped  excision of the base, or by segmental resection of the involved ileum with  end-to-end anastomosis (figure 4). T e base is double clamped with non-  crushing Potts-type clamps in a direction transverse or diagonally across to  the bowel. T e specimen is excised with a scalpel. Traction sutures, A and  B, of 00 silk are placed to approximate the serosal surface of the intestinal  wall just beyond either end of the incision (figure 5). When tied, these  sutures, A and B, serve to stabilize the intestinal wall during the subsequent  closure. Sutures of 00 silk are placed at either end of the incision, and a row  of interrupted 0000 silk horizontal mattress sutures is placed beneath the  clamp (figure 6). T e clamp is then removed, the sutures tied, and any  excess intestinal wall excised. T en an inverting layer of interrupted 0000  silk horizontal mattress sutures is placed (figures 6 and 7). T e patency  of the lumen is then tested between the surgeon’ thumb and index f nger.  Alternatively, some surgeons prefer to amputate the diverticulum with a  stapling instrument. T e diverticular mesentery is divided and its vessels  are ligated, as in figure 3. T e diverticulum is splayed transversely to the  axis of the bowel using a pair of stay sutures at either side. A linear stapling  device may be used, according to the surgeon’ preference. After removal of  the diverticulum, the transverse staple line is then inverted with a series of  000 silk mattress sutures. Again, the patency and integrity of the suture line  is tested by the surgeon.    Posto Perat Ive care Postoperative care is similar to that for appen-  dectomy or small bowel anastomosis. Fluid and electrolyte balance is  maintained intravenously until intestinal motility returns. T e nasogastric  tube is then removed and progressive alimentation begun. Any subsiding  inflammation, peritonitis, or drained abscess is treated with the appropriate  systemic antibiotics plus blood and plasma replacement. T e major post-  operative complications are obstruction, peritonitis, and wound infection,  which may require further appropriate surgical therapy. m    IndIcatlIons T is resection is usually an emergency procedure utilized  in the presence of sudden obstruction, such as gangrenous intestine in a  strangulated hernia, or from volvulus. Less frequently, it is used in mes-  enteric thrombosis and obstruction by tumor. Since the end-to-end anas-  tomosis restores more accurately the natural continuity of the bowel, it is  usually preferable to a lateral anastomosis; however, the surgeon should be  familiar with the side-to-side anastomosis, which is favored when there is  marked disparity between the sizes of the ends of bowel to be anastomosed.    Preo Perat Ive PreParatlon Since resection and anastomosis of the  small intestine usually constitutes an emergency procedure, preoperative mea-  sures are necessarily limited. However, before operation is attempted, the stom-  ach is emptied and constant gastric suction maintained. Fluid and electrolyte  balance, including normal sodium, chloride, and potassium levels, should be  established in accordance with the degree of fluid and electrolyte depletion and  the age and cardiac status of the patient. Antibiotic therapy should be insti-  tuted if gangrenous intestine is suspected. T e pulse should be slowed and a  good output of urine established as evidence of adequate blood volume expan-  sion before surgery. Constant bladder drainage may be necessary to determine  accurately the urinary output in the elderly or seriously ill patient.    anestheslIa General anesthesia with an endotracheal tube and cuff, which  permits complete sealing of the trachea, is recommended and, along with pre-  operative gastric decompression, is the best prophylaxis against possible aspi-  ration pneumonia. Spinal anesthesia, either by single injection or continuous  technique, may be used. However, the threat of sudden regurgitation of large  volumes of upper gastrointestinal juices from the obstructed intestine must be  anticipated by readily available competent suction equipment. T e danger of  aspiration is ever present even if an endotracheal tube is used.    IncIslon and exPosure T eé incision is placed over the suspected site  of the lesion. If the location of the small bowel obstruction is not known, a  lower midline incision is often used, since the lower ileum is most frequently  involved. T e incision is made preferably above or below an old abdominal  scar, if present, because the site of the obstruction will most likely be near this  point, especially if the scar was tender before operation. A culture of the peri-  toneal fluid is taken, the amount, color, and consistency being noted. Bloody  fluid indicates vascular obstruction. T e dilated loops of intestine are retracted  or removed carefully from the peritoneal cavity to a warm, moist surface and  covered with gauze packs soaked in warm saline solution. When strangulation  is present, the surgeon must determine the viability of the involved intestine by  taking into consideration these factors: (1) a cadaveric odor; (2) the presence of  bloody fluid indicating venous thrombosis; (3) failure of peristalsis to progress  over the involved intestine; (4) loss of the normal luster and color of the serosal  coat; and, most important of all; and (5) absence of arterial pulsation. What  may at first appear to be nonviable intestine requiring resection will often  return to viability when the cause of the obstruction has been relieved and  when the bowel has been packed for a time in warm, moist gauze. T ere is also  a prompt change in the color of viable bowel when 100% oxygen is inhaled.  Infiltration of the mesentery with 1% procaine hydrochloride solution may  also overcome vascular spasm and bring about arterial pulsations in question-  able cases. T e intra-arterial (or systemic intravenous) injection of fluorescein  followed by ultraviolet lamp illumination may be used to evaluate the regional  perfusion. A handheld Doppler ultrasound device in a sterile cover may also  be useful in verifying the arterial supply.   In the presence of tumor, the mesentery should be explored for meta-  static nodes. If there is any doubt as to the site of the obstruction, the sur-  geon should not hesitate to eviscerate the patient until the offending lesion is  adequately exposed and to pass the bowel between the fingers, section by sec-  tion, from the ligament of Treitz to the cecum. T e surgeon must be certain  no secondary lesion or distal cause of obstruction exists. In the presence of  markedly abnormal anatomy, it may be helpful to start at the ileocecal valve  and follow the decompressed bowel proximally to the point of obstruction.    detalls of Procedure T e intestinal wall should be resected 5 to  10 cm beyond the grossly involved area, even if it means sacrificing several  feet of small intestine (figure 1). T e bowel and mesentery are divided,  preferably the mesentery first (figure 2). T e surgeon must be certain (1)  that clamps are not applied too far downward toward the base of the mesen-  tery, since the blood supply to a long segment of bowel may be accidentally    divided; (2) that the resection extends into the base of the mesentery only  in the presence of malignant disease; and (3) that a sizable pulsating vessel  is preserved to nourish the bowel adjacent to the point of resection. T e  bowel should be cleaned of mesentery for at least 1 cm beyond the pro-  posed line of resection (figure 2) to ensure the safe application of serosal  sutures along the mesenteric border. A pair of narrow, straight clamps with  fine atraumatic teeth is applied to the intestine. T e clamp on the viable  portion is placed obliquely, ensuring not only a better blood supply to the  antimesenteric border but also a larger lumen for anastomosis (figure 3).  T e bowel is divided on both sides of the lesion, and the retained bowel is  covered with warm, moist sponges.   T ecolor of the intestine is again observed to ensure that the blood sup-  ply to the bowel adjacent to the clamp is adequate and that there is suf cient  serosa exposed at the mesenteric border for the placement of sutures. If the  intestine appears bluish, or is there is no pulsation in the mesenteric vessels,  the intestine is resected until the circulation is adequate.   After the bowel ends have been prepared for anastomosis and mobilized  distally and proximally far enough to prevent any tension on the suture line  of the anastomosis, the clamps are rotated to present the posterior serosal sur-  faces for approximation. Enterostomy clamps are placed along the intestine  5 to 8 cm from the crushing clamps to prevent leakage of intestinal contents  after the clamps are removed. Silk mattress sutures are taken in the serosa at  the mesenteric and antimesenteric borders. T e mesenteric border must have  been cleaned far enough so that the sutures include serosa only and no mesen-  teric fat. A layer of interrupted Halsted 000 silk sutures is placed in the serosa  (figure 4). T e posterior mucosa is then closed either by a continuous lock  stitch of absorbable suture or interrupted 0000 silk (figure 5). T e antimes-  enteric angle and anterior mucosa are closed by changing to a Connell invert-  ing stitch (figures 5 and 6). T e anterior serosal layer is then closed with  interrupted Halsted sutures of 000 silk (figure 7). T e mesentery is approxi-  mated with interrupted 0000 silk sutures placed to avoid injury to the vessels.  Invaginating the bowel against the thumb with the finger verifies the patency  of the anastomosis (figur e 8). Silver clips may be used to verify the site of the  anastomosis in subsequent roentgen studies.    alternate Method T e method of lateral anastomosis may be used.  After the bowel is divided in accordance with the procedure explained above,  the severed ends are closed with a continuous inversion suture of absorb-  able suture over the clamp (figure 9). T e wall of the intestine in inverted,  and smooth serosa 1s approximated as the clamp 1s withdrawn (figure 10).  When the clamp is removed, the suture is pulled just tight enough to control  the bleeding and occlude the lumen and is tied at the mesenteric border.  T e open end of the intestine may be closed by interrupted 000 silk sutures.  T e bowel end is closed with a serosal row of interrupted 000 silk mattress  sutures that must not include fat or mesentery (figure 11). In order to avoid  interference with the blood supply, the final suture may pull the edge of the  mesentery up to the point of closure but should not invert or include it.   Straight intestinal noncrushing clamps are applied to the intestine close  to the mesenteric border and near the closed ends to avoid a blind segment  beyond the anastomosis. T e bowel is held in position with Allis, Babcock, or  thumb forceps as the clamps are applied (figure 12). T e clamps are placed  together, and the field is covered with fresh towels. Traction sutures are  placed at either angle of the anastomosis (figure 13). A row of interrupted  000 silk sutures is placed in the serosa. T e bowel wall is incised with a knife  on either side close to the suture line (figure 13). T e incision is lengthened  with electrocautery until a stoma about two or three fingers wide is assured.  T e posterior mucosa is closed with a continuous absorbable suture lock  stitch or interrupted 0000 fine silk sutures (figure 14). T e anterior layer of  mucosa is closed with a Connell inverting stitch and the anterior serosal layer  with interrupted 000 silk mattress sutures (figure 15). T e angles may be  reinforced with several interrupted 000 silk sutures until the closed ends of  intestine are securely anchored to the adjacent bowel (figure 16). T e mes-  entery is approximated using interrupted 000 silk sutures placed in such a  way as to avoid major blood vessels (figur e 16).    Posto PeratIve care T e fluid balance is established and maintained  by the use of the intravenous Ringer’ lactate solution. Blood transfusions  may be indicated until the pulse rate returns toward normal, especially if  the hematocrit is < 30. Constant decompression by continuous gastric suc-  tion or temporary gastrostomy is maintained until normal emptying of the  intestinal tract begins. m=    IndIcatIons_ Various portions of the small intestine are resected for a  variety of reasons. Emergency procedures involving interference with the  blood supply by a strangulated hernia, a volvulus due to a fixed adhesion,  mesenteric thrombosis, traumatic injuries, localized tumors, and regional  enteritis are among the indications for small bowel resection. Occasion-  ally it may be judicious to perform an enteroenterostomy in the presence  of many adhesions or extensive regional ileitis in an effort to avoid fur-  ther resection of the already shortened small bowel resulting from previous  extensive resections.    Preo Perat Ive PreParatlIon T e indications for operation control the  time allotted for fluid, electrolyte, and blood replacement (see Chapter 44).  Constant gastric suction is instituted. An inlying catheter for drainage  of the bladder is useful in monitoring the adequacy of urinary output in  response to treatment. When the pulse 1s elevated and gangrenous intestine  is suspected, plasma expanders or red cells may be administered. Intrave-  nous antibiotics are given, and the patient is aggressively rehydrated using  central venous pressure and urinary output as monitors.    anesthesIa T e stomach should be on constant gastric suction, and  the suction should be adequate to avoid the danger of aspiration of gastric  contents. A cuffed endotracheal tube is advisable to seal off the trachea and  avoid the possibility of aspiration pneumonia.    PosItlIon T e patient is placed in a comfortable position with the oper-  ating table elevated at right angles to the working level of the surgeon. A  modest reverse Trendelenburg position may be helpful in improving subse-  quent exposure as well as in the retraction of dilated small bowel.    IncIslon and exPosure T e incision is made in the general area of  the suspected lesion. In the trauma patient, a long midline incision ensures  adequate exposure for an extensive exploration. When an incarcerated  hernia is likely to contain gangrenous intestine, some prefer to open the  abdomen with an oblique incision above the groin in order to divide the  viable bowel above the point of incarceration, lessening the chances of gross  contamination when the hernial sac is opened. In the presence of previous  scars, especially in the midline, a new incision may be judiciously made  beyond the end or to one side in order to lessen the chance of injuring the  underlying, probably tightly adherent small intestine.    detalls of Procedure A specimen of abdominal fluid is taken for  culture and its color and odor evaluated as predictors of “dead intestine.”  T e release of restrictions by adhesions or a hernia sac is the first priority  in the hope that a return of adequate blood supply will follow. When the  viability of the intestine is questioned, the bowel may be placed in warm,  moist gauze for some minutes. Procaine may be injected carefully into the  mesentery to stimulate visible arterial pulsations. Obviously gangrenous  small bowel should be promptly isolated with towels in order to minimize  infection. In trauma patients, the small as well as the large intestine must    be thoroughly inspected for possible injury, since protruding mucosa may  temporarily block contamination. Injuries to the mesentery with hema-  toma formation require very careful evaluation. Multiple perforations with  extensive mesenteric injury may make resection of a segment of small bowel  a safer procedure than an attempt at multiple repairs of a segment. T e pos-  sibility of another intraluminal cause of obstruction mandates evaluation  of the small intestine beyond the point of intussusception or obstruction.    oPen-lumen anastomoslIs of small IntestIne Noncrushing  Scudder clamps are applied proximal to the planned point of division of the  small bowel as well as distal to the area to be resected. T is prevents gross con-  tamination of the obstructed bowel while controlling the blood supply. T e  specimen is resected (figure 1) af er a thin straight clamp is applied obliquely  to the intestinal wall with a free mesenteric serosal border of lcm or more. T is  leaves a clear serosal area for the application of the TL60 with 4.8-mm staples.    detalls of Procedure T e cutting linear stapler can be used to  approximate the open two ends of the divided small bowel (figur e 2). Af er  the bowel has been divided on the modest oblique plane with 1 cm of freed  mesenteric border, the ends are aligned. T is is accomplished by placing  traction sutures at the mesenteric and antimesenteric borders (figure 2).  T e antimesenteric border is approximated, and each of the cutting linear  stapler forks is inserted. T e bowel must be aligned evenly on the forks  before the instrument is fired (figure 3). T e bowel walls are sewn together  with the stapler and the stoma is established by the cutting knife within the  cutting linear stapler (figure 3a). T e stapled suture line is inspected for  bleeding, which, if present, is controlled with interrupted sutures.   Traction sutures (a, a’) are placed on the mesenteric border of each  segment, and another is placed centrally (b) to permit traction on the end  of the suture line on the antimesenteric border (figure 4). T e common  lumen can be closed with the application of a noncutting linear stapler. T e  excess bowel wall beyond the suturing instrument is excised (figure 5).  Any bleeding points af er the removal of the stapling instrument are con-  trolled with interrupted sutures.   With time and experience, it has been found preferable to close this  opening in a vertical manner from b to b’, thus approximating a to a’. T is  creates crossed staples only at the ends (b and b’), which are then carefully  inspected for possible suture reinforcement. Again, any bleeding points  are controlled with interrupted sutures. T e lines of closure are carefully  inspected, and the excess intestine outside of the staple lines is excised.  T e security of the suture line is evaluated, and the antimesenteric border  can be approximated if desired with interrupted sutures for distance of the  anastomosis.   T e mesentery is completely approximated with interrupted sutures  (figure 6). T e approximation may be performed before the anastomosis  is created. T e mesentery must be completely approximated to avoid any  possibility of later internal herniation of a loop of intestine. T e patency of  the anastomosis is tested by palpation between the thumb and the index    alternative methods An alternative method of anas-  tomosing the small intestine that is similar to the preceding open-lumen  anastomosis may be performed af er first resecting the specimen segment  using the cutting linear stapler (figure 7). T 1s prevents gross contamina-  tion by closing all lumens with a row of staples. Assuming the mesenteric  mobilization, ligation, and divisions have been performed, the specimen  is removed. T e proximal and distal limbs of remaining bowel are then  rotated 180 degrees in order to align the antimesenteric borders. Traction  sutures are placed near the planned staple line and approximately 6 to 8 cm  distally so as to be beyond the apex of the new anastomosis. A portion of  the antimesenteric border staple line is obliquely excised from each limb so  as to create an opening large enough for insertion of the forks of the cut-  ting linear stapler instrument (figure 8). Both forks are inserted fully to  maximize the size of the anastomotic opening. Af er assembling the cutting    linear stapler and aligning the antimesenteric septum appropriately using  the distal traction suture, the stapling instrument is discharged (figure 9).  T e anastomosis is inspected for bleeding, which, if present, is controlled  with interrupted sutures.   Traction sutures are placed at either end of the new opening, and an  additional one is placed centrally, bringing together the newly created sta-  ple lines along the antimesenteric border. T e three traction sutures are  brought within the jaws of a noncutting linear stapler, which then closes  the common opening (figure 10). T e excess tissue is excised above the  stapling instrument and this suture line is inspected for hemostasis. T e  mesentery is reapproximated with interrupted sutures and the patency of  the anastomosis is tested by palpation (figure 11).    IndIcat Ions On occasion, an enteroenterostomy may be used to bypass  an obstructed segment of small intestine involved with regional ileitis,  tumor, or extensive adhesions. A great difference in diameter of the intes-  tine that enters and exits a point of obstruction may make an end-to-end  anastomosis difficult. In some patients, a side-to-side anastomosis can pro-  vide relief of the obstruction with minimum risk and without sacrificing  extensive segments of small intestine. In patients who have had previous  small bowel resection or regional ileitis, it may be the procedure of choice  rather than a radical resection leading to further nutritional problems,  despite the risk of subsequent malignancy in the involved area of enteritis.  T eenteroenterostomy is also used to reestablish the continuity of the small  intestine after a variety of Roux-en-Y procedures.    detalls of Procedure T etwo loops selected for the enteroenteros-  tomy are grasped with Babcock forceps, and noncrushing Scudder clamps  may be applied to control bleeding and limit contamination from the  obstructed intestine (see figure 12, Chapter 44).   Traction sutures are placed in the antimesenteric border beyond the  ends of the planned anastomosis. Several additional sutures may be placed  and tied to provide stabilization of the two sides in preparation for intro-  duction of the stapler (figure 1).   With the area well walled off with sterile towels, a small stab wound is  made with a number 11 knife blade in the antimesenteric border of each  loop. T e opening is made just large enough to admit freely the fork of the  cutting linear stapler instrument. After both forks have been introduced,  the bowel walls are realigned before the instrument is fired. T e knife in the    instrument divides the septum ensuring an adequate stoma between the  two rows of staples (figure 2).   T e cutting linear stapler instrument is removed and the staple line is  inspected for potential bleeding. Additional sutures may be required to  control any bleeding points. Traction sutures re-placed through the ends  of both staple lines to approximate the wound edges in an everted man-  ner while the stoma is held open (figure 3). T e mucosal margins may be  approximated with Babcock forceps, which, along with the angle retention  sutures, ensure a complete inclusion of the bowel walls within the noncutting  linear stapler. T e stapler is fired, and all excess bowel beyond the staples is  excised by cutting along the outside surface of the stapler (figure 4).T enew  staple suture line is inspected for hemostasis. Several additional sutures are  placed to secure the angles of the anastomosis (figur e 5), while some prefer  to place additional sutures inverting the final external staple line. T e ade-  quacy of the stoma is determined by compressing the opposing intestinal  wall between the thumb and the index finger.    Posto PeratlIve care Constant gastric suction is maintained. T e  indications for the procedure and the amount of blood loss at the time of  Operation dictate the need for blood replacement. T e type and duration  of antibiotic therapy will be related to the diagnosis and the presence of  contamination at the time of operation. A careful daily check of fuid and  electrolyte levels and weight is made. T e input and output of the patients  are evaluated daily. While oral liquids may be tolerated, the diet is restricted  until bowel action has resumed. Early ambulation is encouraged and the  patient 1s alerted to report any abdominal cramps, nausea, or vomiting. m    IndIcatlIons_ Enterostomy in the high jesunum may be utilized for feed-  ing purposes in malnourished patients, either before or after major surgical  procedures. Enterostomy in the low ileum may be clinically indicated in the  presence of adynamic ileus when intubation and other methods of bowel  decompression have failed to relieve the obstruction or when the patient’  condition will not permit the removal of the cause. Enterostomy may also  be done to decompress the gastrointestinal tract proximal to the point of  major resection and anastomosis or to decompress the stomach indirectly  after gastric resection by directing a long tube in a retrograde fashion back  into the stomach. Bile, pancreatic juice, as well as gastric juice lost from  intubation or a fistula can be re-fed through the tube.    Preo Perat Ive PreParatlIon T e preoperative preparation is deter-  mined by the underlying conditions found preoperatively. Often an enter-  ostomy is done in conjunction with another major surgical procedure on  the gastrointestinal tract.    IncIslon and exPosure As arule, a midline incision 1s placed close  to the umbilicus. If the enterostomy is performed for adynamic ileus in  the presence of peritonitis, the incision should be so small that few sutures  are necessary in the closure. When the procedure is part of a major intes-  tinal resection or for feeding purposes, the enterostomy tube is brought  out through a stab wound, preferably some distance away from the original  incision. If the enterostomy is primarily for feeding purposes, or for drain-  ing the stomach, the incision should be made in the region of the ligament  of Treitz in the left upper quadrant.    IndIcatlons When used for feeding purposes, either preliminary,  complementary, or supplementary to a major resection, a Stamm enteros-  tomy should be made close to the ligament of Treitz in the jejunum. When  intended to relieve distention in adynamic ileus, the first presenting dilated  loop may be utilized.    detalls of Procedure Inthe enterostomy used as a means of feed-  ing, a loop of jejunum close to the ligament of Treitz is delivered into the  wound, and the proximal and distal ends of the bowel are identified. T e  bowel is stripped of its contents, and enterostomy clamps are applied.  Two concentric purse-string 00 nonabsorbable sutures are taken in the  submucosa of the antimesenteric surface (figure 1). A small stab wound  is made through the intestinal wall in the center of the inner purse-  string suture (figure 2), through which the catheter is slipped into the  lumen of the distal portion of the intestine. T e clamps are removed.  T e inner purse-string suture is tightened about the catheter. T e outer  purse-string suture is pulled snug to anchor the catheter to the intest1-  nal wall and serves to invert a small cuff of intestine about the catheter  (figure 3).    closure T e proximal end of the catheter is brought out through a  stab wound in the abdominal wall. T e intestine adjacent to the catheter  is anchored to the overlying peritoneum with four fine nonabsorbable  sutures (figure 4). T e catheter is anchored to the skin with a nonabsorb-  able suture (figure 5).    IndIcatlons T e Witzel enterostomy may be preferred when a long-  term need for a small bowel enterostomy is clearly indicated. T is proce-  dure provides valvelike protection to the opening into the jejunum.    detalls of Procedure T e loop of small bowel selected for the enter-  ostomy is stripped of its contents and noncrushing clamps may be applied.  A purse-string 00 nonabsorbable suture is placed opposite the mesenteric  border at the planned site of entrance (figure 6). A modest-sized soft cath-  eter with several openings is then brought through the abdominal wall placed  on the intestinal wall while interrupted sutures are placed about | cm apart,  incorporating a small bite of the intestinal wall on either side of the catheter  (figure 7). When these sutures are tied, the catheter is buried within the wall  of the small intestine for 6 to 8 cm. Following this, an incision is made into the  bowel in the midportion of the purse-string suture, and the end of the catheter  is inserted into the small intestine (figure 8) and threaded the desired dis-  tance into the lumen, after which the purse-string suture is tied. T e remain-  ing exposed portion of the catheter and the area of the purse-string suture  are further buried with three or four interrupted 00 nonabsorbable sutures  (figure 9). A stab wound is made in the abdominal wall and a clamp inserted  as a guide to the placement of sutures between the small intestine and the  peritoneum adjacent to the suture line (figure 10). A broad-based attach-  ment is desirable to avoid twisting or angulating the small intestine. After the  first layer of sutures is tied, the catheter is withdrawn through the stab wound,  permitting the anterior layer of sutures to be placed between the peritoneum  and the small intestine, which completely seals off the area of the catheter. It is  advisable to attach the small intestine to the parietes for 5 to 8 cm in order to  avoid volvulus of the small intestine around a small fixed point. T e intestine  should be anchored to the peritoneum in the direction of peristalsis.   Alternatively, a simplified feeding enterostomy may be fashioned using  an 8 or 10 French plastic or Silastic tube introduced through a needle passed  through the abdominal wall some distance from the incision. T e needle  is tunneled intramurally through the bowel wall and the catheter directed  into the bowel lumen. It is secured by one or two purse-string sutures about  the entrance site. T e bowel about the tubing is anchored to the perineum  at its entry through the abdominal wall, and the adjacent segment of intes-  tine is sutured to the peritoneum over approximately 10 cm (three or four  sutures) to prevent rotation and possible volvulus.    closure T e abdomen is closed routinely. T e catheter is anchored to  the skin with a suture and an additional adhesive dressing.    Posto PeratIve care When the enterostomy is performed to relieve an  adynamic ileus, the catheter is attached to a drainage bottle and approximately  30 mL of sterile water or saline may be injected over 2 to 4 hours to ensure  adequate drainage through the tube. If the enterostomy is used for feeding,  the patient’ fuid and calorie requirements can be partially met by homoge-  nized milk and glucose in water or saline or with one of the many commercial  enteral feeding mixtures. T ese may be started through the enterostomy tube  by continuous gravity drip at the rate of 50 mL per hour. T e calorie intake  should be increased slowly because of the common complication of diarrhea  and abdominal discomfort. Enterostomy feedings should not be continued  during the night because of the possibility that distress and/or diarrhea may  develop. T e catheter usually is removed within 10 to 14 days unless it is  required for feeding purposes, or if the obstruction has not been relieved, as  proved by recurrent symptoms after clamping of the catheter. m    IndIcatlIons Acute appendicitis is a bacterial process that is usually  progressive; however, many locations of the appendix allow this organ to  mimic many other retrocecal, intra-abdominal, or pelvic diseases. When  the diagnosis of acute appendicitis is made, prompt operation is almost  always indicated. Delay for administration of parenteral fluids and antibi-  otics may be advisable in toxic patients, children, or elderly patients.   If the patient has a mass in the right lower quadrant when first seen,  several hours of preparation may be indicated. Often a phlegmon 1s pres-  ent and appendectomy can be accomplished. When an abscess 1s found, it  is drained and appendectomy performed concurrently, if this can be done  easily. Otherwise, the abscess 1s drained and an interval appendectomy is  carried out at a later date.   If the diagnosis is chronic appendicitis, then other causes of pain and  sources of pathology should be ruled out.    Preo Perat Ive PreParatlon T epreoperative preparation 1s devoted  chiefly to the restoration of fluid balance, especially in the very young and  in aged patients. T e patient should be well hydrated, as manifest by a  good urine output. A nasogastric tube is passed for decompression of the  stomach so as to minimize vomiting during induction of anesthesia. Anti-  pyretic medication and external cooling may be needed since hyperpyrexia  complicates general anesthesia. If peritonitis or an abscess is suspected,  antibiotics are given.    anesthesla Inhalation anesthesia is preferred; however, spinal anesthe-  Sia 1s satisfactory. Local anesthesia may be indicated in the very ill patient.    IncIslon and exPosure Inno surgical procedure has the practice of  standardizing the incision proved more harmful. T ere can be no incision  that should always be utilized, since the appendix is a mobile part of the  body and may be found anyplace in the right lower quadrant, in the pelvis,  up under the ascending colon, and even, rarely, on the left side of the peri-  toneal cavity (figures | and 3). T e surgeon determines the location of the  appendix, chiefly from the point of maximum tenderness by physical exam-  ination, and makes the incision best adapted for exposing this particular  area. T e great majority of appendices are reached satisfactorily through  the right lower muscle-splitting incision, which 1s a variation of the original    McBurney procedure (figure |, incision A). If the patient is a woman and  laparoscopic evaluation is not available, many surgeons prefer a midline  incision to permit exposure of the pelvis. If there is evidence of abscess  formation, the incision should be made directly over the site of the abscess.   Wherever the incision is, it is deepened first to the aponeurosis of the  outer layer of muscle. In the muscle-splitting incision the aponeurosis of  the external oblique is split from the edge of the rectus sheath out into the  flank parallel to its fibers (figure 4). With the external oblique held aside  by retractors, the internal oblique muscle is split parallel to its fibers up to  the rectus sheath (figure 5) and laterally toward the iliac crest (figure 6).  Sometimes the transversalis fascia and muscle are divided with the internal  oblique, but a stouter structure for repair results if the transversalis fascia  is opened with the peritoneum. T e rectus sheath may be opened for 1 or  2 cm to give additional exposure (figure 7). T e peritoneum is picked up  between forceps, first by the operator and then by the assistant (figure 8).  T e operator drops the original bite, picks it up again close to the forceps  of the first assistant, and compresses the peritoneum between the forceps  with the handle of the scalpel to free the underlying intestine. T is maneu-  ver to safeguard the bowel is important and should always be carried out  before opening the peritoneum. As soon as the peritoneum is opened  (figure 8), the abdominal wall structures are protected with gauze pads to  minimize any potential contamination. T e edges of the peritoneum are  then clamped to the moist gauze sponges already surrounding the wound  (figure 9). Cultures are taken of the peritoneal fluid.    detallsof Procedure Asarule, ifthe cecum presents almost immedi-  ately, it is better to pull it into the wound, to hold it in a piece of moist gauze,  and to deliver the appendix without feeling around blindly in the abdomen  (figure 10). T e peritoneal attachments of the cecum may require division  to facilitate the removal of the appendix. Once the appendix is delivered,  its mesentery near the tip may be seized in a clamp, and the cecum may  be returned to the abdominal cavity. Following this, the peritoneal cavity  is walled of with moist gauze sponges (figure 11). T e mesentery of the  appendix is divided between clamps, and the vessels are carefully ligated  (figures 2 and 12). It is better to apply a transfixing suture rather than a tie  to the contents of the clamps, for when structures are under tension, the  vessels not infrequently retract from the clamp and bleed later into the mes-  entery. With the vessels of the mesentery tied of , the stump of the appendix  is crushed in a right-angle clamp (figure 13).    detalls of Procedure T e right-angle clamp is moved  lcm toward the tip of the appendix. Just at the proximal edge of the crushed  portion, the appendix is ligated (figure 14) and a straight clamp is placed  on the knot. A purse-string suture is laid in the wall of the cecum at the base  of the appendix, care being taken not to perforate blood vessels where the  mesentery of the appendix was attached (figure 15). T e appendix is held  upward; the cecum 1s walled of with moist gauze to prevent contamination;  and the appendix is divided between the ligature and clamp (figure 16).  T e suture on the base of the appendix is cut and pushed inward with the  straight clamp on the ligature of the stump to invaginate the stump into the  cecal wall. T e jaws of the clamp are separated, and the clamp is removed  as the purse-string suture is tied. T e wall of the cecum may be fixed with  tissue forceps to aid in inverting the appendiceal stump (figure 17). T e  cecum then appears as shown in figure 18. T e area is lavaged with warm  saline and the omentum is placed over the site of operation (figure 19). If  there has been a localized abscess or a perforation near the base, so that a  secure closure of the cecum is not possible, or if hemostasis has been poor,  drainage may be advisable. Drains should be soft and smooth, preferably  a Silastic sump drain. On no occasion should dry gauze or heavy rubber  tubing be used, since these may cause bowel injury. Some surgeons do not  drain the peritoneal cavity in the presence of obvious peritonitis that 1s not  localized, relying upon peritoneal irrigation, parenteral antibiotic, and sys-  temic antibiotic therapy to control it.   If the appendix is not obviously involved with acute inflammation, a more  extensive exploration is mandatory. In the presence of peritonitis without  involvement of the appendix, the possibility of a ruptured peptic ulcer or  sigmoid diverticulitis must be ruled out. Acute cholecystitis, regional ileitis,  and involvement of the cecum by carcinoma are not uncommon possibilities.  In the female, the possibility of bleeding from a ruptured graafian follicle,  ectopic pregnancy, or pelvic infection is ever present. Inspection of the pelvic  organs under these circumstances cannot be omitted. On occasion a Meckel’  diverticulum will be found. Closure of the abdomen, with subsequent study  and adequate preparation for bowel resection at a later date, may be indicated.    closure T e muscle layers are held apart while the peritoneum is closed  with a running or interrupted absorbable suture (figure 19). Transversa-  lis fascia incorporated with the peritoneum of ers a better foundation for the  suture. Interrupted sutures are placed in the internal oblique muscle and in the  small opening at the outer border of the rectus sheath (figure 20). T e exter-  nal oblique aponeurosis is closed but not constricted with interrupted sutures  (figure 21).T esubcutaneous tissue and skin are closed in layers. T e skin may  be left open for a delayed secondary closure if pus is found about the appendix.    alternatIve Method Insome instances, in order to avoid rupturing a  distended acute appendix, it is safe to ligate and divide the base of the appen-  dix before attempting to deliver the appendix into the wound. For example,  if the appendix is adherent to the lateral wall of the cecum (figure 22), it is  occasionally simpler to pass a curved clamp beneath the base of the appendix  in order that 1t may be doubly clamped and ligated (figure 23). Following  ligation of the base of the appendix, which is often quite indurated, it is  divided with a knife (figure 24). T e base of the appendix 1s then inverted  with a purse-string suture (figures 25 and 26). T e attachments of the  appendix are divided with long, curved scissors until the blood supply can  be clearly identified (figure 27). Curved clamps are then applied to the  mesentery of the appendix, and the contents of these clamps are subse-  quently ligated with 00 sutures (figure 28).   When the appendix is not readily found, the search should follow the  anterior taenia of the cecum, which will lead directly to the base of the  appendix regardless of its position. When the appendix is found in the ret-  rocecal position, it becomes necessary to incise the parietal peritoneum  parallel to the lateral border of the appendix as it is seen through the peri-  toneum (figure 29). T is allows the appendix to be dissected free from its  position behind the cecum and on the peritoneal covering of the iliopsoas  muscle (figure 30).   On occasion the cecum may be in the upper quadrant or indeed on the  left side of the abdomen when failure of rotation has occurred. A liberal  increase in the size of the incision and even a second incision may be, on  occasion, good judgment.    Posto Perat Ive care T e fluid balance is maintained by the intrave-  nous administration of Ringer’ lactate. T e patient is permitted to sit up  for eating on the day of operation, and he may get out of bed on the first  postoperative day. Sips of water may be given as soon as nausea subsides.  T ediet is gradually increased.   If there has been evidence of peritoneal sepsis, frequent doses of antibiot-  ics are administered. Constant gastric suction is advisable until all evidence  of peritonitis and abdominal distention has subsided. Accurate estimate of  the fluid intake and output must be made.   Pelvic localization of pus is enhanced by placing the patient in a semisit-  ting position. T e patient is allowed out of bed as soon as his or her general  condition warrants. Prophylaxis against deep venous thrombosis is insti-  tuted. In the presence of persistent signs of sepsis, wound infection and  pelvic or subphrenic abscess should be considered. In the presence of pro-  longed sepsis, serial computed tomography (CT) imaging scans beginning  about 7 days after surgery may reveal the causative site. m    IndIcatlIons Acute appendicitis is a clinical diagnosis, the accuracy of  which has improved with modern diagnostic imaging techniques including  CT scan of the abdomen and pelvis, which has an accuracy of 90% or more.  T e diagnosis is made using a combination of history, physical examination,  and laboratory tests plus an elevated temperature and white blood cell count.  A positive imaging study is helpful and gives reassurance about the diagno-  sis. In equivocal cases, serial observations and studies over time improve the  accuracy of diagnosis, but at the risk of an increasing rate of perforation.   Laparoscopic appendectomy is appropriate for virtually all patients and is  preferred in obese patients, who require longer open incisions with increased  manipulation and the resultant increase in surgical-site infections. T elaparo-  scopic technique 1s also indicated in females, especially during the reproduc-  tive years, when tubal and ovarian pathology may mimic appendicitis. Lapa-  roscopy not only provides direct observation of the appendix but also allows  evaluation of all intra-abdominal organs, especially those in the female pelvis.  Laparoscopic appendectomy has been shown to be as safe as open appendec-  tomy in the first trimester of pregnancy; however, there is always risk to the  fetus with any anesthesia or operation. Later or third-trimester pregnancies  as well as any process that creates intestinal distention will make entering the  intraperitoneal space more difficult and leave no room for maneuvering the  instruments for a safe laparoscopic operation. Finally, laparoscopic appen-  dectomy results in less incisional pain after surgery, allows a faster return to  normal function or work, and produces a better cosmetic result.    Preo PeratIve PreParatlon As healthy youngsters and young adults  constitute the most common population with appendicitis, the usual preop-  erative evaluation for anesthesia and surgery is performed. Intravenous fluids  for hydration and preoperative antibiotics are given. Extra time may be needed  in the very young or old for correction of electrolyte and fluid imbalances.  Hyperpyrexia should be treated with antipyretics or even external cooling, so  as to lessen the risk of general anesthesia. Additional discussion concerning  preparation is contained in the discussion accompanying Chapter 48.    anestheslIa General anesthesia with placement of an endotracheal tube  is preferred. After induction, an orogastric tube may be placed by the anes-  thesiologist. T is tube is removed before the end of the case or is replaced  with a nasogastric tube if prolonged decompression 1s anticipated.    PosItIon T e patient is placed in a supine position. T e right arm may be  extended for intravenous and blood pressure cuff access by the anesthesiolo-  gist while the left arm with the pulse oximeter is tucked in at the patient’ side.  T is allows for easier movement by the surgeon and the assistant operating  the videoscope. T e fiber-optic light cable and gas tubing are usually placed  to the head of the table; the video monitor is placed across from the operating  team; and the electrocautery and suction irrigator are placed toward the foot  of the table, where the scrub nurse and Mayo instrument tray are positioned.    detalls of Procedure A typical placement for access ports is shown  at the umbilicus, left lower quadrant, and lower midline (figure 1). Some    surgeons prefer a right upper quadrant port instead of the one in the left  lower quadrant. As in most laparoscopic procedures, some form of triangu-  lation is employed, with the longest and widest angle given to the operating  ports and instruments. T e videoscope port is created first. Although some  use an initial inflation of the abdomen with a Veress needle (see Chapter 12),  most general surgeons employ the open Hasson technique (see Chapter 11).  T e surgeon may enter at the superior or inferior margin of the umbilicus  with either a vertical or semicircular transverse incision. After the Hasson  port is placed and secured with the stay sutures, the abdomen 1s inflated  with CO,. T e surgeon sets the maximum gas pressure (<15 mm Hg) and  flow rate while he or she monitors the actual intra-abdominal pressure  and the total volume of gas insuf ated. T e abdomen then enlarges and  becomes tympanitic.   T e videoscope is attached to the telescopic instrument, which may be  straight (zero degree) or angled. T e system is white-balanced and the focus  adjusted. After the optical end of the instrument has been cleaned with anti-  fog solution, it is introduced down the Hasson port. A careful visualization  of all four quadrants of the abdomen is performed and a record is made of  all normal and abnormal findings.   Under direct vision with the videoscope, two additional 5-mm ports  are put into the abdomen. One is in the left lower quadrant and is placed  lateral to the rectus muscle with its epigastric vessels. T e light of the  videoscope is used to transilluminate the abdominal wall at the pro-  posed site so as to avoid trocar placement through vessels in the oblique  muscles. T e surgeon infiltrates the 5-mm site with local anesthetic. T is  infiltrating needle can be advanced through the abdominal wall and the  videoscope will see the needle enter the anticipated site for this port. A  5-mm skin incision is made and the subcutaneous tissue dilated with a  small hemostat down to the level of the fascia. T e 5-mm port is placed  through the abdominal wall while the surgeon views the safe entrance of  the pointed trocar into the intraperitoneal space. T e third port is placed  through the midline linea alba in a suprapubic position so as to avoid the  bladder, which has been decompressed with a Foley catheter. T e strategy  for a widely spread (hand’s breadth) triangular pattern of port placement  now becomes apparent as the three instruments compete for room to  maneuver.   T e patient is placed in the Trendelenburg position and the right side of  the operating table may be elevated using gravity to hold the small bowel  away from the right lower quadrant. If a normal appendix is found, a search  for other inflammatory processes is begun. Tubo-ovarian diseases, inflam-  matory bowel disease, and Meckel’s diverticulitis are most commonly  found. Once the diagnosis of appendicitis is established, the appendix is  mobilized. T e appendix and its mesentery must be clearly visualized.  T e position of the appendix is quite variable, and it may be covered with  peritoneum or even the cecum (figure 2). Safe opening of any peritoneal  covering or the equivalent of the lateral line of Toldt along the cecum may  require placement of an additional operating port. If the surgeon cannot  obtain complete visualization of the appendix, mesoappendix, and base  of the cecum for a safe transection, the operation is converted to an open    detalls of Procedure Laparoscopic removal begins with  asplaying out of the mesoappendix usinga grasping forcepsupon themesentery  (figure 3).T eimflamed tip of the appendix is not grasped, as this could cause it  torupture. T e surgeon opens through the mesentery at the base of the appen-  dix using a dissecting instrument. If maneuvering of the appendix and its mes-  entery is difficult using the grasping forceps, some surgeons prefer to lasso the  inflamed end of the appendix with a loop suture that 1s applied snugly. T e cut  end of this suture may be grasped more securely with the maneuvering forceps  (figure 4). T e mesoappendix is divided (figure 4) in one or more transec-  tions using an endoscopic vascular stapling instrument that is passed through  the large Hasson port. T is assumes that a 5-mm videoscope is available for  use through the left lower quadrant port. Otherwise, the left lower quadrant  port is enlarged to 10 mm, as both the videoscope and endoscopic vascular  stapler require large ports. T e base of the appendix is divided with the endo-  scopic cutting linear stapler (figure 5). An important maneuver with any divi-  sion using this stapler is to rotate it about 180 degrees, so as to visualize the  entire length and the contents within its jaws (figure 5a). T isrotation should  also be done during the stapling of the mesoappendix.   A small, minimally inflamed appendix can be removed safely through  the shaft of a 10-mm port. Most surgeons place an enlarged or suppura-  tive appendix into a plastic bag for removal through the abdominal wall  (figure 6). T 1s lessens the chances of infection at the surgical site. T e  appendiceal stump and stapled mesoappendix are inspected for security  and hemostasis. T e area is lavaged with the suction irrigator and a regional  inspection is made to verify the integrity of the cecum and small bowel.   Each of the 5-mm ports is removed under direct vision with the video-  scope to make sure that there are no bleeding abdominal wall vessels.    closure T e abdomen is decompressed and the Hasson port removed.  Routinely, only the 10-mm port sites require fascial closure. Some surgeons  tie the stay sutures together if this provides a secure closure to inspec-  tion and finger palpation. Others place new 00 delayed absorbable sutures    through the fascia for its closure. Scarpa’s fascia and the subcutaneous fat  are not closed. T e skin is approximated with fine 0000 absorbable sutures.  Adhesive skin strips and small, dry sterile dressings are applied.    Posto PeratlIve care T e orogastric tube is removed before the  patient awakens from anesthesia. T e Foley catheter is discontinued as  soon as the patient is alert enough to void. If a long-acting local anesthetic  was used at the port sites, postoperative pain can be controlled with oral  medications. T ere may be some transient nausea, but most patients can be  weaned from intravenous fluid to simple oral intake within a day. Antibiotic  therapy is often perioperative but may continue for a few days, depending  on the operative findings. Most patients are discharged home within a day  or two.    alternative Methods T ereare many variations upon the technique  described above. T ese involve the placement of the ports and the methods  for transecting the appendix and mesoappendix.   Virtually all laparoscopic appendectomies begin with placement of the  videoscope through an umbilical site. Insuf ation using the Veress needle  technique is preferred by some, although most general surgeons enter the  abdomen in a more controlled, open manner using the Hasson technique.  Placement of additional ports is determined by the surgeon’s preference.  In general, the sites should be widely spaced to avoid instrument com-  petition. T e size of the second port is a function of whether or not the  surgeon has a 5-mm videoscope and whether he or she plans to use (1) the  vascular stapler or (2) large ultrasonic, cautery, or laser devices for tran-  section and hemostasis. Most of these devices currently require a 10-mm  port.   Alternatively, some surgeons use metal clips for transection of the meso-  appendix and a pair of absorbable loop sutures for occlusion of the stump  of the appendix, whose mucosal center is cauterized. However, vascular  staples are preferred by most for their security and the avoidance of unrec-  ognized thermal damage. m    Several important anatomic facts influence the technique of surgery in the  large intestine. As a consequence of its embryologic development, the colon  has two main sources of blood supply. T e cecum, ascending colon, and  proximal portion of the transverse colon are supplied with blood from the  superior mesenteric artery, while the distal transverse colon, splenic flex-  ure, descending colon, sigmoid, and upper rectum are supplied by branches  of the inferior mesenteric artery (see figure 1).   Advantage may be taken of the free anastomotic blood supply along  the medial border of the bowel by dividing either the inferior mesenteric  artery or the middle colic artery and by depending upon the collateral  circulation through the marginal artery of Drummond to maintain the  viability of a long segment of intestine. T e peritoneal reflection on the lat-  eral aspect of the colon is practically bloodless, except at the flexures or in  the presence of ulcerative colitis or portal hypertension, and may be com-  pletely incised without causing bleeding or jeopardizing the viability of  the bowel. When the lateral peritoneum is divided and the greater omen-  tum freed from the transverse colon, extensive mobilization is possible,  including derotation of the cecum into the right or left upper quadrant.  Care should be taken to avoid undue traction on the splenic flexure lest  attachments to the capsule of the spleen be torn and troublesome bleeding  occur. In the presence of malignancy of the transverse colon, the omentum  is usually resected adjacent to the blood supply of the greater curvature of  the stomach.   After the colon has been freed from its attachments to the peritoneum  of the abdominal wall, the flexures, and the greater omentum, it can be  drawn toward the midline through the surgical incision limited only by the  length of its mesentery. T is mobility of the colon renders the blood supply  more accessible and often permits a procedure to be performed outside the  peritoneal cavity. T e most mobile part of the large bowel is the sigmoid,  because it normally possesses a long mesentery, whereas the descending  colon and right half of the colon are fixed to the lateral abdominal wall.   T e lymphatic distribution of the large bowel conforms to the vascu-  lar supply. Knowledge of this is of great surgical importance, especially in  the treatment of malignant neoplasm, because an adequate extirpation of  potentially involved lymph nodes requires the sacrifice of a much larger  portion of the blood supply than would at first seem essential. T e lym-  phatic spread of carcinoma of the large intestine along the major vascu-  lar supply has been responsible for the development of classic resections.  Local “sleeve” resection for malignancy may be indicated in the presence of  metastasis or because of the patient’ poor general condition.   When a curative resection is planned, the tumor and adjacent bowel  must be suf ciently mobilized to permit removal of the immediate lym-  phatic drainage area.   Basically, the resections of the colon should include either the lymphatic  drainage area of the superior mesenteric vessels or that of the inferior mesen-  teric vessels. While this would approach the ideal, experience has shown that  approximately four types of resections are commonly performed: right col-  ectomy, left colectomy, anterior resection of the rectosigmoid, and abdomi-  noperineal resection. For years lesions of the cecum, ascending colon, and  hepatic flexure have been resected by a right colectomy with ligation of the  ileocolic, right colic, and all or part of the middle colic vessels (a). Lesions  in the cecal area may be associated with involved lymph glands along the  ileocolic vessels. As a result, a segment of the terminal ileum is commonly  resected along with the right colon. Lesions in the region of the splenic flex-  ure are in the one area where left colectomy by a sleeve resection may be per-  formed. Extensive resections can be carried out with good assurance of an  adequate blood supply, since the marginal vessels are divided nearer their  points of origin. In addition to the marginal vessels, the left colic artery near  its point of origin and the inferior mesenteric vein are ligated even before  manipulation of the tumor is carried out to minimize the venous spread of    cancer cells. End-to-end anastomosis without tension can be accomplished  by freeing the right colon of its peritoneal attachments and derotating the  cecum back to its embryologic position on the left side. T e blood sup-  ply is sustained through the middle colic vessels and the sigmoidal vessels.  Although the veins tend to parallel the arteries, this is not the case with the  inferior mesenteric vein. T is vein courses to the left before it dips beneath  the body of the pancreas to join the splenic vein (b).   Lesions of the lower descending colon, sigmoid, and rectosigmoid may  be removed by an anterior resection. T e inferior mesenteric artery 1s  ligated at its point of origin from the aorta (c) or just distal to the origin  of the left colic artery. T e upper segment for anastomosis will receive its  blood supply through the marginal arteries of Drummond from the middle  colic artery. T e viability of the rectosigmoid is more uncertain following  the ligation of the inferior mesenteric artery. Accordingly, the resection is  carried low enough to ensure a good blood supply from the middle and  inferior hemorrhoidal vessels. T is level is usually so low that the anasto-  mosis must be carried out in the pelvis anterior to the sacrum. Here again  the principle of mobilizing the flexures as well as the right colon may be  required to ensure an anastomosis without tension.   T e most extensive resection involves lesions of the low rectosigmoid,  rectum, and anus. High ligation of the inferior mesenteric vessels and liga-  tion of the middle and inferior hemorrhoidal vessels, along with wide exci-  sion of the rectum and anus, are required. Since the lymphatic drainage to  the anus and lower rectum may drain laterally even to the inguinal region,  wide lateral excision of low-lying rectal and anal neoplasms is mandatory.   Since bowel anastomosis must be performed in the absence of tension,  it is imperative that considerable mobilization of the colon, especially of  the splenic flexure, be carried out if continuity is to be restored following  extensive resection of the left colon. T e presence of pulsating vessels adja-  cent to the mesenteric margin, which has been cleared preparatory to the  anastomosis, should be assured. Injection of 1% procaine into the adjacent  mesentery will sometimes enhance arterial pulsation. Occasionally, pulsa-  tions are not apparent since the middle colic artery is compressed as a result  of the small bowels being introduced into a plastic bag and displaced to the  right and outside of the abdominal wall. A sterile Doppler probe may be  used to verify the adequacy of the blood supply.   T e large intestine bears an important relation to a number of vital  structures. T us, in operations on the right half of the colon, the right ure-  ter and its accompanying vessels are encountered behind the mesocolon.  T e duodenum lies posterior to the mesentery of the hepatic flexure and is  always exposed in mobilizing this portion of the bowel. T e spleen is easily  injured in mobilizing the splenic flexure. T e left ureter and its accompany-  ing spermatic or ovarian vessels are always encountered in operations on  the sigmoid and descending colon. In an abdominoperineal resection of  the rectum, both ureters are potentially in danger of injury. T e surgeon  must not only be aware of these structures, but must positively identify  them before dividing the vessels in the mesentery of the colon.   T e anatomic arrangement of the colon that permits mobilization of  low-lying segments sometimes tempts the surgeon to reconstruct the nor-  mal continuity of the fecal current without adequate extirpation of the  lymphatic drainage zones. Extensive block excision of the usual lymphatic  drainage areas, combined with excision of a liberal segment of normal-  appearing bowel on either side of a malignant lesion, is mandatory. Primary  anastomosis of the large intestine requires viable intestine, the absence of  tension, especially when the bowel becomes distended postoperatively, and  a bowel wall of near-normal consistency. Although the danger from sepsis  has decreased substantially in recent years, the fact remains that the surgical  problems concerned with the large intestine are often complex and require  more seasoned judgment and experience than does almost any other field  in general surgery. @    IndIcatlIons A distal loop ileostomy is most commonly used for  temporary diversion of the gastrointestinal contents to protect a colonic  anastomosis. When it is constructed with a dominant proximal limb, this  ostomy provides nearly complete diversion of succus. T e loop ileostomy  has replaced the traditional right transverse colon loop colostomy in many  circumstances, as this loop is easier to construct and close. Additionally, the  loop ileostomy has proven to be no more difficult for the patient to manage  than a proximal colostomy. A loop ileostomy, however, does not decom-  press the colon when the ileocecal valve is intact. In those patients who  require acute colon decompression, a loop colostomy will allow both colon  decompression and colon preparation for a staged procedure.    Preo Perat Ive PreParatlIon Most patients undergoing emergency  or complex operations on the colon are counseled by the surgeon about  the potential need for an ostomy. If available, an enterostomal therapist  should visit the patient prior to surgery. T e potential ostomy site should be  marked with indelible ink (figure 1). An ostomy is best placed near the lat-  eral edge of the rectus muscle and sheath. It may be placed either above or  below the umbilicus. T e position chosen must take into consideration the  span of the ostomy gasket, such that it has a smooth, wide surface for adher-  ence. T e costal margin, indentation of the umbilicus, uneven scars, and  skin folds will not allow secure placement of the ostomy gasket. In general,  the belt line should be avoided, and the patient should both stand and sit  with an appliance in place during this marking. T e patient should be reas-  sured about his or her ongoing care with the enterostomal therapist. Read-  ing material and samples are often provided. If an enterostomal therapist  is unavailable, the surgeon should make every effort to educate the patient  using these written and pictorial aids.    detalls of Procedure T e anesthesia, position, and abdominal inci-  sion and exposure are determined by the colon operation being performed.  When markings are made preoperatively, they should be scratched gently  into the skin with an “X” prior to skin preparation. If this is not done, at the  end of a long and difficult case, the inked markings will likely be gone. Upon  completion of the colon anastomosis and prior to closure of the abdomen, the  ostomy site is revisited. T e cut edge of the abdominal wall, namely, the linea  alba in the midline incision, is grasped with Kocher clamps and retracted  to the central position it will occupy after closure. In patients with a thick  abdominal wall, an additional clamp may be placed on the dermis to hold the  abdominal wall in its usual alignment. A 3-cm circle of skin 1s excised and the  dissection 1s carried down through the subcutaneous fat to the anterior fascia  of the rectus muscle. A two finger—sized opening is made through the fascia.  Some prefer a single slit, while others make a cruciate incision. T e rectus  muscle is spread or retracted medially. Care should be taken not to injure the  epigastric vessels that run deeply in the center of this muscle. Another two  finger—sized opening 1s made through the posterior sheath and peritoneum.  An appropriate segment of terminal ileum, usually about | ft or so proxi-  mal to the ileocecal valve, is selected. T is section of small bowel must have  sufficient mobility to reach through the abdominal wall without stretch or  tension. It should also be proximal enough to allow side-to-side anasto-  mosis at the time of ostomy closure. A blunt Kelly hemostat is used to cre-  ate a mesenteric opening just beneath the wall of the ileum. A segment of  umbilical tape or a soft rubber Penrose drain is drawn through the open-  ing (figure 2) and a seromuscular absorbable suture 1s placed to mark the  proximal limb of the ileum. T e opening in the abdominal wall is checked    again for size relative to the thickness of the ileal loop and its mesentery.  In general, a two finger—sized opening is adequate. T e tape and the ileal  loop are brought through the abdominal wall using gentle traction with a  rocking motion (figure 3). T e loop is oriented in a vertical manner with  the active proximal limb and its marking suture placed at the cephalad or  12 oclock position. T e loop ileostomy should protrude about 5 cm above  the level of the skin. A plastic ostomy rod replaces the umbilical tape or  Penrose drain to prevent retraction following closure of the abdomen.   Closure of the abdomen is generally completed prior to maturing the  colostomy to avoid unnecessary contamination of the abdomen with ileal  contents.   T e caudal or inactive side of the loop is opened transversely for two-  thirds of its diameter in a position about halfway up from the skin level to  that where the tape or Penrose drain penetrates the mesentery. Submucosal  bleeding sites are secured with fine 0000 silk ligatures or cautery. T e distal  inactive stoma is matured first by placing fine 0000 absorbable sutures that  traverse the entire thickness of the ileal bowel wall (figure 4). T is suture  is completed as a transverse subcuticular bite beneath the skin edge. T ree  or four sutures are required for full eversion of the stoma (figure 4a). To  create a Brooke ileostomy the suture includes the mucosa and seromuscular  layer at the open edge of the intestine and also a bite more proximal on the  serosa to allow for greater eversion. T e marking suture is cut or removed,  and the proximal active stoma is everted. T is maneuver is assisted by using  the rounded, blunt end of the scalpel handle. T e handle tip applies coun-  tertraction as the free mucosal edge is brought down to the skin with for-  ceps or a similar grasping instrument (figure 5). T e cephalad bowel wall  is then secured about its perimeter to the subcutaneous skin with inter-  rupted fine absorbable sutures. Rods with “T” ends need not be secured.  Others should be secured by placing a nonabsorbable monofilament suture  at each end of the rod (figure 6). In order to avoid difficulty with appli-  ance application some surgeons prefer not to suture the rod to the skin, but  to rather have the suture placed in either end of the rod and tied so as to  prevent migration into the abdomen.   T e viability of the stoma is rechecked and the intra-abdominal portion  of the loop is examined. T e loop must come up without angulation or ten-  sion, since postoperative ileus may distend the abdomen. Finally, the ileal  loop opening through the abdominal wall is re-evaluated for snugness. An  opening that allows passage of the loop plus one finger is recommended to  minimize constriction or herniation.    closure A sterile ostomy appliance is placed after closure of the main  abdominal incision.    Posto PeratIvecare T e ostomy is observed for viability and its out-  put is measured. As the patient resumes oral intake, the volume of suc-  cus will increase. Careful monitoring of fuid and electrolyte balance is  required, especially if an overly large (= 2 L/day) output occurs. Dietary  regulation may require supplementation with antimotility drugs. T e enter-  ostomal therapist should teach the patient how to care for the stoma. Many  patients will benefit from a home visit by the nurse or therapist, wherein  both patient and caregiver become proficient in changing the appliance.  T e plastic rod is removed 3 to 5 days after surgery, after sufficient time for  the serosa to be adherent to the subcutaneous fat and skin. T e timing for  closure of this temporary diverting loop ileostomy is determined by the  healing of the colon anastomosis being protected. m    IndIcatlIons T eright transverse colostomy is preferred by many over  cecostomy for decompression of the obstructed colon due to a left-side  lesion. T is procedure completely diverts the fecal stream and permits an  efficient cleansing and preparation of the obstructed colon proximal to the  lesion. When simple diversion of the fecal stream 1s needed as a comple-  mentary component of an elective colonic operation, the surgeon should  consider placement of a proximal diverting loop ileostomy (see Chapter 51).    Preo PeratIve PreParatlIon Since this procedure is usually per-  formed to relieve acute obstruction of the left colon, the preoperative prepa-  ration is limited to the correction of fluid and electrolyte imbalance as well  as blood volume deficits. Flat and upright roentgenograms of the abdomen  are made with a marker, such as a coin, on the umbilicus. An emergency  water-soluble contrast enema is indicated to locate conclusively the left-  sided point of obstruction. A sigmoidoscopic or colonoscopic examination  may be done. Prophylactic antibiotics are administered intravenously within  Lhour of incision.    anestheslIa Usually, endotracheal anesthesia, which provides a cuf for  secure closure of the trachea, is indicated to avoid aspiration of regurgitated  gastrointestinal contents.    PosItlon T e patient is placed in a comfortable supine position with the  proposed site for the incision presenting.    IncIslon and exPosure T e incision 1s placed in the right upper  quadrant. A vertical or transverse incision can be made in a location over  the distended colon as indicated from a study of the abdominal roentgeno-  grams. Currently it is believed that the opening should be made through  the rectus muscle with consideration being given for the span of the ostomy  appliance gasket, which should be away from skin folds, bony prominences,  or the valley of the umbilicus. Marking is further discussed in the section  on loop ileostomy. T e tentative site should be checked with the patient  standing and sitting and taking special note of the proximity to the patient’  belt line which should be avoided. T e opening into the abdomen, while  limited in length, must be large enough to permit easy identification and  mobilization of the tightly distended transverse colon. If the bowel is tightly  distended, it is essential to deflate it through a large needle or trocar, since  the collapsed bowel can thus be handled more easily and safely.    detalls of Procedure A knuckle of transverse colon is delivered into  the wound, and the omentum is retracted upward. If the intestine is tre-  mendously distended, a large-bore needle attached to a syringe is inserted  obliquely through its wall to allow gas to escape. Decompression through  a small trocar attached to a suction apparatus may be indicated before the  distended bowel can be safely mobilized. If necessary to avoid contamina-  tion, the small opening is closed with a purse-string suture. Under such  circumstances the decompression of the bowel permits a safe delivery of  a larger segment of the transverse colon through a smaller incision. T e  greater omentum, which is frequently more vascular than usual under  these circumstances, should be dissected free of the colon that is to be  used as a colostomy (figure 1). All bleeding points should be ligated before  replacing the omentum in the abdomen. T e principle utilized is similar to  that described in Chapter 27, figures | and 2. Some surgeons prefer to pass  a curved clamp through an avascular portion of the omentum and trans-  verse mesocolon beneath the colon, following which a finger is inserted as  a guide (figure 2). T e omentum is divided over the presenting portion of  the transverse colon and reflected to either side (figur e 3). It may be neces-  sary to divide several small blood vessels where the omentum is attached to  the colon above the anterior taenia. After an adequate through-and-through    opening has been made beneath the transverse colon, a sterile large rub-  ber catheter (equal to 32 French) is inserted as the finger is removed  (figure 4). T erubber catheter tip 1s cut of and one end is inserted into  the other point. T is joint is then secured with a nonabsorbable suture  (figure 5). T e use of a rubber tube instead of a solid glass or plastic rod  allows it to flex into an ostomy appliance. A liberal amount of transverse  colon should be exteriorized to ensure a complete diversion of the fecal  stream.    closure T e fat tabs on the loop of bowel are now anchored to the adja-  cent peritoneum with fine sutures, great care being taken not to penetrate  to the lumen of the bowel (figure 6). T e use of sutures in anchoring the  intestine to the parietes is advantageous, since these will serve as a guide to  the individual layers when the colostomy is closed. In the presence of great  distention where the intestinal wall is quite thin, it is wiser to depend upon  the fixation of the intestine by the rubber tube and postoperative inflamma-  tion, since perforation of the intestine may take place with resultant leakage  and peritonitis if sutures are taken to anchor the bowel to the abdominal wall.   If a very liberal incision was necessary to deliver the dilated intestine,  the peritoneal opening may be partially closed by interrupted fine sutures  (figure 7). T e peritoneal closure should not constrict the arms of the  knuckle of the intestine but should permit the introduction of the index  finger directly into the peritoneal cavity about the intestine. T e fascia  is approximated with interrupted 00 sutures (figure 7). In general, this  fascial closure should allow the passage of one finger plus the loop. T e  subcutaneous tissue and skin are closed in a similar manner. Subcuticular  interrupted absorbable sutures may be used to provide a firm closure and  a wound less likely to be irritated by the subsequent constant fecal soilage.  T e ostomy is matured in most cases. A transverse incision is made only  after the closure is complete (figure 8). In some cases the bowel requires  decompression with a tube secured by a purse-string suture as shown in  figure 9.T edistal or inactive stoma is matured first by placing fine 0000  absorbable sutures that transverse the thickness of the colon bowel wall.  T e suture is completed as a traverse subcuticular bite beneath the skin  edges (figure 10). T e proximal or active stoma is then matured in a sim1-  lar fashion. In cases of healthy bowel, the proximal end can be made more  prominent by creating the incision closer to the distal end of the exposed  loop, as seen in Chapter 51. In some cases it may be preferred to delay the  opening of the stoma, in which case tube drainage of the proximal limb is  sometimes used.    Posto Perat Ive care It is usually better judgment to open the colos-  tomy before the initial dressings are applied rather than to delay 2 or 3 days  to avoid possible infection of the wound, since the dangers of unrelieved  obstruction are greater than the possible complications of wound infection.   In cases of acute obstruction, it may be desirable to continue constant  gastric suction for several days. Following this, the patient is given fluids  the first day and a soft diet for the next few days, progressively increasing to  a high-vitamin, high-calorie, high-protein, low-residue diet. Early ambula-  tion is permitted. Irrigations of the proximal colon may be given through  the colostomy opening in preparation for secondary surgical procedures  or to establish regular emptying of the colostomy if the colostomy is to be  permanent. Following diversion of the fecal stream, the reaction about the  obstructing tumor tends to subside and the obstruction may be relieved.  T rough-and-through irrigations for cleansing purposes may then be pos-  sible. Blood transfusions, high-calorie solutions, and Ringer’ solution are  given as required, depending on the degree of the patient’ debility. Antibi-  otic therapy is discontinued after a few days or so unless the patient has a  continuing infection. m    IndIcatIons In every instance an interlude that may be as long as 10  weeks should be allowed between the performance of a colostomy and its  closure. T 1s enables the patient’ general condition to improve, the site of  the colostomy to become walled off, local immunity to the infected contents  of the intestine to develop, any infection in the wound to subside, and the  wounds from technical procedures carried out on the distal colon to heal.  T is time may be drastically shortened if the colostomy was performed to  decompress or exteriorize a traumatized normal colon. Occasionally, the  colostomy partially or completely closes itself after the obstruction has  been removed, which permits the fecal current to return to its normal route  through the site of the anastomosis. Closure should be delayed until the  edema and induration of the bowel about the colostomy opening have sub-  sided and the intestine has resumed a normal appearance. T e patency of  any anastomosis of the intestine distal to the colostomy should be assured  by contrast study using fluoroscopy.   A stapled anastomosis may also be created to close a loop colostomy. See  Chapter M4.    Preo Perat Ive PreParatlIon T e patient is placed on a low-residue  diet with oral antibiotics before operation, and the intestines are emptied as  completely as possible. During the 24 hours preceding operation, repeated  irrigations in both directions through the colostomy opening are done to  empty the colon. Other preoperative preparation is in accordance with that  outlined in Chapter 57.    anesthesIa Spinal or general anesthesia may be used.  PosItlon T e patient is placed in a comfortable supine position.    o Perat Ive PreParatIon Supplementary to the routine skin prepara-  tion, a sterile gauze sponge may be inserted into the colostomy opening.    IncIslon and exPosure figure 2 shows the cross-sectional anatomy  of the colostomy. While a piece of gauze is held in the lumen of the intes-  tine, an oval incision is made through the skin and subcutaneous tissue  about the colostomy (figure 1). T 1s incision may include the original scar  or, alternatively, an elliptical incision may be made that includes the entire  scar and colostomy.    detalls of Procedure T eoperator’ index finger is inserted into the  colostomy to act as a guide to prevent incision through the intestinal wall or  opening into the peritoneal cavity as the skin and subcutaneous tissue are  divided by blunt and sharp dissection (figures 3 and 4).   In the case of a colostomy that has been functioning for some time, the  ring of scar tissue at the junction of mucous membrane and skin must be  excised before proceeding with the closure (figure 5). With the index fin-  ger still in the lumen of the intestine, the operator makes an incision with  scissors around the margin of the mucosal reflection (figure 6). T 1s inci-  sion 1s carried through the seromuscular layer down to the submucosa in  an effort to develop separate layers for closure (figure 6).    closure With its margin held taut with forceps, the mucous mem-  brane is closed transversely to the long axis of the bowel. A continuous fine  absorbable suture is used (figure 7). Following closure of the mucosa, the  previously developed seromuscular layer, which has been freed of any fat,  is approximated with interrupted Halsted sutures of fine silk (figure 8).  T e wound is irrigated repeatedly, and clean towels are applied around the  wound. All instruments and materials are removed, gloves are changed, and  the wound is closed only with clean instruments.   T e closed portion of the bowel is held to one side while the adjacent  fascia 1s divided with curved scissors. T e detachment of the fascia from    the bowel is facilitated by exposure of the silk sutures previously placed for  fixation of the bowel at the time of colostomy (figure 9). T e peritoneal  cavity is not opened in this method of closure.   T e patency of the bowel is tested by the surgeon’s thumb and index  finger. If a small opening has been accidentally made in the peritoneum, it  is carefully closed with interrupted sutures. T e wound is irrigated repeat-  edly with warm saline. T e suture line is depressed with forceps, while the  margins of the overlying fascia are approximated with interrupted sutures  of 00 long-lasting absorbable suture (figure 10). T e subcutaneous tissue  and skin are closed in layers in the routine manner (figure 11). Some omit  closure of the skin because of the possibility of infection and perform a  delayed secondary closure.    IncIsIon and exPosure Instead of attempting to incise the ring of  scar tissue at the junction of mucous membrane and the serosa of the bowel,  some operators prefer to divide the full thickness of the bowel adjacent to  the colostomy opening. After the bowel has been freed from the surround-  ing tissues, the surgeon’ index finger may be inserted into the colostomy  to serve as a guide while the bowel is being divided with curved scissors  adjacent to the margin of the presenting mucous membrane (figure 12). It  may be necessary to free the intestine from the peritoneum and open into  the peritoneal cavity in order to mobilize a suf cient amount of the bowel  for a satisfactory closure.    detalls of Procedure T e intestinal wall is excised until the scarred  edges of bowel around the colostomy opening are completely cut away,  leaving normal-appearing intestinal wall to be closed. T e bowel is closed  transversely to the long axis of the intestine to prevent stenosis. T e bowel  wall is held taut with either Allis or Babcock forceps above and below  the angles of the new opening. T e mucous membrane of the intestine  is closed on the inner side with a continuous fine absorbable suture of  the Connell type. Interrupted 0000 silk sutures on a French or straight  milliner’s needle are preferred by many (figure 13). Interrupted mattress  sutures of 00 silk or 00 absorbable synthetic sutures are placed to invert  the mucosal suture line and to approximate the seromuscular layer over it  (figure 14).    closure T e wound is irrigated with saline. All contaminated instru-  ments, gloves, and towels are discarded, and clean materials are used if it  is necessary to open the peritoneal cavity about the margin of the bowel in  order to replace the closure within the peritoneal cavity (figure 15). T e  patency of the lumen of the bowel is assured by palpation between the sur-  geon’s thumb and index finger. If possible, the omentum is tucked over the  site of the closure. T e peritoneum is closed with interrupted sutures of 00  absorbable synthetic suture material, followed by a routine closure of the  layers of the abdominal wall (figures 16 and 17). When gross contamina-  tion has occurred, some prefer to partially approximate the subcutaneous  tissue and omit skin approximation by sutures. T e wound is covered with  a sterile dressing.    Posto PeratlIve care Parenteral fluids are administered for sev-  eral days. A clear liquid diet is given for a few days, followed by a low-  residue diet; a regular diet can be resumed after bowel action has started.  Occasionally, a leak may occur at the closure site, but no immediate effort  is made to repair the fistula (unless it 1s causing systemic illness or peri-  tonitis) because closure is frequently spontaneous. Early ambulation is  encouraged. m    Altern Ative Method—triAngul Ation An alternative method of  open anastomosis for large intestine involves the method of triangulation  using three separate staple lines. It is particularly useful in colocolostomy  anastomoses as in left-sided colectomies since it does not require rotation  of the mesentery. It can also be used to close a loop colostomy as an alterna-  tive to the sutured technique in Chapter 53.    det Ails of Procedure T esection of the bowel to be excised 1s isolated  with Kocher clamps while thin straight clamps, such as Glassman clamps, are  placed transversely on the colon (figure 1). Several inches beyond these,  noncrushing Scudder or rubber-shod clamps are applied to prevent gross  contamination. T e specimen is excised between the Kocher and straight  clamps. T e field is walled of with laparotomy pads and the clamps are  opened. Obvious bleeding points are controlled with fine ligatures. T e two  limbs of open bowel are brought in approximation with correct mesentery-  to-mesentery alignment (figure 2). T e mesenteric opening is closed with  interrupted fine silk sutures (figure 3). Anterior and posterior traction  sutures (A and B) are placed halfway between the mesenteric and antimesen-  teric borders. T e full thickness of bowel wall along the mesenteric border is  aligned with several through-and-through traction sutures or a row of Allis    clamps (figure 4). T enoncutting linear stapler (TL 60) is positioned trans-  versely below the Allises and traction sutures (figure 5). T is ensures inclu-  sion of all bowel wall in the deep staple line. After discharging the stapling  instrument, the excess tissue is cut from above the instrument jaws while  preserving the traction sutures on either end (figure 6).   A bisecting third traction suture (C) is placed through each stoma in a  position corresponding to the apex of the antimesenteric border (figure 7).  T e open jaws of the noncutting linear stapler (TL 60) are positioned for  the second side of the triangle using traction suture (B) to elevate the end of  the posterior staple line within the jaws (figure 8). After discharging the  staple gun, the excess tissues above the jaws are excised, leaving the apical  traction suture (C) intact.   T e procedure is then repeated using the two remaining traction sutures  (C and A). T is final limb of the triangulation must transect each of the  other two staple lines (figure 9). Upon its completion, the excess tissue 1s  excised. T e bowel is inspected for hemostasis and any bleeding points are  secured with fine silk ligatures. Any residual mesenteric defect is closed with  interrupted sutures. T e anastomosis is palpated for patency (figure 10)  and the bowel on either side may be compressed to verify that no leak is  present. m    IndIcatlIons Resection of the right colon is commonly indicated for  carcinoma, inflammatory bowel disease, and more rarely for tuberculosis  or volvulus of the cecum, ascending colon, or hepatic flexure.    Preo Perat Ive PreParatlIon Some tumors ofthe right colon present  as an obstruction and may require relatively urgent operation for exces-  sive cecal distention (=15 cm) in the presence of a competent ileal cecal  valve. Such a patient is resuscitated with correction of fluid and electrolyte  imbalances. T e proximal bowel is decompressed with a nasogastric tube.  Once the patient’ physiologic status 1s optimized, he or she will proceed to  urgent operation, wherein a right colectomy can be performed in an unpre-  pared bowel. T e prudent surgeon should verify that there is not a second  or metachronous colorectal lesion. If the right colectomy is being done in  an elective setting, the entire colon should be evaluated with either colonos-  copy or barium enema. Blood transfusion may be advisable, especially in  older patients with cardiovascular disease, when a silent and unrecognized  iron deficiency anemia has been created by a silent, longstanding neoplasm  of the right colon. Any pre-existing steroid therapy is continued with intra-  venous replacement as the patient prepares for surgery. Perioperative sys-  temic antibiotics are given.    o PeratIve PreParatlon T eskin is prepared in the routine manner  and a sterile drape is applied.    IncIslon and exPosure A liberal midline incision centered about  the umbilicus is made. A transverse incision just above the level of the  umbilicus also provides an excellent exposure. T e lesion of the right colon  is inspected and palpated to determine whether removal is possible. In  the presence of malignancy, the liver is also palpated for the evidence of  metastasis. If the lesion is inoperable, a side-to-side anastomosis may be  performed between the terminal ileum and the transverse colon without  any resection (see Chapter 46). After resection has been decided upon, the  small intestines are walled off with packs and the cecum is exposed.    detalls of Procedure An incision is made in the peritoneal reflec-  tion close to the lateral wall of the bowel from the tip of the cecum upward  to the region of the hepatic flexure (figure 1). A liberal margin should be  ensured in the region of the tumor. Occasionally, the full thickness of the  adjacent abdominal wall may require excision to include the local spread of  tumor. Since the entire hepatic flexure is usually removed as part of a right  colectomy, the hepatocolic ligament, which contains some small blood  vessels, must be divided and ligated, but there will be no blood vessels of  importance in the peritoneal attachments along the right gutter. With the    lateral peritoneal attachment divided, the large bowel may be lifted mesially  with the left hand, while the loose areolar tissue lying under it is dissected  off with a moist gauze sponge over the right index finger (figure 2). In ele-  vating the right colon toward the midline, the surgeon must positively iden-  tify the right ureter and be certain that it is not injured. Care is taken also  toward the top of the ascending colon and near the hepatic flexure to avoid  injury to the third portion of the duodenum, which underlies the large  bowel (figure 3). T e raw surface remaining after the intestine has been  freed and brought outside the peritoneal cavity is covered with warm, moist  gauze pads. T e middle colic vessels are identified, along with the right-  hand branches heading toward the hepatic flexure and the planned zone  of transection. T e mesentery of the large bowel is clamped and divided  just distal to the hepatic flexure or wherever the bowel is to be resected.  T eright branches or all of the middle colic vessels are divided and doubly  ligated. T e bowel at the selected level for division is freed of all mesentery,  omentum, and fat on both sides. All vessels must be carefully ligated. T e  right half of the greater omentum is divided near the greater curvature of  the stomach and excised along with the right colon.   T e terminal ileum is prepared for resection some distance away from  the ileocecal valve, depending upon the amount of blood supply that must  be sacrificed to ensure excision of the lymph node drainage area of the right  colon. After the small intestine has been prepared at its mesenteric border, a  fan-shaped excision of the mesentery to the right colon is carried out. T is  usually includes part of the right branches of the middle colic vessels. In the  presence of malignancy, the lymph node dissection should descend as far  as possible along the course of the right colic and ileocolic vessels without  compromising either the middle colic vessels or the superior mesenteric  vascular supply of the remaining small bowel (figure 4). T e blood vessels  of the mesentery are doubly tied.   A straight vascular clamp, or some other type of straight clamp, is applied  obliquely to the small intestine about 1 cm from the mesenteric border to  ensure a serosal surface for the placement of sutures for the subsequent  anastomosis. Stone, Kocher, or Pace-Potts clamps are next applied across  the large intestine, which is then divided between the clamps. T e interven-  ing section of bowel, with its fan-shaped section of mesentery and nodes,  is excised. T e divided proximal end of the small intestine is covered with  gauze moistened with saline, and closure of the stump of the large bowel is  started unless an end-to-end or end-to-side anastomosis is planned. Many  surgeons prefer to use stapling devices, in which case the colon and term1-  nal small bowel are resected using a linear stapling device. T e ileum and  transverse colon may then be anastomosed in an antimesenteric side-to-  side manner using the technique shown in Chapter 45, Resection of Small  Intestine, Stapled. As staples may not be universally available, the tech-  niques for hand-sewn anastomoses are shown in the continuing figures of    detalls of Procedure T e end of the colon is closed  by a continuous absorbable suture on an atraumatic needle and whipped  loosely over a Pace-Potts or similar noncrushing clamp (figure 5). Inter-  rupted 000 silk sutures placed beneath the clamp may be used. T e clamp  is then opened and removed. If a continuous suture is used, it is pulled up  snugly and tied. A single layer of 000 silk Halsted mattress sutures is placed  about 2 or 3cm from the original suture line; care being taken that no fat  is included. As these sutures are tied, the original suture line 1s invaginated  so that serosa meets serosa (figure 6). T e surgeon must determine before  closing the ends of the colon whether an end-to-end, end-to-side, side-to-  end, or lateral anastomosis 1s to be carried out (figures 14, 16 to 18).   T e end-to-side approximation is physiologic, simple, and safe to per-  form. T e small intestine, still held in its clamp, is brought up adjacent  to the anterior taenia of the colon (figure 7). T e small intestine should  retain a good color and give evidence of adequate blood supply before the  anastomosis is attempted. If its color indicates an inadequate blood sup-  ply, the surgeon should not hesitate to resect a suf cient length until its  viability is unquestionable. Next, the omentum, if not previously excised, is  retracted upward, and the anterior taenia of the transverse colon is grasped  with Babcock forceps at the site chosen for anastomosis (figure 7). Fol-  lowing this, the edge of the mesentery of the small intestine should be  approximated to the edge of that of the large intestine, so that herniation  of the small intestine cannot occur beneath the anastomosis into the right  gutter (figure 14).T is opening is closed before the anastomosis is started,  since on rare occasions the blood supply may be injured by the procedure  and the viability of the anastomosis jeopardized. A small, straight crush-  ing clamp is applied to the anterior taenia, including a small bite of the  bowel wall (figure 8). Following this, the clamps on the terminal ileum,  as well as on the anterior taenia of the transverse colon, are so arranged  that a serosal layer of interrupted 000 mattress or nonabsorbable synthetic  sutures can be placed, anchoring the terminal ileum to the transverse colon  (figure 9). T e two angle sutures are not cut and serve as traction sutures  (figure 9). An opening is made into the large intestine by excising the  protruding contents of the crushing clamp that has been applied to the  anterior taenia (figure 10). An enterostomy clamp is then applied behind  each of the crushing clamps. T e crushing clamps are removed, and the  terminal ileum is opened; likewise, the crushed contents of the transverse  colon are separated. Sometimes it is necessary to enlarge the opening in  the mucosa of the colon, since the previous excision of the contents of the  crushing clamp did not provide a suf ciently large stoma for satisfactory  anastomosis. T e mucosa is then approximated with a continuous locked  nonabsorbable suture on atraumatic needles, which is started in the mid-  line posteriorly. T e sutures, A and B, are continued as a Connell inverting  suture around the angles and anteriorly to ensure inversion of the mucosa    (figures lland 12). Interrupted fine 000 silk sutures are preferred by some  for closing the mucosal layer. An anterior row of mattress sutures completes  the anastomosis. Several additional mattress sutures may be placed to rein-  force the angles (figure 13). T e patency of the stoma is tested. It should  permit introduction of the index finger. If the tension is not too great, the  raw surface over the iliopsoas muscle may be covered by approximating the  peritoneum of the lateral abdominal wall to the mesentery.   T esecond method shown isadirect end-to-end anastomosis (figur es 15  and 16). T e discrepancy in the size of the terminal ileum and the trans-  verse colon can be overcome safely by attending to certain technical details.  Added luminal circumference can be provided by exaggerating the oblique  division of the terminal ileum. During the anastomosis, slightly larger bites  are taken in the colonic side to compensate for the discrepancy between the  two sides of the anastomosis. Following completion of the anastomosis, any  remaining gap between the mesenteries is approximated. T e patency of  the lumen is determined by palpation.   If a side-to-end anastomosis is preferred by the surgeon, the stump of  the small intestine is closed as previously described for the large intestine.  T e small intestine is then brought up to the open end of the large intestine  (figure 17), the posterior row of serosal sutures is placed, the small intes-  tine is opened, and the continuous mucosal suture or the inverting sutures  are placed as well as, finally, the anterior serosal sutures of interrupted 000  silk or nonabsorbable synthetic material. Whenever this type of procedure  is carried out, care should be taken that only a very small portion of small  intestine protrudes beyond the suture line, since blind ends of bowel that  are in the peristaltic line form a stagnant pouch against which peristalsis  tends to work, increasing the chance of eventual breakdown.   In the fourth method, the ends of the large and small intestines are  closed, and a lateral anastomosis is carried out. Only a small portion of  small intestine should protrude beyond the suture line. T e small intestine  should be anchored to the colon with interrupted sutures of silk or nonab-  sorbable synthetic material, including both angles of the stoma as well as  the closed end of small bowel (figure 18). T e stapled equivalent of each of  the variations can be found in earlier chapters illustrating the use of various  stapling instruments in small bowel anastomoses.    closure Drains are undesirable unless gross infection has been encoun-  tered. T e site of anastomosis is covered with omentum. T e abdominal  wall is closed in routine fashion, and a sterile dressing is applied.    Posto PeratIvecare T epatient should be in a comfortable position.  Diarrhea or frequent bowel movements may be satisfactorily controlled by  medication and diet. T e need for continued steroid therapy, particularly  in patients with regional ileitis, should not be overlooked in the immediate  postoperative period. m    IndIcatlIons Laparoscopic colectomy is indicated in both benign and  malignant conditions as long as it is performed by qualified surgeons with  appropriate resources. In general this approach is not recommended in  patients with emergency conditions such as obstruction, perforation, or  massive bleeding.    Preo PeratIve PreParatlon For patients having surgery for pol-  yps and most neoplasms, it is essential to have the lesion tattooed during  colonoscopy or localized by a preoperative barium enema. Identification of  the tumor during laparoscopy is usually difficult. T e use of intraoperative  colonoscopy is difficult during laparoscopic procedures; hence, accurate  preoperative localization 1s necessary. If intraoperative colonoscopy is nec-  essary, the use of CO, insufflation rather than air will speed the resolution  of colonic distention that can greatly impede the laparoscopic approach.  T e patient should receive a standard mechanical bowel preparation, and  prophylactic antibiotics are administered within | hour of the incision and  are to be discontinued within 24 hours of surgery. Subcutaneous heparin  is administered and sequential compression devices are placed for the pre-  vention of venous thromboembolism.    anesthesIa General anesthesia is required. An orogastric or nasogas-  tric tube is inserted.    PosItlon T e patient is positioned in the modified lithotomy position  with the legs supported on stirrups. Padding is used to protect all pressure  points. T e left arm is tucked. T e patient should be secured to the operat-  ing table with tape, as repositioning of the table may be needed to enhance  exposure during the operation. T e operating room setup is shown in  figure la.T esurgeon and camera operator stand to the patient’ left. T e  assistant stands between the patient’ legs. Two video monitors are used as  shown.    o PeratIve PreParatlon T eskin is prepared in the routine manner  and a sterile drape is applied.    IncIslon and exPosure Access to the peritoneal cavity is achieved by  an open or Hasson technique. An infraumbilical incision is made and a 10-  to 12-mm Hasson port inserted. T e abdomen is insufflated to 15 mm Hg.  A 30-degree-angled scope is employed. After the Hasson port is inserted,  there are three commonly used port placements (figure Ib). T e first con-  figuration, shown in figure lb, has a 10- to 12-mm trocar to the left of  the midline in the left lower quadrant with a 5-mm port in the left upper  quadrant and another 5-mm port the right lower quadrant if needed. Using  this method, the extraction incision is made as a vertical midline either at  the level of the umbilicus or in the suprapubic area. T e second configura-  tion is a 10- to 12-mm port in the left lower quadrant and 5-mm ports in the  suprapubic midline and a right upper quadrant in the subcostal location in  the midclavicular line. T e upper 5-mm port on the right side may allow  better mobilization of the hepatic f exure in some patients. With this con-  figuration, the extraction incision is either midline as described above or in  the transverse direction at the site of the 5-mm right upper quadrant port  or a transverse right lower quadrant incision. T e third configuration uses  a hand port in the midline, a 10- to 12-mm port if the left lower quadrant,  and 5-mm ports at the subxiphoid midline location and the right subcostal  area. A hand port is used to extract the specimen.    detalls of Procedure Mobilization of the right colon is shown by a  lateral to medial approach. A medial to lateral approach may be used but is  not described here. In the lateral medial approach, mobilization begins at  the cecum. T e patient is placed in the Trendelenburg position and tilted  30 degrees to the left. T e cecum is grasped with an atraumatic instru-  ment and retracted medially and anteriorly (figure 2). Using a mono-  polar cautery endoscissors or another energy device, an incision is made  in the peritoneal ref ection close to the lateral wall of the bowel at the tip  of the cecum (figure 2). T e assistant then grasps the ascending colon  and retracts it medial and cephalad, permitting the incision to be extended  upward to the region of the hepatic f exure using a traction counter-traction  technique (figure 3). As the dissection begins, care should be taken to avoid  ureteral injury. As one approaches the hepatic fexure, the duodenum may    be visualized and protected (figure 3). For mobilization of the hepatic  fexure, the patient should be placed in the reverse Trendelenburg posi-  tion. If there is a 10- to 12-mm trocar in the right lower quadrant, reposi-  tioning the laparoscope to this sight may provide better visualization. T e  hepatic f exure is then retracted medially and inferiorly. An energy device  is used to divide the peritoneal attachments (figure 3). Care is taken to  avoid injury to the underlying duodenum during hepatic f exure mobiliza-  tion. For mobilization of the hepatic f exure the patient should be placed  in the reverse Trendelenburg. If there is a 10- to 12-mm trocar in the right  lower quadrant reposition the laparoscope to this site may provide better  visualization. T e hepatic f exure is then retracted medially and inferiorly.  An energy device is used to divide the peritoneal attachments (figure 4).  Next the proximal transverse colon is mobilized by dividing the omental  attachments along the line of dissection in figure 2. T e assistant grasps  the omentum and holds this upward. T e surgeon grasps the mesenteric  side of the transverse colon to put tension on the omental attachments. T e  omental attachments are divided with ultrasonic shears or electrocautery  taking care not to injure the colon. Division of the gastro colic ligament is  frequently necessary to completely mobilize the hepatic fexure from the  liver. T e extent of omental detachment may vary depending on the loca-  tion of the lesion and the degree of reach needed.   T e mesentery is divided in the next series of steps. T e ileocolic ves-  sels are grasped and retracted toward the anterior abdominal wall. T e  peritoneum overlying the mesentery is incised at a point beneath the ileo-  colic vessels with electrocautery endoscissors and a window created. For  malignancy, this should be near the root of the mesentery. T e cecum is  grasped and retracted laterally to elevate the ileocolic vessels. T e vessels  are Skeletonized and then divided with the linear laparoscopic stapler with  2.5-mm staples or clips (figure 4a and b). T e dissection is carried toward  the hepatic f exure and the stapling process repeated until the mesentery 1s  divided. T e dissection is continued to and including the right branch of  the middle colic artery.   In figure 4a, the right colic artery 1s being dissected. figur e 4b shows  the ligated ileocolic artery, right colic artery, and the right branch of the  middle colic. T e line of resection is shown in figure 5. After complete  mobilization the bowel is externalized through a 6- to 10-cm incision by  extending the right lower quadrant incision or the umbilical incision.  A plastic wound protector is used. T e terminal ileum and colon are exte-  riorized through this opening. T e proximal and distal margins of the  specimen are then divided using a linear stapler (3.5-mm staples). Larger  staples may be needed depending on the thickness of the bowel wall. A  side-to-side hand-sewn or stapled anastomosis may be performed. To per-  form a side-to-side stapled anastomosis, stay sutures are placed to secure  the two antimesenteric walls of the ileum and the colon. An enterotomy for  the introduction of the stapling device is created by excising a small por-  tion of the staple lines along the ileum and transverse colon with curved  Mayo scissors (figure 6a). T e linear stapler is then introduced and closed  (figure 6a). T e posterior aspect of the bowel is examined to be certain  that no mesentery is included in the closed stapler. Once this is ensured,  the stapler is discharged and the anastomosis created. T rough the enter-  otomies, the staple line is inspected for bleeding. Small bleeding points are  sutured with 000 silk figure-of-eight sutures. T e enterotomy is closed with  a stapler (figure 6b). T e final appearance is shown in figure 6b. T e  mesenteric defect does not require closure and the bowel returned to the  peritoneal cavity.    closure T e incision used to exteriorize the bowel and complete the  extracorporeal anastomosis 1s closed with interrupted or running sutures.  T eport sites greater than 5mm are closed with sutures as well.    Po sto Perat Ive care T e orogastric or nasogastric tube 1s removed  in the operating room. Intravenous fuids are administered and vital signs  and urine output monitored every 4 hours. Prophylactic antibiotics are dis-  continued within 24 hours of the surgery. T e bladder catheter is removed  on postoperative day 1 or 2. An initial postoperative diet consisting of clear  liquids is started immediately or on postoperative day lif there is no disten-  tion or indications of complications and this is advanced as tolerated. m=    IndIcatlIons T e operation is performed chiefly for tumor of the left  colon or a complication of diverticulitis.    Preo Perat Ive PreParatlon ‘Tumors of the left colon are frequently  of the stenosing type. Patients with this condition often come to the sur-  geon with symptoms of impending intestinal obstruction.   When obstruction is not complete, the bowel can best be prepared over  a period of days by oral administration of the appropriate cathartics and  a clear liquid diet for the last 48 hours. T e frequency with which cathar-  tics and cleansing agents are administered will vary depending upon the  amount of obstruction. T e level and nature of the obstruction may be con-  firmed by bartum enema; however, colonoscopy allows biopsy for patho-  logic identification, identification and removal of additional lesions such as  polyps, and potential evaluation of the proximal colon. In the presence of  total obstruction, a nasogastric tube is passed for decompression and the  colon is emptied from below with enemas. Evaluation of the distal colon  with colonoscopy is valuable. A virtual colonoscopy may be obtained with  special CT imaging to evaluate the proximal colon, although it requires  bowel preparation and air insufflation and not an obstruction in patients  with near or complete obstruction. A baseline carcinoembryonic antigen  (CEA) blood test is obtained. If this and enzymatic liver function tests are  elevated, CT or imaging scans of the abdomen and liver may be obtained  to evaluate metastatic spread. Perioperative antibiotics are given. A Foley  catheter is inserted after induction of anesthesia.    PoslItlIon T e patient is placed in a comfortable supine position and  rotated slightly toward the operator. A slight Trendelenburg position may  be used, although it can rarely lead to lower extremity compartment syn-  drome. If the colon tumor or process 1s in the lower left colon or sigmoid  region, most surgeons will position the patient in a modified lithotomy man-  ner using Allen stirrups supporting the knees and ankles. T is will allow for  prepping and draping of the rectal region for potential passage of a circular  stapling device. T e legs are spread and the knees elevated sufficiently to pro-  vide this access to the rectum but not so high or wide as to interfere with the  abdominal portion of the operation. If there is any doubt as to the location of  the tumor, lithotomy position is recommended.    IncIslon and exPosure T eoperator stands on the patient’ left side.  A liberal midline incision is made centered below the level of the umbilicus.  T e liver as well as other possible sites for metastasis are explored. T e small  intestines are then packed away medially with warm, moist packs. A pack is  placed toward the pelvis and another along the lateral wall up to the spleen.    detalls of Procedure Precautions against possible spread of the tumor  should include limited manipulation of the growth. As soon as possible, the  tumor should be covered with gauze and its major blood supply clamped.  With the bowel at the point of the lesion held in the left hand, the lateral  peritoneal reflection of the mesocolon 1s incised close to the bowel except  in the region of the tumor over as wide an area as seems essential for its  free mobilization (figure 1). Following this, the bowel is retracted toward  the midline and the mesentery is freed from the posterior abdominal wall  by blunt gauze dissection. Troublesome bleeding may occur if the left sper-  matic or ovarian vein is torn and not ligated. T e left ureter is identified  because it must not be drawn up with the mesentery of the intestine and  accidentally divided. A fan-shaped incision of sufficient size 1s made so that  the entire left colic artery and vein down to their origins can be removed    in order to maximize removal of regional lymph nodes (figure 2). Some  surgeons perform this division as soon as possible to minimize angiolym-  phatic spread of tumor from manipulation and traction of the specimen. In  this technique, originally called “no touch,’ it is essential that the surgeons  have already identified the left ureter as well as the inferior mesenteric and  sigmoid vessels (see Chapter 7: Anatomy of the Large Intestine, Vessels 8  and 9). At least 10 cm of margin from the gross border on either side of the  lesion should be allowed. T e contents of the clamps applied to the mes-  entery are tied. T e mesenteric border of the bowel at the proposed site  of resection is cleared of mesenteric fat in preparation for the anastomosis  (figure 3).   In most patients, the splenic flexure of the colon is mobilized to avoid  an anastomosis under tension. T 1s maneuver is easier and safer to accom-  plish if the midline incision is extended up to the xiphoid. T is technique  is Shown in figures |5 to 17. Alternatively, the omentum may be removed  in its relatively avascular junction along the left colon until the splenocolic  region is reached. T e descending left colon is then mobilized superiorly  along the extension of the lateral line of Toldt. By approaching both ends  toward the middle, the sometimes difficult splenocolic omental attach-  ments are safely visualized and divided with minimal risk of splenic injury.   Most surgeons would currently use a stapled closure for a left hemico-  lectomy or sigmoidectomy, as described in Chapter 62. In either case, care  must be taken to divide distally below the rectosigmoid junction both to  avoid leaving sigmoid diverticula and because it allows better mobility of  the rectum and easier advancement of the circular stapling device. For cases  where the surgeon does not have access to staplers, the following hand-  sewn method is described. Paired crushing clamps of the Stone or similar  type are placed obliquely across the bowel above the lesion within 1 cm  of the limits of the prepared mesentery (figure 4). T e field is walled of  with gauze, and the bowel is divided. A pair of noncrushing clamps is then  applied to the prepared area below the lesion, and the bowel is divided in  a similar fashion. T e ends of the large intestine are brought end to end to  determine whether the anastomosis can be carried out without tension. T e  clamps are approximated and manipulated so that the posterior serosal sur-  face of the intestine is presented to facilitate placement of a layer of inter-  rupted mattress 000 silk sutures (figure 5). T e mesenteric border should  be free of fat to achieve accurate approximation of the serosa. T e sutures at  the angles are not cut and are utilized for traction (figure 6).   Enterostomy clamps are placed several centimeters from the crushing  clamps, and the crushing clamps are removed (figure 6). T e portions of  excessive bowel that were beyond the clamps may be excised. T e field is  completely walled of with moist, sterile gauze packs, and a direct open anas-  tomosis is carried out. T e mucosa is approximated with a continuous lock  suture on an atraumatic needle starting in the middle of the posterior layer  (figure 7). At the angle, the lock suture is changed to one of the Connell  type to ensure inversion of the angle and the anterior mucosa (figures 8  and 9). A second continuous suture is started adjacent to the first one and  is carried out in a similar fashion (figure 10). After the mucosa has been  accurately approximated, the two continuous sutures, A and B, are tied with  the knot on the inside (figure 11). A layer of interrupted 000 silk sutures or  nonabsorbable sutures 1s utilized to approximate the anterior serosal layer.  Particular attention is given to either angle to ensure accurate and secure  approximation.   Alternative techniques for colon anastomoses include the use of sin-  gle layer of delayed absorbable interrupted sutures with knots within the  lumen and the use of stapling instruments. T e latter technique 1s shown in  Chapter 4, Colon Anastomosis, Stapled.    detalls of Procedure Following the approximation of  the mucosal layer, all contaminated instruments are discarded. T e field is  covered with fresh moist gauze sponges and towels. It is desirable for the mem-  bers of the surgical team to change gloves. T e anastomosis is further rein-  forced by an anterior serosal layer of interrupted 000 silk sutures (figure 12).  It is sometimes advisable to reinforce the mesenteric angle with one or two  additional mattress sutures. Any remaining opening of the mesentery is then  closed with interrupted sutures of fine silk. If there 1s a great deal of fat in the  mesentery, which tends to hide the location of blood vessels, it 1s unwise to  pass a needle blindly through it lest a hematoma form between the leaves of  the mesentery. It is safer to grasp the peritoneal margins of the mesentery with  small, pointed clamps and ef ect a closure by simple ligation of their contents.  Finally, adequacy of the blood supply to the site of the anastomosis should be  inspected. Active, pulsating vessels should be present adjacent to the anasto-  mosis on both sides (figure 13). If the blood supply appears to be interfered  with and the color of the bowel 1s altered, it is better to resect the anastomosis  rather than risk leakage and potentially fatal peritonitis. T e patency of the  stoma is carefully tested by compression between the thumb and the index  finger (figure 14). It is usually possible to obtain a two-finger stoma.   To ensure easy approximation of the open ends of the large bowel, espe-  cially if the lesion is located near the splenic flexure, it is necessary to free  the intestine from adjacent structures. T e abdominal incision may have  to be extended up to the costal margin, since exposure of the uppermost  portion of the splenic flexure may be difficult. After the relatively avascu-  lar peritoneal attachments to the descending colon have been divided, it  is necessary to free the splenic flexure from the diaphragm, spleen, and  stomach. T e splenocolic ligament is divided between curved clamps, and  the contents are ligated to avoid possible injury to the spleen, with trou-  blesome hemorrhage (figure 15). Following this, a pair of curved clamps  is applied to the gastrocolic ligament for the necessary distance required  to mobilize the bowel or remove sufficient intestine beyond the growth.  Sometimes, in the presence of growths in this area, it is necessary to carry    the division adjacent to the greater curvature of the stomach. T e surgeon  should not hesitate to remove a portion of the left gastroepiploic artery, if  indicated, since the stomach has such a good collateral blood supply. In  some instances, a true phrenocolic ligament can be developed, which must  be divided to free the splenic flexure (figure 16).   If it is necessary to free a portion of the transverse colon, the omentum  may be freed from the bowel by incising its avascular attachments adjacent  to the colon (figur es 15-17; see also Chapter 27). In some instances, omen-  tum may be involved with the growth, and it may be desirable to remove all  or part of it. T e splenic flexure is reflected medially following the division  of its attachments, and care is taken to avoid the kidney and the underlying  ureter. It is usually necessary to divide a portion of the transverse mesoco-  lon (figure 18). T is should be done carefully, taking into consideration  possible injury to the underlying jejunum in the region of the ligament  of Treitz. T e large inferior mesenteric vein will also require division and  double ligation as it dips down under the inferior margin of the body of  the pancreas to join the splenic vein. T e bowel is freed of all fatty attach-  ments at the site selected for anastomosis. Noncrushing clamps are applied,  and the bowel is divided (figure 19). Arterial pulsations in the mesentery  on both sides should be verified. T e anastomosis is carried out as previ-  ously described. If it becomes necessary to ligate the middle colic artery,  the entire transverse colon, including the hepatic and splenic flexures, may  need to be resected to ensure an adequate blood supply at the site of anas-  tomosis. In this situation the viability of the colon depends upon the right  colic artery on one side and the left colic artery on the other.    Posto Perat Ive care T e patient is encouraged to cough, sit up, and  ambulate as soon as possible. T e nasogastric tube provides decompression  until bowel activity returns, usually on the first or second day after surgery.  Oral intake of clear liquids is begun and advanced as tolerated, whereupon  intravenous hydration and electrolytes are discontinued. m=    IndIcatlIons Laparoscopic colectomy is indicated in both benign and  malignant conditions as long as it is performed by qualified surgeons with  appropriate resources. In general, this approach is not recommended in  patients with emergency conditions such as obstruction, perforation, or  massive bleeding.    Preo PeratIve PreParatlon For patients having surgery for pol-  yps and occult neoplasms, it is essential to have the lesion tattooed during  colonoscopy or localized by a preoperative barium enema. Identification  of the tumor during laparoscopy is usually difficult. T e use of intraopera-  tive colonoscopy is difficult during laparoscopic procedures, hence accurate  preoperative localization is necessary. T e patient should receive a standard  mechanical bowel preparation and prophylactic antibiotics are administered  within | hour of the incision and are to be discontinued within 24 hours of  surgery. Subcutaneous heparin is administered and sequential compression  devices are placed for the prevention of venous thromboembolism.    IncIslon and exPosure T e setup is similar to the laparoscopic  right colectomy. However, the surgeon and camera operator stand on the  patient’ right and the first assistant on the patient’ left (figure 1). T e  surgeon and camera operator may switch places during the procedure to  facilitate exposure and operating angles. T e surgeon moves between the  legs during portions of the operation, in particular during the creation of  the colorectal anastomosis. T e port placement is the same as the right    colectomy except that the upper abdominal 5-mm trocar is the right upper  quadrant in the midclavicular line (figure 2a and b). T 1s port may facili-  tate mobilization of the splenic flexure (figure 3). figure 2b shows an  alternative port placement.    detalls of Procedure For the initial mobilization of the sigmoid  colon, the patient is rotated to the right. T e sigmoid colon is grasped with  an atraumatic forceps and retracted medially. T e peritoneal attachments  are then divided using the ultrasonic shears and blunt dissection (figur e 3).  Care is taken to identify the ureter and avoid ureteral injury. T e peritoneal  attachment is divided up to the splenic flexure. T is is facilitated by the first  assistant or surgeon providing counter-traction of the colon. As the dissec-  tion nears the splenic flexure, it is best to stay underneath the omentum and  develop a plan between the omentum and the splenic flexure (figure 4).  Dissection between the omentum and the spleen can lead to splenic injury.  T e omentum is separated for a variable distance along the transverse  colon depending on the amount of colon to be removed and the amount  of mobility that will be necessary to complete a tension-free anastomosis.  Mobilization of the splenic flexure and the transverse colon may be facili-  tated by a reverse Trendelenburg position. T e proximal rectum is mobi-  lized (figure 5). In figure 5, the orientation of the dissection is rotated  so the head is to the reader’s left and the foot to the right. T e line of mes-  enteric incision is shown. T e surgeon needs to know the anticipated posi-  tion of the left and right ureter.    detalls of Procedure Next, control and division of the  mesenteric vessels is accomplished. T emesocolon is incised. T e course of  the ureter should be reverified at this point. A window is made in the peri-  toneum near the inferior mesenteric vessels. T e mesenteric vessels may  be divided with linear vascular staples, individually doubly clipped or with  coagulation devices designed for this purpose (figur e 6). figure 6 shows  the line of division of the mesentery. Staple application provides the most  efficient method, but most costly as well. A medial to lateral dissection  may be employed, reserving the mobilization of the lateral attachments  and splenic flexure until the mesocolon has been divided. Once the mes-  entery is divided, the transverse colon is brought into the pelvis ensuring  adequate mobility for a tension-free anastomosis. T e distal colon/rectum  is divided using a transversely placed reticulated linear stapler (figure 7).  T is results in the distal staple line as shown in the figures labeled B. T e  proximal colon may be divided intracorporally with an endoscopic sta-  pler or after the bowel is exteriorized with a linear stapler through exten-  sion of the midline or left lower quadrant trocar incisions. T is results in  the proximal staple line A. T e umbilical incision 1s extended inferiorly to  permit extraction of the specimen, extracorporeal division of the bowel,  and preparation of the proximal colon for the anastomosis. Alternatively  a left lower quadrant transverse or a Pfannenstiel incision may be made.  Prior to bringing the colon through the abdominal wall, a plastic wound  protector is used to prevent contamination of the subcutaneous tissue and  skin. T e anastomosis between A and B 1s created using a double-staple  technique. T e exteriorized proximal colon is cleaned and the staple line  removed. Dilators are used to dilate the opening of the proximal colon (A).    A purse-string suture is placed in the proximal colotomy (figure 8).  T e anvil for the circular stapler is placed in the bowel (figure 9). T e  purse-string suture is tied and the colon returned to the peritoneal cav-  ity. T e circular stapler is inserted transanally, and the stapler spike is  placed through the distal staple line or posterior to it under direct vision  (B). T e spike is removed with a laparoscopic forceps and removed. T e  end of the anvil is then inserted into the circular stapler. T e stapler is  closed and discharged (figure 10). T e stapling device is removed and  the donuts are inspected for completeness. An incomplete donut indicates  an incomplete suture line that will require oversewing. T e abdomen is  filled with saline and rigid proctoscopy with air insuf ation performed in  order to examine the anastomosis and to detect air leakage. If air bubbles  are encountered, the anastomosis is oversewn with nonabsorbable 3-0  sutures and the air insuf ation repeated to verify anastomotic integrity.  T e mesenteric defect does not require closure. T e abdomen should be  visually inspected for bleeding.    closure T e incision is closed with running or interrupted absorbable  sutures. No drains are used. T e fasciae at all large trocar sites (> 5mm) are  closed with sutures. T e skin is closed with staples.    Posto PeratIvecare T eorogastric or nasogastric tube is removed in  the postoperative care unit. Intravenous fluids are administered and urine  output and vital signs monitored every 4 hours. Prophylactic antibiotics  are discontinued within 24 hours of the surgery. T e bladder catheter is  removed on postoperative day 1 or 2. Clear liquids are started according to  institutional protocol (day 0—2) and advanced as tolerated. m    IndIcatIons Abdominoperineal resection of the lower bowel is the  operation of choice for very low rectal malignancies that involve the sphinc-  ter complex or cannot be removed with a 2-cm distal margin. In special  circumstances, young patients may be candidates for a coloanal anastomo-  sis, whereas others may be candidates for local wide excision and adjuvant  treatment for low-grade superficial lesions. T e surgeon must be familiar  with all methods, including resection of the tumor and anastomosis of the  intestine within the hollow of the sacrum.    Preo PeratlIve PreParatlon T e patient’ general condition must  be studied and improved as much as possible, since the operation is one of  the considerable magnitude. Unless there is evidence of acute or subacute  obstruction, the patient is placed on a liquid diet for a day. Most patients  receive a bowel preparation the afternoon or evening prior to surgery.  Following complete evacuation of the colon with laxatives or purgative, appro-  priate nonabsorbable antibiotics may be given. Parenteral antibiotic coverage  is given just prior to surgery. In the presence of low-lying tumors, it may be  advisable to evaluate by cystoscopy whether or not the bladder or other por-  tions of the genitourinary tract are involved. Basal carcinoembryonic antigen  levels are determined before and after resection of the neoplasm. T e extent  of extramural spread or fixation to adjacent organs may be evaluated with  endorectal ultrasound or MRI plus computed tomography (CT) imaging.   In males, an indwelling catheter is inserted into the bladder at the begin-  ning of the procedure to maintain complete urinary drainage throughout  the procedure and to aid in identifying the membranous urethra. Indwell-  ing catheter drainage of the bladder in females is likewise advisable.   Currently, rectal carcinomas below the level of the peritoneal reflection  in the pouch of Douglas are usually given combined radiation therapy and  chemotherapy prior to surgery.    anesthesla General anesthesia with endotracheal intubation and mus-  cle relaxants is the preferred method.    PosItIon T esurgeon stands on the patient’ left side. Most prefer a two-  team approach with the patient in the semilithotomy position using Allen  stirrups. T is allows the perineal portion of the procedure to be carried out  either simultaneously or after the abdominal portion without redraping,  etc. A folded sheet is placed under the lower back so that the buttocks are  lifted up off the bed, allowing better access to the posterior part of the peri-  neal dissection. After an enema with a povidone—iodine solution, the anus  is sutured shut at the anal verge (not distal to it) with a running-locked o  silk suture. A moderate Trendelenburg position may facilitate retraction, as  long as it is well tolerated by the patient.    IncIslon and exPosure A midline incision is made and extended to  the left and above the umbilicus. A self-retaining retractor is inserted.    detalls of Procedure With the left hand, the surgeon thoroughly  explores the abdomen from above downward, palpating first the liver to  ascertain the presence or absence of metastases and then the region of the  aorta and common iliac and hemorrhoidal vessels for evidence of lymph    gland involvement. Finally, by palpation and inspection, the surgeon deter-  mines the extent and resectability of the growth itself (figure 1). T e infe-  rior mesenteric artery and vein may be ligated distal to the origin of the  left colic artery or at its point of origin from the aorta before the tumor is  mobilized, but after identification of the ureters.   After the small intestine has been walled off in a plastic bag, the next  procedure is the mobilization of the sigmoid, which is usually anchored  in the left iliac fossa. T e sigmoid is grasped and reflected medially in  order that the surgeon may obtain a clear view of the fibrous bands that  anchor the sigmoid to the reflection of the peritoneum of the left pelvic wall  (figure 2). T e adjacent adhesive bands are divided with long curved scis-  sors or electrocautery, and the peritoneal reflection is retracted laterally  with forceps. Following this procedure, the sigmoid is usually mobilized  easily toward the midline. T e peritoneal surface on the left side of the  colon is picked up with forceps and divided with long, curved, blunt-nosed  Metzenbaum scissors, which are gently introduced downward beneath the  peritoneum to separate the underlying structures, such as the left sper-  matic, or ovarian, vessels or ureter, from the peritoneum to avoid their acci-  dental injury. T e peritoneum is incised down to the cul-de-sac on the left  side (figure 3).   T e next important step in the operation is the visualization of the left  ureter throughout its course over the pelvic brim and down to the bladder.  T is 1s very important because, on the left side, the ureter may be in close  proximity to the root of the mesentery of the rectosigmoid and may be  included in the division of the latter structures unless it is carefully retracted  to the left side of the pelvis (figure 4). T e ureter will respond with peri-  staltic waves that progress along its length after it is pinched with forceps.   T e next step involves the division of the peritoneum on the right side  of the rectosigmoid. T e same technique that has been described for the left  side may be utilized, or the surgeon may mobilize the rectosigmoid over the  pelvic brim from the left side by blunt finger dissection, taking care to leave  the mesorectal fat intact. T e fingers of the surgeon’ left hand can be passed  completely behind the bowel toward the right side. With the fingers used  as blunt dissectors, the right peritoneal reflection can be tented upward,  separating it from the underlying structures, including the right ureter. T is  enables the surgeon to divide the peritoneum readily and safely with scis-  sors or electrocautery (figure 5).    total Mesorectal excIslIon For almost 100 years, the pelvic dis-  sections for rectal cancers requiring a low anterior or an abdominoperineal  resection have been accomplished with blunt dissection. As described by  the English surgeon Miles, the surgeon’s hands and fingers mobilized this  section of rectum. Little sharp dissection is required except for division of  the lateral suspensory ligaments, as shown in previous editions of the Atlas.  Known complications from this blunt dissection include hemorrhage from  torn presacral veins, perforation into the rectum, and injury to the pelvic  autonomic nerves. An improved dissection, the total mesorectal excision  (TME), has been shown to lessen these complications and to provide a bet-  ter radial margin of tumor clearance. T e TME requires meticulous sharp  or electrocautery dissection under direct vision. T e procedure takes sig-  nificantly more time to perform, but it is associated with a lessened rate  of local recurrence for rectal cancers. T e TME technique is widely used  both with sphincter preservation in very low rectal anastomoses and with  abdominoperineal resection.    detalls of Procedure T e peritoneum along the right  side of the rectosigmoid junction is incised lateral to the inferior mesenteric  and superior hemorrhoidal vessels (figure 6). T 1s incision extends down  to the pouch of Douglas. T e right ureter is identified beneath the residual  peritoneum, and its course over the iliac vessels is exposed with blunt gauze  dissection. T e proximal bowel is retracted anteriorly and laterally. Alter-  natively, the proximal division of the bowel and vascular pedicles can be  completed allowing the proximal end of the specimen to be moved around  to aid visualization (figure 13, Chapter 63). If the tumor 1s very large, this  should be avoided at this point, as it commits one to an excision prior to  complete mobilization of the tumor. T e superior hypogastric nerves are  visualized just below the iliac vessels and the ureters. T e dissection pro-  ceeds behind the superior hemorrhoidal vessels toward the entrance of the  presacral space behind the sacral promontory. Division of the retrosacral  fascia or ligament just below the sacral curvature at about S2 is done sharply    in the midline with scissors or electrocautery, using a long, insulated tip  (figure 7). T erectum is retracted anteriorly with a fiberoptic lighted deep  pelvic retractor, which may be straight or curved. Under direct vision, the  posterior dissection continues down to the level of the coccyx. T e sacral  veins are clearly visualized beneath the parietal fascia, which 1s kept intact,  thus minimizing bleeding.   T e peritoneal reflection in the pouch of Douglas is incised about 1 cm  up its anterior reflection over the bladder in men (shown in this illustra-  tion) or behind the uterus in women. T e bladder or uterus is retracted  anteriorly using a fiberoptic lighted deep pelvic retractor. T e sharp dissec-  tion proceeds anterior to Denonvilliers’ fascia until the prostate and semi-  nal vessels (figure 8) or the rectovaginal septum is seen. T e paths of the  anterior and posterior dissections (figure 9) show the close adherence  to the presacral fascia posteriorly and to the actual prostate and seminal  vesicles anteriorly.    detalls of Procedure T etwo lateral dissections in the  TME are time-consuming, as the surgeon carefully proceeds to expose the  parietal fascia over the lateral pelvic wall structures. T e fiberoptic lighted  deep pelvic retractors are essential for clear visualization during lateral  retraction of the rectum and anterior elevation of the bladder or the uterus  and vagina. Better lighting may also be obtained with the use of a head-  lamp. T e preservation of the pelvic autonomic nerve plexus and the ante-  rior roots of sacral nerves S2, S3, and SM is essential for anal continence and  sexual function. T e plexus is seen as a dense plaque of nerve tissue that  comes close to the rectum at the level of the prostate or upper vagina. T e  TME does not encounter “lateral suspensory ligaments” but rather a fusion  of the lateral mesorectum with tissue that may contain the middle hemor-  rhoidal arteries as the dissection heads toward the autonomic nerve plexus.  T is tissue is divided with electrocautery, and the middle hemorrhoidal  vessels may require a ligature. T e course of the ureters and the autonomic  plexus is noted as the dissection is carried down to the levators (figure 10).  After the rectum is mobilized, the specimen should have a wide zone of  relatively smooth fat about the middle and upper rectum. In a thin patient,  the pelvic nerves and autonomic nerve plexuses may just be visible beneath  the parietal fascia, whereas the prostate and seminal vesicles are uncovered.  After it has been determined that the rectal tumor can be completely  freed from the adjacent structures, the blood supply to the rectosigmoid  is divided. T e venous drainage should be ligated as early as possible to  keep the vascular spread of tumor cells to a minimum. Although involved  lymph nodes may not be evident in the mesentery over the bifurcation of  the aorta, it is desirable to ligate the inferior mesenteric artery just distal to  the origin of the left colic artery (figure 11). T e contents of the proximal  clamps are tied, and the ligation is reinforced by a transfixing suture. Some  prefer to ligate the inferior mesenteric artery as near its point of origin from  the aorta as possible. Usually, this level is surprisingly near the ligament of  Treitz. T e blood supply to the sigmoid to be used as a colostomy is now  derived from the middle artery through the marginal artery of Drummond.  Following this, the abdominal cavity and pelvis are completely walled off  with gauze as a preliminary to transection with a stapling instrument that  divides the bowel between double rows of staples such as a cutting linear  stapler (figure 12).  T e redundant sigmoid, which has been retracted upward over the  abdominal wall, is inspected to determine the best site (figure 11) for    dividing the bowel to serve as a permanent colostomy. T e sigmoid is  divided where it appears to be viable and will extend beyond the surface of  the skin for 5 to 8 cm without being under undue tension. It is better to err  in having extra colon beyond the skin margin rather than too little. Consid-  eration must be given to the thickness of the subcutaneous tissues as well  as postoperative distention in testing the length of colon mobilized for the  permanent colostomy. T e proximal end of the specimen is then divided  at this point with a cutting linear stapler (figure 13). Excessive fat tabs  and thick fatty mesentery, if present, should be excised about the terminal  end of the colon in anticipation of inversion of the mucosa with immediate  fixation to the adjacent skin. T e surgeon is now ready to begin the peri-  neal portion of the resection. If available, a second surgical team may begin  the perineal portion of the operation as the abdominal team completes the  rectal mobilization.    PerIneal resectlon T e surgeon must be satisfied with the patient’  condition before proceeding with the perineal excision of the rectosigmoid.  T e estimated blood loss from the abdominal procedure, often more than  realized unless accurately determined by the circulating nurse, should be  replaced by blood transfusions, and the pulse and blood pressure should  be established at a satisfactory level. Some prefer the two-team approach so  that the perineal excision is carried out simultaneously with the abdominal  procedure.    PosIt lon Historically, Miles then placed the patient on his or her left  side in a modified Sims’ position. Some surgeons prefer to change the  patient to the lithotomy position by adjusting the stirrups to hold the  legs. Some place the patient in prone-jackknife to complete the perineal  resection. T e change in position must be done gently and carefully; sud-  den shifts have been known to precipitate hypotension and shock. T e  pulse and blood pressure should be stabilized after the change in posi-  tion before the final resection is started. Today, most surgeons prefer  perform this operation as a one-stage procedure. T e patient is positioned  in lithotomy.    o Perat Ive PreParatlon T eanusand adjacent skin surfaces are pre-  pared with the usual skin antiseptics. T e legs and buttocks are covered  with sterile drapes. For a one-stage procedure, the perineum is prepped and  draped as part of the initial prep.    IncIsIon and exPosure T erectum is dissected from the  abdomen in to the pelvis as far as possible (figure 14). T is must include a  wide mesenteric excision. T e extent of the perineal excision is indicated in  figure 14. Ifthe lesion is low and near the anus, a more radical excision 1s car-  ried out. Operations for anal cancer will need to be extensive enough to excise  the tumor with negative margins. Ifa large excision is contemplated, preopera-  tive consultation should be made with a plastic surgeon, as myocutaneous flap  reconstruction may be necessary. If the dissection has been carried down far  enough from above, the perineal excision of the rectum and anus should be  accomplished easily without undue loss of blood (figur e 14). To prevent con-  tamination, the anus is sealed securely, either by several interrupted sutures  of heavy silk or by a purse-string suture (figures 15 and 16). An incision  is outlined around the anus with anterior and posterior midline extensions  (figure 16). T e skin in the region of the anal orifice 1s seized with several  Allis forceps, and the incision is made through the skin and subcutaneous  tissue at least 2 cm away from the closed anal orifice (figure 17). All blood  vessels are clamped and tied to prevent further loss of blood as the operation  progresses (figure 18). T e entire dissection may be accomplished with an  energy source such as electrocautery with clamps and ligatures for larger ves-  sels .T e margins of the wound are retracted laterally to assist in the exposure.    detalls of Procedure T e posterior portion of the incision is  extended backward over the coccyx, and the anus is tipped upward to  enable its attachments to the coccyx to be severed more readily. After the  anococcygeal raphe is severed and the presacral space is entered, the accu-  mulated blood from above is suctioned out. T e surgeon can then insert the  index finger into the presacral space (figure 19). T e finger is swept later-  ally to identify the levator and muscles on either side. T e levator muscle is  exposed on one side and, with the finger held beneath it, is divided between  paired clamps as far from the rectum as possible (figure 20). Care must  be taken to avoid bringing the dissection too close the rectum at this point,  creating a specimen with a “waist;’ as this risks compromising the circum-  ferential margin. T e dissection from the perineum will meet the proximal  dissection above the levators. Curved clamps should be applied to the leva-  tor ani muscles as they are divided to prevent the retraction of bleeding  points. Following the ligation of all bleeding points on one side, a similar  division of the levator ani muscles is carried out on the opposite side. Alter-  natively, the levator muscles may be transected with electrocautery, which  can also control bleeding vessels. Vessels that are not easily coagulated with  electrocautery should be individually secured with mattress or figure-of-  eight absorbable sutures.    detalls of Procedure T e procedure in the male is  illustrated because the dissection between the rectum, membranous ure-  thra, and prostate poses more problems than dissection in the female.  Palpation of the inlying urethral catheter will facilitate the procedure by  localizing the urethra and preventing accidental injury to the above-men-  tioned structures (figure 21). T e skin and subcutaneous tissue of the  perineum are retracted upward, while the anus is pulled downward and  backward to assist in the exposure. T e rectum is pulled down, the remain-  ing attachments of the levator ani muscles and transversus perinea are  divided, and all bleeding points are ligated. In the female, the dissection  between the rectum and the vagina is more easily accomplished if counter-  resistance is applied to the posterior vaginal wall by the surgeon’ fingers.  In the presence of extensive infiltrating growths, it may be necessary to  excise the perineal body as well as a portion of the posterior vaginal wall.    T e upper end of the bowel segment is grasped and delivered posteriorly  over the coccyx (figure 22). A retractor is introduced anteriorly to assist in  exposure, while any remaining anterior attachments of the rectum are divided  (figure 23). T e large pelvic space is thoroughly inspected under direct illu-  mination in order to clamp and ligate any active bleeding point. T e cavity is  packed with dry sponges until the field is free of oozing (figure 24). When  a two-team approach is used, irrigation may now be carried out from above.    closure Itis usually possible to approximate the divided levator ani mus-  cles in the midline (figure 25). Two closed suction Silastic catheter drains  are placed in the presacral space and brought out through the skin lateral  in the incision and secured to the skin. T e subcutaneous tissue and skin  are closed with very large and widely spaced interrupted vertical mattress  sutures of no. Inylon or silk. T ese are tied loosely (figur e 26).    Posto PeratlIve care T e blood loss must be replaced  during the operation and postoperatively. Intravenous Ringer’ lactate solu-  tion is given and the hourly urine output monitored. With accelerated post-  Operative care pathways, urinary catheters are now often removed on the  first postoperative day. T 1s does not obviate the need for careful attention  to voiding as described in the more traditional approach below.   T e patient is traditionally maintained on constant bladder drainage for  5 to 7 days. In males the loss of bladder tone may result in one of the most  distressing postoperative complications. Frequent and thorough evaluation  of the patient’ ability to empty the bladder is essential until good function  has returned. T e catheter should be clamped for several hours at a time to  determine whether the patient actually has retained the sensation arising  from a full bladder. In many cases, especially in males, a cystometric study  should be considered before removing the catheter. T e catheter should be  removed early in the morning to permit all-day observations on the patient’  ability to void. Overdistention should be rigorously avoided by catheterizing  the patient for residual urine every 4 to 6 hours, depending upon his or her  fluid intake. Diuretic liquids, such as coffee and tea, should be withheld from  the evening meal in an effort to avoid overdistention of the bladder during  the night. Frequent urination of small amounts indicates retention, and rein-  sertion of the catheter for a few days should be considered. Rigid attention to  the care of the bladder with assistance from the urologic surgeon pays rich  dividends in the patient’ postoperative progress.   T e suction catheters are removed in a few days when the drainage  output has markedly decreased.   T e patient is instructed in the care of a colostomy before being dis-  charged from the hospital.    detalls of Procedure After completion of the perineal resection,  the pelvis is examined for bleeding and meticulous hemostasis obtained.  A closed suction drain is placed and brought out through the perineum  or abdominal wall. T e pelvic space may be left open; some prefer to close  this peritoneum. T e margins of the peritoneum are mobilized in order to  close the peritoneal floor securely. T e peritoneum is grasped with toothed  forceps and mobilized by the surgeon’ hand or by blunt gauze dissection  (figure 27). T e peritoneum in the pouch of Douglas is mobilized as  widely as possible to facilitate closing the pelvic floor. T e location of the  ureters is reaf rmed from time to time to avoid their accidental ligation or  injury. In females the uterus and adnexa may be used, if necessary, to close  the new pelvic floor. At times it may be possible to close the pelvic floor in  a straight line, but, more frequently, a radial type of closure is necessary to  avoid undue tension on the suture line (figure 28). All raw surfaces should  be covered whenever possible. T e omentum is placed over the peritoneal  closure (figure 29). Some make no attempt to close the peritoneum and  rely on muscular closure.    When the patient’ anatomy permits, a pedicled omental flap based on  the left or right gastroepiploic artery can be created and laid into the pelvic  defect. When enough omentum 1s available, this both fills the volume of the  pelvis and covers the raw surfaces of the dissection. Some surgeons prefer  to anchor the sigmoid to the lateral parietal peritoneum in order to close  the left lumbar gutter and to avoid the possibility of an internal hernia.  Whenever possible, these sutures should include the fat tabs or mesentery  to avoid possible perforation of the bowel.    closure T e omentum is returned to the region of the new pelvic floor  and the table is leveled. T e colostomy is created through a separate 3-cm  (14 inch) opening selected and marked prior to surgery. In general, it 1s mid-  way between the umbilicus and the left anterior superior spine (figur e 30).  As this colostomy will be a permanent one, it is wise to choose and mark the  site prior to surgery consultation with the enterostomal therapist. T e adhe-  sive ring of the colostomy bag must conform to the contour of the abdomen  and must be secure when the patient is standing, bending, or sitting. After  excision of the circle of skin, a two-finger-sized opening is made through the  abdominal wall. T e colon is grasped with Babcock forceps and brought out  through the opening without undue rotation of the mesenteric blood supply.  Late herniation about the colostomy can be minimized by tailoring the open-  ing in the abdominal wall such that the colon plus one finger is a snug fit.   T e abdominal wall is closed with interrupted 00 silk sutures or 00  synthetic absorbable sutures. Subcuticular closure of the skin should be  considered since this ensures a sealed wound about an area repeatedly  contaminated from the adjacent colostomy. In patients with marked  obesity or cachexia, retention sutures may be utilized. T e exteriorized  portion of the bowel is then inspected to make certain that active pulsa-  tion 1s present in its blood supply. Suf cient intestine should have been  provided to ensure at least 5 to 6 cm of viable bowel protruding above the  skin level (figure 31).   Immediate opening of the colostomy after the remainder of the wound  has been covered is preferred to leaving a clamp on the exposed area com-  pletely obstructed intestine for several days. T e stapled suture line is  excised and the mucosa within the lumen of the bowel grasped with one  or two Babcock forceps to provide fixation for the eversion of the mucosa  (figure 31). It may be necessary to excise several large fat tabs and addi-  tional thickened mesentery, especially in the obese patient, to facilitate the  eversion of the mucosa. T e mucosa is anchored to the margin of the skin  with interrupted sutures or 000 synthetic absorbable sutures on a curved  cutting needle (figure 32). Asuf cient number of sutures is taken to con-  trol bleeding as well as to seal off the subcutaneous tissue about the colos-  tomy (figure 33). T e mucosa should be pink in color to ensure viability.  T e surgeon may insert a gloved finger into the colostomy to make cer-  tain the lumen is free and adequate without undue constriction within the  abdominal wall. When the operation is complete, an ostomy appliance is  applied. m    IndIcatlIons T emost common elective indications for total colectomy  are ulcerative colitis and familial polyposis. However, sphincter-conserving  procedures such as the ileoanal anastomosis (Chapter 64) should be con-  sidered in good-risk patients. In the very poor risk patient with ulcerative  colitis, particularly with a complication such as a free perforation, it is judi-  cious to perform the operation in two stages. T e removal of the rectum  is delayed until the patient’ condition is less critical. T e possibility of  malignancy in patients with ulcerative colitis of many years’ duration must  be considered. Conservation of the anus and lower rectum by ileoproctos-  tomy should be considered in congenital polyposis, where the polyps in the  retained rectum that do not disappear spontaneously can be destroyed by  repeated fulguration. Total colectomy 1s also performed for severe colitis of  other etiologies, especially pseudomembranous colitis.    Preo Perat Ive PreParatlIon Unless total colectomy is done as an  emergency procedure, efforts should be made to improve the patient’  nutritional status with a high-protein, high-calorie diet. Total parenteral  nutrition may be used. T e blood volume is restored and supplemental vita-  mins are provided. T e surgeon must carefully evaluate the status of the  steroid therapy. T e patient requires special psychologic preparation for the  ileostomy. T is should include a visit by an enterostomal therapist who can  demonstrate successful rehabilitation following this procedure. T e patient  should be shown the permanent type of ileostomy appliance and should  be encouraged to read the literature available from an ileostomy club to  prepare him or her for postoperative management. In addition, the site of  the ileostomy should be selected away from bony prominences and previ-  ous scars as described in Chapter 51. A permanent type of appliance may  be glued to the patient’ skin for 1 to 2 days to allow him or her to move  about with it in place and make any final adjustments in its eventual loca-  tion. T is point is marked with indelible ink to assure accurate placement  of the stoma. A liquid diet is given for 1 or 2 days, followed by laxative purg-  ing the afternoon and evening prior to surgery. T e male patient should be  informed of the possibility of postoperative impotence, retrograde ejacula-  tion, and difficulty in voiding. Women of child-bearing age should be coun-  seled regarding the risk of decreased fertility after pelvic dissection.    PoslItIon T e patient is placed in a moderate Trendelenburg position.  For total proctocolectomy, during the perineal portion of the operation,    the patient may be repositioned in the lithotomy position with the thighs  widely extended. Alternatively, the legs may be placed in the modified  lithotomy position using the Allen stirrups for support of the feet and  knees. T is allows a single positioning for preparation and draping but may  compromise the perineal exposure. A large rectal tube is used to lavage out  the rectosigmoid with a povidone—iodine solution. T is tube may be left to  dependent drainage until the perineal resection begins, or the anus may be  sutured closed after the enema and before skin preparation.    o PeratIve PreParatlon T eskin is prepared in the routine manner,  and the ileostomy site just below the halfway mark between the right ante-  rior iliac spine and the umbilicus is re-marked, usually by scratching the  skin with the side of a hypodermic needle prior to skin preparation.    IncIslon and exPosure T e surgeon stands to the patient’ left side.  T e incision must extend sufficiently high in the epigastrium to provide  an easy exposure of the colonic f exures, lest undue traction of the friable  bowel result in perforation and gross contamination (figure 1).   After general exploration of the abdomen, the small bowel may be placed  in a plastic bag. T e dissection is started in the region of the tip of the cecum  (figure 2). T e right colon is retracted medially as the peritoneum in the  right lumbar gutter is incised with curved scissors (figure 2). Because of  the tendency to increased vascularity, it may be necessary to ligate a number  of blood vessels in the free margin of the peritoneum along the right lumbar  gutter.   T e peritoneal attachments to the terminal ileum are divided and the  cecum and terminal ileum mobilized well outside the wound (figure 3).  T e peritoneum is tented upward before it is incised to avoid injuring the  underlying right spermatic vessels and ureter. Blunt gauze dissection is uti-  lized to push these structures away from the adjacent mesentery. T e right  ureter should be identified throughout its course up to the right kidney  and down to the pelvic brim. Any adhesions between gallbladder, liver,  and hepatic f exure are divided. During the mobilization of the ascending  colon and hepatic f exure, care must be taken to identify the retroperitoneal  portion of the duodenum, which may come into view rather unexpectedly.  Blunt gauze is utilized to sweep away the duodenum from the overlying  mesocolon. T e thickened, contracted, and highly vascular greater omen-  tum is divided between curved clamps and ligated (figure 4). T e greater  omentum is retracted upward and the lesser omental sac entered from the    IncIslon and exPosure T e thickened and vascular  greater omentum is retracted upward in preparation for its separation from  the transverse colon. An incision 1s made in the omental ref ection along  the superior surface of the colon (figure 5). Since the omentum may be  quite adherent to the colon, it may be easier to divide the gastrocolic omen-  tum nearer the stomach than the transverse colon. T is can be facilitated  if the surgeon places his or her left hand, palm upward, in the lesser sac in  order to better define the gastrocolic omentum. Most of the dissection can  be done with electrocautery, especially if the relatively avascular plane is  present where the omentum joins the transverse colon. If large vessels are  encountered, paired curved clamps are applied and their contents ligated.  Special attention is required during the division of the thickened  splenocolic ligament to avoid tearing the splenic capsule by undue    tension (figure 6). T esplenocolic ligament is divided at some distance,  if possible, from the inferior pole of the spleen (figure 7). When the  splenic f exure and descending colon have been partially freed down to  the region of the sigmoid, the surgeon may wish to return to the region of  the right colon and control the blood supply to the bowel before remov-  ing it in order to facilitate the eventual exposure of the pelvis for the  exploration of the rectum. T e mobilized right colon is drawn outside  the peritoneal cavity, and the vessels in the mesentery can be identified  easily (figure 8). Enlarged lymph nodes often fill in the arcades about  the mesenteric border. Unless malignancy has been found, the blood sup-  ply can be ligated near the bowel wall as shown in figure 8. Before the  blood supply is ligated, the ureter is protected posteriorly by warm, moist    IncIsIon and exPosure After the blood supply to the  region of the appendix and the right colon has been divided, the terminal  ileum may be further mobilized. An incision is made into the mesentery of  the terminal ileum with a clear view of the ureter at all times to avoid its  injury. It is often necessary to remove a portion of the terminal ileum because  of its possible involvement with the inf ammatory process (figure 9).  Considerable time is required to separate the blood supply proximally  from the site where the ileum 1s to be divided. Several centimeters of ileum  can be denuded of blood supply in preparation for the development of an  ileostomy (figure 9). T e blood supply to this portion of the ileum should  be divided very carefully, almost one vessel at a time, maintaining the large  vascular arcade at some distance from the mesenteric border. A noncrush-  ing vascular-type clamp is applied to the ileal side and a straight Kocher    clamp to the cecal side in preparation for the division of the intestine  (figure 10). Most commonly, however, the ileum is divided with a cutting  linear stapler stapling instrument. T e contents of the Kocher clamp can  be ligated with heavy silk or absorbable suture to facilitate handling of the  right colon (figure 11).   T ecolon is then retracted medially, and the mesentery is divided up to the  region of the middle colic vessel (figure 12). Two half-length clamps should  be applied proximally on the middle colic vessels because of their size and  the increased vascularity in ulcerative colitis. T e mesentery of the transverse  colon is divided rather easily between pairs of clamps and the contents carefully  ligated. T 1s can be done at some distance from the inferior surface of the pan-  creas. As additional portions of colon are freed, they are incorporated in towels  to avoid tearing the bowel wall and possible gross contamination.    IncIslon and exPosure An incision is made down the  left lumbar gutter, and because the thickened and vascular peritoneum  has a tendency to contract, all bleeding points should be carefully ligated  (figure 13). T e peritoneum 1s lifted up until the left gonadal vessels and  ureter are identified. Both should be identified throughout most of their  course down over the brim of the pelvis (figure 14).   In total abdominal colectomy, without planned proctectomy, the recto-  sigmoid junction should now be divided. T e remaining vasculature to the  colon can be divided close to the bowel. T e superior hemorrhoidal ves-  sels and presacral space should not be violated. When a second procedure  (either ileorectal anastomosis or proctectomy and ileoanal pouch recon-  struction) is contemplated, these planes should be left as virgin territory to  facilitate that subsequent procedure.    total Proctocolectomy T e remaining description applies to the  completion of a single-stage total proctocolectomy. As shown in figure 15,  the mesentery is divided adjacent to the rectosigmoid rather than up over  the iliac artery bifurcation, as would be done in carcinoma. T e peritoneum  adjacent to the bowel 1s divided after identification of the ureters on either  side, and the peritoneum in the pouch of Douglas between the rectum and  bladder or cervix is incised. T is fap is carefully elevated. T is dissection    along with that into the presacral space is facilitated by using lighted deep  pelvic retractors, a focused headlight on the surgeon, and an extra-long  insulated electrocautery tip. T e dissection proceeds into the same presa-  cral space as the mesorectal dissection, but the surgeon can stay closer to  the rectum laterally and anteriorly, as this operation does not require the  wide margins necessary for a malignancy. At this point, the rectum may  be divided with a cutting linear stapler or endoscopic reticulating stapler  or it may be transected between clamps (figure 16). T e distal stump is  then oversewn (figure 17). At this time, sharp dissection about the rectum  should be carried out to free it as low as possible in order to lessen the blood  loss during the subsequent perineal excision.   In the presence of multiple polyposis, a segment of rectum can be  retained 5 to 8 cm above the pouch of Douglas or at a distance that can  be easily reached by the sigmoidoscope for subsequent fulguration of the  multiple polyps. When this is done, the terminal ileum is anastomosed to  the rectal pouch in a side-to-end manner.   Absorbable sutures are used to close the peritoneal f oor. T e location of  the ureters should be ascertained from time to time to avoid injury during  the reconstruction of the pelvic f oor. As in abdominoperineal resection, a  pedicled omental f ap can often be constructed to fill the pelvis after exci-    total Proctocolectomy After the pelvis has been  reperitonealized, some of the raw surfaces in the left lumbar gutter also can  be covered if the tissues are sufficiently lax (figure 18). Again, the sutures  should be placed so as to avoid injuring the underlying ureters and gonadal  vessels. To complete the total proctocolectomy, the anus is excised as  described in the perineal section of abdominoperineal resection (Chapter  59). T e only exception is that it is not necessary to go wide on the levators  when a simple extirpation of the sphincter muscles and bowel wall itself is  carried out. T e incision for the excision of the anus 1s shown in figure 19.  Primary closure with catheter suction can be used.    Illeostomy T e construction of the ileostomy is of major importance.  T esmall intestine may be removed from the plastic bag and the site selected  for ileostomy exposed. T e location of the previously marked ileostomy site  is evaluated. T e midway point between the umbilicus and anterior iliac  spine is again verified by a sterilized ruler. T e ileostomy site is placed a  little below the midway point (figure 1, Chapter 60). With Kocher clamps  applied to the fascial edge of the incision after removal of the self-retaining  retractor, a 3-cm circle of skin is excised. After the button of skin and the  underlying fat have been removed, all bleeding points are controlled. T en,  while applying traction against the abdominal wall from underneath with  the left hand, the surgeon makes a stellate incision through the entire thick-  ness of the abdominal wall. Any bleeding that is encountered, especially  in the rectus muscle, is clamped and ligated. An opening large enough to  admit two fingers easily is usually more than sufficient.   Noncrushing vascular-type forceps are inserted through the ileostomy  site and applied just proximal to the similar forceps on the terminal ileum  (figure 20). T e original forceps are removed, and the ileum is withdrawn  through the abdominal wall with the mesentery cephalad. At least 5to 6 cm  of mesentery-free ileum should be above the skin level so that an ileostomy  of adequate length can be constructed. It may be necessary, especially in the  obese patient, to undercut the terminal ileum under the mesenteric blood  supply to attain this essential length. T e viability is then reevaluated after  the ileum is pulled up through the abdominal wall. T e mesentery can be  anchored to the abdominal wall or brought up into the subcutaneous tissue  (figure 21). It may be advisable to anchor the mesentery of the ileum to  the parietes laterally before constructing the ileostomy because of the pos-  sibility of interfering with the blood supply to the terminal ileum. T e right  lumbar gutter should be closed off to avoid the potential of a postoperative  internal hernia. At times it may be difficult to approximate the mesentery  of the right colon and ileum to the right lumbar gutter and effect a closure  (figures 2land 22). T esurgeon should palpate the right gutter repeatedly    and place whatever sutures are necessary to close it completely or else leave  it completely open. T e completed ileostomy should extend upward from  the skin level at least 2.5 to 3cm. T e mucosa is anchored with interrupted  fine synthetic absorbable sutures to the serosal edge of the bowel at the  level of the skin and then to skin (figur e 22). Likewise, the mesentery may  be anchored to the peritoneum, but no sutures should be taken between  the seromuscular coat of the terminal ileum and the peritoneum. When the  terminal ileum is divided with a cutting linear stapler, the maturation of the  stoma is delayed until after closure of the abdominal wounds, the staple line  is excised, and the stoma matured as described.    closure A double-looped (0 or no. 1) delayed absorbable suture is used  for running closure of the midline linea alba incision. In very large patients,  two sutures are used that begin at either end of the incision. Interrupted  fine absorbable sutures may be placed in Scarpa’ fascia. T e skin is closed  with staples, although some prefer to use absorbable subcutaneous sutures  followed by adhesive skin strips. At the end of the case, a dry sterile dress-  ing covers the abdominal incision and an ostomy appliance is put about  the ileostomy. In the presence of marked emaciation and prolonged steroid  therapy, the use of retention sutures should be considered.    Posto PeratIve care Blood should be replaced as it is lost during the  procedure. Additional blood or colloids may be required on the afternoon  of surgery and during the early postoperative period. Constant bladder  drainage is traditionally maintained for at least 4 or 5 days. Some surgeons  now remove the catheter on the first postoperative day. If the patient has  been on steroid therapy, this is continued during the postoperative period.  A transparent temporary-type ileostomy appliance 1s placed over the ileos-  tomy before moving the patient to the recovery area. T is permits frequent  observations of the stoma to make sure it maintains a pink and viable color.  A strict intake and output chart must be maintained at all times following an  ileostomy. Likewise, daily electrolyte determinations are essential because  of excessive losses of electrolyte-rich fuid. Excessive amounts of fuid are  occasionally lost, and large amounts of intravenous fuids, electrolytes, and  colloids will be required to maintain fuid balance. T e nasogastric tube is  removed early and oral intake of liquids advanced as tolerated. T e drains  should then be removed, with serial observations as described in the dis-  cussion of abdominoperineal resection (Chapter 59). T ese patients require  frequent and prolonged observation because of the tendency to a variety  of complications ranging from abscess formation to intestinal obstruction.  T ey should be in contact with an enterostomal therapist, who ideally may  be available during office visits to the surgeon. m    IndIcatlIons T ismaybe the operation of choice in selected individuals  with malignant lesions in the rectosigmoid or low sigmoid area in order  to re-establish the continuity of the bowel. T e operation is based on the  premises (1) that the viability of the lower rectum can be sustained from  the middle or inferior hemorrhoidal vessels and (2) that carcinoma in this  region as a rule metastasizes cephalad, only rarely metastasizing 3 to 4 cm  below the primary growth. It 1s questionable whether an anterior resection  should be advised for growths occurring within 8 cm of the pectinate line.  While most patients prefer restored continuity over a permanent colos-  tomy, there is a significant risk of postoperative bowel dysfunction (post  low-anterior syndrome) that is highest in patients with preoperative dys-  function such as incontinence. T e absolute indications for abdominoperi-  neal resection are discussed in Chapter 59. T e ideal situation would appear  to be a small tumor located at the junction of the rectum and the sigmoid.  However, there are many times when the growth can be mobilized much  more than anticipated, especially when the bowel is released down to the  levator muscles. T e exposure is another factor that may influence the sur-  geon for or against a low anastomosis. A low anastomosis is much easier  and safer in the female than in the male, especially if the pelvic organs of  the former have been removed previously. A loop ileostomy (Chapter 51)  is sometimes done at the time to divert the fecal stream temporarily from  the end-to-end anastomosis or to ensure decompression of an inadequately  emptied colon. A side-to-side (Baker) anastomosis should be considered  when there is considerable discrepancy between the sizes of the two lumina  or an excess of fat that may encroach unduly upon the lumen of an end-  to-end anastomosis. Most prefer a stapling device for the anastomosis  (Chapter 62).    PoslItlIon T epatient is placed in the Trendelenburg position. T e oppo-  site position is useful while the splenic flexure is being mobilized.    o PeratIve PreParatlon T eskin is prepared in the usual manner. A  Foley catheter is inserted into the bladder.    IncIslon and exPosure A midline incision is made from the sym-  physis to a level above and to the left of the umbilicus. T e liver and the  upper abdomen are carefully palpated to determine the existence of any  metastases. T e site of the tumor is examined with special consideration  as to its size and location, the amount of dilation of the bowel proximal to  the growth, and the ease of exposure. In many instances the type of resec-  tion cannot be determined until the lower segment of the bowel has been  mobilized.    detalls of Procedure T e small intestines are walled off and a  self-retaining retractor is inserted into the wound. T e peritoneum of the  pelvic colon is freed from the region of the sigmoid downward on either side  (figure 3). It is important at this point to identify and isolate both ureters  and the spermatic or ovarian vessels. T e peritoneum is divided anterior  to the rectum at the level of the base of the bladder or cervix. T e growth  can be further mobilized by mesorectal dissection (Chapter 59, figure 8).  After the peritoneal attachments have all been divided, and the rectum is  freed both posteriorly and anteriorly, it is possible to bring this growth up  into the wound and gain considerable distance as a result of freeing and  straightening the rectum (figures | and 2). T e blood supply to the dis-  tal segment from the inferior hemorrhoidal vessels is adequate, should the  middle hemorrhoidal vessels be ligated to ensure additional mobilization.  T e inferior mesenteric artery is ligated at the level of the superior hemor-  rhoidal vessels or as it arises from the aorta (figure 3) and the inferior  mesenteric vein is divided. T 1s provides maximum lymphatic lymph node  removal and gives additional mobility to the descending colon. T e blood  supply to the colon must now come from the middle colic artery through  the marginal vessels of Drummond (figure 3).   T e bowel should be prepared for division at least 5 cm below the gross  lower limits of the growth to assure removal of all adjacent lymph nodes.  A Stone or a Pace-Potts anastomosis clamp is applied across the previously  prepared site of division of the bowel, and a long, right-angle clamp may be    utilized for the proximal clamp (figure 4). T e bowel is divided between  the clamps. T e bowel containing the growth is then brought outside the  wound, and clamps are applied to the previously prepared site well above  the lesion (figure 5).T e surgeon must now determine that the upper seg-  ment of the bowel is suf ciently mobile to be brought down for anasto-  mosis without tension. In order to accomplish this, it may be necessary to  divide the lateral peritoneal attachment of the left colon up to and including  the splenic flexure. Unless the sigmoid is very redundant, the left half of  the transverse colon along with the splenic flexure must be mobilized. T e  midline incision is extended at this point to ensure a good exposure, since  undue traction on the colon may tear the capsule of the spleen. T e splenic  flexure is also mobilized, as in Chapter 57. T e lesser sac is entered after the  splenic attachments to the colon have been divided. T e greater omentum  is freed from the transverse colon as shown in Chapter 27, figure |. Extra  mobility and length of bowel are provided until repeated trials clearly dem-  onstrate that the proximal segment will easily reach the site of anastomosis.  T e adequacy of the blood supply should be determined even when the  bowel is extended down into the pelvis preliminary to the anastomosis.   T e serosa along the mesenteric border of the upper segment should  be cleared of fat for at least 1 cm proximal to the Pace-Potts clamps  (figure 5). Likewise, the margins and especially the posterior wall of the  lower segment must be cleared of fat adjacent to the Pace-Potts clamp  (figure 5). Careful dissection with repeated application of small clamps  may be necessary to accomplish a clean serosal boundary of 1 cm adjacent  to the clamp in preparation for a safe anastomosis. Following this, the two  ends of the clamps are approximated and then manipulated so that a pos-  terior serosal layer of 000 silk can be placed easily (figure 6). T e ends of  these sutures are cut, except those at either angle, which are retained for  traction. As a preliminary to removing the clamp, the field is walled off with  gauze, and an enterostomy clamp is gently applied to the upper segment to  prevent gross soiling (figure 6). T e crushed contents of the clamps may  be excised. T e lower clamp is then removed, and the crushed margin of  bowel is excised and opened (figure 7). Suction is instituted to avoid any  gross contamination of the field. Fine silk sutures may be inserted for trac-  tion in the midportion of the lower opening and at either angle. T ese trac-  tion sutures tend to facilitate the anastomosis (see Chapter 63, figures 16  and 17). T e posterior mucosal layer is approximated with several Babcock  forceps, and the mucosa is approximated with interrupted 000 silk sutures.  T e anterior mucosal surface is closed with interrupted 000 silk sutures of  the Connell type, with the knot on the outside. T e mucosa may be closed  with a continuous 000 synthetic absorbable suture (figure 8) rather than  interrupted silk sutures. Following this, the anterior serosal layer is care-  fully placed, using interrupted Halsted sutures of fine 000 silk (figure 9).  T e peritoneum is anchored adjacent to the suture line. T e patency of the  anastomosis, as well as the lack of tension on the suture line, should be  tested. T e peritoneal floor is closed with interrupted absorbable sutures  (figure 10). T e raw surfaces are covered by approximating the mesen-  teric margin of the sigmoid to the right peritoneal margin (figure 10).T e  sigmoid is loosely attached to the left pelvic wall by anchoring the fat pads,  not bowel wall, to the left peritoneal margin to prevent subsequent tension  on the anastomosis as well as to cover the raw surfaces. A transverse colos-  tomy or diverting loop ileostomy (Chapter 51) should be considered if there  is any suspicion regarding the technical perfection of the anastomosis. A  drain may be inserted into the left side of the pelvis and brought out at the  lower angle of the wound. Some operators prefer to have a rectal tube in  place, which can be guided up beyond the anastomosis to assist in decom-  pressing the bowel during the early postoperative period. T e rectal tube is  anchored in position by a silk suture placed at the anal margin. Some prefer  to use a surgical stapling instrument for the anastomosis. See Chapter 62.    Posto PeratIvecare T erectal tube is left in place for a few days and  enemas should be avoided. T e patient is gradually allowed to resume a  full diet. Mineral oil may be given. If a proximal diverting loop ileostomy is  used, the patency of the anastomosis should be tested by contrast fluoros-  copy before closure is affected several weeks after surgery. See postoperative  care, Chapter 62, for general postoperative care. m    INDICATIONS T e stapler offers certain advantages in the performance of  a low anterior resection, provided the surgeon is thoroughly familiar with  the technique. T ose favoring this method of approximating the sigmoid  to a short rectal stump emphasize the ease of the anastomosis, especially  in the narrow pelvis of the male. T e time required for the operation may  be shortened and the indications for a temporary proximal diverting loop  ostomy decreased. Use of the stapler does not alter the principles of ade-  quate resection of tumors at approximately 8 cm or less from the anus. T 1s  is because anastomoses lower than 3 cm from the anus may be associated  with incontinence and because a distal margin of 2 to 3cm below the cancer  is recommended to minimize the rate of local anastomotic recurrence. T e  success of a properly performed anastomosis depends on an adequate blood  supply to the residual bowel segments, which can be brought together easily  without tension. Cancers below the peritoneal reflection in the pouch of  Douglas should be evaluated with endorectal ultrasound for their staging  and spread. Preoperative radiation therapy and chemotherapy should be  considered for these lesions.    PREOPERATIVE PREPARATION An empty colon results from 1 day of  liquid diet. T e usual bowel preparation is given the day prior to surgery,  while parenteral antibiotics are administered just prior to the start of the  procedure. Since the stapler is to be introduced through the anus, it 1s man-  datory that the lower colon and rectum be carefully emptied and cleansed  just before the procedure is started. A large mushroom catheter 1s com-  monly introduced into the rectum for a saline irrigation until clear. Several  ounces of a mild antiseptic solution such as 10% povidone-iodine can be  instilled at the time the procedure is started. An inlying bladder catheter is  essential for good exposure.    POSITION T e patient is placed in a semi lithotomy position using Allen  stirrups and in a modest Trendelenburg position to enhance exposure of  the deep pelvis and permit the introduction of the stapling instrument via  the anus.    OPERATIVEPREPARATION Not only the abdominal wall from the xiphoid  to the pubis, but the skin over the perineum, groin, and especially the anal    region are prepared since the instrument will be introduced through the  anus.    INCISION AND EXPOSURE A long midline incision 1s made starting just  above the symphysis and extending to the umbilicus and around it on the  left side to provide easy access to the splenic flexure (figure 1). T e liver  is palpated for possible metastasis, and the location and mobility of the  growth as well as the presence or absence of metastatic lymph nodes are  verified by palpation. T e small intestine may be placed in a plastic Lahey  bag to which some saline solution is added. T e mobility of the transverse  and descending colon is evaluated with special reference to the adequate  exposure of the splenic flexure. Undue traction on the omentum or colon  in the region of the spleen may result in troublesome bleeding from a tear  in the splenic capsule, hence many surgeons routinely mobilize the splenic  flexure.    DETAILS OF PROCEDURE T e indications for an anterior resection are  reconfirmed, and the sigmoid and transverse colon are mobilized using the  same incision and exposure techniques as in Chapter 61(figur es 2 and 3).  A high ligation of the inferior mesenteric lymphovascular pedicle is carried  out following exposure and clear identification of the left gonadal vein and  ureter. T e sigmoid artery is ligated near the inferior mesenteric artery with  preservation of the arcade between the ascending and descending branches  of the left colic artery. T e mesentery of the left colon is divided over to the  junction of the sigmoid and descending colon (figure 2).  Two methods of stapled closure are presented.    METHOD 1—RECTAL STAPLING A point on the sigmoid is selected for  division, and the mesenteric border is meticulously cleared for a distance  of approximately 2 cm (figur e 3). Active pulsations must be present in the  mesentery, and the cleared area must be free of diverticuli. A total meso-  rectal excision (Chapter 59) is carried out to at least 2 cm, preferably 5 cm,  below the tumor. A linear stapler is fired across the rectum at that level  (figure 4) and the mesorectum is divided. Some staplers close both sides  while cutting between the staple lines, while others fire only one line of  staples and hence require a clamp on the proximal (‘specimen’) side. T e  rectosigmoid specimen is then lifted out of the pelvis.    METHOD 1—RECTAL STAPUING T e end of the sigmoid is  then opened. If there is doubt as to the size of stapler needed, retraction stay  sutures are placed and circular stapler sizers can be passed into the sigmoid  to determine the largest size that fits easily (figure 5). A circumferential  purse string of 00 polypropylene suture is placed (figure 6). T e open  end of the sigmoid is gently manipulated over the end of the anvil, and the  suture is securely tied (figure 7). T e assistant gently dilates the anus and  inserts the curved stapler of appropriate diameter (figure 8). T e surgeon  assists from above in the passage of the instrument as the spike advances  through the rectum, usually just posterior to the stapled stump so as to  avoid overlap with this staple line (figure 9). Alternatively the spike may  be advanced just anterior or posterior to the rectal staple line. In this case  the staple line will be included in the donut.   T e adequacy of the previously placed purse-string suture is carefully  determined. T e completeness of the mucosal closure is rechecked to be  certain there is no gap between the shafts of the purse-string closure. Bulky  puckering of excess tissue must be avoided, lest failure to compress the  tissues adequately will lead to failure of the anastomosis. As the assistant  closes the instrument from below (figure 8), the surgeon from above, pre-  vents fatty tissues or the posterior wall of the vagina from being trapped  between the bowel ends. T e assistant verifies that the stapler 1s tightened  to the correct thickness for the height of its staples as shown by a color-bar  indicator in the handle of the stapler. T e trigger is released and the handles  squeezed to fire and create the anastomosis.   After firing the stapler, the manufacturer’ routine for releasing the  instrument is followed carefully to avoid the possibility of disrupting the  line of staples during its removal (figure 10). Additional interrupted  sutures may be placed around the anastomosis, and all raw surfaces in the  pelvis are reperitonealized where possible.   Before closure of the abdomen, the “doughnuts” created by the instru-  ment must be carefully inspected for 360-degree continuity (figure 11). A  gap indicates a possible leak which will require additional external inter-  rupted sutures. T e integrity of the anastomosis is confirmed by filling the  pelvis with sterile saline, and air is injected through a catheter or procto-  scope in the rectum. T e appearance of air bubbles identifies the presence  of a leak that must be repaired by interrupted sutures. If there is any doubt  concerning the security of the final anastomosis, a temporary proximal  diverting loop ileostomy (Chapter 51) should be considered.   Most surgeons prefer temporary drainage of the presacral space with  closed suction silastic drains. T e drains are left in place for a few days until  the fluid becomes more serous and smaller in volume. If large volumes of  rather clear fluid are noted, then a urea or creatinine content should be  checked and the bladder and ureters evaluated.    METHOD 2—RECTALPURSE-STRING A point on the sigmoid is selected  for division, and the mesenteric border is meticulously cleared for a dis-  tance of approximately 2 cm. Active pulsations must be present in the mes-  entery. T e cleared area must be free of diverticuli. T e purse-string clamp  is applied obliquely to the bowel so as to preserve the 2-cm cleared bowel  proximally. T is is necessary as the 2-cm zone will be enclosed within the  stapler anvil and will become the upper “doughnut.” If the wall is not care-  fully cleaned of fat, or if too thick, a turn-in is created with a purse-string    suture that is placed freehand, the entire circumference of the bowel may  not be brought inside the instrument. T is will result in an incompetent  anastomosis and leak. Accordingly the placement of the purse-string  sutures and the examination of the upper and lower “doughnut” rings for  intact purse-string sutures with 360 degrees of full-thickness bowel wall  turn-in are most important steps with these instruments. A 00 polypro-  pylene suture on a long, straight Keith needle is passed through the spe-  cial openings in the purse-string clamp, and a purse-string suture results.  A straight Kocher clamp is applied on the colon distal to the purse-string  clamp and the bowel is divided in between. T e rectosigmoid is retracted  forward toward the symphysis as the peritoneum is incised and the rectal  segment mobilized from the presacral space using mesorectal dissection  (Chapter 59). T e posterior rectal wall is cleared of fat until at least 2 cm  of only the bowel wall is exposed approximately 5 cm or more distal to the  tumor. In the male and very obese patient, it is dif cult to properly place  the purse-string clamp and even more dif cult to insert the Keith needle to  complete the purse-string anastomosis. Under such circumstances, a non-  crushing vascular clamp is placed across the area cleared for the anasto-  mosis similar to that shown in figures 4 and 5 on Chapter 61. A Kocher  clamp secures the proximal specimen and the bowel is divided. T e end  of the sigmoid should be brought down to the divided end of the rectum  to verify once again the adequacy of mobilization in order to avoid any  chance of tension on the suture line of staples. Additional mobility may be  gained by ligating and dividing the inferior mesenteric vein just below the  inferior margin of the pancreas. T e decision now must be made whether  to perform an open sutures anastomosis as shown in figures 8 and 9 on  Chapter 61 or to use the transrectal circular stapler after placing the rec-  tal stump purse-string suture by hand in a very low anastomosis. In these  cases some surgeons prefer to place the purse-string suture in the very  short rectal stump from below using an anal speculum. More frequently, it  is technically easier to maintain compression of the rectal wall with a right  angle vascular clamp while a purse-string suture is placed in the protruding  mucosa. Absorbable traction sutures can be placed to serve as stay sutures,  while the purse-string suture of 00 polypropylene sutures includes both in  the muscular and mucosal layers. Also this suture must be placed close to  the cut edge so as to ensure a snug approximation of the entire bowel wall  about the stapling instrument when it is tied. Circular stapler sizing instru-  ments are passed into the open proximal bowel lumen and into the rectum  to define the largest-diameter stapler possible. T e assistant gently dilates  the anus and inserts the circular stapler from below. T e remainder of the  procedure is same as described in METHOD 1.    POSTOPERATIVE CARE Some postoperative rectal bleeding may occur  but usually stops spontaneously. T e diet is slowly resumed after the patient  passes flatus. Some prefer to insert a catheter in the anus beyond the anas-  tomosis for the venting of gas and anchor the catheter with a silk suture to  the perianal skin. T e Foley catheter is removed after 5 days with careful  observation of the volume and patterns of voiding, or earlier, depending on  institutional protocol. T e patients may complain of increased frequency  and urgency that may persist for several months. A tight anastomosis may  require eventual gentle dilations. m=    INDICATIONS T e low-lying lesions of the rectum and rectosigmoid may  be resected and bowel continuity established anterior to the sacrum in a  variety of ways. Although the end-to-end anastomosis (Chapter 61) can be  used, side-to-end anastomosis is advantageous in cases with considerable  discrepancy in size between the resected bowel and the rectal stump, par-  ticularly in obese patients. When the lesion is so low that abdominoperi-  neal resection, with sacrifice of the rectum, ordinarily would be indicated,  and in the presence of distant metastases, or when the patient refuses to  give permission for a permanent colostomy, bowel continuity can be estab-  lished by a very low side-to-end anastomosis. T is approach may occasion-  ally be needed in colostomy (Hartmann’) closure, and a similar ileorectal  anastomosis can be used in closing an ileostomy (e.g., after total colectomy  for pseudomembranous colitis).   T e principles of cancer surgery should be observed, including en bloc  excision of the lymphatic drainage area and early ligation of the inferior  mesenteric vessels near the point of origin (figures | and 2). T e blood  supply to the sigmoid will be sustained through the marginal artery of  Drummond via the middle colic artery arising from the superior mes-  enteric artery. At least 2 cm and preferably 5 cm of the bowel should be  resected below the malignant tumor to assure removal of all adjacent lymph  nodes. T e continuity can be reestablished after the descending colon, the  splenic flexure, and the left portion of the transverse colon are mobilized  (figure 3).   T e entire right colon can be freed from its lateral peritoneal attach-  ments and rotated to its embryologic position on the left side of the abdo-  men, if more mobility is desired.   T e advantages of the side-to-end anastomosis include assurance of a  larger and more secure anastomosis than may be possible by the end-to-  end method.    PREOPERATIVE PREPARATION After the lesion has been proved to be  malignant by microscopic examination, and polyps or secondary lesions  ruled out by appropriate colonoscopic and barium studies of the colon, the  patient is shifted to a clear liquid diet for a day or so before surgery. A  preliminary computed tomography scan with IV contrast may reveal dis-  tant spread and locate the courses of the ureters. For cancers below the  peritoneal reflection, an endorectal ultrasound study will aid in the staging  of the extent of disease. Appropriate tumors should be evaluated for radia-  tion therapy and chemotherapy prior to operation. T e rectum is irrigated  with saline or a povidone-iodine solution. T e tube is left in place for rectal  decompression. An indwelling urethral catheter ensures a collapsed blad-  der, providing better exposure of deep pelvic structures. Systemic antibiot-  ics are given.    ANESTHESIA. General endotracheal anesthesia 1s satisfactory. Spinal anes-  thesia may be used.    POSITION T e patient is placed near the left side of the table and so  immobilized that the Trendelenburg position can be assumed during the  final anastomosis without difficulty.    OPERATIVE PREPARATION T e¢ skin is prepared from the symphysis up  to the epigastrium. If a stapled anastomosis is planned, Allen stirrups are  used to create a modified lithotomy position allowing concurrent prepara-  tion and draping for later access to the rectum. T e perineum and rectum  are prepared and included in the draping if stapling is planned.    INCISION AND EXPOSURE A midline incision is made, starting just  above the symphysis and extending down to the umbilicus and around it on  the left side. T e height to which the incision 1s carried in the epigastrium  depends on the location of the splenic flexure. Because it will be necessary  to detach the splenic flexure, easy exposure of this area must be provided.  Undue tension of the left half of the colon and splenic flexure will tear the  splenic capsule, causing blood loss and risking splenectomy.   After the abdomen is opened, a self-retaining retractor is inserted, and  the liver 1s palpated for evidence of metastasis. Palpation should be carried  out well over the top of both lobes of the liver as well as on the undersurface.  Likewise, lymph nodes along the course of the inferior mesenteric artery  and at the bifurcation of the aorta are inspected for evidence of involve-  ment. T e position and fixation of the tumor are ascertained by palpation.  In the presence of metastasis to the liver or seeding throughout the general  peritoneal cavity, a sleeve type of segmental resection 1s indicated. When a  palliative resection is carried out, wide dissection of the inferior mesenteric  blood supply up to the point of origin in the region of the ligament of Treitz  is not necessary.    DETAILS OF PROCEDURE After it has been decided that the lesion is  resectable, that an anterior resection is warranted, and that adequate bowel  can be resected distal to the tumor, the small intestines are walled off and  the transverse colon and splenic flexure are mobilized (figure 4).   While the omentum is held upward, sharp dissection is used to divide  the attachment of the omentum to the transverse colon. A few blood ves-  sels may need to be ligated during this procedure. Opening into the lesser  sac above the transverse colon ensures an easier and safer separation of the  omentum from the splenic flexure of the colon, particularly in the obese  patient. Again, great care must be exercised as the splenocolic ligament 1s  divided in order to avoid tearing the splenic capsule. Clamps should be  applied in this area so that the contents of the splenocolic ligament can be  carefully divided and ligated (figure 5).    DETAILS OF PROCEDURE T e peritoneum over the region  of the left kidney is divided as gentle traction 1s maintained downward and  medially on the splenic flexure of the colon. T ere is a tendency to grasp the  colon and to encircle 1t completely with the fingers. T is tends to puncture  the thinned out mesentery. Rents can be avoided if a gauze pack is used to  gently sweep the splenic flexure downward and medially (figur e 6). Usu-  ally, it is unnecessary to divide and ligate any vessels during this procedure.  T e peritoneum in the left lumbar gutter 1s divided, and the entire descend-  ing colon is swept medially.   T e rectosigmoid is freed from the hollow of the sacrum as shown in  Chapter 59. T e sigmoid is first separated from any attachments to the iliac  fossa on the left side, and the left gonadal vessels and the ureter are identi-  fied throughout their course in the field of operation (figure 7). Often,  especially in the female, a very low-lying lesion can be mobilized and lifted  up well into the wound.    After the bowel has been freed from the hollow of the sacrum, the fingers  of the left hand should separate the right ureter from the overlying perito-  neum by blunt dissection (figure 8). T e peritoneum is incised some dis-  tance from the tumor, and the rectum is freed further down to the region of  the levator muscles using the mesorectal dissection (Chapter 59). Division of  the middle hemorrhoidal vessels with the suspensory ligaments may be nec-  essary to ensure the needed length of bowel to be resected below the tumor.  T e surgeon should not hesitate to divide the peritoneal attachments in the  region of the pouch of Douglas, to free the rectum from the prostate gland in  the male and from the posterior wall of the vagina in the female. T e inferior  mesenteric artery is freed from the underlying aorta to near its point of origin  (figure 9).T ree curved clamps are applied to the inferior mesenteric artery,  and the vessel is divided and ligated with 00 silk. T e inferior mesenteric vein  should be ligated at this time, before the tumor has been palpated and com-  pressed due to the manipulation required during resection.    DETAILS OF PROCEDURE After the mesenteric vessels have  been ligated and the rectum has been mobilized adequately, a Pace-Potts  noncrushing clamp is applied across the bowel at least 5cm to 10 cm below  the tumor (figure 10a). T e position of both ureters should once again  be identified before the clamp is applied. A straight clamp is applied 1 cm  proximal to the noncrushing clamp, and the bowel is divided (figure 0b).  As soon as possible the specimen is wrapped in a large pack held in place by  encircling ties (figure 11).   It is reassuring for the surgeon, especially in obese patients, to see active  pulsations at the anastomotic site, and the surgeon should take the time  to free the mobilized colon and to loosen any tension on the middle colic  vessels. Procaine, 1%, can be injected into the mesentery to strengthen pul-  sations in elderly patients or in the presence of large fat deposits in the  mesentery (figure 11). T e Doppler apparatus may be used to verify the  adequacy of the blood supply. T e small bowel should be returned to the  abdomen from the plastic bag, since the base of the mesentery of the small  intestine can compress the middle colic vessels, particularly if the small  intestine is placed on the abdominal wall above and to the right of the  umbilicus (figure 12). T e blood supply improves as the colon resection    nears the middle colic vessels, since the descending colon is now dependent  upon the marginal vessels of Drummond arising from the middle colic ves-  sels (figure 12). T e entire transverse colon as well as the right colon may  be mobilized by detaching the omentum and the peritoneal attachments as  indicated by the dotted line (figure 12).   T e mesentery is divided up to the bowel wall (figure 13) where active  pulsations have been identified. T e mesentery to the sigmoid is further  mobilized and divided until a sufficient amount of bowel has been isolated  proximal to the lesion.   T e remaining colon must be sufficiently mobilized then to reach the  rectal stump loosely and without tension. Extra mobility is mandatory,  since postoperative distention of the bowel and subsequent tension on the  suture line must be anticipated.   A decision is made for an end-to-end anastomosis with or without a  stapling instrument or a side-to-end anastomosis. T e adequacy of the  exposure, the amount of omental fat, and finally, the discrepancy between  the sizes of the upper and lower lumens may influence the final technical    DETAILS OF PROCEDURE T e bowel is divided obliquely  after the mesentery has been cleared off to about 1 cm from the clamp  (figure 14). T e mobility of this segment of bowel is tested by bringing it  down to the region of the rectal stump to be absolutely certain that side-to-  end anastomosis can be carried out without tension. If the initial segment is  too tight, additional transverse colon may be mobilized. T e hepatic flexure  can be freed as well as the entire right colon. Any attachments constrict-  ing the mesentery of the descending colon can be divided. T e presence of  active arterial pulsations should be determined while the closed end of the  colon is held deep in the pelvis. T e end of the bowel is closed using a run-  ning absorbable suture followed by 000 interrupted silk Halsted mattress  sutures. Alternatively, a stapled closure and division with a cutting linear  stapler can be used. Some surgeons oversew this staple line with inter-  rupted 000 silks for better security and inversion.   T e taenia adjacent to the mesentery along the inferior surface of the  mobilized segment is grasped with Babcock forceps, and traction sutures  (A and B) are placed at either end of the proposed opening (figure 15).  T ese sutures keep the inferior taenia under traction during the subse-  quent placement of the posterior serosal row of interrupted 00 silk sutures  (figure 16). T e traction suture (B) should be within 2 cm of the closed  end of the bowel, since it is undesirable to leave a long blind stump of  colon beyond the site of the anastomosis. After this, the Pace-Potts clamp  is removed. T e margins of the rectal stump are protected by gauze pads  to avoid gross spilling and contamination. It is advisable to excise the edge  of the rectal stump if it has been damaged by the clamp. T e color of the  mucosa and viability of the rectal stump should be rechecked. Any bleed-  ing points on the edge of the rectal stump are grasped and ligated with  0000 absorbable sutures. It has been found useful for exposure to insert  a traction suture (C) in the midportion of the anterior wall of the rectum  (figure 17). T 1s keeps the bowel under modest traction and aids in subse-  quent placement of mucosal sutures. A noncrushing clamp may be applied  across the colon to avoid the possibility of gross contamination. An incision  is made between the traction sutures (A and B) along the taenia, and the  lumen of the proximal bowel is opened (figure 15). All contamination is  removed in both angles of the openings. T e same type of traction suture  (C) can be placed in the midportion of the wall of the sigmoid. Interrupted  000 silks are placed full thickness through the posterior edges of both the  descending colon and rectal stump (figure 16). T e knots are tied within  the lumen and then cut. T is layer provides absolute full thickness control  for the posterior suture row. A double-ended running 00 absorbable suture  is tied in the posterior midline. T is proceeds laterally as a running, lock-  ing, and continuous suture until each suture line reaches the corner. A Con-  nell inverting suture is then used as the closure proceeds from both corners  to the midline. T ereafter, an interrupted row of 00 nonabsorbable sutures  are placed in a submucosal mattress manner for inversion and security of  the completed anterior anastomosis (figure 18).   T is provides a large stoma. T e patency of the stoma is determined by  palpation and the integrity of the anastomosis can be checked by filling the  pelvis with saline and then insuf ating the rectum with air using an Asepto  syringe. T e appearance of air bubbles signals the needs to reevaluate the  suture line or even in the entire anastomosis.   After completing the anastomosis, the surgeon should recheck the ade-  quacy of the distal blood supply and be certain that the proximal colon  is not under tension. T e hollow of the sacrum is irrigated with saline    and the placement of a closed-system Silastic catheter in this region 1s  optional.   To release tension from the suture line as the bowel becomes dilated in  the early postoperative period, it is useful to anchor some fat pads to the  peritoneal reflection in the iliac fossa. T is seals off entrance into the pelvis  as it anchors the bowel in this area. Likewise, the free medial edge of the  mesentery should be approximated to the right peritoneal margin in order  to cover all raw surfaces. As this peritoneum is closed, the course and loca-  tion of both ureters must be identified repeatedly to avoid including them  in a suture.    ALTERNATE STAPLED TECHNIQUE T e Baker’ side-to-end anasto-  mosis as illustrated is a very safe approach when the surgeon must per-  form a hand-sewn anterior or low anterior resection. Most surgeons,  however, have access to and proficiency with stapling instruments. In  these circumstances, the proximal descending colon is transected with  a cutting linear stapler while the rectal stump is divided between a pair  of suture lines created with a noncutting linear stapler stapling device  (figure 19). T erectum is divided between the staple lines and the speci-  men removed. T e staple line of the proximal colon is partially resected  along the antimesenteric border so as to create an opening that allows pas-  sage of a circular stapler anvil, whose shaft will exit through the taenia,  approximately 5cm proximal to this opening. A purse string is then applied  about the anvil shaft and tied in a snug manner (figure 20). T e open  cut end of the proximal colon is closed with the noncutting linear stapler.  T e main circular stapler instrument is passed, with its disposable trocar  retracted within, until it reaches the staple line of the rectal stump. Under  direct vision, the surgeon guides the circular stapler trocar out through  the posterior rectal bowel wall about 0.5 cm behind the suture line. A  purse string is carefully placed about the penetrating trocar. T e trocar is  removed and the anvil inserted into the circular stapler instrument within  the rectum. T e rectal purse string is tightened and both purse strings are  inspected. T e two segments of bowel are carefully brought together and  the instrument is fired. T e firing and release require adherence to the  manufacturer’ instructions to verify correct tightness or compression of  the tissue before firing and the correct amount of loosening for the cap to  tilt before careful removal. T e surgeon verifies the presence of two intact  tissue rings (donuts) containing the purse strings of both the proximal  and distal colon walls. After inspection of the anastomosis, the air bub-  ble test described above is most useful, as the surgeon cannot always see  fully around the anastomosis. An advantage of bringing the circular stapler  stapler trocar out posterior to the rectal stump staple line is that it places  the junction of the two staple lines (corners) somewhat anteriorly, where  they may be most easily reinforced with interrupted 000 nonabsorbable  mattress sutures.    POSTOPERATIVE CARE T e Foley catheter is removed in 1 to 5 days,  depending upon how much bladder and presacral dissection was per-  formed. Careful observation of the voiding pattern, volumes, and residual  volumes determines successful recovery. T e initial liquid diet is advanced  as tolerated. T e presacral drain is monitored for output and blood content.  It is usually removed in a few days unless a urine leak is suspected on the  basis of a large output of clear fluid with an elevated urea content. m    INDICATIONS A permanent ileostomy following removal of the colon can  be avoided in selected patients by removing all diseased colon and rectum  down to the top of the columns of Morgagni or the pectinate line, followed  by construction of an ileal reservoir, with anastomosis of the anal canal  (figure |). Patients with ulcerative colitis (UC) and polyposis are candi-  dates for this procedure, but those with Crohn’ disease are generally not,  because of the potential for involvement of the small intestine. T e patient  must have an adequate anal sphincter by digital examination or, better yet,  by manometry. T e rectum should be free of ulcerations, abscesses, stric-  ture, fissures, or fistulae. T is is especially important in patients with UC.  T is procedure can be considered in patients who are strongly opposed  to an ileostomy and who are available for prolonged close follow-up. T e  patient should thoroughly understand the uncertainties of postoperative  anal control and the need to have patience during the early months after  the operation. T e procedure is not recommended for frail, elderly patients  and those who have fecal incontinence. Obesity may make it impossible to  perform the anal pouch anastomosis. In patients with familial adenomatous  polyposis (FAP) desmoid tumors involving the small bowel mesentery can  make it difficult to obtain adequate length to reach the anus with the pouch.  All patients should realize that a permanent ileostomy can sometimes be  required due to factors not known until the procedure 1s underway.   Various surgical procedures have been used in an effort to improve long-  term anal continence. It is questionable whether any procedure currently  used is always completely successful, and the patient should be informed of  this uncertainty. Increasing experience suggests the use of some type of anal  pull-through procedure has a reasonable chance of providing more comfort  than the terminal ileostomy or the ileal abdominal pouch.   A prolonged period of preoperative hyperalimentation or nonalimenta-  tion with catabolism may be avoided by a staged procedure, especially in  the presence of toxic megacolon, poor general condition, or rectal disease.  A permanent ileostomy is performed with subtotal colectomy, leaving the  rectum in place, and the superior hemorrhoidal vessels undivided. T is also  offers the chance to review the pathology of the colon to further exclude  Crohn’ disease. After several months, an ileoanal anastomosis 1s considered  and a diverting ileostomy is created at the time of the pouch. After a suit-  able recovery the temporary ileostomy is closed making this a three-stage  procedure. Various pouches have been advocated. T ey include the J pouch  (figure 2a), the three loop S pouch (figure 2b), the lateral isoperistaltic  ileal reservoir (figure 2c), and the four-loop W reservoir (figure 2d).    PREOPERATIVE PREPARATION Documentation of the pathologic pro-  cess involved is done with biopsies taken from the anal canal as well as  the rectum or colon. T e stomach and duodenum are inspected by gastro-  duodenoscopy. Patients with polyposis and UC patients with high-grade  dysplasia should be informed of the potential for malignancy. It is impor-  tant to have medical and surgical agreement that surgical removal of the  entire colon is in the best long-term interest of the patient. Time is usually  required for the patient to accept the recommendation and the patient can  benefit from talking with another patient who has undergone this proce-  dure. T e patient’ medications, including steroid therapy for UC, must  be considered, and steroid therapy continued. Intravenous antibiotics are  given before operation, and any major blood volume deficit is corrected.  Patients receive a clear liquid diet for a day or two and an oral bowel prepa-  ration the day before.   In severe cases, some prefer a 6-week period of intense medication to  keep the colon at rest permitting the infammatory reaction to subside.  Such patients may be placed on total parenteral alimentation, systemic ste-  roids and steroid enemas, and systemic antibiotics when UC is present. T e  rectal mucosa is evaluated by sigmoidoscopic examination immediately  prior to the operation. A large rectal tube 1s placed for irrigation with saline  and povidone-iodine antiseptic solution.    Preoperative consultation with an enterostomal therapy nurse can help  with the patient’ understanding of the diverting and possibly permanent  ileostomy as well as help to position the stoma appropriately. Excellent  patient-oriented literature is also available from professional and patient  support groups, which may aid the patient’ understanding of both the pro-  cedure and its wide variety of possible complications.   Men should be counseled regarding the risk of impotence and retro-  grade ejaculation due to the pelvic dissection, and women should be coun-  seled regarding the risk of decreased fertility due to scarring in the pelvis.    POSITION T e patient is placed in the modified lithotomy position using  Allen stirrups. T is allows the abdominal as well as perineal dissections to  be performed without repositioning of the patient.    OPERATIVE PREPARATION T e rectum is given a very limited low-  pressure irrigation, and the perianal skin and buttocks are given the routine  skin preparation. Constant bladder drainage is instituted and a nasogastric  tube is inserted. T e pubis and abdominal skin are also prepared in the  routine fashion, and sterile drapes are applied.    INCISION AND EXPOSURE A lower midline incision that extends to the  left of the umbilicus is made, and the abdomen is explored. Particular atten-  tion is given to the entire small intestine to make certain there is no evi-  dence of Crohn’s disease, which would contraindicate the operation. T e  involvement of the colon with infammation or polyposis is evaluated. In  the presence of polyposis, the possibility of encountering an unsuspected  site of malignancy or metastases to the liver is ever present. If there is any  question of Crohn’ colitis, the colon is resected and sent to the pathologist  for gross and microscopic verification.    DETAILS OF PROCEDURE T e colon may be constricted, friable, and  quite vascular, with firm attachments to the omentum. Gentle traction 1s  applied to avoid tearing the friable bowel with resulting gross contamina-  tion. T e mesentery of the colon can be divided and blood vessels ligated  relatively near the bowel wall, except in diffuse polyposis, where there is  always a possibility of metastases to regional lymph nodes. It is judicious to  have the pathologist evaluate the entire specimen as soon as possible.   Before proceeding with the removal of the mucosa from the lower seg-  ment and before constructing the ileal reservoir, it is essential that sufficient  ileum has been mobilized to construct the pouch. Approximately 50 cm of  terminal ileum is required for the construction of the ileal reservoir. Such  mobilization is accomplished by dividing the ileocolic vessels and the mesen-  tery down to near the arcade of vessels at the very end of the ileum, but none  of the latter is ligated (figur e 3). It may be necessary to evaluate the mobility  of the small bowel all the way up to the ligament of Treitz with division of any  bands that tend to limit the mobility of the small intestine (figure 4). Inci-  sions within the posterior peritoneum may be worthwhile to provide added  mobility. Some divide the last ileal arcade (figure 4). T e adequacy of the  blood supply involved should be evaluated frequently to be certain a vigorous  blood supply is sustained to the end of the mobilized ileal terminal. T e end  of the proposed pouch should reach at least to the pubis, and preferably to the  edge of the Bookwalter ring being used for retraction.   T e dissection below the rectosigmoid junction is carried out close  to the bowel wall to avoid damage to the presacral and parasympathetic  nerves. T e rectal stump is washed out with povidone-iodine, and the  bowel divided at the anorectal junction. T is leaves a stump about 3 to 4cm  in length (figure 5). Some prefer to have a longer rectal anal stump, which  requires resection of the rectal mucosa from above rather than entirely  through the anus. Others use a stapling instrument for closure of the rectal    DETAILS OF PROCEDURE Many surgeons advocate leav-  ing about 2 cm of mucosa above the columns. Recurrence of inf ammatory  bowel disease and malignant degeneration are possible and careful follow-  up is essential. In general, avoidance of rectal dilatation or eversion of the  stump plus a high level of anastomosis results in better fecal continence. In  patients with high-grade dysplasia in the rectum, a traditional mucosectomy  may be a better option, as 1t removes all the mucosa. If this technique is done,  a hand-sewn ileoanal anastomosis would be required. T e J pouch is con-  structed by rotating the terminal ileum clockwise to create a “J” shape (as  seen from anteriorly) 15cm long. T e anterior ends are held by semicircular  000 silk sutures (figure 6). T e length is then checked as described above  to ensure it will reach the pelvis. T e distal antimesenteric end of the pouch  is opened with electrocautery. A linear stapler is then inserted and fired, cre-  ating a pouch from the two limbs (figure 7). Multiple firings are used to  complete the full length of the pouch (to reach the upper end, the distal end  is telescoped onto the stapler). A 2-0 Prolene suture is then used to create a  ‘“Wwhip-stitch” purse-string suture around the opening in the tip of the pouch.  An anvil of the circular stapler is then inserted and the purse-string tied  around it (figure 8). T e anvil must sit so that the antimesenteric aspect of  the ileum 1s draped across it. T e circular stapling instrument is then inserted  gently into the rectum by an assistant. It is advanced up to the level of the  stapled rectal stump. T e sharp spike then pierces through the stump just  posterior to the staple line and it is approximated with the anvil (figure 9).  T e device is then closed and fired, taking care not to include adjacent    structures such as the vagina. Naive or too-vigorous insertion of the circular  stapler instrument will rip through the very short rectal stump and make  the procedure much more difficult. figure 10 demonstrates the completed J  pouch with ileorectal stump anastomosis.   If the rectal mucosa is severely diseased, then a complete mucosal proc-  tectomy may be indicated. T e mucosa is excised from the dentate line up  to include the 3 or 4 cm of mucosa in the rectal stump. Some prefer to  outline the dentate line with electrocoagulation followed by the submuco-  sal injection of 1:300,000 adrenaline solution (figure 11). T is tends to  elevate the mucosa and facilitate the dissection in a more bloodless field.  All mucosa must be completely removed. T is dissection is often the most  time-consuming part of the technical procedure and must be done with the  greatest care (figure 12). T e underlying muscle and nerves must not be  injured. A dry field is essential.   Some prefer to grasp the stump with a Babcock forceps in the anus and  everted out the anus (figure 13). T 1s facilitates the removal of the mucosa  under direct vision but may result in poor fecal continence (figure 14).   Others prefer to divide the mucosa at the top of the columns of Mor-  gagni (figure 5, page 231). T 1s avoids telescoping the rectal stump and  lessens the possibility of nerve injury where the patient may not be able to  differentiate stool from f atus postoperatively.   If a mucosal proctectomy is performed, then a hand-sewn ileoanal anas-  tomosis must be completed. T isis demonstrated on page 2351n this chapter.    DETAILS OF PROCEDURE T e adequacy of the blood supply  to the reservoir is again double-checked. Two interrupted sutures with nee-  dles attached (figur e 15) are anchored on each side of the two-finger open-  ing in the reservoir. T ese sutures are passed by the surgeon down through  the anus, and the reservoir is placed in the proper position from above.   T e two sutures on each side are then anchored to either side of the  opening at the level of the dentate line (figure 16). An additional suture  is placed in the midline anteriorly and posteriorly. Eight or ten additional  sutures may be required to ensure an accurate anastomosis. T ese sutures  include the full thickness of the ileal wall, as well as a portion of the internal  sphincter (figure 17).   Any openings in the mesentery are closed with interrupted sutures to  avoid intestinal hernia. T e pelvic peritoneum is closed about the pouch  to avoid twisting or displacement. A suture may be placed to anchor the  pouch to each side of the muscular rectal cuff to secure the pouch in posi-  tion and lessen the possible tension on the suture in the dentate line anasto-  mosis. Some prefer to insert a rubber drain between the wall of the pouch  and the rectal cuff. T e rubber tissue drain is brought out anteriorly.   While it 1s tempting to avoid an ileostomy, fewer postoperative complica-  tions result if a complete diversion of the fecal stream 1s accomplished by  ileostomy. T e defunctioning ileostomy is performed through a small open-  ing in the left lower quadrant about 40 cm from the pouch (figure 18). It  is advisable to ensure complete diversion of the fecal stream (figure 19)  by intussuscepting up the proximal limb or stoma over the rod (see also  Chapter 51).    POSTOPERATIVE CARE Steroid therapy is gradually decreased until it  can be omitted completely. T e bladder catheter is removed after testing for    sensation after a few days. T e diet is slowly increased, but may need to be  adjusted or limited depending upon the incidence of diarrhea.   Incidental obstruction, pelvic sepsis, and local problems around the ile-  ostomy are occasional complications after the operation. Before closure, the  integrity of the pouch and the anal anastomosis is evaluated by radiographic  procedures with water-soluble contrast. Direct evaluation of the anastomo-  sis for patency is also necessary. Frequently it strictures or develops a web  across it requiring examination with sedation in the GI laboratory. Pouchos-  copy can also be performed at this time. If no problems exist, the ileostomy  is closed within 4 months.   T e major consideration involves the degree of anal continence that has  been achieved. Patience is required during the first year, as the capacity of  the pouch increases and sphincter control gradually improves. T e control  of diarrhea during the day and soiling at night are of major concern and  may require adjustment in bulk and type of food, as well as special medi-  cation. T e number of daily stools varies, with an average of six per day  and one or two per night. Patients with polyposis usually have fewer bowel  movements per day than patients with UC.   A troublesome complication is a poorly defined syndrome known as  pouchitis. T e stools are increased in frequency with malaise, fever, and  bloody stools, along with abdominal cramps. T is complication is far more  common in patients with UC than in those with multiple polyposis. Spe-  cific medication and dietary adjustments are indicated. T is procedure is  believed to be associated with chronic residual stasis. Intestinal obstruction  may occur in 10% more of the patients.    INDICATIONS Operative correction of complete rectal prolapse in chil-  dren is rarely indicated. However, in adults (especially in older groups)  effective operative repair is worthwhile. Relatively commonly, rectal pro-  lapse is found to be associated with or related to neurologic and psychiatric  disorders as well as degenerative arteriosclerotic diseases. True prolapse  of the rectum involves a herniation of the pouch of Douglas through the  dilated and incompetent sphincter muscles. To correct this defect, the her-  nial pouch must be eliminated and the weakened pelvic floor strengthened.  Obliteration of the pouch of Douglas and fixation of the rectum can be  accomplished by the perineal, abdominal, or combined approach.   True prolapse of the rectum starts as an internal intussusception at the  level of the levator muscles anteriorly. T e rectum slides from this weak  point through the anal canal. A true prolapse can be identified by circu-  lar rings of the prolapsed rectum as all layers of the bowel are present. In  a first-degree prolapse, only the mucosa of the bowel is prolapsed, which  is usually identified by three radial folds rather than circumferential folds.  Rectal prolapse, if allowed to persist, can result in dilatation and incompe-  tent anal sphincters. Prolapse is often present in elderly women who have  perineal descent and weakness of the pelvis floor muscles. Perineal descent  may often be associated with either a retocele or acystocele. T ere is often an  antecedent history of multiple pregnancies and pelvis surgery including hys-  terectomy. Operative correction by the perineal approach is usually reserved  for individuals who are elderly and would otherwise be unable to tolerate a  sigmoid colectomy and rectopexy, which is the ideal repair for this problem.    PREOPERATIVE PREPARATION Colonoscopy or a bar1um enema and sig-  moidoscopic examination are essential. T e use of a low-residue diet, cathar-  tics, and enemas is necessary to obtain a clean and empty large bowel. T e  prolapse is reduced and reduction sustained by the application of a T-binder  to minimize the associated edema and encourage the healing of any super-  ficial ulcerations. T e procedure requires a complete bowel prep including  both mechanical cleansing and oral and preoperative intravenous antibiotics.    ANESTHESIA General or spinal anesthesia is satisfactory; however, gen-  eral is usually preferred.    POSITION T e patient is placed in a lithotomy position with the legs  widely separated. T e table is in a slight Trendelenburg position to decrease  the venous ooze and enhance the anatomic dissection.    OPERATIVE PREPARATION T e prolapse is reduced and the rectum irri-  gated with sterile saline. T e skin about the perineum 1s cleansed in a rou-  tine manner. T e area may be dried and a plastic drape used if desired. T e  bladder is catheterized, and the catheter left in place.    INCISION AND EXPOSURE T e prolapse tends to present without dif-  ficulty (figure 1), and Babcock or Allis forceps are applied for traction  purposes to determine the extent of the prolapse. T e relationship of the  prolapse to the pouch of Douglas and the sphincter muscles of the anus  is shown in figure 2. T e protruding mass is palpated to make certain  the small intestine is not entrapped in the hernia sac anteriorly. Absorb-  able 000 sutures are placed in midline (figur e 3a) anteriorly, posteriorly,  and at the halfway point on either side (figure 3b and b),) near the anal  margin, not only to serve as a retractor but for subsequent landmarks at  the completion of the procedure. T e identification of the pectinate line 1s  important, since the incision through the presenting rectal mucosa will be  made 3 mm proximal to this anatomic landmark. T 1s minimal amount of  mucosa is adequate for the final anastomosis and is short enough to pre-  vent postoperative protrusion. A sharp knife or electrocautery can be used  (figure 3). T 1s area tends to be quite vascular, and meticulous hemosta-  sis by electrocoagulation or individual ligation 1s essential (figure 4). T e  incision through the outer sleeve should divide the full thickness of bowel  wall, including mucosa as well as the muscularis. T e pouch of Douglas 1s  not entered. T e dissection is facilitated 1f the surgeon inserts his index fin-  ger in a developed cleavage plane between the two layers of prolapsed bowel    INCISION AND EXPOSURE After the mucosa and muscularis  of the protruding segment have been completely divided, traction is main-  tained downward on the cuff of incised mucosa and muscularis (figure 6).  Any attachments between the bowel wall and the underlying segment are  divided with the electrocoagulant unit or sharp knife, and all bleeding points  are controlled. T is cuff is pulled off easily and results in a segment twice as  long as the original protrusion (figure 7). T e bowel wall is not amputated at  this time, but downward traction is maintained as an attempt is made to iden-  tify the prolapsed pouch of Douglas (figure 7). T e resection may be started  in the midline anteriorly and continued upward through the fat until the glis-  tening wall of the peritoneum 1s identified. T e peritoneum is gently opened  (figure 8), and the pouch of Douglas 1s explored with the examining finger.  Any attachments between the small bowel or adnexa in the female should be  separated to ensure freeing of as much of the pouch of Douglas as possible and  to permit mobilization of the redundant rectosigmoid into the wound.   After the peritoneum is opened, the presenting intestine lying on  the posterior side of the sliding hernia is grasped with forceps to deter-  mine how much mobile large intestine will require amputation to correct  the tendency toward recurrent prolapse. T e peritoneal opening should be  extended laterally to either side. T e blood supply, surrounded by a thick  layer of fatty tissue, is usually identified posteriorly and on the right side  of the presenting intestines (figure 9). Half-length forceps and the sur-  geon’s index finger are used as blunt dissectors until the mesentery to this    segment of the bowel has been separated without injuring the bowel wall  itself. At least three half-length clamps are applied to ensure a safe double  ligation with 0 absorbable suture (figure 10). T e most proximal one of  these sutures should be of the transfixing type, since the tissues are under  some tension, and bleeding may develop unless the contents of these clamps  are tied securely. No effort should be made to strip the bowel from the mes-  entery; however, it may be necessary to reapply clamps from either side, as  well as in the midline posteriorly, until all the redundant large intestine has  been pulled freely into the wound.   After the blood supply has been ligated and as much of the intestines as  necessary mobilized into the wound, the pouch of Douglas can be closed in  several ways. If the opening is rather large and the prolapse has included a  segment of the large intestine well above the base of the pouch of Douglas,  an inverted T-type closure of the peritoneum can be carried out (figure 1)).  T e peritoneum is closed in the midline anteriorly with interrupted or con-  tinuous 00 absorbable suture.   T e closure approximates the peritoneum around the bowel wall, and  the continuous suture is tied. A suture starting at this point, including a bite  of the peritoneum as well as of the bowel wall, continues around to the right  side until it is anchored in the region of the ligated mesentery blood supply  (figure ll). T e attachment of the peritoneum is made secure in a similar  manner on the left side. T is accounts for the so-called inverted-T closure  of the peritoneum.    INCISION AND EXPOSURE In some instances, especially  when the prolapse is not particularly marked, the pouch of Douglas may  be developed from the anterior rectal wall similar to a direct hernial sac  (figure 12). T e peritoneum is then carefully incised and the margins  held apart by traction with two or three forceps (figure 13). T e surgeon’  index finger should be inserted to ascertain that the pouch of Douglas is  free from attachments to either the small bowel or the adnexa in the female.  It may be necessary to enlarge such an opening and insert a small retractor  to accomplish this with good visualization. T e pouch of Douglas should  be closed as high as possible with a purse-string 00 absorbable suture  (figure 14). Considerable time may be required to make certain that the  pouch of Douglas has been obliterated as high as possible. If the obliteration  cannot be done satisfactorily, it may be judicious to obliterate the pouch of  Douglas by a transabdominal approach as part of a plan for a second-stage  or a two-stage procedure. After the peritoneum has been closed, the redun-  dant peritoneum is amputated, and additional sutures are taken to control  bleeding and reinforce the pouch of Douglas (figure 15).   T e next step involves identification of the levator muscles, since the  reinforcement of the pelvic floor is essential to prevent recurrence. T e pro-  cedure to be followed is not unlike the approximation of the levator muscles  in the performance of a posterior perineorrhaphy. A small narrow retrac-  tor can be inserted anteriorly as the surgeon inserts the index and middle  fingers of the left hand to better define the levator ani muscles on the left  side. An Allis or Babcock clamp grasps the levator muscles to better define  their margins, and a deep 00 absorbable suture is inserted (figure 16).T e  first suture can be applied at either the top or the bottom of the proposed  closure, depending on which is easier. In figure 17, the first suture shown  is placed in the bottom of the approximation, and a right-angle clamp  depresses the bowel wall to provide a snug approximation by the levators.  An additional three or four sutures are required to approximate the levators  farther up in the midline (figure 18).   Only after the levators are approximated should the prolapsed bowel  be prepared for amputation. It 1s essential that the normal anatomic posi-  tion of the bowel be retained. For this reason it has been found judicious  to split the anterior as well as the posterior wall of the prolapsed large    intestine almost up to the region where the bowel will be divided. T is  should be done carefully so that suf cient bowel is available for approxi-  mation to the pectinate line, yet a suf cient amount is removed to prevent  recurrence (figure 18). After the bowel has been divided, the surgeon  should insert a finger into the lumen of the bowel to again check snugness  of the approximation of the levator muscles. Enough room should be avail-  able to admit the index and middle fingers easily. If the approximation of  the levators seems to be too snug and the blood supply to the bowel com-  promised, one of the sutures may be removed, or, if too large, an additional  approximation of the levators should be considered.   Before the bowel wall is divided up as high as eventually required, the  midline anteriorly should be tested for length. T e bowel wall is divided up  to a point where a retraction suture can be placed in the midline approxi-  mating the mucosa with the pectinate line without tension (figure 19). A  quadrant of the mucosa is then divided, and the mucosa is approximated  to the pectinate line with either the continuous lock or interrupted 00  absorbable sutures. T e mucosa can be approximated more accurately if a  planned quadrant anatomic fixation is carried out as shown in figures 19  and 20. T e importance of the traction sutures in the midline and at the  halfway point on either side readily becomes apparent as the satisfactory  approximation of the mucosa to the pectinate line 1s finally accomplished  (figure 20). T ere should be an easy approximation of the mucosa to the  pectinate line, and it should have a nice pink color. T e sutures should not  be tied so tight as to produce bleaching of the mucosa. After completion of  the procedure, the surgeon should introduce a well-lubricated finger care-  fully through the anastomosis to make certain of its patency as well as its  adequacy (figure 21). No drainage is indicated.    POSTOPERATIVE CARE Fluid balance is maintained by intravenous  administration of water, glucose, and electrolytes. A liquid diet is gradually  progressed to a low-residue diet. Mineral oil in doses of 1 0z two times per  day is given. Digital examination is delayed unless undue distress devel-  ops about the site of operation. T e possibility of development of a peri-  rectal abscess, which may require incision and drainage, is an ever-present  threat. m    INDICATIONS T is is an office procedure generally reserved for grade 1  or 2 hemorrhoids with minimal symptoms. T e anatomy of internal and  external hemorrhoids is shown in figure I.    POSITION T e patient is usually placed in a standard kneeling position  on a Ritter table, although this may also be done in the left lateral position.    DETAILS OF PROCEDURE T e hemorrhoidal bander is prepared with  two rubber bands loaded. After digital examination, a Hirschman anoscope  is inserted in the anal canal, the obturator removed, and the internal hem-  orrhoids are evaluated. After evaluation, which includes inspection of the  internal hemorrhoids in their cardinal positions (right anterior, right pos-  terior, and lateral), a decision is made as to which hemorrhoid is the most  suitable for banding. T is is usually the largest hemorrhoid. T e Hirschman  anoscope 1s positioned over the target hemorrhoid to allow prolapsed into  the anoscope. Care must be taken to ensure that the site of the banding  (all of the tissue encompassed by the band) is above the dentate line. An  Allis clamp is first placed through the Hirschman anoscope to test the area  (figure 2a).T ehemorrhoid in question is grabbed with the Allis clamp.  If the patient has significant discomfort, the clamp is too far distal and  needs to be moved more proximal. Once the correct position of the clamp  is determined, the bander is placed through the Hirschman anoscope,  and the hemorrhoid is prolapsed with the Allis clamp into the bander  (figure 2b). If there is no discomfort, the bander is fired, and the band is  placed on the hemorrhoid. T e instruments are then removed.   If the patient has significant, sharp pain immediately after placement of  the band, it should be removed. T is is done by incising the band with the  tip of an 1]-blade scalpel or with suture-removal scissors.   It is generally unsafe to place more than one or two bands at any one sit-  ting. If more than two hemorrhoids are banded, they should be done at two  or more office visits over the course of a couple of months. It is not unusual  for the symptoms to improve after a single banding. Banding the largest  hemorrhoid involved will sometimes resolve the patient’ symptoms for a  significant period of time.    POSTOPERATIVE CARE T e patient will usually report some bleeding  when the hemorrhoid sloughs in 4 to 7 days, which is entirely normal.  However, the patient should be instructed to call immediately if he or she  develops urinary retention or fever, as these may be early indications of  pelvic sepsis. T e procedure may be repeated in 6 weeks if symptoms have  failed to completely resolve.    INDICATIONS Hemorrhoidectomy is usually an elective procedure per-  formed in good-risk patients with persistent symptoms referable to proven  hemorrhoids. Bleeding, protrusion, pain, pruritus, and infection are the  more common indications when palliative medical measures have failed.  Large external skin tags may require removal because of local pruritus. In  the female, a pelvic examination is made to eliminate tumor or pregnancy  as the etiology. In the male, the status of the prostate gland must be thor-  oughly evaluated. In older patients, a thorough colonoscopy or sigmoidos-  copy and bartum enema are mandatory. T e presence of a serious systemic  disease, such as cirrhosis of the liver, or a probable short life expectancy  from advanced age or any other cause should be a general contraindication  to operation unless anal symptoms are marked.   Simple internal hemorrhoids that prolapse may be treated by rub-  ber banding using the technique shown in figure 2a, b and c. Larger    hemorrhoids may require excision as the first procedure, or if hemor-  rhoidal banding has failed.    PREPARATION A thorough cleaning enema is given the night before or  early in the morning of operation, preferably several hours before opera-  tion, since residual enema fluid is more disturbing than the presence of a  small amount of dry fecal material.    ANESTHESIA Spinal, epidural, or local anesthesia is satisfactory. If an  inhalation anesthesia is given, it should be remembered that dilatation of  the anus stimulates the respiratory centers. Spinal anesthesia must be used  with caution because it may so completely relax the anal sphincter such that  it cannot be properly identified by palpation.    POSITION T e positioning of the patient depends on the type of anesthe-  sia used. With spinal anesthesia, the prone jackknife position af ords the  surgeon the best exposure. If general anesthesia is used, an exaggerated dor-  sal lithotomy position is preferred, with the buttocks extending beyond the  edge of the table and the legs held in stirrups.    OPERATIVE PREPARATION Extensive dilatation of the anus before hem-  orrhoidectomy is undesirable because it distorts the anatomy, making it  impossible to remove all hemorrhoids at one operation without fear of ste-  nosis. Gentle dilatation may be used if no more than three hemorrhoids are  removed at one time.    DETAILS OF PROCEDURE Anoscopy is done, and any associated pathol-  ogy is identified so that hypertrophied papillae or deep crypts may be  removed.   T e anal canal may be gently dilated to about two fingers’ width to per-  mit adequate exposure. A suitable self-retaining retractor is inserted into  the canal, and further inspection is made. A gauze sponge is introduced  into the rectum, and the retractor is withdrawn (figure 3). T e surgeon  makes gentle traction on the sponge, reproducing, in ef ect, the passage  of a bolus through the canal. As the sponge is withdrawn, the prolapsing  hemorrhoids may be identified and are picked up with hemorrhoid clamps  (figure 4). Clamps are placed on all the prolapsing hemorrhoids and left in  place as markers during the operation. Opposite the hemorrhoid a straight  hemostatic forceps is placed on the anal verge, which is the external bound-  ary of the anal canal. T e hemorrhoid is placed under tension by simul-  taneous traction on the forceps and the hemorrhoid clamp (figure 5).  A triangular incision is made from the anal verge to the pectinate line  (figure 6). By traction on the two clamps and careful blunt and sharp  dissection with the scalpel, it is possible to dissect of the triangular area  of skin and the hemorrhoidal tissue from the outer edge of the external  sphincter muscle. Many small fibrous bands will be found running upward  into the hemorrhoidal mass. T ese represent the continuation downward  of the longitudinal muscle and may be divided with impunity (figure 7).  Dissection is carried to the outer edge of the external sphincter. T e anal  skin must be divided to and slightly beyond the pectinate line. T ere now  remain mucosa and the deep veins entering the hemorrhoidal mass. T e  tissue is secured with a straight clamp and a transfixing suture is placed  at the apex of the hemorrhoidal mass (figure 8). T e hemorrhoidal tis-  sue is removed with a knife, and an over-and-over continuous suture 1s  made in the mucosa (figure 9). T e clamp is removed and a continuous  suture approximates the mucosa, including the two edges of the pectinate  line. As the suture 1s continued externally, small bites are taken in the exter-  nal sphincter muscle (figure 10). T e deep portion of the skin is closed  by a subcutaneous approximation (figure 11), and the skin edges are  left open to provide for better drainage and prevent postoperative edema    DETAILS OF PROCEDURE Each hemorrhoidal mass 1s sim1-  larly removed. All possible mucosal tissue must be preserved to prevent ste-  nosis. However, relatively large areas of skin may be safely removed in the  triangular incision.   With extensive hemorrhoids it may be necessary to excise one-half of  the mucosa of the entire canal in this fashion. T e triangular incision may  extend from the anal verge and reach the pectinate anteriorly and poste-  riorly. T e mucosa is divided horizontally, taking small bites of tissue in  a series of hemostats (figure 13). T 1s mucosal flap is sutured into the  external sphincter horizontally to prevent stenosis (figure 14). All redun-  dant incisional skin margins should be excised to minimize the subsequent  development of potentially damaging perianal skin tags.    POSTOPERATIVE CARE A sterile protective dressing is applied to the  anus. Petrolatum may be applied locally. T e diet is restricted for the first 2  or 3 days, but by the third day the patient may be allowed a full diet. Min-  eral oil (30 mL) is given. T e patient is encouraged to have a bowel move-  ment and usually will do so by the third day. Local application of heat is  useful in alleviating discomfort. T e patient may take sitz baths as desired.  Weekly anal dilatation may rarely be needed postoperatively until healing  is complete.    heavy lifting or women late in their pregnancy may experience thromboses.  T ese patients usually complain of significant pain. Diagnosis is made by  inspection. T e thrombosed hemorrhoid will generally be located in either  the right lateral or the left lateral position. Depending upon the size of the  hemorrhoid, removal might be accomplished successfully in the office. If  the thrombosed hemorrhoid has been present for more than a few days, it  may be unnecessary to do anything, as these will usually resolve with time.  Occasionally, thrombosed hemorrhoids will present with extrusion of the  clot and possible contamination, and in cases such as this, they should be  removed.    PROCEDURE Once the decision is made to remove the thrombosed hem-  orrhoid in the office, the patient should be placed on the Ritter examina-  tion table in the standard kneeling position. With an assistant, hold the  buttock apart to expose the anal canal and the thrombosed hemorrhoid.  T e area is first painted with betadine, and then injected with 2 to 3 mL  of 1.0% xylocaine with epinephrine. T is will provide both good analge-  sia and allow the patient comfort on the way home. T e hemorrhoid is  then grasped with a small hemostat and using dissecting scissors, excised  using an elliptical incision (figure 15). It is important to excise, and not to  simply incise, the hemorrhoid as much as possible, to prevent further clot  accumulation. T is may be facilitated by using a small curette (figure 16).  T e open wound is not closed. It is treated with silver nitrate and a pressure  dressing placed. T e patient is instructed to keep the dressing on until the  next morning or bowel movement and to begin sitz baths the next day. m    INDICATIONS T e anatomy of the anal region is shown in figure l.  Abscesses around the anal canal arise from infection of the anal crypt of  Morgagni (figure 2) and can be either superficial perianal abscesses (80%)  or deeper ischiorectal abscesses (20%) (figure 3). A perianal abscess is  found adjacent to the anal canal, either on the right or left side, anterior or  posterior. T e patient usually complains of pain that may be, but not always,  associated with a fever. T e diagnosis is made by inspection of the perianal  area, which will reveal a red, angry, and often fluctuant abscess. A digital  examination should not be done due to the painful nature of the problem.  figure 3 shows the location of perianal and perirectal abscesses. Abscesses  are classified according to the spaces they invade. Most superficial perianal  abscesses can be drained safely in the office and do not require operative  drainage. T e most difficult to treat are those that track proximally or cir-  cumferentially within the intersphincteric plane or within the ischiorectal  fossa or postanal space. Examination under anesthesia may be required to  determine the location and extent of the abscess. An ischiorectal abscess,  however, is large, involves either the right or the left ischiorectal space or the  deep postanal space, and requires operative drainage.    PREPARATION For office drainage, the patient should be placed in the  standard kneeling position on a Ritter table. For operative drainage, a prone,  jackknife position is best. If done in the operating room, a general or spinal  anesthetic is desirable.    OFFICE PROCEDURE For a perianal abscess, the skin over the abscess  is numbed with ethylene chloride. Injection of the site with Xylocaine is  excessively painful and unnecessary. Once the area is sufficiently numbed,  a stab incision is made over the abscess to drain pus. T is should be suf-  ficiently large to allow adequate drainage. T ere is no need to excessively  probe this abscess. T e incision should be made as close to the anal canal  as possible so that if a fistula-in-ano does develop, the fistula tract will be  as short as possible.    INDICATIONS Ischiorectal abscesses are drained immediately. Careful  palpation often shows evidence of fluctuation not seen in the perianal tis-  sue. Operation is not delayed until fluctuation is obvious, because a perirec-  tal abscess may rupture through the levator muscle into the retroperitoneal  tissue.    PREOPERATIVE PREPARATION No special preoperative preparation is  required. Antibiotic therapy is given.    ANESTHESIA General anesthesia with endotracheal intubation may be  used; however, regional anesthesia, either spinal or epidural, is satisfactory.    POSITION T e prone or jackknife position is preferred for drainage.    INCISION AND EXPOSURE T e common locations of ischiorectal  abscesses are shown in figure 3. Abscesses may be located extraperitoneally  above the levator ani muscle. Careful rectal and sigmoidoscopic examina-  tion should be performed to detect associated pathologic processes after the  patient has been anesthetized. An incision is made at the maximum point  of tenderness (figure 3) and placed either parallel or radial to the anus. If  the abscess lies above the levator, great care should be taken in its drainage.  Supra-levator abscesses are frequently caused by an abdominal source (e.g.,  diverticulitis), which should be treated through the abdomen rather than  turned into an extrasphincteric abscess by perianal drainage.    DETAILS OFPROCEDURE After incision and drainage, the cavity is explored  with the index finger to ensure complete drainage and to ascertain that no  foreign body 1s in the ischiorectal space. A specimen of the draining material  is obtained for bacteriologic studies. Usually, there is no communication with  the rectum. If the abscess is small and a clear communication with the rectum  is identified, the tract may be excised. T e outer opening must be sufficiently    large, for the common error is to drain a large cavity through a comparatively  small incision, resulting in the development of a chronic abscess.    POSTOPERATIVE CARE Moist compresses and sitz baths reduce inflam-  mation and promote rapid healing. Postoperative dressings to ensure heal-  ing from the bottom are as important as the operation. An ischiorectal  abscess is prone to result in an anal fistula; however, in about half of the  cases, there will be primary healing with proper postoperative care. It is  helpful to discuss the possibility of fistula formation with the patient preop-  eratively lest they feel that the fistula is a failure of the drainage procedure.    INDICATIONS T e majority of anal fistulae result from infection arising  in a crypt, extending into the perianal musculature, and then rupturing  either into the ischiorectal fossa or superficial perirectal tissues. Operative  obliteration of the fistula is always indicated if the patient’ general condi-  tion is good.    ANATOMIC CONSIDERATIONS ‘Treatment of anal fistulae presupposes a  knowledge of anal anatomy, particularly of the sphincter muscles and their  relation to the anal crypts. A study of figure | will clarify several impor-  tant points. As shown in figure |, the external sphincter muscle can be  divided into three portions: the subcutaneous, superficial, and deep por-  tions. T e subcutaneous portion lies just beneath the skin and below the  lower edge of the internal sphincter (figure 1). T e superficial and deep  portions surround the deeper part of the internal sphincter and continue  upward to join with the levator muscle (figure 1). T e levator ani sur-  rounds the anal canal laterally and posteriorly, but it is absent anteriorly  (figure 1). T e longitudinal muscle of the anus is the continuation down-  ward of the longitudinal muscle of the large bowel (figure 1). T e internal  sphincter muscle is a bulbous thickening of the circular muscle coat of the  large bowel. T e superficial external sphincter is palpated as a band sur-  rounding the anal canal just beneath the skin (figur e 1). Just above it 1s felt  a slight depression, the intersphincteric line, and the slight swelling above  this point is the lower edge of the internal sphincter (figur e 1). Ifthe finger  is introduced into the canal and hooked around the entire anorectal ring  anteriorly, it contacts the deep portion of the external sphincter, the levator  being absent in this location (figure 1). As the finger is rotated posteriorly,  in contact with the midline of the canal laterally, a distinct thickening is felt  as the levator ani (figure 1) joins the canal, and posteriorly the anal canal  feels thicker than it does anteriorly. Incontinence will not occur if any por-  tion of the external sphincter or levator muscle remains intact.   Most fistulae arise in the anal glands at the base of the crypts of Mor-  gagni; therefore, the abscess usually lies within the substance of the internal  sphincter (figure 2). It extravasates through the muscle, tending to fol-  low the tissue planes created by the fibromuscular septa of the longitudinal  muscle. Fistulae rarely arise from perforations of the anal canal associated  with foreign bodies or abscesses, as in tuberculosis or ulcerative colitis.  T e internal opening may be above the pectinate line and may traverse the  entire sphincter or portions of the levator (figure 4). It may be necessary  to operate in stages or to use the seton technique (Chapter 68) to avoid  incontinence.   Fistulae-in-ano usually follow Salmon—Goodsall’ rule. If located anter1-  orly, there is a radial tract (figur e 5a); if posterior, there 1s a curved track  (figure 5b—d). Simple anal fistulae (figur e 5a) follow a direct route in the  anus. Complicated fistulae (figure Sb and c) follow a more devious route,  often horseshoe in shape and with numerous openings. Most complicated  fistulous tracts open into the posterior half of the anus. Should the fistula  have multiple sinuses, the main exit will usually be posterior, even though  one opening is anterior to the dashed line (figure 5); a single fistulous  opening anterior to the dashed line usually extends directly into the ante-  rior half of the anus (figur e 5a ) (Goodsall’s rule).    PREOPERATIVE PREPARATION Local abscesses are drained  if there is pocketing or cellulitis. If there is no severe local inflammation, a  cleaning enema is given the night before operation. No cathartic 1s necessary.    ANESTHESIA Inhalation anesthesia is the procedure of choice when deal-  ing with a complicated fistula. Spinal anesthesia is satisfactory for simple  fistulae and may be used for more complicated fistulae; however, it provides  such complete relaxation of the musculature that palpation and recogni-  tion of the divisions of the external sphincter and levator are sometimes  impossible.    DETAILS OF PROCEDURE T e anal canal may be dilated just enough  to permit introduction of a self-retaining retractor. T e pectinate line is  directly visualized, and anal crypts that may reveal the internal opening are  inspected. Gentle probing of suspected crypts may reveal an unusually deep  crypt, which, from the position of its external opening, can be recognized as  the source of the fistula (figur e 6). Ifa normal pectinate line is found, with  shallow crypts or no crypts at all, it 1s likely to be a local perianal abscess    with no direct communication with the anal canal. Some surgeons prefer  to inject hydrogen peroxide into the external opening to trace the fistulous  tract to its inner opening.   After the internal opening of a simple fistula has been identified, a probe  is introduced into the external opening and gently passed down the tract  into the internal opening (figure 7). Care is taken to avoid creation of a  false passage. T e incision is made on the probe, and the tract is laid open  (figure 8). It is not necessary to excise the fistula. T e tract should lie open  as shown in figure 9. In a simple superficial fistula, the entire tract may  be stabilized with a probe as it is excised with scissors with electrocautery.    DETAILS OF PROCEDURE For complex fistulae such as a horseshoe fis-  tula with an external opening anterior to the midanal line and an inter-  nal opening in the posterior midline, extensive incisions are avoided.  T e main posterior tract is identified with a probe (figure 10). A short  posterior portion of the tract is unroofed and the involved crypt excised  (figure 11). T e anterior tracts are curetted and drained via soft rubber  (Penrose) drains through secondary incisions along the tracts (figure 12).  T e posterior tract is marsupialized (figure 13).    DETAILS OF PROCEDURE If a large transsphincteric fistula involving a  significant amount of external sphincter muscle is present, a seton should  be placed. T e probe is first passed from the external opening to the inter-  nal opening, and a 0 silk suture is tied around the groove in the probe  (figure 14). T e probe with the suture is then pulled back through the fis-  tula track, and the 0 silk suture is tied tightly around the muscle. All fat and  skin are removed leaving the seton compressing sphincter muscle only. Silk  is an irritant, and with time the silk will cut through the sphincter muscle.  However, the fistulotomy will be performed incrementally giving time for  the sphincter to heal. T e fistula is slowly drawn out by the seton. T is pro-  tects against incontinence, by preventing the sphincter muscle from sepa-  rating, as would happen during a fistulotomy. A non-cutting seton using a  vessel loop is indicated in chronic perianal disease.    POSTOPERATIVE CARE T e patient may be out of bed as soon as the  anesthesia has worn of. T e patient 1s allowed a light diet, and there is no  attempt to restrain bowel movements. Stool softeners are prescribed. Sitz  baths may be started on the second day following operation. Patients may  be discharged the day of surgery and are seen within 1 week.    An alternative therapy for a complex fistula is an endorectal advancement  flap (figure 15). A flap with mucosa and submucosa is created to include  the internal opening (figure 16). T e dissection is carried far enough  proximal until the flap can be advanced distally without tension. T e inter-  nal opening is excised, and then the flap is matured to the intersphincteric  eroove (figure 17). T e external sphincter may be plicated to close the fis-  tula opening and then the flap is sutured to the intersphincteric groove with  interrupted absorbable sutures (figure 17). T is ef ectively treats a com-  plex fistula-in-ano with minimal risk of injury to the sphincter muscles.    INDICATIONS Fissure in ano is a common painful condition that can be  found in children and adults alike. T ese wounds usually heal spontaneously  in children but may require operative correction in adults. It is usually caused  by constipation or a large traumatic bowel movement, and it 1s almost always  located posterior. T e fissure, which runs between the dentate line and anal  verge, if deep enough exposes the internal sphincter muscle. T is causes  considerable spasm and pain. Chronic fissures may be associated with a  hypertrophied anal papilla and a skin tag. Over a period of time, the internal    sphincter muscle hypertrophies, becoming more ef ective in keeping the  wound open, and preventing spontaneous closure of the fissure. Topical  salves and fiber are usually ef ective early on. Once the wound becomes  chronic, surgical repair is usually necessary.    PREOPERATIVE PREPARATION No preoperative preparation is neces-  sary. T e cleaning enema, which is such an excruciating procedure to the  patient, is omitted.    OPERATIVE PREPARATION T e field is prepared with local antiseptic  solution. No attempt is made to dilate the canal and irrigate the rectum.    DETAILS OF PROCEDURE T e patient is placed in the position as shown  and prepped and draped in the usual fashion. T e prone jackknife posi-  tion may be used. A Hill-Ferguson retractor 1s placed in the anal canal,  and the anal canal is inspected. T e fissure is usually posterior and may be  associated with a right posterior hemorrhoid (figure 18). T e fissure and  the hemorrhoid, if necessary (figure 19), are excised and the anal mucosa  and anoderm closed with a running 2-0 chromic suture (figure 20). A  lateral internal sphincterotomy is performed to reduce sphincter spasm. A  separate incision is then made in the left lateral position, again excising  the hemorrhoid in that location if necessary, to expose the hypertrophied  internal sphincter muscle. A partial lateral internal sphincterotomy is done  in this position. T 1s wound 1s closed with a running 2-0 chromic stitch.   T e procedure may be done as a closed technique. With the finger in  the anal canal, an 1I-blade is inserted into the intersphincteric plane stay-  ing below the dentate line (figure 21). T e blade is then moved medi-  ally, dividing the inferior one-third to one-half of the internal sphincter  (figure 22).   An open technique may be done. A skin incision is made (figure 23).A  hypertrophied band of internal sphincter is freed and elevated (figure 24).  T e internal sphincter is then partially divided (figure 25). T e wound  is left open. T e sphincterotomy is done in the lateral position to avoid  creating a keyhole deformity, a complication of the procedure that can be  challenging to correct. T is procedure removes the chronic fissure in ano  and releases the tension on the anal canal sufficiently enough to allow the  fissure to heal.    POSTOPERATIVE CARE Patients are allowed out of bed and encouraged  to move their bowels as soon as possible after operation. Sitz baths can be an  ef ective method of pain control. T e patient should be kept under weekly  observation after discharge until healing is complete. m    INDICATIONS Pilonidal cysts and sinuses should be completely excised or  exteriorized (figure la and b). Acutely infected sinuses should be incised  and drained, followed later by complete excision after the acute infection  subsides. T e more limited procedure of exteriorization (marsupialization )  is effective when the sinus tract is well defined (figure lb). Regardless of  the various surgical approaches, such lesions may recur.    PREOPERATIVE PREPARATION In complicated sinuses with several  tracts present, a dye such as methylene blue may be injected for better iden-  tification, although if a careful dissection is carried out in a bloodless field,  the surgeon can identify the sinus tracts. It 1s important that this be done  several days before the operation to avoid excessive staining of the opera-  tive area, which may occur if the injection is done at the time of operation.    ANESTHESIA Light general anesthesia is satisfactory. T e patient’ posi-  tion requires that special care be taken to maintain an unobstructed airway.  Spinal anesthesia should not be used in the presence of infection near the  site of lumbar puncture.    POSITION T e patient is placed on his or her abdomen with the hips  elevated and the table broken in the middle (figure 2).    OPERATIVE PREPARATION Two strips of adhesive tape are anchored  snugly and symmetrically about 10 cm from the midline at the level of the  sinus and pulled down and fastened beneath the table (figure 3). T 1s  spreads the intergluteal fold for better visualization of the operative area.  A routine skin preparation follows after the skin is carefully shaved.    DETAILS OF PROCEDURE An ovoid incision is made around the opening  ofthe sinus tract offthe midline about lcm away from either side (figur e 4).  Firm pressure and outward pull make the skin taut and control bleeding.   An Allis forceps is placed at the upper angle of the skin to be removed,  and the sinus is cut out en bloc (figure 5). T e subcutaneous tissue is  excised downward and laterally to the fascia underneath. Great care is exer-  cised to protect this fascia from the incision, as it offers the only defense  against deeper spread of infection (figure 6). Small, pointed hemostats  should be used to clamp the bleeding vessels in order that the smallest  amount of tissue reaction be incurred. Electrocoagulation may be used  to control bleeding and to keep the amount of buried suture material to a  minimum. Some prefer to avoid burying any suture material by using com-  pression or electrocoagulation to control all the bleeding points. Extreme  care should be taken in the dissection of the lower end of the incision, as  many small, troublesome vessels are encountered frequently that tend to  retract when divided. After careful inspection of the wound to make sure  that all sinus tracts have been removed, the subcutaneous fat is undercut  at its junction with the underlying fascia (figure 7). T is undercutting  should extend only far enough to allow approximation of the edges without  tension (figure 8).    CLOSURE After all bleeding points are controlled, the wound should be  thoroughly washed with saline. T e chances for primary healing are greatly  enhanced if the field is absolutely dry. If unexpected infection has been  encountered, the wound should be packed open. In uncomplicated sinuses,  the wound is closed after all bleeding is controlled. T e closure should be  off the midline. Rather than bury sutures, the skin can be closed and the  dead space eliminated by a series of interrupted vertical mattress sutures  (figure 9). T e suture is introduced | cm or a little more than the margins  of the wound to include the full thickness of the mobilized f ap of skin and  subcutaneous tissue. A second bite includes the fascia in the bottom of the  wound (figure 9). T esutureis then continued deep into the opposite f ap.  T e suture is directed back to the original side as it passes back through the  skin margins (figure 10). When tied, this obliterates the dead space and  accurately approximates the skin margins (figure Il). T e sutures should  be placed at intervals of not more than | cm. Skin approximation must be  very accurate, since even a small overlap may be surprisingly slow to heal  in this area. A pressure dressing is applied with great care, and the sutures  are allowed to remain in place for 10 to 14 days.    EXTERIORIZATION When the sinus appears small and in the presence  of recurrence, a probe may be inserted into the sinus, and the skin and  subcutaneous tissue divided (figure la). T e entire sinus, including any  tributaries, must be laid wide open and all granulation tissue wiped away  repeatedly with sterile gauze or a curette. T e thick lining of the sinus  forms the bottom of the wound. A wedge of subcutaneous tissue is excised  to facilitate the sewing of the mobilized skin margins to the thick wall of  the retained sinus. T is ensures a cavity that can be dressed easily with a  minimum of drainage as well as discomfort to the patient. T e raw mar-  gins of the wound are held apart by a gauze pack until healing is complete  (figure lb). T 1s method has the advantage of being a procedure of less  magnitude than complete excision. T e period of hospitalization and reha-  bilitation is shortened and insurance against recurrence enhanced.    POSTOPERATIVE CARE Complete immobilization of the area and pro-  tection against contamination are essential. Early ambulation is advisable,  but sitting upon the incision in a hard chair is not. T e patient should be  encouraged always to sit on a cushion or to sit to the side on one buttock or  the other. T e diet is restricted to clear liquids for several days, followed by  a low-residue diet to decrease the chances of contamination from a bowel  movement. When the sinus is packed open or exteriorized, the patient is not  immobilized. Regardless of the method used, frequent and repeated dress-  ings are indicated to avoid possible early bridging of the skin with recur-  rence and prolonged discomfort and disability. T e importance of keeping  all hair removed from the intergluteal fold until healing is complete cannot  be overemphasized. Depilatory agents may be used several times per month  provided that pretesting for sensitivity to the agent has been negative. m    INDICATIONS Cholecystectomy is indicated in symptomatic patients with  proven disease of the gallbladder, and the indications for laparoscopic chole-  cystectomy are essentially the same as those for open cholecystectomy. T ese  include, but are not limited to, symptomatic cholelithiasis, acute calculus  and acalculous cholecystitis, gallstone pancreatitis, biliary dyskinesia, and  gallbladder masses and polyps that are concerning for malignancies. Chole-  cystectomy for mild gallstone pancreatitis should be performed during the  initial admission for pancreatitis and deferred for several weeks in patients  with severe pancreatitis. Contraindications include small bowel obstruction  secondary to gallstone ileus, coagulopathy, and medical comorbidities pro-  hibiting surgery. Relative contraindications are decreasing as the minimally  invasive surgical experience of surgeons’ increases. Factors associated with  increased surgical risk include cirrhosis with portal hypertension, previous  intra-abdominal surgery with adhesions, and acute gangrenous cholecystitis.    PREOPERATIVE PREPARATION Following a history and physical exami-  nation, the diagnosis of biliary disease is typically documented with ultra-  sound examination of the right upper quadrant. T e remainder of the  gastrointestinal tract may require additional studies. A chest x-ray and elec-  trocardiogram may be performed as indicated. Routine laboratory blood  tests are obtained and should include a liver function panel. Coagulation  studies should be ordered if there is a concern for hepatic insufficiency or  other causes of coagulopathy. T e risks of laparoscopic cholecystectomy  include bleeding, infection, trocar injuries to viscera or blood vessels, and  bile duct injury. T ese should be discussed with the patient as well as the  possibility of conversion to an open procedure. T e management of patients  with gallstones and suspected common duct stones is based on risk strati-  fication. Preoperative endoscopic retrograde cholangiopancreatography  (ERCP) with sphincterotomy and stone extraction, if necessary, is indicated  in patients with jaundice and should be considered in patients with dilated  bile ducts on imaging and/or elevated liver function tests.    ANESTHESIA General anesthesia with endotracheal intubation 1s recom-  mended. Preoperative prophylactic antibiotics for anticipated bile patho-  gens are administered such that adequate tissue levels exist, although there  is evidence that there may be limited benefit for low-risk patients    POSITION As laparoscopic cholecystectomy makes extensive use of sup-  porting equipment, it is important to position this equipment such that it 1s  easily visualized by all members of the surgical team (figure 1).   T esurgeon must have a clear line of sight to both the video monitor and  the high flow CO, insufflator such that he or she can monitor both the intra-  abdominal pressure and gas flow rates. In general, all members of the team  are looking across the operating table at video monitors. T e positions of  the video monitors may require adjustment once all members step to their  final positions at operation. T e patient is placed supine with the arms either  secured at the sides or out at right angles so as to allow maximum access to  monitoring devices by the anesthesiologist at the head of the table. An orogas-  tric tube 1s passed after the patient is asleep. Sequential pneumatic compres-  sion stockings should be placed for deep vein thrombosis (DVT) prophylaxis.  T e dispersive electrode (electrocautery grounding pad) is placed near the  hip, avoiding any region where internal metal orthopedic parts or electronic  devices may have been implanted. T e possible need for fluoroscopic exami-  nation of the abdomen in the event that an intraoperative cholangiogram 1s  performed should be considered when positioning the bed and patient. T e  legs, arms, and upper chest are covered with blankets to minimize heat loss.    OPERATIVE PREPARATION T e skin of the entire abdomen and lower  anterior chest is prepared in the routine manner.    INCISION AND EXPOSURE T e abdomen is palpated to find the liver  edge or unsuspected intra-abdominal masses. T e patient is placed in a  mild Trendelenburg position and an appropriate site for the creation of the  pneumoperitoneum is chosen. T e initial port may be placed by an open,  or Hasson, technique and this is generally preferred. Alternatively, a Veress  needle technique may be used. T ese techniques are described in Chapters  lland 12.    DETAILS OF THE PROCEDURE Topical antifog solution is applied to the  optical end of the telescope, which may be either angled (30 degrees) or flat  (0 degrees) (figure 2). T e CO, source is attached to the port, and the vid-  eoscope is inserted after white-balancing and focusing the system. A gen-  eral examination of the intra-abdominal organs is performed taking special  note of any organ pathology or adhesions. T e finding of any trocar-related  injuries to intra-abdominal viscera or blood vessels requires an immediate  repair using advanced laparoscopic techniques or more commonly open  laparotomy.   T ree additional trocar ports are placed, using direct visualization  of their sites of intra-abdominal penetration. T e second 10-mm trocar  port is placed in the epigastrium about 1-2 cm below the xiphoid, with  its intra-abdominal entrance site being just to the right of the falciform  ligament (figure 3). Some surgeons use a 5-mm port at this site. Two  smaller 5-mm trocar ports for instruments are then placed: one in the  right upper quadrant near the midclavicular line, several centimeters  below the costal margin and another quite laterally at almost the level of  the umbilicus. T ese sites may be varied according to the anatomy of the  patient and the experience of the surgeon. T e patient is placed in a mild  (10—15 degrees) reverse Trendelenburg position with slight rotation of the  patient slightly to the left (right side up) for optimal visualization of the  gallbladder region.   T e apex of the gallbladder fundus is grasped with a ratcheted forceps  (A) through the lateral port. T e gallbladder and liver are then lifted supe-  riorly (figure 4). T is maneuver provides good exposure of the undersur-  face of the liver and gallbladder. Omental or other loose adhesions to the  gallbladder are gently teased away by the surgeon (figure 5).   T einfundibulum ofthe gallbladder is grasped with forceps (B) through  the middle port. Lateral traction with the middle forceps exposes the region  of the cystic duct and artery. Dissecting forceps or hook cautery (C) are  used by the surgeon through the subxiphoid port to open the peritoneum  over the presumed junction of the gallbladder and cystic duct (figure 6).  With gentle teasing and spreading motions, the cystic duct and artery are  exposed (figure 6). Each structure is exposed circumferentially. If pos-  sible, both structures are dissected free and identified prior to clipping and  division. To minimize bile duct injury the concept of the “critical view of  safety’ is helpful. In this technique, the neck of the gallbladder must be  dissected of the liver bed (1.e., unfolding Calot’s triangle) to achieve con-  clusive identification of the two structures to be divided: the cystic duct and  cystic artery. In the classic view the liver is seen posterior to Calot’s triangle  (figure 7). Division of the peritoneum to the right of the infundibulum  and cystic duct can be helpful for the initial dissection and minimizes the  use of blind dissection closer to the area of the common bile duct.   T e window may be verified and elongated by sweeping back and forth  through the space with an instrument (figure 7). If the dissection is dif-  ficult because of inflammatory swelling and scarring, the surgeon should  consider conversion to an open procedure. Whenever there is concern  about unclear anatomy, there should be consideration for intraoperative  cholangiography or conversion to an open procedure.    DETAILS OF THE PROCEDURE T ecystic artery is cleared for  a l-cm zone and its path followed onto the surface of the gallbladder. T eclear  zone is then secured with metal clips both proximally and distally (figur e 8).  T ecystic artery may be divided with endoscopic scissors. T e cystic duct is  also cleared for about 2 cm or so such that the surgeon can clearly identify  its continuity with the gallbladder and achieve the critical view of safety. A  metal clip is applied as high as possible on the cystic duct where it begins  to dilate and form the gallbladder. (figure 9) If no cholangiogram is to be  performed, then two clips are placed on the proximal cystic duct and the  duct is divided. If a cholangiogram is to be performed, the surgeon should  be certain that all the equipment is available. T is includes a catheter of  choice, two syringes (one for saline and one for contrast), a stopcock for  the syringes, and extension tubing. All of the air must be emptied from  the tubing prior to performing the cholangiogram. In preparation for  insertion of the cholangiogram catheter, the cystic duct is opened and bile  is noted (figure 10). If necessary, the opening may be dilated with the  scissor tips. T e cholangiogram catheter of choice is passed through the  middle port or through a 14-guage angiocath inserted into the abdominal  wall between the midclavicular trocar and that in the anterior axillary line.  T e duct is cannulated and the catheter secured (figure 10). Some cath-  eters are secured within a winged clamp, whereas others rely on an inflated  intraluminal Fogarty-like balloon. A simple straight plastic catheter such  as a 4 French ureteral catheter may be secured with a gently applied metal  clip over the lower cystic duct containing the catheter. T is should be snug  enough to prevent leakage but loose enough to avoid crimping the catheter  and preventing dye injection. In preparation for the cholangiogram, the    videoscope and metal instruments are removed. T e radiolucent ports are  aligned in a vertical axis so as to minimize their appearance on the x-ray.  T e field is covered with a sterile towel and the x-ray equipment positioned.  Simple dye injections under fluoroscopy are performed. T e principal ducts  are visualized in order to ensure anatomic integrity, the absence of duc-  tal stones, and flow into the duodenum. Upon completion of a satisfactory  cholangiogram, the lower cystic duct is doubly clipped and the cystic duct  divided with endoscopic scissors (figure 11). In the event that an abnor-  mal or confusing cholangiogram is obtained, the surgeon should convert to  an open procedure with full anatomic verification. If choledocholithiasis is  identified, the surgeon may choose to perform laparoscopic common bile  duct exploration or to complete the cholecystectomy and plan for a post-  operative ERCP.   T ecystic duct—gallbladder junction is grasped with forceps through the  middle port and the gallbladder is removed from its bed beginning infer1-  orly and carrying the dissection up the gallbladder fossa. Most surgeons  score the lateral peritoneum for a centimeter or so with electrocautery  (figure 12) and then elevate the gallbladder from the liver bed. Appropri-  ate traction, often to the sides, is required to provide exposure of the zone  of dissection with an electrocautery instrument between the gallbladder  and its bed (figure 13). Vigorous traction with the forceps or dissection  into the gallbladder wall may produce an opening with spillage of bile and  stones. Such openings should be secured if possible using forceps, metal  clips, or a suture loop, which is first placed over the forceps and then closed  like a lasso over the hole and the adjacent gallbladder wall that 1s tented up  by the forceps.    DETAILS OF THE PROCEDURE As the dissection proceeds  well up the gallbladder bed, it may be necessary for the first assistant to  actively position and reposition the two forceps on the gallbladder so as to  provide good exposure for the surgeon. When the dissection is almost com-  plete and traction on the gallbladder still allows superior displacement of the  liver with a clear view of the gallbladder bed and operative site, the surgeon  should reinspect the clips on the cystic duct and artery for their security  and the liver bed for any bleeding sites. T e region is irrigated with saline  (figure 14) and the diluted bile and blood are aspirated from the lateral  gutter just over the edge of the liver. T e final peritoneal attachments of  the gallbladder are divided from the liver and the gallbladder is positioned  above the liver, which has now fallen back inferiorly to its normal position.   T e videoscope is removed from the umbilical port and inserted in the  epigastric one. If a 5-mm port was used at the subxiphoid site in order to  reduce the incidence of incisional hernia, then a 5-mm laparoscope is sub-  stituted for the 10-mm scope. Consideration should be given to contain  the gallbladder in a laparoscopic retrieval bag prior to removal, especially  if there is a concern for malignancy, infection, or if spillage has occurred.  A grasping forceps is passed through the umbilical port so as to pick up  the end of the specimen in the region of the cystic duct or the specimen  retrieval bag (figure 15). T is exchange may be somewhat disorienting to  the surgeon and first assistant as left and right are now reversed in a mirror-  image manner on the monitor screens. If the gallbladder stones are small,  one is usually able to withdraw the gallbladder, forceps, and umbilical port  back out to the level of the skin where the gallbladder is grasped with a  Kelly clamp (figure 16). Bile and small stones may be easily aspirated  whereupon the gallbladder will exit easily through the umbilical site under    direct vision of the videoscope in the epigastric port. Extraction of large  stones or many medium-sized stones may require crushing prior to extrac-  tion (figure 17) or require that the linea alba opening be enlarged. After  extraction, the umbilical site is temporarily occluded with the assistant’  gloved finger so as to maintain the pneumoperitoneum. Alternatively, the  gallbladder may be removed through the 10-mm subxiphoid port.   After removal of the gallbladder and final inspection of the abdomen, all  ports are removed and the sites closely inspected for bleeding. T e video-  scope is removed and the pneumoperitoneum is evacuated so as to lessen  postoperative discomfort. Placement of peritoneal drains may be consid-  ered if there was considerable inflammation, bleeding, a wide cystic duct,  or common bile ducts stones identified on intraoperative cholangiography.    CLOSURE T e operative sites may be infiltrated with a long-acting local  anesthetic (bupivacaine) (figure 18), and the fascia at the 10-mm port sites  is sutured with one or two absorbable size 0 sutures (figure 19). T e skin  is approximated with absorbable subcuticular sutures. Adhesive skin strips  and dry sterile dressings are applied.    POSTOPERATIVECARE T e orogastric tube is removed in the operating  room prior to emergence from general anesthesia. Pain at the operative  site is usually well controlled with oral medications. Although patients  have some transient nausea, most are able to take oral liquids soon after  surgery and may be discharged to home on the day of surgery. Follow-  up by the surgeon is important, as biliary injuries are often occult and  delayed in presentation. Prolonged or new, unexpected pain should be  evaluated with physical examination, laboratory tests, and appropriate  imaging studies. =    INDICATIONS Cholecystectomy is indicated in patients with proven dis-  eases of the gallbladder that produce symptoms. T e incidental finding of  gallstones by imaging studies, or a history of vague indigestion, is insuffi-  cient evidence for operation in itself and does not justify the risk involved,  particularly in the elderly. Today, most patients have laparoscopic removal  of their gallbladder. T e procedure described here is called “open” and is  most commonly performed at a conversion to open when the initial laparo-  scopic approach encounters complex technical events (swollen, gangrenous  gallbladder, confusing anatomy, or abnormal cholangiograms, etc.) or major  complications (ductal, blood vessel, or bowel injury) that are best treated  with open exposure. Although open cholecystectomy is no longer the pri-  mary operation of choice, its mastery is essential for surgeons who perform  laparoscopic cholecystectomy. A safe surgeon knows when it is appropriate  to convert to an open operation, and does risk endangering the safety of the  patient in order to complete the procedure laparoscopically at all costs.    PREOPERATIVE PREPARATION Following a history and physical exami-  nation, the diagnosis of biliary disease is typically documented with ultra-  sound examination of the right upper quadrant. T e remainder of the  gastrointestinal tract may require additional studies. A chest x-ray and elec-  trocardiogram may be performed as indicated. Routine laboratory blood  tests are obtained and should include a liver function panel. Coagulation  studies should be ordered if there is a concern for hepatic insufficiency or  other causes of coagulopathy. T e risks of cholecystectomy include bleed-  ing, infection, visceral injuries, and bile duct injury.    ANESTHESIA. General anesthesia with endotracheal intubation 1s recom-  mended. Deep anesthesia is avoided by the use of a suitable muscle relaxant.  In those patients suffering from extensive liver damage, barbiturates as well  as other anesthetic agents suspected of hepatotoxicity should be avoided.  In elderly or debilitated patients, local infiltration anesthesia 1s satisfactory,  although some type of analgesia is usually necessary as a supplement at  certain stages of the procedure.    POSITION T e proper position of the patient on the operating table is  essential to secure sufficient exposure (figure 1). Arrangements should be  made for an operative cholangiogram in the event that one is necessary. A  fluoroscopic C-arm requires sufficient space to be centered under the patient  to ensure coverage of the liver, duodenum, and head of the pancreas. T e  exposure can be enhanced by tilting the table until the body as a whole is in  a semi-erect position. T e weight of the liver then tends to lower the gall-  bladder below the costal margin. Retraction is also aided in this position,  because the intestines have a tendency to fall away from the site of operation.    OPERATIVE PREPARATION T e skin is prepared in the routine manner.  Patients are administered appropriate prophylactic antibiotics prior to the  time of incision. T e use of prophylactic antibiotics appears to be more  efficacious in patients undergoing open cholecystectomy as compared to  laparoscopic surgery, particularly for low-risk patients.    INCISION AND EXPOSURE Two incisions are commonly used: the  vertical high midline and the oblique subcostal (figure 2). A midline    incision is used if other pathology, such as hiatus hernia or duodenal  ulcer, requires surgical consideration. Benefits of the subcostal incision  include good exposure, minimal early postoperative wound discomfort,  and decreased risk of incisional hernia. T e choice of incision is based  on surgeon preference and experience. Af er the incision is made, the  details of the procedure are identical, irrespective of the type of incision  employed.    DETAILS OF PROCEDURE Af er the peritoneal cavity has been opened,  the gloved hand, moistened with warm saline solution, is used to explore  the abdominal cavity, unless there is an acute suppurative infection  involving the gallbladder. T e stomach and duodenum are inspected and  palpated. A general abdominal exploration is performed. T e surgeon  next passes the right hand up over the dome of the liver, allowing air  between the diaphragm and liver to aid in displacing the liver downward  (figure 3).   An external ring self-retaining retractor with adjustable retracting blades  (such as a Bookwalter type) may be used advantageously. A half-length  clamp is applied to the falciform ligament and another to the fundus of the  gallbladder (figure 4). Most surgeons prefer to divide the falciform liga-  ment between half-length clamps, and both ends should be ligated; other-  wise, active arterial bleeding will result. Downward traction is maintained  by the clamps on the fundus of the gallbladder and on the round ligament.  T is traction is exaggerated with each inspiration as the liver is projected  downward (figure 4). Afer the liver has been pulled downward as far as  easy traction allows, the half-length clamps are pulled toward the costal  margin to present the undersurfaces of the liver and gallbladder (figur e 5).  An assistant then holds these clamps while the surgeon prepares to wall off  the field. If the gallbladder is acutely inflamed and distended, it is desirable  to aspirate some of the contents through a trocar before the half-length  clamp is applied to the fundus; otherwise, small stones may be forced into  the cystic and common ducts. Adhesions between the undersurface of the  gallbladder and adjacent structures are frequently found, drawing the duo-  denum or transverse colon up into the region of the ampulla. Adequate  exposure is maintained by the assistant, who exerts downward traction  with a warm, moist sponge. T e adhesions are divided with curved scis-  sors or electrical energy until an avascular cleavage plane can be developed  adjacent to the wall of the gallbladder (figure 6). Af er the initial incision  is made, it is usually possible to brush these adhesions away with gauze  sponges held in thumb forceps (figure 7). Once the gallbladder is freed  of its adhesions, it can be lif ed upward to afford better exposure. In order  that the adjacent structures may be packed away with moist gauze pads,  the surgeon inserts the lef hand into the wound, palm down, to direct the  gauze pads downward. T e pads are introduced with long, smooth forceps.  T e stomach and transverse colon are packed away, and a final gauze pack  is inserted into the region of the foramen of Winslow (figure 8).T e gauze  pads are held in position either with a retractor or by the lef hand of the  first assistant, who, with fingers slightly flexed and spread apart, maintains  moderate downward and slightly outward pressure, better defining the  region of the gastrohepatic ligament.    DETAILS OF PROCEDURE Af er the field has been adequately  walled off, the surgeon introduces the lef index finger into the foramen of  Winslow and, with finger and thumb, thoroughly palpates the region for  evidence of calculi in the common duct as well as for thickening of the head  of the pancreas. A half-length clamp, with the concavity turned upward, 1s  used to grasp the undersurface of the gallbladder to attain traction toward  the operator (figure 9). T e early application of clamps in the region of  the neck of the gallbladder is one of the frequent causes of accidental injury  to the common duct. T 1s is especially true when the gallbladder 1s acutely  distended, because the neck of the gallbladder may run parallel to the com-  mon duct for a considerable distance. If the clamp is applied blindly where  the neck of the gallbladder passes into the cystic duct, part or all of the com-  mon duct may be accidentally included in it (figure 10). For this reason  it is always advisable to apply the half-length clamp well up on the under-  surface of the gallbladder before any attempt is made to visualize the region  of the neck of the gallbladder. T e enucleation of the gallbladder is started  by dividing the peritoneum on the inferior aspect of the gallbladder and  extending it downward to the region of the neck. T e peritoneum usually  is divided with electrocautery or long Metzenbaum dissecting scissors. T e  incision 1s carefully extended downward toward hepatoduodenal ligament  (figures ll and 12). By means of blunt gauze dissection, the region of the  neck is freed down to the region of the cystic duct (figure 13). Afer the  neck of the gallbladder has been clearly defined, the clamp on the undersur-  face of the gallbladder is reapplied lower to the region of the infundibulum  or neck.   With traction maintained on the infundibulum, the cystic duct is defined  by means of blunt dissection (figure 13). A long right-angle clamp is then  passed behind the cystic duct. T e jaws of the clamp are separated cau-  tiously as counter-pressure 1s placed on the upper side of the lower end of  the gallbladder by the surgeon’ index finger. Slowly and with great care, the    cystic duct is isolated from the common duct (figure 14). T ecystic artery  is likewise isolated with a long right-angle clamp. If the upward traction on  the gallbladder is marked, and the common duct is quite flexible, it is not  uncommon to have it angulate sharply upward, giving the appearance of a  prolonged cystic duct. Under such circumstances, injury to the common  duct or its division may result when the right-angle clamp is applied to what  is thought to be the cystic duct (figure 15 and inset). Such a disaster may  occur when the exposure appears too easy in a thin patient because of the  extreme laxity of the common duct.   Af er the cystic duct has been isolated, it is thoroughly palpated to ascer-  tain that no calculi have been forced into it or the common duct by the appli-  cation of clamps, and that none will be overlooked in the stump of the cystic  duct. T e size of the cystic duct is carefully noted before the right-angle clamp  is applied. Intraoperative cholangiography may be performed routinely or  selectively and 1s performed through the cystic duct af er it has been divided.  Because it is more difficult to divide the cystic duct between two closely  applied right-angle clamps, a curved half-length clamp is placed adjacent to  the initial right-angle clamp. T e curvature of the half-length clamp makes  it ideally suited for directing the scissors downward during the division of  the cystic duct (figure 16). Whenever possible, unless occluded by severe  inflammation, the cystic duct and cystic artery are isolated separately to per-  mit individual ligation. Under no circumstances should a right-angle clamp  be applied to the presumed region of the cystic duct in the hope that both the  cystic artery and duct be included in one mass ligature. It 1s surprising how  much additional cystic duct can of en be developed by maintaining traction  on the duct as blunt gauze dissection is carried out. Af er the cholangiogram,  the cystic duct is ligated with a transfixing suture (figure 17) or ligature,  being sure not to encroach on the common duct. In general, the free length  beyond the tie should approximate the diameter of the duct or vessel. It may  be helpful to reinforce suture ligatures with metal hemoclips.    DETAILS OF PROCEDURE If the cystic artery was not divided  before the cystic duct, it is now carefully isolated by a right-angle clamp simi-  lar to those used in isolating the cystic duct (figure 18). T e cystic artery  should be isolated as far away from the region of the hepatic duct as possible.  A clamp is never applied blindly to this region, lest the hepatic artery lie in an  anomalous location and be clamped and divided (figure 19). Anomalies of  the blood supply in this region are so common that this possibility must be  considered in every case. T e cystic artery is divided between clamps similar  to those utilized in the division of the cystic duct (figure 20). T e cystic  artery should be tied as soon as it has been divided to avoid possible difficul-  ties while the gallbladder is being removed (figure 21). Again, the use of  reinforcing metal hemoclips may be useful. If desired, the ligation of the cys-  tic duct can be delayed until af er the cystic artery has been ligated. Some pre-  fer to ligate the cystic artery routinely and leave the cystic duct intact until the  gallbladder is completely freed from the liver bed. T is approach minimizes  possible injury to the ductal system as complete exposure 1s obtained before  the cystic duct is divided. If the clamp or tie on the cystic artery slips off,  resulting in vigorous bleeding, the hepatic artery may be compressed in the  gastrohepatic ligament (Pringle maneuver) by the thumb and index finger  of the lef hand, temporarily controlling the bleeding (figure 22). T e field  can be dried with suction by the assistant, and, as the surgeon releases com-  pression of the hepatic artery, a hemostat may be applied safely and exactly  to the bleeding point. T e stumps of the cystic artery and cystic duct are each  inspected thoroughly and, before the operation proceeds, the common duct  is again visualized to make certain that it is not angulated or otherwise dis-  turbed. Blind clamping in a bloody field is all too frequently responsible for  injury to the ducts, producing the complication of stricture. Classic anatomic  relationships in this area should never be taken for granted, since normal vari-  ations are more common in this critical zone than anywhere else in the body.  Af er the cystic duct and artery have been tied, removal of the gallblad-  der is begun. T e incision, initially made on the inferior surface of the  gallbladder about 1cm from the liver edge, is extended upward around the  fundus (figure 23). With the lef hand, the surgeon holds the clamps that  have been applied to the gallbladder and, using electrocautery, divides the  loose areolar tissue between the gallbladder and the liver. T is allows the  gallbladder to be dissected from its bed without dividing any sizable vessels.  An operative cholangiogram (figure 24) may be performed to identify    common bile duct stones or confirm the biliary anatomy. Syringes of saline-  diluted contrast media should be connected by a three-way adapter in a  closed system to avoid the introduction of air into the ducts. T e cholangio-  gram catheter is filled with saline and it is introduced a short distance into  the cystic duct. T e tube is secured in the cystic duct with a tie or clip. All  gauze packs, clamps, and retractors are removed as the table is returned  to a level position by the anesthesiologist. Five milliliters diluted water-  soluble of contrast media are injected under fluoroscopic visualization.  Limited amounts of a dilute solution prevent the obliteration of any small  calculi within the ducts. A second injection of 15to 20 mLis made to outline  the ductal system completely and to ensure patency of the ampulla of Vater.  T e tube should be displaced laterally and the duodenum gently pushed  to the right to ensure a clear image without interference from the skeletal  system or the tube filled with contrast media. If no further studies are war-  ranted, the tube is removed and the cystic duct is ligated. If the cystic duct  cannot be used for the cholangiogram, a fine gauge needle, such as a but-  terfly, can be inserted into the common duct (figure 25). T e metal needle  may be bent anteriorly as shown in the lateral view inset to facilitate its  placement. T e puncture site in the common duct 1s oversewn with a 0000  absorbable suture and some surgeons place a closed suction Silastic suction  drain (Jackson—Pratt) in Morrison’ pouch. A common bile duct explora-  tion should be performed in all patients found to have choledocholithiasis  on intraoperative cholangiography at the time of open cholecystectomy.   T e portal vessel area and the gallbladder bed are inspected for hemo-  stasis. Culture of the gallbladder bile is performed in cases where there is a  concern for infection.    CLOSURE For a right subcostal incision, the fascia is closed in two layers  using running, slowly absorbable, monofilament suture. T e skin may be  sutured or clipped closed. Most surgeons do not use drains when the field  is dry and there is no evidence of leakage from accessory ducts.    POSTOPERATIVE CARE A nasogastric tube may be beneficial for a day or  two if significant infection, ileus, or debility is present. Perioperative anti-  biotics should be discontinued within 24 hours unless the patient has an  infection that requires treatment. Coughing and ambulation are encouraged  immediately. T e diet is advanced to as tolerated, and intravenous fluids are  continued until the patient is tolerating adequate oral intake. m=    INDICATIONS Common bile duct exploration should be performed in all  patients with common bile duct stones who have either failed, or are not  candidates for, endoscopic therapy and who do not have medical conditions  that prohibit surgical intervention. Alternative therapies, such as extracor-  poreal shockwave lithotripsy and dissolving solutions, are not widely avail-  able and have limited efficacy. Percutaneous transhepatic cholangiography  (PTHC), electrohydraulic lithotripsy, and laser lithotripsy may be useful  in a small number of selected patients who are not candidates for surgery  or endoscopic therapy. Laparoscopic common bile duct exploration, open  common bile duct exploration, and postoperative ERCP with stone removal  are all options for the treatment of common bile duct stones identified by  intraoperative cholangiography and decision making should be guided by  patient-specific considerations, training and experience of the surgeon, and  available endoscopic expertise.   Open common bile duct exploration remains an important technique  and should be part of every gastrointestinal surgeon’ armamentarium for  treating hepatobiliary diseases. Open common bile duct exploration may  be performed in patients requiring open cholecystectomy, for patients who  have failed or suffered complications from laparoscopic common bile duct  exploration, and in circumstances where necessary equipment, experience,  and/or resources are limited. figure | depicts schematically the more com-  mon locations of calculi.    PREOPERATIVE PREPARATION In the past, significant time was spent  improving hepatic function, as it was believed that anesthesia and surgery were  very hazardous in the presence of significant jaundice. Obviously, any coagu-  lopathy must be corrected with vitamin K and blood products, while antibiotics  should be given for sepsis or cholangitis. PTHC with retrograde catheter place-  ment for decompression has been largely replaced by endoscopic retrograde  cholangiopancreatography (ERCP) with sphincterotomy. T is allows stone  extraction or stent placement to relieve the obstruction. Appropriate preop-  erative studies should be obtained (labs, chest x-ray, EKG) as indicated. T e  patient should be well hydrated and any electrolyte imbalances corrected.    ANESTHESIA General anesthesia with endotracheal intubation is recom-  mended. Anesthetic agents suspected of hepatotoxicity should be avoided.  Blood is promptly replaced as it is lost so as to avoid the development of  hypotension.    OPERATIVE PREPARATION T e skin is prepared in the routine manner.  Patients are administered appropriate prophylactic antibiotics prior to the  time of incision.    INCISION AND EXPOSURE T e abdomen is most commonly opened  through a right upper quadrant subcostal incision, although a midline  approach is acceptable as well. T e use of self-retaining retractors greatly  facilitates visualization. T e proximal cystic duct should be ligated to pre-  vent gallstones from migrating from the gallbladder into the cystic duct and  common bile duct. T e liver should be retracted superiorly, the duodenum  retracted inferiorly, and the stomach retracted to the left.    DETAILS OF PROCEDURE Dissection is carried out on the antero-  lateral common bile duct. T e peritoneum overlying the common bile    duct in the hepatoduodenal ligament is incised distal to the cystic duct  (figure 2). Aspiration of the common duct for bile may be performed  in order to confirm the anatomy and to prevent inadvertent vascular  injury (figure 3). 4-0 monofilament, absorbable stay sutures are placed  on the common bile duct just above the level of the duodenum and the  duct is opened longitudinally with a scalpel, preserving the lateral blood  supply (figure 4). Traction on these sutures can facilitate visualization  of the duct contents and instrumentation of the duct (figure 5). Te  choledochotomy can then be extended with Potts scissors to a length  of approximately 15 cm. Stones can initially be extracted using a stone  scoop or forceps gently inserted into the common bile duct. If this is  not possible, balloon extraction can be performed with biliary Fogarty  catheters, clearing the proximal duct before the distal duct. T ese cath-  eters are less traumatic than metal forceps and may be preferred. Saline  irrigation can facilitate the removal of fragmented debris by fushing  (figures 6 and 7). Choledochoscopy with wire basket retrieval can be  employed in the unlikely event that balloon extraction is unsuccessful.  A 14-F or larger T-tube should be placed and secured using interrupted  4-0 monofilament, absorbable sutures (figures 8 and 9). T e suture line  is tested by injecting saline through the T-tube (figure 10). Completion  T-tube cholangiography should always be performed prior to closure in  order to confirm duct clearance and to rule out bile leaks. Transduodenal  sphincteroplasty or choledochoduodenostomy may be performed for dis-  tally impacted stones and failures of open common bile duct exploration  (CBDE). In the postoperative period a retained stone may be amendable  to percutaneous extraction through a mature T-tube tract.    CLOSURE T e closure of the gallbladder bed may be accomplished as  shown (figure Il) but is usually unnecessary. A closed-system suction  catheter made of Silastic is introduced down past the foramen of Winslow  into Morison’ pouch (figure 11). T e catheter and drain are brought out  through a stab wound at a level that avoids acute angulation of either the  drain or the T-tube (see Chapter 72, figure 9). T e catheter is attached to  the skin of the abdomen with a skin suture and adhesive tape. T e abdomen  is closed in a routine manner.    POSTOPERATIVE CARE If the bile loss is excessive, sodium lactate or  bicarbonate should be added to compensate for the excessive sodium loss.  T e fuid balance is maintained by daily administration of approximately  2,000 to 3,000 mL of Ringer’ lactate solution. T e T-tube catheter is con-  nected to a drainage bag, and the amount of drainage over a 24-hour period  is recorded. In the presence of jaundice with a bleeding tendency, blood  products and vitamin K are given. T e patient is ambulated and returned to  oral intake as tolerated. In the absence of cholangitis antibiotics are discon-  tinued within 24 hours. T e T-tube should be clamped prior to discharge as  long as there are no signs of cholangitis or bile leakage. Patients should be  instructed to fush the catheter with 10 mL of sterile saline one to two times  a day. T e closed suction drain is removed in two to five days unless there  is excessive bile drainage. T e common duct catheter can be removed in  28 days provided a T-tube cholangiogram shows a normal ductal system  and no retained stones. m    DETAILS OF THE PROCEDURE Sometimes it is impossible to dislodge a  stone impacted in the ampulla of Vater by careful and repeated manipu-  lation, and a more radical procedure is necessary. Under such circum-  stances the duodenum is mobilized by the Kocher maneuver, and the  common duct is exposed throughout its course down to the duodenal  wall. An incision is made in the lateral part of the peritoneal attachment  of the duodenum, making it possible to mobilize the second portion  of the duodenum (figure 1). After the peritoneal attachment has been  incised, blunt gauze dissection is used to sweep the duodenum medially.  Occasionally, this will expose the retroduodenal portion of the common  duct and will allow more direct palpation (figure 2). A blunt metal probe  is introduced downward to the point of the obstruction, and the location  of the stone is more accurately determined by palpation. A scoop is passed  down to the region of the ampulla of the common bile duct, and its course 1s  directed carefully with the index finger and thumb of the surgeon’ left hand  (figure 3). With the tissues being held firmly by the thumb and index fin-  ger, it is usually possible to break up the impacted calculus with the scoop.  Should this prove unsuccessful, it is necessary to open the anterior duode-  nal wall and to expose Vater’s papilla (figure 4).   Since opening the duodenum tends to increase the risk of complica-  tions, it should not be considered until all indirect methods have been tried.  In fact, many surgeons will proceed directly to choledochoduoenostomy  (Chapter 73), particularly in cases where there is a dilated common bile  duct.   By exerting gentle pressure on a uterine sound or a biliary Fogarty  inserted in to the common duct, the surgeon can determine the exact loca-  tion of the papilla by palpation over the anterior wall of the duodenum. With  the duodenal wall held taut in Babcock forceps or by silk sutures, an incision  3 to 4 cm long is made over this area, parallel to the long axis of the bowel.  A transverse duodenotomy is also acceptable if the location of the ampulla  has been identified adequately and transverse closure of defect results in less  narrowing and deformity of the duodenum. T e field must be completely  walled off by gauze sponges, and constant suction must be maintained to  avoid contamination by bile and pancreatic juice. Small gauze sponges are  then introduced upward and downward within the lumen of the duodenum  to prevent further soiling. Long silk sutures are attached to each of these  gauze sponges to ensure their subsequent removal (figure 5). Even at this  point the calculus may be dislodged by direct palpation. If this 1s still 1mpos-  sible, the probe is reintroduced and directed firmly against the region of  the papilla to determine the direction of the duct, so that a small incision  may be made directly parallel to it (figure 5). T 1s incision enlarges the  papilla so that a calculus can either be expressed or be removed with fenes-  trated stone forceps (figure 6). Following this, the patency of the com-  mon duct is ascertained by introducing a small and soft red rubber catheter  (8 French) into the opening of the common duct and downward through the    papilla (figure 7). Any bleeding points from the incision into the papilla  are controlled by fine 0000 interrupted absorbable sutures (figure 8).T e  pancreatic duct must not be occluded by these sutures. No effort is made  to reconstruct the papilla to its natural size, the opening being allowed to  remain enlarged as a result of the incision. A sphincterotomy or sphinctero-  plasty can be performed through this exposure. T ese procedures involve  the pancreatic duct as well as the common duct.   T e small gauze sponges that plug the duodenum are withdrawn, and  the intestine is closed. T e bowel is closed in the opposite direction from  that in which the incision was made. T is avoids constricting the lumen of  the bowel (figure 9). T e duodenal wall is sutured with interrupted 3-0  silk sutures, starting at the angle adjacent to one of the Babcock clamps.  T e serosa may be reinforced with a layer of interrupted Halsted mattress  sutures of 00 silk (figure 10). T is closure must be watertight and secure  to avoid the complication of duodenal fistula. A T-tube catheter is intro-  duced into the common duct, and the duodenum is distended with normal  saline to make certain that there is no leakage. A No. 14-French T-tube is  then directed into the initial opening of the common duct, and the tech-  nique from this point on is observed as described in Chapter 71, figures 9,  10 and 11. Aclosed-system suction catheter made of Silastic is inserted down  past the foramen of Winslow into Morrison’ pouch in all cases and remains  there until there is no danger of duodenal fistula. It is advisable to bring the  common-duct catheter and the drain out through a stab wound lateral to  the incision (figure 1]). It 1s safest to avoid clamping the common-duct  catheter, permitting it to drain into a sterile gauze sponge until it is attached  to a drainage plastic bag. T e bile is cultured for bacterial content and anti-  microbial sensitivities.    CLOSURE T e abdomen is closed in the routine manner (see Chapter 10,  pages 34-39).    POSTOPERATIVE CARE If the bile loss is excessive, sodium lactate or  bicarbonate should be added to compensate for the excessive sodium loss.  T e fuid balance is maintained by daily administration of approximately  2,000 to 3,000 mL of Ringer’ lactate solution. T e T-tube catheter 1s con-  nected to a drainage bag, and the amount of drainage over a 24-hour period  is recorded. In the presence of jaundice with a bleeding tendency, blood  products, and vitamin K are given. T e patient is ambulated and returned  to oral intake as tolerated. Antibiotics are discontinued within 24 hours.  T e T-tube should be clamped prior to discharge as long as there are no  signs of cholangitis or bile leakage. Patients should be instructed to fush  the catheter with 10 mL of sterile saline one to two times a day. T e Silastic  drain is removed in 2 to 5 days unless there is excessive bile drainage. T e  common duct catheter can be removed in 10 to 14 days after a T-tube chol-  angiogram shows a normal ductal system, but we prefer to leave them in  place for four weeks. m    INDICATIONS T is is a procedure favored by many in place of the trans-  duodenal approach for stones impacted in the ampulla, and is indicated  for the treatment of primary common bile duct stones with a dilated com-  mon bile duct, or benign strictures of the distal bile duct. T e procedure  should not be considered for a nondilated common duct, recurrent pancre-  atitis, sclerosing cholangitis, or common bile duct stone amenable to endo-  scopic removal. T e procedure of choledochoduodenostomy in properly  selected patients may be far safer, with long-term results more satisfactory,  than those that follow more complicated procedures for the excision of  diverticuli.    PREOPERATIVE PREPARATION Liver function studies are evaluated, and  consultation with an endoscopist should be considered. Antibiotics are  given preoperatively.    ANESTHESIA General anesthesia is preferred. T e anesthesiologist must  consider liver function studies as well as age and general condition of the  patient in selecting the type of anesthetic to be administered.    POSITION T e patient is placed flat on the table with the feet lower than  the head. Slight rotation toward the side of the surgeon may improve  exposure.    OPERATIVE PREPARATION T e skin is prepared from the lower chest to  the lower abdomen.    INCISION AND EXPOSURE A right subcostal incision or an upper mid-  line incision is made. Adhesions to the peritoneum are carefully freed up,  including those that tend to prevent mobilization of the liver needed for  exposure of the common duct.    DETAILS OF PROCEDURE Following a general abdominal exploration,  special attention is given to the size of the common duct as well as any  evidence of ulcer deformity or acute inflammatory involvement of the first  portion of the duodenum. A biopsy of the liver may be considered and  needle aspiration of bile from the common duct is obtained for culture  to guide appropriate antibiotic therapy. T e diameter of the duct 1s mea-  sured and should be 2 to 24 cm in diameter. If the gallbladder has not been  removed previously, it should be excised, particularly if stones are pres-  ent. T e cystic duct and the common duct are carefully palpated for pos-  sible calculi. Any calculus, especially in the lower end of the common duct,  should be removed when the common duct is opened for the anastomosis.  Any inflammatory involvement of the duodenum should be noted, as this  may contraindicate the planned procedure.   T e duodenum and head of the pancreas should be mobilized by incis-  ing the peritoneum from the region of the foramen of the Winslow around  to the third portion of the duodenum (figure 1). T e entire duodenum  should be freed up by the Kocher maneuver and further mobilized by the  hand placed under the head of the pancreas.   T e anterior aspect of the common duct is cleaned as far down as pos-  sible. T e surgeon should not be tempted to perform a convenient side-  to-side anastomosis between the dilated common duct and the duodenum  as the resultant small stoma dooms the procedure to failure. T e secret of  success is related to the adequate mobilization of the duodenum, the ade-  quate size of the stoma, and finally the triangularization of the anastomosis  in accordance with the technique of Gliedman. T is type of anastomosis  decreases the potential for the development of the sump syndrome due to  the collection of food particles and calculi in the blind segment of the lower  end of the common duct.    Before making the incision, the mobilized duodenum is brought up  alongside the common duct to be certain the anastomosis will be free of  tension (figure 2).   An incision about 2.5 cm long is made carefully in the middle of the  common duct below the entrance of the cystic duct. T e location for the  anastomosis obviously will vary depending upon the anatomy presented.  A slightly smaller incision is made in the adjacent duodenum in a longitu-  dinal direction.   It should be remembered that the early success of this procedure may  rest upon the accuracy of the right-angle approximation of the vertical inci-  sion in the common duct to the transverse incision in the duodenum.   Usually three traction sutures (a, b, and c) are placed to ensure that the  vertical incision in the common duct will be similar in length to the trans-  verse incision in the duodenum. Special attention must be given to the  placement of the first suture (midpoint a), which involves the midportion  of the incision in the duodenum and the lower angle of the incision in the  common duct. Similar sutures (angles b, c) are placed through either end  of the duodenal incision (figure 3). T ese angle sutures pass from either  end of the duodenal stoma fissure from outside to inside and from inside to  outside in the midportion of the incision in the common duct.   Traction on these angle sutures (b, c) verifies the trian gularization of the  stoma in the common duct. Delayed absorbable or nonabsorbable poly-  propylene sutures may be used. Silk should be avoided as it can result in a  focus for infection or stone formation. T e proper placement of these early  sutures ensures the subsequent accuracy of the anastomosis. T e posterior  row is approximated using interrupted sutures placed 2-3 mm apart. T e  knots for the posterior row will be inside the stoma. It 1s best for the sur-  geon to start at one end and sew towards him or herself. T e sutures are  secured with atraumatic clamps until the row has been completed. When  the posterior row has been completed, all sutures are tied and then cut  except the original angle sutures (b, c) (figure 4).   Before closing the anterior layer, a guide traction suture (midpoint  D) may be passed from outside to inside the midportion of the duodenal  opening to inside to outside the apex of the longitudinal suture in the com-  mon duct. Traction on this suture ensures more accurate placement of the  interrupted sutures for closing the anterior layer (figure 5). Again, the  sutures are placed 2 to 3mm apart and held in place with atraumatic clamps  with the surgeon sewing towards him or herself. Once all of the sutures  have been placed, the knots are tied and then the suture is cut. T e sutures  should be placed so that the knots will be on the outside of the anterior row  (figure 6).   An additional suture is taken at either angle to affix the duodenum either  to the capsule of the liver laterally (x) or to the hepatoduodenal ligament  medially (x’) (figure 7).   T eplateau of the stoma is tested by finger compression against the duo-  denal wall (figure 8). T e anastomosis should be free of tension and the  angles secure. A closed-suction-system Silastic drain may be placed adja-  cent to the anastomosis and down into Morison’ pouch.    CLOSURE Closure of the abdominal wall is accomplished in a routine  manner.    POSTOPERATIVE CARE Antibiotics are given. If there is an insignificant  output from the closed-suction drain, it is removed af er a few days. Naso-  gastric suction may be indicated for a day or so. Diet is advanced as tolerated.  Liver function tests should be restudied as needed during the postoperative  recovery period. m=    INDICATIONS Cholecystectomy from the fundus downward is the desir-  able method in many cases of acute or gangrenous cholecystitis, where  exposure of the cystic duct is difficult and hazardous. Extensive adhe-  sions, a large, thick-walled, acutely inflamed gallbladder, or a large calculus  impacted in the neck of the gallbladder makes this the safe and wiser pro-  cedure. Better definition of the cystic duct and cystic artery is ensured with  far less chance of injury to the common duct. Some prefer this method of  cholecystectomy as a routine procedure.    PREOPERATIVE PREPARATION In the presence of acute cholecystitis, the  preoperative treatment depends on the severity and duration of the attack.  Early operation is indicated in patients seen within 48 hours after the onset,  as soon as fluid balance and antibiotic coverage have been established.  Frequent clinical and laboratory evaluation over a 24-hour period is neces-  sary. Antibiotic therapy is given. Regardless of the duration of the acute  manifestations, surgical intervention 1s indicated if there is recurrence of  pain, a mounting white cell count, or an increase in the signs and symp-  toms suggesting a perforation. T e gallbladder may show advanced acute  inflammation despite a normal temperature and white count and negative  physical findings. It is generally recommended that patients undergo sur-  gery within 72 hours of the onset of symptoms as delays longer than this are  associated with an increased risk of common bile duct injury. Percutaneous  cholecystostomy may be considered for patients with a delayed presenta-  tion, or for those who are too ill to tolerate surgery. T ese patients may  undergo interval cholecystectomy in 6 weeks.    POSITION T e patient is placed in the usual position for gallbladder sur-  gery. If local anesthesia is used, the position may be modified slightly to  make the patient more comfortable.    OPERATIVE PREPARATION T e skin is prepared in the usual manner.    INCISION AND EXPOSURE Incision and exposure are carried out as  shown in Chapter 70 T e omentum must be separated carefully by either  sharp or blunt dissection from the fundus of the gallbladder, care being  taken to tie all bleeding points. An oblique incision below the costal margin  is preferred, especially if the mass presents rather far laterally.    DETAILS OF PROCEDURE Blunt dissection only is utilized to free the  omentum and other structures from the gallbladder wall. It is safer to  empty the contents of the gallbladder immediately to decrease the bulk and  to give more exposure. A short incision is made through the serosa of the  fundus, a trocar introduced, and the liquid contents are removed by suc-  tion. Cultures are taken. A fenestrated forceps is introduced deep into the  gallbladder to remove any calculiin the ampulla. T e opening is closed with  a purse-string suture, which prevents further soiling and serves as traction.   Incisions are made into the serosa of the gallbladder along both sides  about 1 cm from the liver substance with a scalpel or electrocautery  (figure 1); otherwise, excessive traction will result in avulsion of the gall-  bladder from the liver bed. Separation is accomplished by blunt or scissors  dissection, especially since the loose tissue beneath the serosa is edematous  in the presence of acute cholecystitis (figure 2). T e cuf of gallbladder  serosa in the region of the fundus 1s held with forceps, while the gallbladder  is further freed by scissors dissection (figure 3).   As an alternative method, since the contents have been aspirated and  are frequently sterile, the opening in the fundus is enlarged, permitting the  index finger or a gauze sponge to be inserted to give counter-resistance and  to aid in dissecting within the developed cleavage plane.   T e serosa is incised on each side down to the ampulla of the gallblad-  der. Since there may be difficulty from oozing because the cystic artery    is intact, all bleeding points should be meticulously clamped or cauter-  ized. As the cuf at the margin of the liver is held by a curved, half-length  clamp, a relatively dry field is obtained if the cuf is closed with interrupted  sutures as the dissection progresses down to the ampulla (figure 4). Most  surgeons, however, leave the cuf edges free. Great care must be taken in  mobilizing the infundibulum and neck of the gallbladder. Alternate sharp  and gauze dissection 1s advisable until the majority of adhesions have been  separated. T e gallbladder is retracted medially and outward to assist in  identifying the cystic duct and cystic artery. T e cystic duct is isolated with  a right-angle clamp cautiously introduced from the lateral side to avoid  injury to the common duct and to the right hepatic artery (figure 4).T e  cystic artery is isolated with any accompanying indurated tissue. T e artery  may be much larger than normal, and the right hepatic artery may be in an  anomalous position. It 1s safer to isolate the cystic artery as near the gall-  bladder wall as possible. T e cystic artery and adjacent tissues are divided  between a half-length and a right-angle clamp (figure 5) and ligated.   T e cystic duct is palpated carefully, especially if acute cholecystitis  is present, to ensure that a stone has not been overlooked. T e common  duct is palpated carefully, and exploration is avoided unless cholangiog-  raphy shows clear-cut evidence of a choledocholithiasis. If common bile  duct exploration is not indicated, the cystic duct is divided between right-  angle and half-length clamps (figure 6) and tied unless a cholangiogram  is planned through the cystic duct. After thorough inspection of the area  for oozing, the clamp is removed from the liver margin. Since inflammation  and technical difficulties have made this procedure necessary, placement of  a drain should be considered, particularly 1f raw liver parenchyma has been  exposed.   If a classic open cholecystectomy appears hazardous because of advanced  inflammation, if the gallbladder is partially buried in the liver, or if struc-  tures in the cystic duct region cannot be safely identified, the full thickness  of the gallbladder is left within the liver bed. A very specific indication  for this procedure occurs in patients with cirrhosis of the liver and por-  tal hypertension. Attempts to remove the back wall of the gallbladder will  result in significant hemorrhage that can be extremely difficult to control.  T e gallbladder is aspirated, and traction is exerted on the fundus. T einfe-  rior surface is divided cautiously down to the infundibulum, which may be  densely adherent to the adjacent structures (figur e 7). Calculi impacted in  theneck or cystic duct are removed with fenestrated forceps(figure&).T e  gallbladder wall beyond the liver margin is excised, and any bleeding  points are controlled with electrocautery or interrupted sutures. T e  mucosa in the retained portion of the gallbladder head is fulgurated by  electrocautery. If the cystic duct can be intubated with a small catheter  (figure 9) and acholangiogram may be performed. Often the gangrenous  cystic duct cannot be found and closed suction drains are placed in the  general region of the duct. Fortunately, the spiral valves in the retained  cystic duct stump usually scar shut. T e duct and artery should be ligated  if they are identified.    POSTOPERATIVE CARE NG decompression is rarely used if needed.  T e patient should be treated with a 5- to 7-day course of broad spectrum  antibiotics and intraoperative cultures can be used to guide therapy. Liver  function tests should be monitored. T e diet is advanced as tolerated, and  intravenous fluids are continued until the patient is tolerating adequate oral  intake. Drains should be left in until the output is minimal. Cholangiog-  raphy by MRCP or ERCP should be considered in patients with persistent  bilious drainage or elevated liver function tests, although most bile leaks  will resolve without the need for intervention. m=    INDICATIONS Cholecystostomy, while not recognized as routine treat-  ment for cholelithiasis, may be a lifesaving procedure. Today cholecystos-  tomy is usually placed under image guidance by a percutaneous technique.  Surgical cholecystostomy may be needed in some situations. It is the oper-  ation of choice in some elderly patients with acute cholecystitis, in poor  surgical risks who present a well-defined mass, in seriously ill patients in  whom minimum surgery is desirable, and when technical difficulties make  cholecystectomy hazardous. If there is obstruction of the common duct with  long-standing jaundice and a tendency toward hemorrhage that cannot be  controlled by vitamin K and transfusions or percutaneous transhepatic bili-  ary tube drainage, preliminary cholecystostomy for decompression may be  the procedure of choice.    INCISION AND EXPOSURE A small incision 1s made with its midportion  directly over the maximum point of tenderness in the right upper quad-  rant. Occasionally, when unsuspected technical difficulties or inflamma-  tion more severe than anticipated are encountered, the procedure is carried  out through the usual upper right rectus or infracostal incision. T e adhe-  sions are not dissected from the undersurface of the gallbladder unless it is  thought that cholecystectomy might be feasible (figure 1).    DETAILS OF PROCEDURE T e fundus is walled off with gauze before the  evacuation of its contents. An incision is made just through the serosa of  the bulging fundus (figure 2). A trocar is inserted to remove the liquid  contents (figure 3). Suction is maintained adjacent to the incision in  the fundus as the trocar is withdrawn. A culture is taken routinely. T e  edematous wall is then grasped with Babcock forceps, and the opening  is extended (figure 4). A purse-string suture of fine absorbable material  is placed about the opening in the fundus to control oozing and to close  the fundus about the drainage tube. Any liquid or debris remaining in the    lumen of the gallbladder is removed by suction. Since there is usually an  impacted stone in the neck of the gallbladder, a determined effort is made  to remove it to permit drainage of the gallbladder. A small, flexible scoop,  such as a Cushing pituitary curette, 1s directed down to the neck (figure 5).  If the scoop cannot dislodge the stones, a fenestrated forceps is used. T e  lumen of the gallbladder is repeatedly flooded with saline. A small rubber  catheter or mushroom catheter is inserted into the lumen of the gallbladder  and anchored with an interrupted silk suture (figur es 6 and 7) or a Foley  catheter may be used. T e previously placed purse-string suture is tied  snugly about the drainage tube (figure 7). If the inflammation is severe,  if an abscess was encountered, or if there has been soiling about the wall, a  closed suction drain is inserted along the wall of the gallbladder. T e com-  mon duct must be decompressed if suppurative cholangitis is suspected.    CLOSURE Stitches are taken to anchor the fundus to the overlying perito-  neum to prevent the soiling of the peritoneal cavity before the area is sealed  off (figure 8). Routine closure is performed. Af er a sterile dressing has  been applied, the drainage tube is anchored to the skin with a suture or  adhesive tape and is connected to a drainage bottle.    POSTOPERATIVE CARE See Chapter 74. Antibiotics should be adminis-  tered for 5to 7 days af er drainage. While the drainage tube 1s in place, con-  trast may be injected and a cholangiogram taken for evidence of overlooked  calculi. If the patient is in good condition, and the postoperative recovery 1s  uncomplicated, a subsequent cholecystectomy may be performed through  the original wound af er 6 weeks. A secondary operation af er cholecystos-  tomy is not recommended in the extremely poor-risk patient. For high-risk  patients who survive their attack of cholecystitis, the cholecystostomy tube  may be removed if cholangiography through the catheter demonstrates a  patent cystic duct with good flow of contrast into the duodenum. m    In this chapter two techniques of Roux-en-Y choledochojejunostomy are  described. T e first is a direct mucosa-to-mucosa anastomosis and is the pre-  ferred technique. T e alternate procedure of a mucosal graft was described  by Sir Rodney Smith in situations where there is a very high structure or  injury precluding direct visualization of the proximal biliary tree.    DETAILS OF PROCEDURE T e surgeon is occasionally faced with the dif-  ficult problem of finding the strictured area or blind end of the hepatic duct.  T e adhesions between the duodenum and hilus of the liver are divided  carefully by sharp and blunt dissection (figure 1). Great care must be exer-  cised to avoid unnecessary bleeding and possible injury to the underlying  structures. Usually, it is easier to start the dissection quite far laterally and to  free up the superior surface of the right lobe of the liver from the adherent  duodenum, hepatic flexure of the colon, and omentum. Sharp dissection is  used along the liver margins to avoid tearing the liver capsule, which results  in a troublesome ooze. After the edge of the adhesion has been incised, blunt  dissection will be more effective and safer in freeing up the undersurface of  the liver. T e exposure should be directed toward identifying and expos-  ing the foramen of Winslow. T e stomach may or may not have to be dis-  sected away from the liver. Usually, the duodenum is drawn up into the old  gallbladder bed and fixed by dense adhesions. T e second portion of the  duodenum is mobilized medially (Kocher maneuver), following division  of the peritoneum along its lateral margin (figure 2). As the duodenum is  reflected downward the undersurface of the liver is retracted upward. T e  scar tissue around the porta hepatis may obscure the biliary ductal system.  It is best to approach the duct from the lateral side. Identifying the cystic  duct stump is helpful in delineating the location of the biliary tree and will  facilitate dissection. T e upper portion of the dilated duct may be verified  by aspiration of bile through a 25-gauge needle (figure 3). A cholangio-  gram may be performed. Sharp dissection should be used to identify the  duct. An effort is made to free up the entire circumference of the ductal  system in order to create an end to side anastomosis with the jejunum. A  retrocolic Roux-en-Y arm of jejunum is prepared in the usual way using a  linear staple to divide the small intestine. If the intestine is divided between  clamps then the end of the mobilized jejunal limb is closed with two layers  of interrupted silk. On the antimesenteric border of the jejunum about 5 to  10 cm distal to the divided end of the intestine, an incision slightly smaller  than the duct opening is made with electrocautery. T is should be easily  approximated to the hepatic duct with no tension.    DIRECT MUCOSA TO MUCOSA CHOLEDOCHOJEJUNOSTOMY For a  direct anastomosis, the duct is identified and the circumference exposed. If  the lumen is narrow then an additional opening can be achieved by dissect-  ing the left hepatic duct and opening it longitudinally stopping short of the  bifurcation of the left hepatic duct. An enterotomy is made, slightly smaller  than the circumference of the bile duct as the opening will tend to enlarge  secondary to the elasticity of the intestine. A single layer end duct to side jeju-  nal anastomosis is created. Fine absorbable double-armed sutures are used.  T ese may be 4-0 to 6-0 depending on the caliber of the duct and the tissue  thickness. Stay sutures are placed. With gentle traction the posterior wall  of the bile duct and the jejunum are visualized. T e posterior row of the  anastomosis is then completed between the hepatic duct and the jejunum.  Sutures are placed full thickness in the bile duct and the jejunum. T e knot  may be on the inside. (figure 4). T ese may be held with fine hemostats  and tied in sequence as a group (preferred) or tied as you go. Once the  posterior anastomosis is completed and if a pigtail catheter was placed to  decompress the biliary tree, then it is now repositioned in the intestine by  advancing it through the bile duct opening and into the opening made in  the jejunum. T e anterior row is then completed (figur e 5). T e Roux-en-  Y loop is securely tacked in place beneath the liver by several absorbable  sutures placed through the seromuscular coat   In dif cult cases in which there is posterior displacement of the duct  it may help to place the initial sutures in the anterior wall of the hepatic  duct. T ese are then individually clamped with fine hemostats and placed  on the abdominal wall with mild tension so as to lift the anterior duct wall  and expose the posterior wall. Once all the anterior sutures are placed, the  posterior wall of the duct will be easily exposed by gentle traction of the  anterior row. T e posterior sutures are then placed. Once these are tied and  the posterior row completed then the anterior sutures are tied completing  the anastomosis.    MUCOSAL GRAFT CHOLEDOCHOJEJUNOSTOMY, RODNEY SMITH  TECHNIQUE In some situations the duct cannot be dissected and in these  cases an option would be to use the Rodney Smith mucosal graft technique  (figures 6 to 8). In this situation the needle 1s left in place as a guide and  an incision is made alongside the needle until a free flow of bile is obtained.  T en a blunt-nosed, curved clamp is inserted upward into the dilated duct  and the opening gradually enlarged by dilatation, which may include an  additional incision to enlarge the opening. In the mucosal graft technique,  the mucosa 1s intussuscepted well up into the duct without a direct end-to-  end anastomosis may be used. (figur es 7 and 8). Most patients with a high  stricture or injury will have a transhepatic biliary catheter in place that will  facilitate the location of the proximal biliary tree and placement of a Silastic  stent as described below.   To create a mucosal graft the technique described below is used. Fol-  lowing the opening of the dilated hepatic duct, a long, curved clamp is  inserted, usually toward the left side, and extended up through the liver  substance. A rubber or preferably a Silastic tube (14 or 16 French) is  pulled down through the liver and partially out through the duct opening  (figure 6). A transhepatic biliary drain placed preoperatively will facilitate  placement of the Silastic stent. Additional holes that will be above and below  the anastomosis are made in this tube. Following this, a Roux-en-Y limb of  jejunum is prepared as described above. On the antimesenteric border of  the jejunum a 5-cm segment of the seromuscular coat is excised approxi-  mately 5cm from the closed end (figure 6). Care should be taken to avoid  making any additional openings in the mucosa except in the very apex of  the protruding mucosal pocket. T e tube that was pulled down through the  liver is now directed through the small opening made in the apex of the  mucosal pocket and directed down into the arm of the jejunum for 10 cm  or more. A purse-string suture of absorbable suture is placed in the mucosa  about the tube and tied. After the tube has been passed the desired distance  down the Roux-en-Y limb, a 2-0 absorbable suture is passed completely  through the jejunal walls and around the tube to fix it in position when  tied just distal to the mucosal outpocketing. A centimeter or two distally a  similar absorbable suture is taken to ensure further fixation. T ese are the only  sutures utilized to fix the tube to the wall of the jejunum (figure 8). T ese  sutures ensure fixation of the jejunal mucosa to the tube as it is withdrawn.  Several holes are cut around the tube just above the mucosal graft to ensure  drainage of the right as well as the left hepatic duct. Traction then is placed  on the end of the tube coming out of the dome of the liver in order to  pull the mucosal graft carefully and firmly up into place inside the com-  mon hepatic duct. T is provides an intussusception of the jejunal mucosa  up into the dilated common hepatic duct and ensures direct mucosa-to-  mucosa approximation (figure 8). In very high strictures it may be nec-  essary to use a tube into the left as well as the right hepatic radical. T e  Roux-en-Y loop is securely anchored in place beneath the liver by several  absorbable sutures placed through the seromuscular coat and the scar  tissue around the opening into the duct system (figure 7). T e tube 1s  brought out through a separate stab wound to one side or the other of the  incision and anchored securely in place with nonabsorbable suture mate-  rial. A closed suction drain is placed.   Rarely the situation may warrant an end-to-end anastomosis or primary  repair of the common duct. T is is associated with a greater stricture rate  than Roux-en-Y reconstruction and hence not used very often. Please refer  to the electronic supplement for a description of this procedure.    CLOSURE T e wound is closed in layers after suction drainage is instituted  to the undersurface of the liver by a plastic tube with many perforations.    POSTOPERATIVE CARE T e tube going through the anastomosis is placed  on gravity drainage to divert bile until the newly made junction 1s healed.  T e drain is removed when there is no evidence of bile leakage. T e appro-  priate antibiotic therapy should be adjusted following culture and sensitiv-  ity studies of the bile. T e tube may be irrigated with saline intermittently to  wash out all debris or small calculi. In addition, the tube provides a means  of taking postoperative transhepatic cholangiograms from time to time to  evaluate the security of the anastomosis and the evidence of regression in  the size of the formerly obstructed ducts. Ordinarily, the tube is left in place  for a minimum of 4 months. A complete evaluation with liver function  studies and several cultures of the bile should be made, as well as a cholan-  giogram, before it is advisable to remove the tube. m    INDICATIONS Cholangiocarcinomas arising at or near the confluence of  the right and left hepatic ducts, commonly referred to as Klatskin tumors, are  being diagnosed earlier and treated more promptly by palliative or curative  surgical procedures. T ese may be termed hepatic duct bifurcation tumors  or hilar tumors. T e majority of patients exhibit jaundice of increasing inten-  sity and many have had recent biliary exploration, where the diagnosis was  suggested by operative cholangiography. T ere is a wide patient age range  and occasionally a preceding history of ulcerative colitis or sclerosing chol-  angitis. Although the number who can be cured is limited, many patients are  benefited by palliative procedures.    PREOPERATIVE PREPARATION T eé seriousness of the lesion, the diffi-  culty in determining the extent of involvement, and the necessity for avoid-  ing infection from preoperative studies in an obstructed jaundiced patient  requires meticulous preoperative evaluation. Early endoscopy of the com-  mon duct and consultation with an expert in interventional radiology are  essential in planning when and if access to the biliary tree 1s necessary. T e  decision to instrument the obstructed biliary tree should be made only  after treatment goals are defined. T e jaundiced patient selected for biliary  decompression should undergo percutaneous transhepatic cholangiography  with appropriate prophylactic antibiotics given. T ese procedures should be  undertaken by an experienced interventional radiologist. Following cholan-  giography, pigtail catheters may be placed bilaterally (although unilateral is  usually sufficient), directed if possible through the obstructing lesion into  the duodenum for palliation of the jaundice (figure 1). If there 1s cholan-  giographic evidence of tumor extending into the right or left hepatic ducts,  the patient may eventually be explored to relieve the obstruction on the side  of the involved duct. Palliation, however, is usually possible with internal  drainage into the duodenum through the pigtail catheters. T e catheters also  serve as invaluable technical aids to the surgeon at the time of laparotomy.   High-resolution cross-sectional imaging is mandatory for evaluating  hilar vasculature prior to any attempt at resection. MRI/MRCP with contrast  enhancement and delayed imaging (1e., cholangiocarcinoma protocol) is  ideal at identifying occlusion of the hepatic artery or encasement of the main  portal vein, either of which complicates and may contraindicate attempt at  resection of the tumor. T e vast majority of patients will show a stage of  tumor involvement that makes attempts at surgical excision impossible.   Appropriate antibiotic therapy, intravenous alimentation, and vitamin K  are given, and blood volume deficits are corrected.    ANESTHESIA T e deeply jaundiced patient should be considered a poor  surgical risk meriting special consideration by the anesthesiologist in plan-  ning the anesthesia.    POSITION T e patient is placed on the table in a slightly reversed Tren-  delenburg position. Intravenous catheters should be placed in both arms.  Catheter drainage of the bladder may be advisable as well as nasogastric  suction.    OPERATIVEPREPARATION T eskin of the lower chest and upper abdomen  as well as the right flank should be prepared.    INCISION AND EXPOSURE Either a liberal bilateral subcostal incision or  a midline incision from over the xiphoid to below the umbilicus is made.    DETAILS OF PROCEDURE Bimanual palpation of the liver and peritoneal  surfaces is carried out in a search for possible metastases. Metastatic ade-  nopathy at the root of the mesentery can impede reconstruction so should  be evaluated early. Despite the history of deep jaundice, the gallbladder  and common duct appear normal. Any enlarged lymph nodes are excised  for immediate frozen section examination if outside of the porta hepatis.  T e tumor tends to be well hidden and careful palpation of the previously  placed pigtail catheters is performed up into the hilus of the liver until the  tumor is localized. T e distortion of the pigtail catheters is helpful in local-  izing the area of tumor involvement.   Before proceeding with the tumor excision, some prefer to divide the  falciform ligament and ligate both ends with a transfixing suture. T is pro-  cedure may enhance the exposure (figur e 2). Ifa hepatic bridge or plate is  present, it is divided. T e exposure of the tumor area is further improved by  dividing and ligating the cystic duct followed by enucleation of the gallblad-  der from the liver bed.   A Kelly hemostat is applied to the fundus of the attached gallbladder to  be used for improved traction of the common duct. T e duodenum is thor-  oughly mobilized by the Kocher maneuver and the common duct dissected  free as far downward as possible.   T e anterior wall of the lower most portion of the common duct is  opened and the ends of the pigtail catheters brought out (figure 3). T e  common duct is divided and the distal end is oversewn at the level of the  head of the pancreas.   T e gallbladder and end of the common duct are reflected upward to  expose the posterior aspects of the region of the tumor (figure 4). T isis  the most delicate portion of the procedure. Very gently the adhesions above  the posterior aspects of the tumor and adjacent structures, such as branches  of the hepatic artery, must be gently determined and divided. Likewise the  portal vein is very close as well as the caudate lobe of the liver. Involvement  of the caudate lobe of the liver with tumor is commonplace with prompt  recurrences of the tumor if overlooked. T e possibility of removing the cau-  date lobe should be considered standard.   All bleeding is controlled by metal clips or ligature. T e lower small  hepatic vein going to the caudate lobe may be ligated.   T e tissue about the left hepatic duct is carefully divided to provide  sufficient exposure of the left duct for a right-angle clamp to be carefully  inserted under the duct to permit the placement of a blood vessel loop for  possible traction (figure 5). T educt should be palpated for possible tumor  involvement. T is maneuver should be considered carefully as aberrant  biliary anatomy is common.    DETAILS OF PROCEDURE T e right duct is freed up a short  distance and a blood vessel loop passed around it for traction (figur e 6). If  the tumor has involved the wall of either major duct with probable extension  into the liver, the need for added lobectomy must be seriously considered.  Occasionally, a third large duct, or even more, may be found on the right  side, which must be conserved for implantation. Traction sutures are placed  in the major ducts at the point of division for each duct (figure 7).   T etwo ducts of the specimen should be marked with dif erent colored  sutures for specific identification by the pathologist of possible infiltration  of tumor at the point of division. Should this be found on frozen section  study, more duct must be resected.   T e Silastic transhepatic biliary stents are positioned using a Coudé  catheter as a preceding dilator that is drawn up the ducts and through  the liver by the pigtail catheters. First, the pigtail catheters with the guide  wires inside are brought out the open left and right hepatic ducts. Each  curled (pigtail) end is cut of and the remaining straight pigtail catheter is    placed into the cut leading end of a No. 16 French Coudé catheter. Each  pigtail catheter is then secured with a mattress suture through itself and  the Coudé. Both catheters are pulled up into the ducts (figure 8) using  traction on the pigtail catheter at the surface of the liver. T e Coudé cath-  eters may need to be manipulated back and forth so as to dilate the ductal  systems.   A No. 14 French Silastic transhepatic biliary stent 1s positioned in the  open end of the No. 16 Coudé French catheter and anchored with mattress  sutures of silk which are passed through the wall of the Coudé catheter.  With traction on the Coudé catheters the Silastic stents with multiple holes  are drawn into the liver in a position with no holes beyond the exit of the  plastic tubes (figure 9). T us, there are holes present within the liver and  the portion that projects into the Roux-en-Y of the jejunum. Short horizon-  tal mattress sutures of absorbable material are placed around the stents on  the surface of the liver at their point of exit. T e liver is compressed without  disruption about each catheter.    DETAILS OF PROCEDURE A Roux-en-Y loop of upper jeju-  num is brought into the right upper quadrant through an avascular area of  the mesocolon and anterior to the second and third portions of the duo-  denum. T e opening in the mesocolon 1s closed about the jejunum and its  mesentery after making certain the end of the Roux-en-Y extends up to and  slightly beyond the hepatic duct openings. T e end of the jeyunum 1s closed  with staples or in layers of running or interrupted sutures. T e posterior  wall of the jejunum in the region of the anastomosis should be anchored to  the capsule of the liver or adjacent tissue.   It is helpful to insert interrupted sutures through the lateral angles of each  open duct for positioning and sizing an accurate anastomosis on the jejunum  (figure 10). A posterior row of absorbable sutures is placed using the full  thickness of each duct. None of these sutures 1s tied until all posterior sutures  are in place for each duct. T e middle suture in the posterior row may also be  used to tie about the stent, so as to help prevent migration of this tube.   T e knot of the back suture line will be on the inside. T e sutures are cut  at the knot, except for the suture at each angle. A small incision parallel to  the posterior suture line is made in the jejunum (figure 1I).    T e ends of the Silastic biliary stents are gently introduced into the  lumen of the jejunum (figure 12). Anterior, full-thickness suture lines are  closed on both ducts (figures [3 and 14). Finally, the jejunum is anchored  to the adjacent liver. Regional closed-system Silastic suction catheters are  placed and the Silastic transhepatic stents are doubly sutured to the skin  with 5-0 nylon (figure 15). T e abdomen is closed in a routine manner  and the stents are connected to a sterile plastic bag to allow drainage by  gravity.    POSTOPERATIVE CARE T e closed system Silastic suction drains are  removed early in the postoperative course unless there 1s a significant bile  output or a leak is shown on cholangiography. If no leaks are found from  the superior surface of the liver or the anastomosis, three-way stopcocks are  attached to the end of the catheters. T e patients are trained to self-admin-  ister injections of sterile saline into the stents three times per day. T e stents  can be removed as an outpatient 4 to 6 weeks after surgery. Consultation  with radiation medicine and medical oncology is recommended to guide  the next steps in therapy. m=    INDICATIONS It is not uncommon during an exploratory laparotomy to  remove a small fragment of the liver for histologic study. Biopsy of the liver  is indicated in most patients who have a history of splenic or liver disease,  or in the presence of a metastatic nodule. T e specimen should not be taken  from an area near the gallbladder, since the vascular and lymphatic connec-  tions between the liver and gallbladder are such that a pathologic process  involving the gallbladder may have spread to the neighboring liver, and as a  result the biopsy would not give a true picture of the liver as a whole.    DETAILS OF PROCEDURE Two deep 2-0 absorbable sutures, a and b, are  placed about 2 cm apart at the liver border (figure la) using an atraumatic  type of needle. T e suture is passed through the edge of the liver and back  through again to include about one-half the original distance (figure lb).  T is prevents the suture from slipping off the biopsy margin with resultant    bleeding. T ese sutures are tied with a surgeon’ knot, which will not slip  between the tying of the first and second parts (figure lb). T e suture  should be tied as snugly as possible without cutting into the liver, for the  tension under which these knots are tied is the important factor in the pro-  cedure. Such sutures control the blood supply to the intervening liver sub-  stance. T etwo sutures are placed not more than 2 cm apart, deep in the liver  substance; yet as they are tied, at least 2 cm of liver are included at the free  margin to increase the size of the biopsy by making it triangular in shape. An  additional mattress suture, c, may be taken at the tip of the triangular wound  (figure 2). Af er the biopsy isremoved with ascalpel(figur e 3), the wound  is closed by tying together the sutures, a and b, or by placing an additional  mattress suture (2-0 absorbable), d, beyond the limits of the original sutures  (figures 4 and 5). T e area of biopsy is covered with some type of antico-  agulant matrix and omentum. m    SURGICAL ANATOMY OF LIVER T e¢ liver is divided into eight major  subsegments or sectors (including the caudate lobe), with the principal  line (Cantlie’s line) of division between the right and left sides extending  cephalad and obliquely from the middle of the gallbladder fossa to the  center of the inferior vena cava between the right and left main hepatic  veins (figure l,a—a’).T e true anatomic left lobe thus defined is divided  into medial (segment IV) and lateral segments (segments II and III)  approximately along the line of the falciform or round ligament, and each  of these segments is then subdivided into a superior (cephalad, II) area  and an inferior (caudad, III) sector (figure 2). In contrast, the right lobe  (segments V—VIII) is divided into anterior and posterior segments by a  plane from the anteroinferior edge of the liver that extends both super1i-  orly and posteriorly. T is cleavage is similar to the oblique fissure above  the right lower lobe of the lung, and it is roughly parallel to it. T ese seg-  ments of the right hepatic lobe are then split into superior (segments VII  and VIII) and inferior (segments V and VI) areas similar to those on the  left (figure 2).   Although the segmentation of the liver appears straightforward, suc-  cessful segmentectomy or lobectomy depends upon a thorough under-  standing of the diference between the portal vein, biliary duct, and  hepatic artery distribution as opposed to the hepatic vein drainage. In  general, the portal triad structures bifurcate in a serial manner and ulti-  mately lead directly into each of the eight sectors. T e specific exception to  this rule is the paraumbilicalis of the left hepatic branch of the portal vein,  as this structure straddles the division between the left inferior medial  (IV) and lateral (III) segments. T us, it lies roughly under the round lig-  ament (figure |, #7). T e superior and inferior areas of the left lateral  lobe have a portal venous supply from either end of the paraumbilicalis  (figure 1, #9 and #10); however, special note should be made of the paired  medial supply to the superior and inferior areas of the medial segment  (figure 1,#8 and #12). It is equally important at this point to examine the  biliary and arterial supply of this area (figure 6). T e main left hepatic  duct and artery proceed with the expected bifurcations out through the  superior and inferior divisions of the left lateral segment; however, the left  medial segment duct and artery (figure 6, #13) do not divide and send  a large branch to the superior and inferior areas, but rather send long,    paired structures out in each direction from the junction of the two areas  (figure 6, #12 and #13).   In contrast, the portal triad distribution to the right hepatic lobe is by a  straightforward arborization with major divisions first into anterior and pos-  terior segments, followed by secondary divisions into superior and inferior  subsegmental vessels (figure 1, #2 through #5). Interestingly, the caudate  lobe straddles the major right and left cleavage plane and simply receives  its portal supply directly from the right and left main branches of the portal  vein, hepatic arteries, and biliary ducts. Its venous return, however, is usually  a single caudate lobe hepatic vein that enters the inferior vena cava on its left  side just caudal to the main hepatic veins (figure 1, #1]).   T e hepatic veins, in general, run between the hepatic segments in a man-  ner analogous to the pulmonary veins. T e right hepatic vein lies in the major  cleft between the anterior and posterior segments on that side (figure 1, #14).  T eleft hepatic vein (figure 1,#15) drains predominantly the lateral segment,  while the middle hepatic vein (figur e 1, #16) crosses between the left medial  segment and the right lobe. It 1s imperative to know that this middle vein is  variable where it joins the main left hepatic vein within a few centimeters of  the junction with the vena cava and that this vein has two major tributaries  that cross over into the right anterior inferior and the left medial inferior  areas (figure |, #17). Appropriate preservation of these channels is, of course,  important in specific segmental resections, as hepatic venous occlusion may  result in congestion of the entire area(s) involved. Two common variations in  the termination of the middle hepatic vein may be found. T e first is shown in  this chapter where it joins the left hepatic vein (Figur e 1). T e other variation  is Shown in Chapter 83 (Figur e 8, page 303) where it has an entrance into the  inferior vena cava that is separate from the left hepatic vein.   T e remaining figures demonstrate the four most common hepatic  resections, whose specific details are covered in the operative text (Chapters  80 to 83). Of specific note are the “danger points” along the paraumbilica-  lis of the left branch of the portal vein (figures 3, 4, and 5). It is in these  areas that the surgeon must be certain of the integrity of the hepatic venous  drainage before dividing any major venous branches. Also shown 1s the use  of interlocking full-thickness mattress sutures for hemostasis in the partial  and total left lateral segmentectomies, a common technique (figure 3), as  is the finger-fracture technique. m   . Right posterior inferior portal vein  Right posterior superior portal vein  . Left branch of portal vein    1. Common hepatic duct 9. Caudate process duct 17. Lateral superior duct  2. Right hepatic duct 10. Caudate lobe duct (right and left) 18. Gallbladder   5. Anterior superior duct 13. Medial inferior ducts 21. Right hepatic artery  6. Anterior inferior duct 14. Lateral segmental duct 22. Cystic artery    INDICATIONS A persistent rise in the carcinoembryonic antigen (CEA)  level measured every 2 to 3 months during the postoperative years follow-  ing resection of a colorectal malignancy is an indication for a thorough  search for a possible recurrence. T e original operation and pathologic  reports are reviewed because they may provide a clue as to where the recur-  rence 1s located. A complete survey of the colon and rectum is done and the  liver is fully studied with liver function tests and imaging scans (CT, MRI,  PET-CT) as it is the principal site for metastatic disease. Evidence of metas-  tases to the lungs or diffuse involvement of the abdomen or bone generally  contraindicates surgical intervention, but local excision 1s usually consid-  ered in a good risk patient with a definite steady increase in the CEA level.  Further, a hepatic lobectomy may be considered for a metastasis too large  for local excision. T e 5-year survival rates following the removal of hepatic  metastases tend to be encouraging. T e patient should be fully informed of  the uncertainty of being cured of recurrence of malignancy.    PREOPERATIVE PREPARATION Multivitamins and adequate caloric  intake are urged during the days of preoperative investigation. Antibiotics  are given.    ANESTHESIA A general endotracheal anesthetic is given. Catheters are  placed in both arms for replacement of fluid and blood products if required.    POSITION T e patient is placed supine on the operating table in a slightly  reverse Trendelenburg position.    OPERATIVE PREPARATION T eskin is prepared over the chest and abdo-  men down to the pubis.    INCISION AND EXPOSURE An extended or bilateral subcostal incision  can provide excellent exposure. Alternatively a liberal midline incision  beginning over the xiphoid may be used.    DETAILS OF PROCEDURE T e peritoneum, the small and large intes-  tines, the cul de sac, mesentery, and omentum are all inspected for  evidence of metastases. T e major concern will be the liver, especially if  preoperative studies indicate probable liver involvement. If only one or  two very small metastases are found in readily accessible locations, they  can be excised or destroyed by cauterization. Diffuse multiple metastases  should be considered to contraindicate extensive attempts at surgical exci-  sion of many sites of recurrence. Formal lobectomy may be considered in  such circumstances.   T e liver is carefully inspected and palpated bimanually. In addition, the  use of hand-held intraoperative ultrasound is very useful in the search for  deep metastases and to map out the internal anatomy of the liver. Suffi-  cient mobilization of the liver is advisable to visualize the dome and poste-  rior aspects of the liver. T e falciform and triangular ligaments are divided  to ensure direct vision of all aspects of the liver. Fixation of the liver with  tumor invading into the diaphragm posteriorly complicates the resection  and should only be undertaken in experienced hands with great trepidation.   T e size and location of the metastases as well as the age and general  condition of the patient are factors to be considered in determining whether  local excision or lobectomy are to be performed. A metastasis tends to be  spherical but usually is not as deep as it is wide. T e technique for liver  biopsy is shown in Chapter 78.    Local excision is usually performed when the lesion can be completely  excised with expectation of negative margins without injury to major cen-  tral vascular or biliary structures.   When the metastatic nodule is near the margin of the lef lobe of the  liver, a wedge resection is easily performed (figure 1). A safety zone of  at least 1 or preferably 2 cm is outlined with an electrocautery around the  metastatic nodule, since at least lcm of normal liver should be excised with  the lesion.   Distal to the cautery line and parallel to it, a series of deeply placed chro-  mic mattress sutures on slightly curved large thin needles are placed in the  liver tissue to provide hemostasis (figure 2). T ese chromic sutures are  carefully tied to compress the liver tissue without lacerating the surface of  the liver.   One or more traction sutures (A) may be placed in the safety zone  between the tumor and the line of compression sutures. T e traction  sutures should never be placed through the tumor, since seeding may take  place. Such sutures are valuable in lif ing up the tumor as the dissection  progresses (figure 3). Traction on these sutures helps in keeping a safe dis-  tance from the metastasis as the tumor nodule is retracted upward. Every  precaution is taken to ensure a safe zone of normal liver tissue beyond the  neoplasm, especially in the deepest portion of the resection. Electrocau-  tery may be used for the division of the liver tissue as well as to control  bleeding. Some surgeons use the Cavitron Ultrasonic Surgical Aspirator  (CUSA) ultrasonic instrument for dissection, while others find the Argon  beam electrocoagulator very useful for obtaining hemostasis. Several other  modern energy devices are available and should be used at the discretion  of the surgeon.   Any visible vessels or bile ducts may be clipped (figure 4). However,  most liver surgeons prefer individual ligation of vessels and ducts. Evalua-  tion of the completeness of the resection by the pathologist prior to closure  is of en beneficial.   Sometimes several metastases of various sizes may be excised in a simi-  lar fashion. Some prefer to pack the cavity lef by the excision for a few  minutes with a hemostatic agent. Blood loss is rarely a troublesome factor  in the excision of liver metastases, unless the lesion is located rather deep  and near a sizable blood vessel in an unusual location. T e risk of excising  such lesions must be carefully weighed against the potential gain of their  removal. In such instances, anatomic resection with pedicle control may be  a safer option.    CLOSURE If the field is dry, drainage is not necessary (figure 5), other-  wise, Silastic closed-system suction drains are inserted in the area. If bile is  noted to escape into the liver tissue, an effort should be made to ligate the  area of drainage and consider closed suction drainage.   When the margins of the metastasis are questionable, additional liver  tissue is excised for study by the pathologist.    POSTOPERATIVE CARE Patients with proven metastases might be consid-  ered candidates for chemotherapy. T e CEA levels are measured every 2 or  3months, and the patient is surveyed for evidence of other recurrences. Mea-  surements should be continued indefinitely, although the interval between  tests can be lengthened af er several years if the CEA level and CT scans as  well as other evaluation procedures remain within anormal range. m    INDICATIONS T esuccessful local excision of benign liver tumors has fos-  tered a more aggressive surgical approach to the excision of hepatic metas-  tases of colorectal malignancies. During the first 2 or more years after the  removal of a colorectal tumor, carcinoembryonic antigen (CEA) levels are  measured every 3 months. When the CEA level begins to rise, recurrence  must be considered. In the absence of proof of metastasis or recurrence in  the rectum, colon, lung, or peritoneal cavity, a search is made for hepatic  metastases. Imaging by CT, MRI, or PET scans is performed. Hepatic angi-  ography is usually not necessary and has been replaced by CT or MRI with  coronal reconstruction to define regional anatomy. Any evidence of liver  metastases requires an evaluation of the number, size, and location of the  metastases. It is hoped that none or only one or two solitary metastases will  be verified in locations easily accessible to the surgeon. T e age and general  condition of the patient, as well as the size, number, and locations of metas-  tases, are considered in making a decision to attempt curative resection.  Given the sensitivity of modern imaging, “blind” abdominal exploration  for rising CEA in the absence of radiographic abnormalities is discouraged.  T e patient should be fully informed and should participate in making a  decision to re-operate. T e patient should be made aware that a major por-  tion of the liver may need to be excised. A residual of 20% or more of nor-  mal liver tissue remaining in the left lobe is essential for survival but this  number may exceed 30% if heavily pretreated with chemotherapy.    PREOPERATIVE PREPARATION Perioperative antibiotics are given, and  any blood deficiency is corrected. Studies should have ruled out metastases  to the lungs and general peritoneal cavity insofar as possible.    ANESTHESIA A general anesthetic that has minimal potential to harm the  liver is required.    POSITION T e patient is placed flat on the table with arms extended and  accessible to the anesthesiologist.    OPERATIVE PREPARATION T e skin of the thorax and abdomen is pre-  pared, since the incision may extend from over the lower sternum to below the  umbilicus. Bilateral large bore IVs are mandatory in anticipation of substan-  tial blood loss. Central venous catheters should be considered standard for  major liver surgery and intraoperative monitoring of central venous pressure  is helpful. Resistance to large volume resuscitation so as to maintain a CVP  <6 greatly reduces blood loss. Once parenchymal transection is complete  and large bleeding points addressed, aggressive fluid resuscitation should be  undertaken. Continuous arterial pressure monitoring 1s mandatory.    INCISION AND EXPOSURE A long right subcostal incision that extends  across the midline as a bilateral subcostal incision provides excellent expo-  sure. Alternatively, a liberal midline incision extending from well above the  xiphoid to or below the umbilicus may be used but makes mobilization of a  large liver lobe much more dif cult, particularly in a larger patient.    DETAILS OF PROCEDURE T e extent of tumor involvement in the right  lobe is verified by inspection and bimanual palpation (figure 1). T e  imaging scans available in the operative room are reviewed to reconfirm  the location of the lesion. In patients with colorectal metastases, it is essen-  tial to palpate and visualize the pouch of Douglas for metastases as well  as the entire colon, small bowel, mesentery, omentum, and peritoneum. If  there is suspicion of intraperitoneal spread, many surgeons will first view  the peritoneal space with a diagnostic laparoscopy. Multiple seeding would  cancel the procedure, although some prefer to excise an occasional small  metastasis and proceed with the liver section. T e extent and location of all  hepatic metastases is noted using ultrasound directly on the liver surface.  Understanding the relationship of lesions in question with major vascular  structures is essential to minimizing blood loss.   T e liver is mobilized by dividing the falciform and right triangular  ligaments as well as freeing the liver posteriorly from the diaphragm  (figure 2). Some surgeons prefer not to cut the triangular ligament, as it  provides stabilization and support for the left lobe. T e cystic artery and  cystic duct are ligated and the gallbladder removed, since the gallbladder  bed is the dividing line between the left and right lobes of the liver. T e right  hepatic duct is easier to visualize after removal of the gallbladder. A clear  exposure of the right hepatic duct is the safest way to avoid interference  with the area of confluence with the left hepatic duct.   T eright hepatic duct is divided under clear vision and double-sutured  with one or more transfixing sutures (figure 3). Great care must be taken  when passing a clamp behind the right hepatic duct as aberrant insertion  of the left hepatic duct can be inadvertently injured. After the right duct is  divided, the variable arterial supply is exposed. T e surgeon should at this  time review imaging, alert to the possibility that the right hepatic artery  may arise from the superior mesenteric artery. T e right hepatic artery 1s  ligated and divided (figure 4). T e left hepatic artery must be visualized  to be certain it has not been obstructed or compromised in any way. Varia-  tions in the arterial blood supply between the right and left lobes of the liver  should be remembered by the surgeon during the dissection in this area.   T e right and left branches of the portal vein are clearly exposed before  the right branch of the portal vein is doubly clamped with straight Cooley  vascular clamps. Both ends of the portal vein are oversewn with a continuous  4-0 nonabsorbable suture. For additional security, the end of the proximal  vein may be doubly closed with horizontal mattress sutures (figure 5a).  Alternatively, the right portal vein may be divided using a vascular stapler  (figure 5b).   Special attention must be given to taking down the hilar plate, followed by  freeing up the left hepatic duct, the left hepatic artery, and the left branch of the  portal vein from the undersurface of the overlying liver. T ese vessels enter the  liver near the falciform ligament. After the vessels and other structures are gently  dissected away from the liver, a logical area is exposed for the division between  the right lobe and the medial segment of the left lobe of the liver.    DETAILS OF PROCEDURE T e right hepatic lobe is freed up  from the diaphragm and rotated medially away from the diaphragm, exposing  the small hepatic veins communicating with the inferior vena cava (IVC). T ese  small vessels are carefully and securely ligated (figure 6a). T e caval ligament  must be divided to expose the inferior border of the right hepatic vein. Caution  must be executed as an accessory right hepatic vein may traverse this ligament  and drain into the IVC (figure 6b). T e main right hepatic vein 1s exposed.   A loop is passed around the large right hepatic vein, and the liver tissue  gently pushed away to permit the application of two curved Cooley vascular  clamps to the vein. Suf cient vein must extend beyond the vascular clamps in  order to secure the open ends. After the vein has been divided, two rows of  nonabsorbable vascular sutures are used to secure the ends of the right hepatic  vein (figure 7a). Alternatively a vascular stapler may be used (figure 7b).   T e concave line of demarcation following the color change subsequent  to ligation of the blood supply may be superficially outlined with a cau-  tery. Starting at the inferior border of the line of demarcation, deeply placed  mattress sutures may be inserted to control bleeding. T e mattress sutures  are tied to compress the liver substance but not to crush it, thus leading to  more bleeding. After three or four mattress sutures are placed on either  side of the lower end of the zone of demarcation, the liver tissue 1s divided  with an ultrasound dissector, electrocautery unit, or other energy device  (figure 8). Larger vessels and branches from the middle hepatic vein may  require double ligation. Surface coagulation may be obtained with an argon  beam electrocautery device. Alternatively, the hepatic parenchyma can  be transected using multiple applications of an endoscopic cutting linear  stapler with vascular loads. T is approach should only be used after clear    mapping of the internal vascular anatomy using the ultrasound probe. After  all bleeding and bile leakage has been controlled (figure 9), the omen-  tum may be brought up to cover the raw surface of the left lobe. Suf cient  sutures are taken to secure the omentum in place.   If low CVP was utilized throughout the dissection and parenchymal tran-  section, time should be given to allow volume resuscitation (often 2 L)  and restoration of the natural liver turgor prior to closure as new points of  bleeding may become evident.   T e pathologist examines the specimen to determine adequate clear  margin. T e structures going into the left lobe are inspected to ensure that  no structures are obstructed by angulation.   T e falciform ligament is reapproximated to ensure stability of the left  liver lobe. Closed system Silastic suction drainage is used selectively when  there is concern about bile leakage.    POSTOPERATIVE CARE Daily blood and liver function studies should  be carried out. Significant blood loss may require replacement. Meticu-  lous attention must be paid to minimizing infectious risks. Leakage of  fluid from the wound should not be tolerated and aggressively corrected. If  there is a bile leak of greater than 100 mL/day, then an endoscopic biliary  stent should be considered. If there is an ascites leak, the wound should be  revised. Long-term follow-up should include frequent examinations with  periodic liver function tests and CEA assays for patients with colon cancer.  Rising abnormal values will signal the need for complete reevaluation, as  described under Indications. m=    INDICATIONS T ere are a number of indications for removal of all or part  of the left lobe of the liver. T e most common indication is evidence of one  or more metastases from a previously resected colorectal cancer. T e diag-  nosis 1s supported by a rising carcinoembryonic antigen (CEA) level during  repeated postoperative evaluations. Liver function studies are performed  and evaluated. Imaging scans verify the location, size, and probable num-  ber of metastases. T e initial operative notes and the pathologist’ report  should be carefully studied for evidence of metastasis at the time of the in1-  tial operation. Studies to identify abdominal and lung metastases, including  colonoscopy, must be negative. A period of delay may be chosen to reassess  the trend of the CEA levels and CT scans, as well as to evaluate the risk of  a second-look procedure in an elderly patient. PET/CT to identify occult  intra- and extrahepatic disease should be undertaken.    PREOPERATIVE PREPARATION An informative discussion with the  patient and the family is part of the preoperative preparation. Antibiotics  are given and cross-matched blood is made available.    ANESTHESIA A general anesthetic agent with the minimum of potential  for injuring the liver is administered.    OPERATIVE PREPARATION T e skin is prepared over the entire abdomen  and the chest. Bilateral large bore IVs are mandatory in anticipation of sub-  stantial blood loss. Central venous catheters should be considered standard for  major liver surgery and intraoperative monitoring of central venous pressure  is helpful. Resistance to large volume resuscitation so as to maintain a CVP  <6 greatly reduces blood loss. Once parenchymal transection is complete  and large bleeding points addressed, aggressive fluid resuscitation should be  undertaken. Continuous arterial pressure monitoring is mandatory.    INCISION AND EXPOSURE Various incisions have been used, but the  bilateral subcostal incision provides excellent exposure. Extra assistants  may be needed, unless special self-retaining retractors are available to  retract the left costal margin. Alternatively, a long midline incision that can  be extended can be used.    DETAILS OF PROCEDURE T e abdominal cavity is carefully inspected for  evidence of pinpoint or large metastases in the pouch of Douglas, colon,    mesentery, small bowel, omentum, or peritoneum. Any suspicious areas are  excised for frozen section examination. T e liver surface is inspected for  evidence of metastases, followed by bimanual palpation to verify the diag-  nostic procedures suggesting metastasis in the left lobe of the liver. Metas-  tases deep within the left lobe rather than superficially are best evaluated  with a hand-held ultrasound probe. Metastases readily seen on the surface  of the left lobe can be locally excised with a l-cm margin. Metastases near  the inferior liver margin can be removed by wedge incision.   T e line of transection is outlined extending into the bed of the gallblad-  der. T e left hepatic vein is the major vessel in the dome of the left lobe  (figure 1). When the tumor is located deep in the left lobe, the left lobe is  mobilized by division of the falciform and coronary ligaments (figure 2).   Since the median margin of the left lobe extends into the gallbladder  bed, a cholecystectomy is performed after ligation and division of the cystic  artery and cystic duct. Removal of the gallbladder improves the exposure  for the identification of the major hepatic ducts and vessels to be divided  and ligated (figure 3).   T e hilar plate is incised and the bridge of liver parenchyma overlying  the umbilical fissure, if present, is divided to enhance the exposure of the  structures entering the left lobe. T e left hepatic duct is freed up for the  suf cient distance to allow passage of a right-angle clamp. T is is done  carefully so as to not injure any aberrant ducts which may be inserting  from the right lobe of the liver. T e duct is doubly ligated and then divided  (figure 4). T e division of the left hepatic duct exposes the underlying left  hepatic artery, which usually arises from the proper hepatic artery. T e sur-  geon should seek out the presence of aberrant arterial anatomy. T e most  common variation is the abnormal origin of the left hepatic artery from  the left gastric artery. In this case, the left hepatic artery will run through  the cranial portion of the hepatogastric ligament (pars densa) in the lesser  omentum.   T e left hepatic artery is gently freed up a short distance from its point  of origin and doubly tied with 2-0 nonabsorbable sutures proximally  (figure 5). T e area of the arterial bifurcation is inspected to be certain  the blood supply to the right lobe is intact and then the artery is divided  between the ligatures.    DETAILS OF PROCEDURE T e left branch of the portal vein is  now exposed. T e area of the bifurcation of the portal vein 1s carefully freed  up and the left branch mobilized for a suf cient distance to permit the appli-  cation of a pair of curved Cooley vascular clamps without compromising the  bifurcation of the portal vein. T e left branch of the portal vein is divided a  short distance beyond the clamps to permit closure of the proximal end of  the branch of the portal vein with a continuous horizontal mattress suture of  4-0 synthetic nonabsorbable suture that is then run back as an over-and-over  suture after the method of Cameron (figur e 6). If the caudate (Segment 1) is  to be preserved, the surgeon must take care to divide the left portal vein distal  to the caudate branch at the base of the umbilical fissure. Alternatively, the  portal vein can be divided using a vascular stapler. A final inspection deter-  mines that the blood supply to the right lobe 1s functioning normally.   T e blood loss should be lessened if the left hepatic vein is ligated before  the liver tissue is divided. T e left hepatic vein is freed of liver substance  until a suf cient distance is gained to permit the application of a pair of  long curved Cooley vascular clamps. T e left lateral segment (Segments  2 and 3) can be lifted to expose the ligamentum venosum. When this is  divided at its most cranial extent, a window 1s opened along the inferior  border of the left hepatic vein as well as the middle hepatic vein depend-  ing upon their point of convergence. T e path of the middle hepatic vein  must be visualized as separate from the left hepatic vein. T e end of the  vein projecting beyond the clamps is closed first with a continuous mat-  tress suture and then back with an over-and-over suture (figure 7). T e  clamps are removed and a final check is made that the proximal caval end  of the divided left hepatic vein is secure. A vascular stapler may be utilized  to control the left hepatic vein.   A line of demarcation between the right and left lobes develops after  the portal structures have been divided. T is line tends to curve in a con-  cave manner to the left until the dome of the liver is reached. Ultrasonic    dissecting instruments are available for dividing (figure 8) and aspirat-  ing the liver tissue with easier exposure for ligation of the larger ducts and  vessels, especially the venous branches of the median hepatic vein. Alter-  natively, an electrocautery or other energy device may be used to divide  the liver parenchyma or an endoscopic GIA stapler can be used once the  internal vascular anatomy is clearly definedsonographically.   Some have used deeply placed absorbable mattress sutures, starting  at the anterior lower liver edge and progressing upward along the line of  demarcation. T e liver tissue should be compressed with the capsule intact  and not crushed. T e liver may be divided in a variety of ways but ligatures  or clips must be applied to the larger vessels or bile ducts on the cut surface  of the right lobe. Clips are usually adequate on the left lobe side, which is  to be resected. T e deeply placed interrupted sutures near the dome of the  liver do not go completely through all the liver tissue in the region of the  dome.   T e raw surface of the right lobe is carefully inspected for bleed-  ing points as well as for bile leakage, which may require a suture ligature  (figure 9). Surface coagulation may be obtained with an argon beam  electrocautery system. T is may lessen the need for application of various  hemostatic materials to the cut surface of the residual liver. T e omentum  can be mobilized and anchored over the divided surface of the right lobe.  Closed-system Silastic suction drains can be considered if there is concern  for bile leakage.   Resuscitation should be initiated by the anesthesiologist until normal  liver turgor has returned while the abdomen is still open as small bleeding  points may develop.    POSTOPERATIVECARE Antibiotics are given and the amount of blood or  bile drainage is recorded daily. m    INDICATIONS Malignant tumors involving a large part of the right lobe  with extension into the medial segment of the left lobe are a possible  indication for extended right hepatectomy (or trisegmentectomy). Lesions  straddling midway between the right and left lobes will require trisegmen-  tectomy. T is is a major surgical procedure that requires a highly skilled  team trained in this field.    PREOPERATIVE PREPARATION Antibiotics are given and any blood  deficiency is corrected. Imaging scans (CT, MRI, or PET-CT) localize the  metastases in the liver. Hepatic angiography is not routinely necessary.  T e lungs must be free of metastases, and studies should not have dem-  onstrated any gross abdominal or colorectal recurrence. T e patient must  be made aware that a major portion of the liver may need to be excised.  Survival of the patient can be anticipated if 20% or more of normal liver tis-  sue remains in the left lobe. If the volume of the remaining live is estimated  by three-dimensional reconstruction to be less than 20%, then right portal  vein embolization may be performed in order to enhance the residual liver  volume through post-embolization hypertrophy of the left lateral segment.  If pretreated with greater six cycles of chemotherapy at least 30% of the liver  should be retained as the remnant.    ANESTHESIA A general anesthetic 1s required. Bilateral large bore IVs are  mandatory in anticipation of substantial blood loss. Central venous cath-  eters should be considered standard for major liver surgery and intraopera-  tive monitoring of central venous pressure is helpful. Resistance to large  volume resuscitation so as to maintain a CVP <6 greatly reduces blood  loss. Once parenchymal transection is complete and large bleeding points  addressed, aggressive fluid resuscitation should be undertaken. Continuous  arterial pressure monitoring is mandatory.    POSITION T e patient is placed supine on the operating table with arms  extended for access as needed by the anesthesiologist.    OPERATIVE PREPARATION T e skin of the thorax and abdomen is pre-  pared, since the incision may extend from over the lower sternum to below  the umbilicus.    INCISION AND EXPOSURE A long right subcostal incision that extends  across the left subcostal region provides excellent exposure. Alternatively, a    long midline incision starting above the xiphoid and extending below the  umbilicus may be used. T is procedure requires liberal exposure.    DETAILS OF PROCEDURE T e extent of tumor involvement of both the  right lobe and the medial portion of the left lobe is verified by inspection,  bimanual palpation, and ultrasonic imaging (figure 1).   T escans are reviewed to reconfirm the location of the lesion and review  the vascular supply to the liver. In patients with colorectal metastases, it is  essential to palpate and visualize the pouch of Douglas for metastases as  well as the entire colon, small bowel, mesentery, omentum, and peritoneum.  Multiple seeding would cancel the procedure, although some prefer to excise  an occasional very small metastasis and proceed with the liver resection.   T e liver is mobilized by dividing the falciform and both triangular  ligaments as well as freeing up the liver posteriorly from the diaphragm  (figure 2).   When mobilization of the liver has been completed by dividing the  right coronary ligament, the procedure outlined for a right hepatectomy is  followed. Ligation of the cystic artery and cystic duct is performed, and the  gallbladder is removed, resulting in a better exposure of the deeper structures  that are to be divided. A clear exposure of the right hepatic duct is essential to  confirm the absence of interference with the area of confluence with the left  hepatic duct (figure 3).   After the right duct is divided, the variable arterial supply is exposed.  T esurgeon should be alerted to the possibility that the right hepatic artery  may arise directly from the superior mesenteric artery. T e left hepatic  artery must be visualized to be certain it has not been obstructed or inter-  fered with in any way. T e variability of the arterial blood supply between  the right and left lobes should be kept in mind by the surgeon during the  dissection in this area. Under clear vision, the right hepatic artery 1s divided  and double-tied with a transfixing suture (figure 4).   T eright and left branches of the portal vein are clearly exposed before  the right branch of the portal vein is doubly clamped with straight Cooley  vascular clamps. Both open ends of the portal vein are oversewn with a  continuous 4-0 nonabsorbable vascular suture. T e ends of the proximal  vein are also approximated with horizontal mattress sutures. T e end going  to the right lobe is doubly ligated or oversewn (figure 5). Alternatively, the  right portal vein may be divided using a vascular stapler.    Extended Right Hepatectomy (Segments 4, 5, 6, 7,8 + Segment 1) 301    DETAILS OF PROCEDURE Special attention must be given to  taking down the hilar plate, followed by carefully mobilizing the left hepatic  duct, the left hepatic artery, and the left branch of the portal vein from the  undersurface of the overlying liver. T ese vessels enter the liver at the base  of the umbilical fissure. After the vessels and other structures are gently dis-  sected away from the liver, an area is exposed for the incision between the  medial and lateral segments of the left lobe of the liver (figure 6). T ebridge  of hepatic parenchyma across the umbilical fissure does not contain a major  vascular structure and can be divided with electrocautery. Branches to Seg-  ment 4 from the left portal vein can be individually controlled along the right  border of the round ligament as it traverses the umbilical fissure.   T e right lobe is rotated medially away from the diaphragm, exposing  the small hepatic veins communicating with the inferior vena cava. T ese  small vessels are carefully and securely ligated, followed by exposure of the  main right hepatic vein (figure 7). As in right hepatectomy, the caval liga-  ment is carefully divided to expose the right hepatic vein.   A vessel loop is passed around the large right hepatic vein, and the liver  tissue gently pushed away from this large vein to permit the application of  two curved Cooley vascular clamps to the vein. Suf cient vein must extend  beyond the vascular clamp to enable oversewing of the open ends after the  vein has been divided. Two rows of nonabsorbable vascular sutures are  used to secure the end of the right hepatic vein. T e middle hepatic vein  can be treated in a similar manner or its branches ligated individually as the  medial and lateral segments are divided (figure 8). T e hepatic veins can  similarly be controlled using a vascular stapler.   T e division of the liver lobes is made nearer the falciform ligament,  rather than in the line of the vascular demarcation between the right and  left lobes. Deeply placed stay sutures are placed parallel a few centimeters  away from the falciform ligament. T ese sutures are placed on either side  of the incision and tied to control the bleeding, but care is taken not to    crush the liver substance. T e liver is divided with an ultrasound dissector  or electrocautery unit between the area supplied by the middle hepatic  vein and medial to the left hepatic vein. Any structures losing blood or  leaking bile are ligated with a transfixing suture or clips (figur e 9). Alter-  natively, the hepatic parenchyma can be transacted using multiple applica-  tions of endoscopic cutting linear stapler (GIA) with vascular loads. Great  care must be taken along the inferior border of Segment 4B so as not to  compromise the integrity or vascular supply of the left hepatic duct.   After removal of the right lobe and involved portion of the left medial  lobe, the falciform ligament is reapproximated to ensure stability of the  remaining portion of the left lobe (figur e 10). Special care is taken to avoid  injuring the ducts and blood vessels that may be exposed as they enter the  smaller residual left lobe.   T e pathologist examines the specimen to determine that adequate  margins are present and free of tumor.   A variety of materials ranging from tissue glue to prepared hemostatic  sterile dressings, as well as omentum are used to cover the raw surfaces of  the remaining left lobe of the liver. Closed-system Silastic suction drains  should be considered.   Volume resuscitation should be initiated until the liver has returned to  normal turgor prior to closure as new bleeding points may become evident.    CLOSURE A routine surgical closure is used. Closed-system Silastic suc-  tion drains are inserted.    POSTOPERATIVE CARE Antibiotics are discontinued within 24 hours.  Blood and liver function studies should be done on a daily basis postop-  eratively. Blood losses from drains should be replaced. Patients can do well  despite extensive hepatic resection. Meticulous attention should be paid to  minimizing infectious risks. (Leakage of fluid from the wound should not  be tolerated and should be aggressively corrected.) m=    Extended Right Hepatectomy (Segments 4, 5, 6, 7,8 + Segment 1) 303    INDICATIONS Pseudocysts of the pancreas are not an uncommon sequela  of acute pancreatitis, chronic pancreatitis, and blunt abdominal trauma  with resultant traumatic pancreatitis. Pancreatic pseudocysts should be  suspected when the serum amylase remains elevated after apparently sat-  isfactory response to treatment of the acute episode. However, the serum  amylase may be normal, and quantitative urinary amylases may establish  the diagnosis. Blood calcium levels should be followed during severe epi-  sodes. A palpable mass can usually be detected in the upper abdomen, most  frequently in the mid-epigastrium or the left upper quadrant. T ese cysts  do not have an epithelial lining as do the true pancreatic cysts. T ey are  most commonly found in the body and tail of the pancreas but also may  be found in the neck and head of the pancreas. Ultrasonography, comput-  erized tomographic scans, and retrograde cannulation of the pancreatic  duct with injection of dye and x-ray opacification (endoscopic retrograde  cholangiopancreatography or ERCP) may demonstrate a pseudocyst. Films  of the chest and abdomen may demonstrate elevation of the left hemidia-  phragm with or without basilar atelectasis or pleural effusion. Treatment of  cysts that do not regress spontaneously consists most commonly of internal  drainage via the stomach, duodenum, or jejunum. External tube drainage  with subsequent fistula may be rarely indicated. Alternatively, some radi-  ologists may drain mature pseudocysts attached to the posterior wall of the  stomach using computerized axial tomography. A transgastric needle and  then catheter is introduced via a gastrostomy usually created by the percu-  taneous endoscopic gastrostomy technique (Chapter 18).   T e ideal time to drain these pseudocysts internally is 6 to 8 weeks after  their appearance, when the cyst is intimately attached to the surrounding  structures and the surrounding inf ammatory reaction is quiescent. At this  time the cyst wall is strong enough for the technical anastomosis. External  tube drainage of the cyst may be necessary if the cyst wall is friable or if  the patient is septic or has a rapidly expanding pseudocyst. In all cases the  interior of the cyst should be thoroughly examined and the cyst wall biop-  sied. Externally drained cysts usually close spontaneously, but pancreatic  fistulas can occur. Cysts may resolve gradually, particularly those associated  with stones in the common duct and acute pancreatitis. In general, patency  of the ampulla and the proximal pancreatic duct should be established by  ERCP prior to any operative procedure.    PREOPERATIVE PREPARATION It is most important that these patients  be in satisfactory metabolic condition before surgery. Accordingly, defi-  ciencies in electrolytes, red cell mass, serum protein, or prothrombin levels  are corrected preoperatively, and total parenteral nutrition should be con-  sidered. A clear liquid diet is given on the day before surgery, and the colon  is emptied by the use of oral cathartics.    POSITION T e¢ patient is placed in a comfortable supine position as near  the operator’s side as possible. T e knees are f exed on a pillow. Moderate  elevation of the head of the table facilitates exposure. Facilities for operative  pancreatic cystogram as well as cholangiogram should be available.    OPERATIVE PREPARATION T e lower thorax and abdomen are prepared  in the usual manner.    INCISION AND EXPOSURE An epigastric midline incision can be used  for this procedure. Resection of the xiphoid process will give an additional  5to 75cm of exposure if necessary.    DETAILS OF PROCEDURE After the peritoneal cavity is entered, thor-  ough exploration is carried out with particular emphasis on the gallbladder  and common duct. Fat necrosis in the omentum or transverse mesocolon  is commonly found. T e cysts of the pancreas are best drained into that  portion of the upper gastrointestinal tract most intimately adherent to the  cyst, as shown in figure la. Cystogastrostomy or cystoduodenostomy 1s  quite satisfactory when it can be performed easily. Loop cystojesunostomy  or Roux-en-Y cystojejunostomy may be performed also (figure lb). T e  Roux-en-Y is the preferred method for drainage unless the cyst 1s inti-  mately attached to the posterior gastric wall. It has the added advantage  of preventing ref ux of intestinal contents into the cyst, with less chance of  leakage about the suture line.   After the field 1s walled off by gauze pads, the omentum overlying the  cyst is opened and all bleeding points ligated (figure 2). T e diagnosis of  a cyst is confirmed by needle aspiration of the suspected area. T e cyst is  then partly aspirated, permitting the operator to determine the thickness of  the cyst wall and confirm the diagnosis (figure 3). Specimens of the cyst  contents are sent for culture and sensitivity, amylase and electrolyte deter-  mination. At this time operative cystography can be performed. Since the  cyst fuid will dilute the contrast medium, it is better to inject 5to 10 mL of  an undiluted contrast medium into the cyst.   Guide sutures A and B are placed into the wall of the cyst, and a 2- to  3-cm opening 1s made at the desired level for drainage (figure 4). Suction  should be available for aspirating the cyst contents. A full thickness biopsy  of the cyst wall must be taken to rule out any malignancy (figure 4).   T esurgeon should explore the interior of the cyst with the index finger,  carefully checking for coexistent neoplasm and pocketing within the cystic  cavity (figure 5). To prevent tension on the cystoduodenostomy, it is advis-  able to perform a Kocher maneuver to mobilize the duodenum.    DETAILS OF PROCEDURE Gentle tension is put on the duo-  denum with non-crushing clamps, and a posterior row of 00 interrupted  silk horizontal mattress sutures 1s placed (figure 6).   Traction angle sutures are placed at the angles of the proposed opening  in the duodenum. T e incision into the duodenum is made slightly smaller  than that in the cyst. All bleeding points are meticulously ligated with  0000 silk (figure 6). T e full thickness of the cyst wall 1s approximated  to the full thickness of the duodenal incision, using interrupted 0000 silk  sutures (figure 7). T rough the duodenal incision, adequate exposure of  the ampulla of Vater can be obtained. If a sphincterotomy is considered, a  small probe or French woven whistle-tip catheter, No. 10 or No. 12 French,  is passed through the papilla of Vater into the duct (figure 8).T e patency  of the common bile duct as well as the pancreatic duct is determined. Con-  trast medium is injected in a search for calculi or area of stenosis, as well as  documentation of the size of the ducts. T e superior margins of the ampulla  are grasped by straight mosquito forceps. T ese clamps are placed in an  anterolateral position to avoid injuring the pancreatic duct which enters on  the medial side (figure 9). A full thickness of tissue between the clamps  can be excised for a biopsy. T e contents of the clamps are oversewn with  fine atraumatic sutures.    repeated until the opening is the approximate size of the common duct.  Because of the wide range in the length of the intramural course of the  ducts, the length of the incision will vary from 6 to 10 mm. T e opening  must be free of constriction when tested with a catheter or Bakes dilator. It  is absolutely essential that one or more figure-of-eight stitches be taken in  the apex of the incision to avoid duodenal leakage at this point.   T e avascular septum between the lower end of the pancreatic duct  and the common duct is divided after the introduction of a small catheter  into the pancreatic duct. T e septum should be divided in patients who  have had recurrent pancreatitis (figure 10). After hemostasis has been  obtained and an adequate f ow of bile observed upon compressing the gall-  bladder, the pancreatic duct likewise is probed. T e septum between the  common bile duct and the pancreatic duct may be divided if stenosis is  present. A biopsy of tissue is taken from the ampulla and ductal walls at  the time of the sphincteroplasty. After the patency of the ducts has been  determined, the full thickness of the cyst wall and the full thickness of the  duodenum are approximated with interrupted 0000 delayed absorbable  suture as inverting sutures (figure 11). T eseromuscular layer of the duo-  denum is approximated to the cyst wall in order to provide the outer layer  of the two-layer anastomosis (figure 12). T is layer is carried well beyond  the margins of the interior anastomosis in order to prevent tension on the    DETAILS OF PROCEDURE Pseudocysts of the body and tail  of the pancreas usually are drained most easily by transgastric cystogastros-  tomy (figure 13). T elesser sac is explored carefully to determine where the  posterior stomach wall is adherent to the pancreas. T is can be done either  above the lesser curvature or by separating the greater omentum from the  mid-transverse colon for a short distance. As shown in figure 14, the field 1s  walled off with gauze pads, and guide sutures are placed in the anterior wall of  the stomach over the most prominent portion of the palpated cyst and where  the cyst 1s most adherent to the stomach. An incision is made in the anterior  gastric wall parallel to the blood supply. T e margins of the gastrotomy are  grasped with noncrushing clamps for exposure as well as hemostasis.   T e cyst is localized by partial aspiration through the posterior wall  of the stomach at the point where the cyst and stomach are intimately  attached. Aspiration confirms the diagnosis and provides a specimen of  the cyst fuid for culture as well as amylase and electrolyte determination  (figure 15). At this point, operative cystography can be performed to deter-  mine the size and extent of the cyst. T e mucosa of the posterior wall of the  stomach is grasped gently with fine-toothed forceps by the surgeon and the  assistant, and the full thickness of the posterior wall of the stomach and  the full thickness of the cyst wall are then incised (figure 16) as a wedge  biopsy. T e contents of the cyst cavity are then aspirated with suction. T e    interior of the cyst is explored with the index finger, and biopsy of the cyst  wall performed. All bleeding points are ligated with 0000 silk or absorbable  sutures and a full thickness biopsy of the cyst wall must be taken to rule  out any malignancy. Firm attachment between the cyst wall and stomach is  essential rather than dependence upon suture approximation. All bleeding  points should be suture ligated. A one-layer anastomosis using interrupted  00 or running 00 nonabsorbable sutures is performed (figure 17a). It is  imperative that the full thickness of the stomach as well as the full thickness  of the cyst wall be included in each suture (figure I7b).   Upon completion of the cystogastrostomy anastomosis, the gastrotomy  is closed in two layers, using an inner layer of absorbable sutures and an  outer layer of interrupted 00 horizontal mattress sutures (figure 18). Cho-  lecystectomy may be performed in good-risk patients with calculi, as may  operative cholangiography.   CLOSURE T e abdomen is then closed in the usual manner.   POSTOPERATIVE CARE Nasogastric suction is maintained until gastro-  intestinal function resumes. Frequent blood amylase determinations are  made. T e initial liquid diet is advanced as tolerated; however, frequent    INDICATIONS Drainage of the pancreatic duct by anastomosis to the jeju-  num may be indicated in the treatment of symptomatic chronic recurrent  calcific pancreatitis. Before this procedure is carried out, all stones from  the biliary tract should be removed by cholecystectomy and choledochos-  tomy. T ere should be evidence of free drainage of bile through the papilla  of Vater into the duodenum. Decompression of the obstructed pancreatic  duct should be considered because of recurrent or persistent pain and  evidence of progressive destruction of the pancreas.    PREOPERATIVE PREPARATION All too often, these patients are addicted  to alcohol and/or narcotics because of persistent pain. Evidence of advanced  pancreatic disease may be diabetes, steatorrhea, and poor nutrition. T e  entire gastrointestinal tract should be surveyed with barium studies or endos-  copy. T e pancreatic and biliary systems are evaluated with endoscopic ret-  rograde cholangiopancreatography (ERCP) and with dye study of both duct  systems. Stones in the gallbladder or the common duct should be suspected,  and ulceration of the duodenum is not uncommon. Evidence for or against  gastric hypersecretion should be determined by secretion studies. T e stools  should be examined to determine the degree of pancreatic insufficiency, inso-  far as fats are concerned. Particular attention should be given to restoring the  blood volume and controlling existing diabetes. Blood calctum and phospho-  rus levels should be determined to rule out a parathyroid adenoma.    POSITION T e patient is placed supine on the table that is positioned for a  cholangiogram or pancreatogram.    OPERATIVE PREPARATION T e upper abdomen is prepared in the usual  manner.    INCISION AND EXPOSURE A curved incision following the costal mar-  gin on the left and extending across the midline around to the right or a  long midline incision, which may extend below the umbilicus on the left  side, may be used. An upper midline incision may be used.    DETAILS OF PROCEDURE T e stomach and duodenum should be evalu-  ated thoroughly for evidence of an ulcer. Likewise, the gallbladder should    be palpated carefully for evidence of stones, and the size of the common  duct determined. In the presence of stones the gallbladder is removed and a  cholangiogram is taken through the cystic duct. A small amount of contrast  medium (5 mL) is first injected to avoid a dense shadow, which may hide  small calculi in the common duct. Sufficient contrast medium should be  injected subsequently to determine the patency of the papilla of Vater by  visualization of the duodenum. It is advisable to carry out a Kocher maneu-  ver to palpate the head of the pancreas, especially if there is radiographic  evidence of an enlarged C-loop. Under such circumstances, needle aspira-  tion may be carried out to search for evidence of a pancreatic cyst. T e  omentum, which is often quite vascular, is freed in the usual fashion from  the transverse colon across to the region of the splenic flexure. T e lesser  sac may be obliterated, and sharp dissection may be required to separate  the adhesions between the stomach and the pancreas that may be due to  chronic pancreatitis. T e stomach should be freed until the entire length of  the fibrotic and lobulated pancreas can be explored easily (figure 1). T e  transverse colon is returned to the peritoneal cavity, while the stomach 1s  retracted upward with a large S retractor. T e posterior wall of the antrum  should be freed from the pancreas so that the pancreatic duct can be pal-  pated and opened as far to the right as possible to remove any calculi that  might be impacted in the duodenal end (figure 2). After the lobulated  fibrotic pancreas has been exposed clearly, an ef ort is made to identify the  location of the pancreatic duct by needle aspiration (figure 1). Occasion-  ally, it is desirable to aspirate pancreatic juice from the dilated pancreatic  duct and then to inject a limited amount of contrast medium to ensure  x-ray visualization of the pancreatic duct. Evidence of calculi in the duct  is obtained as well as evidence to indicate whether the papilla of Vater is  blocked or patent.   If there is evidence of a large and obstructed pancreatic duct, decom-  pression is performed by anastomosing it to the jesunum. T e capsule of the  pancreas is incised directly over the needle (figure 3). T is is done with  a small scalpel or with an electrocautery unit. Some prefer the electrocau-  tery unit to control the bleeding; otherwise, the bleeding points need to be  grasped with fine forceps and ligated as the fibrotic pancreas overlying the  duct is divided.    DETAILS OF PROCEDURE A rather liberal incision is made  in the pancreatic duct and carried over toward the right side but not  up against the posterior wall of the duodenum, lest the pancreaticoduo-  denal vessels be divided and massive hemorrhage occur. A dilated pan-  creatic duct is usually encountered, and intermittent lakes or segmental  dilatations may be found (figure 4). As the pancreatic duct is divided,  the fibrotic margins are grasped by Allis forceps, and all bleeding points  are controlled (figure 4). An ef ort can be made to establish the patency  between the remaining segment of the pancreatic duct in the head of the  pancreas and the lumen of the duodenum through the papilla of Vater.  Frequently one or more calculi may need to be dislodged with a gallblad-  der type of scoop or small, fenestrated type of forceps commonly used to  remove ureteral calculi (figur e 4). Considerable time may be consumed in  clearing the major pancreatic duct of calculi. A French woven catheter can  be directed into the pancreatic duct to determine the patency of the papilla  of Vater (figure 5). Patency can be proved by distention of the duodenum  after an injection of saline. In case of doubt, it may be advisable to inject  contrast medium followed by a roentgenogram to visualize the remaining  short segment of the pancreatic duct.   Ordinarily, the pancreatic duct 1s opened for 6 to 8 cm, and a decision  then must be made as to the type of anastomosis that will be carried out:  the Roux-en-Y arm as in a jejunal “fishmouth” lateral anastomosis, full-  width side-to-side anastomosis, or implantation of the mobilized pancreas  into the lumen of the jejunal segment. T e jejunum is prepared for the  Roux-en-Y anastomosis by dividing it 10 to 15cm below the ligament of Tre-    itz (Chapter 31, figures 16—21). T e vessels in the mesentery of the upper  jeyunum are visualized, and several vascular arcades are divided some dis-  tance from the mesenteric border. T is permits mobilization of a sufficient  length of jeyunum to allow it to reach up into the region of the pancreas. An  opening is made in the mesocolon to the left of the middle colic vessels in  an avascular portion near the base of the mesentery. T e arm of the jeju-  num is then tested for length and is turned with the open end to the right  as well as to the left to determine which position of the mobilized jejunum  produces the least interference with the blood supply. Many procedures can  be followed in accomplishing the pancreaticojeyunostomy.    FIRST TECHNIQUE: LATERAL FISHMOUTH ANASTOMOSIS T e  antimesenteric border of the Roux limb may be opened with a cutting lin-  ear stapler stapling instrument. T e distance required is longer than that  for the opening in the pancreatic duct (figure 6). T is usually requires  two firings of the cutting linear stapler. Any active bleeding sites along the  stapled cut edge are secured with fine silk sutures (figure 7).   T e pancreas is anchored to the opened jejunum with one layer of  interrupted 00 silk or nonabsorbable sutures (figure 8). T ese sutures  go through the entire wall of the jejunum but through only the capsule of  the pancreas. T e full thickness of the fibrotic pancreatic wall down to the  opened pancreatic duct should not be sutured because there are numer-  ous intramural smaller ducts that would be blocked and then would deliver  pancreatic secretions into the peripancreatic tissue instead of to the intesti-    HIRST TECHNIQUE: LATERAL FISHMOUTH ANASTOMOSIS  T e open end of the jejunal arm is anastomosed over the opened pancre-  atic duct (figure 9). T e jejunum is anchored to the capsule of the tail of  the fibrotic pancreas just beyond the end of the incision into the duct, and  the full thickness of the jejunal wall is anchored to the cut margins of the  capsule of the pancreas throughout the full length of the opened pancreatic  duct. T e open (fishmouth) end of the jejunum may need to be tailored  from time to time, as outlined by the dotted lines (figure 9), to ensure a  sealed anastomosis around the duct. Again, only the capsule is included in  these sutures, and the fibrotic wall of the pancreas is left free to promote  drainage of the fine ducts, many of which are filled with small calculi. T e  anterior layer is also made with interrupted sutures, and the free end of the  jeyunum is anchored to the capsule with three or four additional sutures  toward the tail of the pancreas (figure 10). When the pancreas is shortened  and thickened, a splenectomy may be necessary to adequately mobilize the  pancreas and facilitate this anastomosis.    SECOND TECHNIQUE: FULL-WIDTH SIDE-TO-SIDE ANASTOMOSIS Some  prefer to close the end of the Roux-en-Y arm of jeyunum with two layers of  interrupted silk sutures (Chapter 31, figures 18 and 19) and anastomose the  jejunum to the pancreas in a manner similar to a lateral anastomosis of small  intestine (figures ll and 12). Only one layer of sutures is used, but they must  be placed accurately and close enough together to prevent subsequent leakage.   When the Roux-en-Y principle is used, the jejunum near the ligament of  Treitz is anastomosed to the arm of the jejunum going to the pancreas by an  end-to-side anastomosis (figure 13). T e free margin of the mesentery should  be secured by interrupted sutures (A) to the ascending jejunum to obliterate  any opening for the subsequent development of an internal hernia (figure 13).  T e opening in the mesocolon is closed about the jejunal arm.    THIRD TECHNIQUE: PANCREATIC IMPLANTATION WITHIN JEJUNUM  In addition to the previous procedures described, drainage of  the body and tail of the pancreas may be accomplished by implanting the  left end of the pancreas into the open end of the arm of jejunum that has  been brought up for a Roux-en-Y type of anastomosis.   When the pancreas is severely inflamed, small, and contracted, it may  be advisable to mobilize as much of the tail and body as possible and to  remove the spleen in anticipation of implantation into the jejunum. Once  the presence or absence of a dilated duct is confirmed by needle aspiration  and palpation (figure 14), the peritoneum is incised superior and inferior  to the body and tail of the pancreas, care being taken not to injure the infe-  rior mesenteric vein (figure 14). After the peritoneum has been incised,  the surgeon inserts his index finger behind the pancreas and can very easily,  by a backward and forward motion, free the posterior wall of the body and  tail of the pancreas from adjacent tissues. T e finger is inserted completely  around the pancreas, including the splenic artery and vein, which run along  the superior surface of the pancreas (figure 15). A rubber drain is passed    through this opening in order to provide gentle traction on the pancreas  for the dissection of the tail and exposure during the freeing of the remain-  der of the pancreas and the splenectomy (figure 16). T e gastrosplenic  ligament is divided, and the blood supply along the greater curvature of  the stomach is transfixed to the gastric wall with interrupted 00 sutures.  Alternatively, an ultrasonic dissector can be used to coagulate and divide  the short gastric vessels. Any attachments between the superior pole of the  spleen and the diaphragm are divided, and the spleen is mobilized well into  the wound. T e pedicle of the attachments between the inferior surface of  the spleen and the colon 1s likewise divided, as is the posterior splenorenal  ligament (see Chapter 90). T e blood supply to the spleen is divided and  ligated. T e vessels then are doubly ligated with 00 nonabsorbable liga-  tures (figure 17). In the younger age-groups, it is desirable to make every  ef ort to save the spleen because of the risk of subsequent sepsis. T e mobi-  lization of a chronically inflamed tail and body of the pancreas requires  ligation of numerous small blood vessels entering the major splenic blood    THIRD TECHNIQUE: PANCREATIC IMPLANTATION WITHIN JEJUNUM  T e tail and body of the pancreas, now freely mobilized, are  rotated toward the midline so that the courses of the splenic artery and  vein are clearly visualized (figure 18). T esplenic artery should be doubly  ligated and divided near its point of origin. It 1s advisable to remove the  artery from this point of ligature out to the tip of the pancreas. Likewise,  the splenic vein should be carefully dissected free of the adjacent pancreas  and doubly ligated very near its junction with the inferior mesenteric vein  (figure 18). After the artery and vein have been removed from the distal  half of the pancreas, the tail of the pancreas is stabilized with a suture or  Allis forceps, and the end of the pancreas is transected carefully until the  pancreatic duct is identified (figure 19). T e small amount of bleeding  that occurs can be controlled easily by compressing the pancreas between  the thumb and index finger, clamping the individual bleeding points, and  then ligating them with 0000 silk (figure 19). As soon as the pancreatic  duct is located, a probe is inserted into the duct (figure 20). T e duct  is usually a little nearer to the superior than to the inferior margin of the  pancreas. T e surgeon then grasps the pancreas with the thumb and index  finger and makes an incision directly down onto the probe, completely    exteriorizing the major pancreatic duct (figure 21). T e incision should  be carried medially, and soon the pancreatic duct will greatly enlarge. With  intermittent strictures and dilatations, there is a tendency of the duct to  form a chain of individual lakes. Multiple calculi may be encountered and  small calcifications noted in many small ducts within the wall of the fibrosed  pancreas. T e incision 1s carried from the tail of the pancreas downward as  near as possible to the medial border of the duodenum (figure 22). T is  is accomplished by stabilizing the pancreas with the left hand and inserting  scissors into the lumen of the duct and carrying the dissection medially  (figure 22). T e finger is inserted into the enlarged proximal portion of  the dilated duct, and any calculi are removed. A small probe may be intro-  duced into this area to determine whether or not there is free communica-  tion between the pancreatic duct and the duodenum through the ampulla,  but this is not absolutely necessary (figure 23). During the dissection the  fibrotic wall of the pancreas is grasped with multiple Allis forceps, usually  at the points of active bleeding. When these clamps are removed, the indi-  vidual points are carefully ligated with interrupted absorbable sutures. No  ef ort is made to approximate the wall of the duct and the fibrous capsule  so that free drainage from the smaller ducts will be possible.    THIRD TECHNIQUE: PANCREATIC IMPLANTATION WITHIN JEJUNUM  T e jejunum is held up out of the wound. By transillumina-  tion, the surgeon can study the vascular arcades and select more accurately  the blood vessels to be divided for mobilizing the arm of the jejunum to be  brought up to the pancreas (Chapter 31). T e jeyunum is divided at a point  10 to 15cm beyond the ligament of Treitz. A small opening is made in the  mesocolon to the left of the middle colic vessels, just over the ligament of  Treitz. T e jeyunum is pulled through this opening and measured along the  full length of the pancreas (figure 24). T e length of the pancreas from  just beyond the end of the opened duct to the end of its tail is marked, point  X, on the jejunum, by Babcock forceps placed on its antimesenteric border  (figure 24). T e tail of the pancreas will be drawn into the bowel lumen  and approximated to point X. Here the surgeon must be certain that there  is adequate jejunal length and that the mesenteric vascular pedicle will  reach easily without angulation. Traction sutures (A and B) of 00 silk are  placed on the superior and inferior borders of the capsule of the pancreas  (figure 25) to aid in pulling the tail to pomt X. T e Potts forceps are  removed from the open end of the jejunum and replaced by Babcock for-  ceps at the antimesenteric border. T e jeyunum is gently stretched between  the two Babcock forceps as the needles, with attached traction sutures A  and B, are introduced into the lumen of the bowel. During insertion the  needles are held parallel to the long axis of the holder with points backward  to ensure that the bowel wall is not punctured (figure 26a). At point X,  the needle is sharply retracted to puncture the wall and carry the suture  externally (figure 26b). Gentle traction is maintained upon these sutures  to aid in pulling the pancreas up into the jeyunum. When the pancreas 1s  completely encased inside the bowel, sutures A and B are tied together,  bringing the tail to point X (figure 27). T e opened end of the jejunum is  then circumferentially tracked down to the capsule with interrupted non-  absorbable 00 sutures. T e posterior row 1s placed first, beginning at the  mesenteric border and proceeding superiorly to the antimesenteric surface.    T e anterior row is also begun at the mesenteric border of the jejunum.  If the jejunal circumference is too small, the bowel may be longitudinally  incised to accommodate the girth of the pancreas (figure 27).   T e adequacy of the blood supply of the jejunum is repeatedly checked.  Intestinal continuity is established through a Roux-en-Y jejunojejunos-  tomy, beyond the ligament of Treitz, using two layers of fine nonabsorbable  sutures (figure 28). All free edges of the mesentery should be closed with  interrupted 0000 silk sutures, care being taken that the marginal blood  supply within the mesentery is not compromised. Before closure the blood  supply of the jejunum should be rechecked carefully. A few sutures are  taken to anchor the vascular margin of the mesentery to adjacent structures  to prevent its rotation and the formation of an internal hernia. T e window  in the mesocolon is also secured to the pancreatic arm of the Roux-en-Y.    CLOSURE If biliary tract surgery has been performed simultaneously, a  closed-system suction catheter made of Silastic is inserted in the foramen  of Winslow. If T-tube drainage of the common duct has been instituted,  the tube is brought out through a separate stab wound on the right side.  Drainage is unnecessary for the pancreaticojejunostomy itself. T e incision  is closed in a routine manner. In the presence of impaired nutrition, 1t may  be advisable to supplement the closure with retention sutures.    POSTOPERATIVE CARE Although varying degrees of pancreatitis can be  anticipated following this procedure, the postoperative course is surpris-  ingly mild. Blood amylase and sugar levels are determined and attention  given to the narcotic requirements. T ese patients tend to be addicted to  narcotics and may be difficult to sedate because of chronic alcoholism. Pan-  creatic enzyme therapy should be instituted, the diabetic tendency should  be regulated, and any previous addiction should be corrected, if possible,  before the patient is discharged from the hospital. An ulcer type of dietary  program should be followed, with a gradual return to amore liberal diet. m    INDICATIONS T e more common indications for resecting the body and  tail of the pancreas include localized adenocarcinoma in this area, islet cell  adenomas, cysts, and chronic calcific pancreatitis. T 1s procedure may be  the initial approach for total pancreatectomy for carcinoma of the pancreas.    PREOPERATIVE PREPARATION T e preparation is related to the preop-  erative diagnosis. If splenectomy is contemplated then vaccines for pneumo-  coccus, haemophilus influenza, and meningococcus should be administered  prior to the surgery.   T e patient with an insulinoma, suggested by repeated fasting blood  sugars of below 50 mg/dL, requires supplementary glucose by mouth or  intravenously at regular intervals for 24 hours preceding surgery and intra-  venously during surgery.   When an ulcerogenic tumor is suspected, the fluid and electrolyte bal-  ance should be corrected, particularly if there have been large losses of gas-  tric secretion or losses from enteritis. Serum gastrin levels may establish the  diagnosis, and the patient may require a total gastrectomy in the future. Every  effort should be made to localize one or more endocrine tumors by CT, MRI,  somatostatin scintigraphy, or selective arteriography and selective arterial  stimulation with either secretin (for gastrinoma) or calcium (for insulinoma).    ANESTHESIA General anesthesia with endotracheal intubation is used.  POSITION Supine position with the feet lower than the head.    OPERATIVE PREPARATION T e skin is shaved from the level of the nip-  ples well out over the chest wall and down over the abdomen, including the  flanks. T e skin is prepared in the routine manner.    INCISION AND EXPOSURE Either a long vertical midline or an extensive  curved incision parallel to the costal margins, as described for pancreatico-  duodenectomy (Chapter 88).    DETAILS OF PROCEDURE When the procedure is carried out for an  inflammatory lesion of the body and tail of the pancreas, a direct explo-  ration of this region is performed. When the procedure is carried out for  tumor, a thorough exploration of the abdomen, with particular reference to  the liver and the gastrohepatic ligament in the region of the celiac plexus,  should be made for evidence of metastasis. A possible microscopic diagno-  sis of adenocarcinoma is sought by biopsy before proceeding with a total  pancreatectomy from the left-side approach. Since the adenomas can be  distributed throughout the pancreas, the head of the pancreas must be  thoroughly explored by visualization and palpation preliminary to a defini-  tive type of procedure on the left half of the pancreas. Evidence of gastric  hypersecretion, as indicated by increased vascularity and thickening of the  gastric wall, along with a hyperemic and hypertrophic duodenum and an  ulcer in the duodenum or beyond the ligament of Treitz, adds support to  the potential diagnosis of gastrinoma tumor of the pancreas. Likewise, the  inner wall of the duodenum should be carefully palpated in the search for  small adenomas extending into the lumen of the duodenum from the pan-  creatic side. Finally, a sterile ultrasound probe for intraoperative scanning  of nonpalpable lesions is advocated by most surgeons.    After the abdomen has been explored and the region of the head of the  pancreas evaluated, the greater omentum is reflected upward, and down-  ward traction is maintained on the transverse colon as the omentum 1s sepa-  rated by sharp dissection and the lesser sac entered (figure 1). Usually, the  stomach is easily separated from the pancreas, but sharp dissection may be  required to separate it from the capsule of the pancreas, especially if there  have been repeated bouts of acute inflammation. Sharp as well as blunt  dissection is used to sweep the posterior gastric wall away from the pan-  creas, particularly in the region of the antrum, to make certain the middle  colic vessels have not been angulated upward and attached to the poste-  rior gastric wall. A clear view must be ensured of the entire pancreas and  the first part of the duodenum all the way over to the hilus of the spleen  (figure 1). To avoid troublesome bleeding, it is usually desirable to divide  the communicating vein between the right gastroepiploic vessels and the  middle colic vein inferior to the pylorus. T is permits better mobilization  in the region of the antrum. Large S retractors can be used to retract the  stomach upward as the transverse colon is either pulled downward outside  the wound or returned to the abdomen and packed away. T e pancreas  should be inspected thoroughly and palpated to verify the pathology. It is  safer and far easier to mobilize and remove the spleen rather than attempt  to separate the pancreas from the splenic artery and vein running along the  superior surface of the body and tail of this organ.   In carcinoma the tumor’ mobility and the presence or absence of regional  metastasis must be determined before a radical resection is planned. It is  less uncommon to find a resectable carcinoma involving the tail or body  of the pancreas. In insulinomas it is more common to find only one tumor;  this may be enucleated without removing a large segment of the pancreas,  depending on the adenoma’ location and relationship to the major pancre-  atic duct and vessels. Finding a solitary gastrinoma of considerable size may  tempt the surgeon to do a local excision only, followed by vagotomy, pylo-  roplasty, and proton pump inhibitor therapy postoperatively. Any enlarged  lymph nodes around the pancreas are excised for frozen section examina-  tion searching for evidence of metastases. For gastrinoma, the duodenum  must be opened and explored to search and remove a possible duodenal  primary lesion.   When the lesion cannot be seen or palpated by digital examination of  the anterior surface of the gland, the body and tail must be mobilized for  direct palpation with the thumb and index finger and for visualization of  the under-side of the pancreas. T is is accomplished by incising the peri-  toneum along the inferior surface of the pancreas (figure 2). Only a few  small blood vessels are encountered. T e inferior mesenteric vein should be  identified, and the incision should avoid it as well as the middle colic ves-  sels. After the inferior surface of the peritoneum has been incised, a finger  can be introduced rather easily underneath the pancreas, and the substance  of the gland can be palpated quite easily between the thumb and index fin-  ger (figure 3). As a matter of fact, the finger can be inserted completely  around the pancreas following the incision in the peritoneum just above the  splenic artery and vein. Finally, a hand-held ultrasound unit is very useful  in finding nonpalpable lesions within the pancreas.    DETAILS OF PROCEDURE In the presence of a tumor that  necessitates removal of the left half or all of the pancreas, steps should be  taken to mobilize and remove the spleen. T e splenic artery is doubly ligated  with 00 silk near its point of origin. T 1s tends to decrease the blood loss fol-  lowing manipulation of the spleen and permits blood to drain from this organ  into the systemic circulation during the subsequent steps of its removal. T e  left gastroepiploic vessel is doubly clamped and ligated, and the short gastric  vessels are then divided all the way up to the diaphragm. T e blood supply on  the greater curvature should be ligated by transfixing sutures that incorporate  a bite of the gastric wall to prevent hemorrhage if gastric distention should  occur and the ligature slip off the gastric side (figure 4). Alternatively, the  ultrasonic dissector can be used to coagulate and divide the short gastric  vessels. T e splenorenal ligament is divided as the surgeon pulls the spleen  medially with his left hand (figure 5). Blunt and sharp dissection may be  carried out to free the tail of the pancreas, but this is rather easily done by fin-  ger dissection as the organ is reflected medially (figure 6). T e left adrenal    and kidney are clearly visualized as well as a segment of the left renal vein.  T e inferior mesenteric vein is ligated and divided (figur e 6) at the inferior  border of the pancreas. T e splenic artery is divided near its point of origin  and ligated and then transfixed distally with double ties of 00 silk. T e splenic  vein 1s cleared and separated from the posterior surface of the pancreas and is  followed over to the point where it joins the superior mesenteric vein to form  the portal ven (figure 7). T e splenic vein is gently freed from the pan-  creas, using blunt-nosed right-angle clamps (figure 7). T e vessel is ligated  and is transfixed proximally to this tie to avoid any possible late hemorrhage.  T espleen and body of the pancreas can then be mobilized suf ciently to be  brought outside the peritoneal cavity.   T is approach is useful in performing a total pancreatectomy since  it ensures a good exposure for the identification of veins coming off  the medial aspect of the portal vein. T e superior surface of the portal vein  is free of venous tributaries. However, the resection may be restricted due to  involvement of the portal vein by adenocarcinoma.    DETAILS OF PROCEDURE After the spleen and the tail of the  pancreas have been mobilized outside the peritoneal cavity, the entire pancreas  is palpated once again for evidence of tumor involvement. T e pancreas can  be divided with electrocautery to the left of the portal vein or, if need be, even  to the right side of the portal vein, provided that a finger has been introduced  between the vein and the pancreas to free its anterior margin (figure 8).   T e surgeon usually finds it advisable to make multiple serial sections  of the pancreas in searching for additional adenomas and in determining  whether his line of incision is free of tumor. Frozen section consultations  may be obtained, although pancreatic tissue is dif cult to evaluate under  these circumstances, and the final diagnosis may have to be delayed until  the permanent sections have been made.   T ecut end of the pancreas is examined and the pancreatic duct 1s identi-  fied. T e pancreatic duct is closed with a 0000 nonabsorbable monofilament  suture (figure 9a). T e end of the pancreas is closed with interrupted over-  lapping 000 silk sutures of the mattress type (figure 9b). Additional sutures  are taken, particularly where there is persistent bleeding (figure 10). Alter-  natively, the pancreas may be divided and secured with staples using a linear  stapler.    CLOSURE A closed-system suction catheter made of Silastic is used to  drain the stump of the pancreas. T e drain is brought out either directly    through a stab wound in the midportion of the abdomen or to either side  through a separate stab wound incision. T e incision is closed in the rou-  tine manner.    POSTOPERATIVE CARE T e postoperative care is routine except for  repeated laboratory checks on the blood sugar and amylase levels. A mild  degree of pancreatitis may occur, and colloids and other solutions should  be given in adequate amount. A transient diabetic tendency may occur; on  the other hand, it is dif cult to determine in the immediate postoperative  period what effect the surgical procedure will have on total pancreatic func-  tion. Oral replacement of pancreatic enzymes may be indicated. Determi-  nation of amylase in the drain output is necessary prior to drain removal.  An amylase concentration less than serum is generally required for the  closed-suction drain to be removed.   When total pancreatectomy is planned, the pancreas is not divided  but used for traction as the head of the pancreas and the duodenum are  excised in the Whipple operation. Systemic symptoms associated with the  gastrinoma, a hormone-producing islet cell tumor, may be controlled par-  tially, but rarely completely, for years by resection of a solitary tumor. T ose  associated with other apudomas (vipoma, glucagonoma, insulinoma, and  so forth) may respond to local excision in the absence of malignancy and  metastases.    INDICATIONS Laparoscopic resection of the body and tail of the pancreas  is limited to certain pancreatic neoplastic diseases including pancreatic  neuroendocrine tumors such as insulinomas, pancreatic cystic neoplasms,  and pseudopapillary tumors. T e approach is not recommended for chronic  calcific pancreatitis. For adenocarcinoma of the body and tail of the pan-  creas, splenectomy should be performed. Splenic preservation 1s recom-  mended and should be attempted in the absence of a malignant neoplasm.    PREOPERATIVE PREPARATION T ¢ preparation 1s related to the preopera-  tive diagnosis. As splenic preservation 1s not always possible, it is recommended  to vaccinate the patient 2 weeks prior to the surgery against encapsulated organ-  isms including pneumococcus, haemophilus influenza, and meningococcus.    POSITION A cushioned beanbag should be placed on the operating table  prior to bringing the patient into the room. After insertion of a bladder  catheter, the patient should be positioned in a partial lateral position at  about 45 degrees with the left arm crossing the chest and supported on an  arm board or pillows (figure la). T eright arm is placed on an arm board  and an axillary roll is used. Liberal padding is used between and around  both arms. T e abdomen and flank area should be exposed. T e left knee is  flexed, with a padding of blankets or pillows between the legs. Alternatively,  the patient may be positioned in a modified lithotomy position, also using  a cushioned beanbag and taking care not to flex the thighs excessively so as  to avoid interference with the range of motion of the instruments.    OPERATIVE PREPARATION Hair removal is accomplished with skin clip-  pers from the level of the nipples well out over the chest wall and down over  the abdomen, including the flanks. T e skin is prepared in the routine mannet.    INCISION AND EXPOSURE T e surgeon stands on the patient’ right side  similar to a laparoscopic left adrenalectomy (figure la).T e camera opera-  tor stands to the right of the surgeon and the assistant on the left side of the  patient. If the modified lithotomy position is employed, the surgeon is posi-  tioned between the legs and the camera operator to the patient’ right and  the assistant to the patient’ left. Port placement is shown in figure lb. A  10-mm 30-degree laparoscope is placed above the umbilicus using the open  technique of Hasson as described in Chapter 11. T e abdomen is insufflated to  15mm Hg pressure. T e laparoscope is introduced and all four quadrants of  the abdomen are examined for metastatic disease. Two 5-mm ports are placed:  one in the midline and one to the left side midway between the umbilicus  and the xiphoid process at the midclavicular line. T e ports are place about  5to 8 cm apart in the craniocaudal orientation to permit bimanual operation  without physical restriction. A 10—12 or 15-mm port is placed on the left side  at the level of the umbilicus in the anterior axillary line. An additional 5-mm  port 1s placed just below the right subcostal margin in the midclavicular line.  A 15-mm port is required for an endoscopic stapler with 4.8-mm staples that  may be used to divide a thicker pancreas, whereas a stapler with 3.8-mm sta-  ples or less will be able to be introduced through a 12-mm port.    DETAILS OF PROCEDURE T e stomach 1s grasped with an atraumatic lap-  aroscopic clamp and retracted superiorly. T e lesser sac is then entered using  a harmonic scalpel to divide the omentum along the greater curvature of the  stomach (figure 2). T e opening in the lesser sac should be generous and  allow exposure of the body and tail of the pancreas. T e lateral extent of the  incision is carried to the level of the short gastrics. T e short gastric vessels are  not divided when planning splenic preservation. Medial exposure 1s essential;  therefore, the opening in the omentum is carried to the right gastroepiploic  vessels. Sharp as well as blunt dissection is used to sweep the posterior gas-  tric wall away from the pancreas, particularly in the region of the antrum, to  make certain the middle colic vessels have not been angulated upward and  attached to the posterior gastric wall. T e surgeon must ensure a clear view  of the entire pancreas and the first part of the duodenum all the way over to  the hilus of the spleen (figur e 2). To avoid troublesome bleeding, it is usually  desirable to divide the communicating vein between the right gastroepiploic  vessels and the middle colic vein inferior to the pylorus. T is permits better  mobilization in the region of the antrum. T e pancreas should be visually  inspected to identify the pathology. Intraoperative ultrasound may be helpful.   T eoperation will be carried out in a medial to lateral direction, as opposed to  the lateral to medial direction for an open distal pancreatectomy as shown in the  preceding Chapter 86. An incision is made in the peritoneum along the inferior  border of the body and tail of the pancreas (figur e 2). Gentle dissection along  the neck of the pancreas will expose the superior mesenteric vein and the por-  tal vein (figure 3). T e splenic vein is identified. An incision is then made  along the superior edge of the pancreas to the left of the gastroduodenal artery    Resection of the Tail of the Pancreas with  Splenic Preservation, Laparoscopic    and inferior to the hepatic artery. A plane between the portal vein and the neck  of the pancreas is created by gentle blunt dissection in the inferior to superior  direction with a blunt nose laparoscopic dissector (figure 4). Once the open-  ing is complete and the blunt-tipped dissector can be seen protruding from the  superior edge of the pancreas, a half-inch Penrose drain shortened to 12 cm is  placed into the abdominal cavity through the 12- or 15-mm port. It isthen passed  underneath the neck of the pancreas and the ends are secured with an endoloop  (figure 5). T is will allow anterior traction of the pancreas, which is essential  to dissecting the plane along the superior mesenteric vein and the neck of the  pancreas, and will also facilitate mobilization of the splenic vein away from  the proximal body of the pancreas. T e assistant grasps the Penrose drain and  pulls it superiorly and anteriorly. T e surgeon then begins to gently dissect the  mesenteric vessels and portal vein away from the neck. T e splenic vein will  come into view, and prior to division of the pancreas, small branches of the  vein are divided with the ultrasonic dissector and larger branches are clipped.  T is dissection is carried out in the medial to lateral direction for 2 to 3. cm. It  may be necessary to place a shortened vessel loop around the splenic vein to  provide countertraction and proximal vascular control. Once 2 to 3cm of the  vein has been dissected free, the neck of the pancreas is divided. T 1s is accom-  plished with a reticulated endoscopic stapling device with 3.8- or 4.8-mm sta-  ples. T e staple line may be reinforced with a commercial material (figure  6). Both the proximal and the distal staple lines are inspected for bleeding,  and if bleeding is found, it is controlled with electrocautery or the ultrasonic  dissector. T e Penrose drain may be removed at this point, as retraction of the  pancreas may be obtained by grasping the distal staple line. Once the pancreas  is divided, the body of the pancreas is retracted superiorly (figure 7). T is  will permit the branches of the splenic artery to be divided. T e splenic artery  will come into view superior to the splenic vein. Small braches of the splenic  artery are then divided with the ultrasonic dissector and larger branches are  clipped. (figure 7). Asecond shortened vessel loop may be passed around the  splenic artery in order to provide counter traction as well as proximal vascular  control. Once the branches of the proximal splenic artery are divided, the  remaining branches of the splenic vein are ligated. T e distal pancreas is pulled  downward to further expose the splenic artery (figure 8). T e branches of  both the artery and the vein are very fragile and unavoidable avulsion will  occasionally occur. For small branches, bleeding may be controlled with pres-  sure. Larger branches should be grasped with a Maryland dissector to control  the bleeding and then clipped if there is suf cient length or ligated with a 4-0  or 5-0 monofilament suture if their length is insuf cient. T e peritoneum is  further divided along the inferior edge of the pancreas. T e posterior margin  of the dissection will be the splenic vein and artery. T e proximal jejunum may  be seen and should be retracted inferiorly. Defects in the mesocolon should be  closed with sutures to prevent internal hernias. T e peritoneum is also divided  along the superior edge of the pancreas with the ultrasonic dissector. As dis-  section proceeds, the vein will next be seen as it exits the splenic hilum. Shortly  thereafter, the artery will be seen entering the spleen. T e distance between the  end of the tail of the pancreas and the spleen is variable. T e final attachments  are divided with the harmonic ultrasonic dissector. T e specimen is extracted  from the abdominal cavity using a specimen retrieval bag or similar device  (figure 9). It is removed from the abdominal cavity from the umbilical port.  Once it is removed, the abdomen is reinsufflated and the lesser sac exposed to  permit inspection of the splenic artery and vein for bleeding. If vessel loops  have been used, they are removed at this point.    CLOSURE T especimen should be examined to determine that the pathol-  ogy has been removed. A frozen section at the margin should be obtained  for pancreatic cystic tumors and intraductal mucinous neoplasms. A  closed-suction Silastic drain may be placed by passing the external portion  of the drain through the 12- or 15-mm port and withdrawing from one of  the 5-mm port sites. T e 12- or 15-mm port site is closed with #1 absorbable  suture. T e umbilical port site is closed with #1 absorbable suture.    POSTOPERATIVE CARE A nasogastric tube is not necessary. Crystal-  loids should be given in an adequate amount. Pain management will require  intravenous narcotic analgesics for 1 to 2 days. Antibiotics are discontinued  within 24 hours. Glucose monitoring should be performed as a transient dia-  betic state may occur. T e hemoglobin and electrolytes should be checked on  the first postoperative day and repeated as deemed necessary by the clinical  course. An initial postoperative diet may be started on the first postoperative  day. T e drain amylase should be measured prior to removing the closed-suc-  tion drain. T e drain should not be removed if the amylase 1s greater than two  times the upper limit of normal. Supplemental pancreatic enzymes are usually  not necessary. T e patient is discharged when tolerating a diet. m=    INDICATIONS T echead of the pancreas is usually removed for malignancy  involving the ampulla of Vater, the lower end of the common duct, the head  of the pancreas, or the duodenum. With increasing frequency, Whipple is  indicated for the risk of malignancy associated with the presence of a cys-  tic neoplasm with worrisome features. Far less frequently, the procedure  is carried out to manage intractable pain associated with a chronic calcific  pancreatitis or for massive trauma when there has been irreparable “burst”  damage to the head of the pancreas, the ductal structures, and the duode-  num. In the presence of malignancy, the resection 1s indicated in the absence  of proven metastases and if the tumor is of such a limited size that the por-  tal vein is not involved beyond the ability of the surgeon to accomplish a  safe vascular resection and repair. Total pancreatectomy may be considered  in some cases due to central location of a malignant tumor or extensive  main duct involvement by papillary mucinous epithelium (IPMN). While,  total pancreatectomy decreases the incidence of postoperative complica-  tions related to the leakage of pancreatic Juice from an anastomosis, the  subsequent endocrinopathy can be profound. T e patient should be made  aware of the problem of diabetes mellitus after operation as well as the need  for daily pancreatic enzyme replacement.    PREOPERATIVE PREPARATION Patients will have had imaging includ-  ing CT, MRI, and possibly endoscopic ultrasound prior to the procedure.  Some patients may have had biliary stents placed by an endoscopic or  transhepatic route. T e electrolyte levels should be returned to normal  and particular care should be taken that the INR is normal and that renal  function is not impaired, as shown by creatinine and blood urea nitrogen  levels. Patients with jaundice may have occult vitamin K deficiency that  may not become apparent until blood loss occurs. Unexpected blood loss  can be substantial so blood should be available for transfusion as needed,  preferably via a central venous catheter. It is advisable to have a catheter  in the bladder in order to follow the postoperative hourly output of urine.  Antibiotic therapy should be started prior to operation. T is 1s particularly  important for patients with stents, as they are prone to wound infections.    ANESTHESIA <A nasogastric tube is inserted. General anesthesia with  endotracheal intubation is recommended.    POSITION T e patient is placed supine on the table with the feet slightly  lower than the head. Facilities should be available for performing a cholan-  glogram or pancreaticogram.    OPERATIVE PREPARATION T e skin should be shaved from the level  of the nipples well out over the chest wall and down over the abdomen,  including the flanks.    INCISION AND EXPOSURE Diagnostic laparoscopy is indicated in some  patients to identify metastatic disease that may have been missed by preop-  erative imaging. Pancreaticoduodenectomy for pancreatic or periampullary  adenocarcinoma should not be performed if there are liver or peritoneal  metastasis. A type of incision should be selected that will ensure the extensive    and free visualization of the upper abdomen, especially on the right side.  While an upper midline (figure la) incision that may extend below the  umbilicus is useful, many prefer an oblique or curved incision that parallels  the costal margins (figure lb). When the xiphoid is long and the xipho-  costal angle narrow, further exposure may be obtained by excision of the  xiphoid process. On the other hand, very good exposures can usually be  obtained by the oblique or curved incision, first carried out over the right  upper quadrant and then extended across the midline and as far to the left  as the surgeon believes necessary to ensure a liberal exposure. All bleed-  ing points must be carefully controlled to keep blood loss at a minimum,  especially in jaundiced patients. Regardless of the type of incision used, the  round ligament is divided (figure 2). T e contents of the curved clamps  must be securely ligated or divided with an energy device to avoid bleeding  from a vessel in the round ligament. Further mobility of the liver can be  obtained if the falciform ligament is divided well up over the dome of the  liver but is often not necessary (figure 2). After the falciform ligament has  been divided, a self-retaining retractor can be inserted.    DETAILS OF PROCEDURE T e type, location, and extent of the patho-  logic process now must be determined by thorough exploration. Evidence  of metastatic spread to the peritoneum, liver, the lymph nodes around the  celiac axis, and the region above the pancreas, as well as in the hepatoduo-  denal ligament, should be sought by careful exploration.   Initial determination of resection begins with mobilization of the duode-  num and head of the pancreas by the Kocher maneuver (figure 3).T eduo-  denum is grasped with one or more Babcock forceps and retracted medially  as the peritoneum along the lateral wall of the duodenum is incised. Usu-  ally, it is not necessary to ligate vessels in this area; in the presence of jaun-  dice; however, it is advisable to carry out a meticulous hemostasis. Finger or  gauze dissection is used to push the posterior wall of the pancreas from the  underlying vena cava and right kidney. An avascular cleavage plane can eas-  ily be developed (figure 4). A column of peritoneum that remains forms  the lower boundary of the foramen of Winslow (figure 5).T e surgeon can  place this column of peritoneum under tension by inserting the index and  middle fingers on either side of the peritoneum and should incise it very  carefully, avoiding injury to the underlying vena cava. In the presence of  recurrent ulceration in the region of the second part of the duodenum, con-  siderable scarring and fixation in this area may be encountered. Attention  should be paid to avoid injury to an aberrant right hepatic artery, if present,  traversing the posterior hepatoduodenal ligament from the superior mesen-  teric artery.   After the posterior wall of the duodenum and head of the pancreas have  been inspected carefully for evidence of tumor or metastatic involvement,  further freeing of the second or third part of the duodenum is indicated  to determine whether the lesion is operable. Care should be exercised  in sweeping away the middle colic vessels that, surprisingly enough, fre-  quently cross to the hepatic flexure of the colon high up over the second  part of the duodenum (figure 6).    DETAILS OF PROCEDURE T e gallbladder, antrum of the  stomach, head of the pancreas, and duodenum have been separated to call  attention to the various relationships, including the blood vessels that must be  ligated in this procedure. T ese structures are numbered for convenient iden-  tification. T e gallbladder is rendered nonfunctional so is routinely removed.  To ensure adequate lymphadenectomy of the hepatoduodenal ligament, the  common hepatic duct should be divided just below the confluence, well  above the cystic duct junction. T e common hepatic artery and its branches  must be identified carefully. T e right gastric artery may be divided, even  when pylorus preservation is planned. T e gastroduodenal artery (GDA) is  controlled with suture ligatures after test occlusion assures that distal hepatic  artery flow is not dependent upon collateral flow arising from the SMA. Once  the GDA 1s divided this gives access to the region of the portal vein just above  the neck of the pancreas. Since no vessels enter at the anterior surface of the  portal vein, this is the logical point for dividing the head of the pancreas from  the body and tail. A number of pancreatic veins enter at the lateral border of  the portal vein opposite the point where the splenic vein joins the superior  mesenteric to form the portal vein. T e middle colic artery and vein should  be preserved but the vein may be safely divided in most cases, if necessary, for  exposure of the superior mesenteric vein.   Before the blood supply of the head of the pancreas is compromised, the  antrum of the stomach is transected, using the landmarks for hemigastrec-  tomy (see Chapter 24). If a pyloric-sparing anastomosis is planned, the first    portion of the duodenum is divided. Otherwise, the antrum is transected.  Either of these divisions provides a direct approach to the pancreas in the  region of the portal vein.   T e pancreatic duct varies in size, depending on the amount of obstruc-  tion that may have occurred as a result of a prolonged block by calculi or  tumor formation. If it is quite small, direct implantation of the duct may  not be possible, and direct implantation of the tail of the pancreas into the  lumen of the jejunum or back of the stomach can be carried out. Usually,  there is one blood vessel that needs to be ligated above the pancreatic duct  in the substance of the gland and two below.   Since marginal peptic ulceration may occur in a prolonged survival,  the ability of the stomach to produce acid may be controlled with truncal  vagotomy and by removing the entire antrum of the stomach. T e latter can  be accomplished by hemigastrectomy, selecting as the point of division the  stomach at the level of the third vein on the lesser curvature and the point  on the greater curvature where the epiploic vessels are nearest the gastric  wall (see Chapter 24). Patients should routinely be treated with lifelong  acid-reducing medication.   One of the most difficult parts of the procedure 1s the freeing of the third  part of the duodenum, because of the short mesentery in this area. A portion  of the upper jejunum should be resected along with the duodenum to ensure  free mobilization of the upper jejunum, which is to be brought through the  opening in the mesentery to the right of the middle colic vessel.   2. Duodenum  3. Pancreaticoduodenal artery and vein: (a) Superior (b) Inferior  4. Right gastroepiploic artery and vein  5. Right gastric artery    DETAILS OF PROCEDURE When the second and third parts  of the duodenum are well mobilized, the surgeon may or may not have  proved the presence and the extent of a tumor. Additional information can  be obtained by palpating the head of the pancreas between the thumb and  index finger (figure 7). It should be remembered that pancreatic lesions  are occasionally found extending into the wall of the duodenum on the  inner curvature side. T e presence of a tumor involving the lower end of  the common duct, and particularly ulceration with tumor involvement in  the region of the ampulla of Vater, may be verified by palpation. A major  concern when a tumor is felt or visualized is to determine whether it is a  benign or malignant lesion and whether the portal vein is involved. Unless  the surgeon is skilled in potential resection and repair of the portal vein,  there should be good evidence that the tumor does not extend into or  about the portal vein before deciding to proceed with the radical extirpa-  tion of the head of the pancreas.   It is not unusual to have considerable difficulty in proving the presence  or absence of a malignant tumor deep in the head of the pancreas that is  producing an obstructive jaundice. A surgeon is often reluctant to mobilize  the head of the pancreas adequately and to carry out a biopsy to prove the  presence of tumor because of potential complications, such as hemorrhage  or a pancreatic fistula and because of the poor accuracy of frozen section in  dif erentiating between adenocarcinoma and chronic pancreatitis. A trans-  duodenal needle biopsy is utilized by some to obtain sufficient material for  frozen-section diagnosis. Proof of the diagnosis may not be possible before  proceeding with pancreaticoduodenectomy. T e surgeon must use his  judgment to establish a reasonable diagnosis based on the gross findings. If    the lesion is not resectable and definitive diagnosis was not obtained preop-  eratively, then microscopic proof of cancer diagnosis is required. Biopsy of  a mass in the head of the pancreas should be undertaken using a Tru-Cut  needle via a transduodenal approach (figure 8). Careful guidance with  the tumor in hand should prevent inadvertent puncture of retropancreatic  structures. T e puncture site in the duodenum can be oversewn with a fig-  ure-of-eight or purse-string suture.   Next, the surgeon should proceed with further mobilization of the pan-  creas by entering the lesser sac (figure 9). T eomentum is retracted upward  and the incision made into the lesser sac for more thorough evaluation of  potential metastases above the pancreas and about the region of the celiac  axis. Since some tumors of the pancreas are multiple, it is important that the  entire pancreas be visualized and palpated, especially if a diagnosis of gas-  trinoma has been considered. It is usually advisable to open the lesser sac  completely by freeing the omentum from the underlying transverse colon all  the way over to and including the region of the splenic flexure of the colon  (figure 10). It should be kept in mind that the blood vessels to the colon may  be angulated upward and attached for several centimeters to the undersurface  of the omentum. T e incision, therefore, should be made several centimeters  away from the visualized bowel wall, as shown in figure 10. It may be neces-  sary to free the spleen, especially during the exploration of the pancreas for  islet cell adenomas. Next, the surgeon explores the structures above the first  part of the duodenum (figure 11). T e contents of the enlarged gallbladder  can be aspirated if exposure is limited. T e peritoneum 1s incised over the  superior border of the duodenum, which is an initial step in isolating the  common duct from the adjacent vascular structures.    DETAILS OF PROCEDURE Mobilization of the superior part  of the duodenum is continued in an ef ort to isolate as long a segment of  the common duct as possible. T is can be accomplished by gently spread-  ing a right-angle clamp about the dilated common duct and meticulously  controlling all bleeding (figure 12).   An ef ort should be made to free this portion of the common duct com-  pletely and it is encircled with a vessel loop. T e surgeon can then palpate  behind the duodenum with the index finger in an ef ort to develop a cleav-  age plane between the duodenum and portal vein, and at the same time to  determine more accurately whether there is fixation by the tumor to this  vein. Once the surgeon is sure that resection 1s safe without injury to the por-  tal vein, he or she proceeds to ligate the blood supply necessary for antrec-  tomy. T e right gastroepiploic vessels should be ligated and tied (figure 13).  Following this, the antrum can be encircled with tape, gentle medial and down-  ward traction 1s applied to the stomach, and the right gastric vessels are identi-  fied (figure 14). An alternate procedure that saves the antrum and pylorus  may be chosen at this point. T e duodenum 1s transected a few centimeters  beyond the pylorus and later anastomosed, as shown in figure |Sand l6a.   It is helpful to insert a straight clamp above the duodenum and  spread the clamp parallel to the small right gastric vessels in order to  better define the vascular pedicle to be divided (figure 14). In the stan-  dard whipple procedure the antrum is resected. T e stomach 1s there-  fore divided as shown in figure 15. In the illustration the antrum is  resected prior to the duodenum and head of the pancreas (figure 16). It    may be resected en bloc with the duodenum and head of the pancreas  (figure 15). If there is a question about resectability, the division of the  stomach should be deferred until the plan is established between the rest  of the pancreas and the portal vein. Since peptic ulceration is one of the  late complications following radical amputation of the head of the pan-  creas and duodenum, it is essential to control the acid-producing ability of  the remaining stomach. T is can be accomplished by use of proton pump  inhibitors or other medications to suppress acid production after surgery  or by truncal vagotomy and hemigastrectomy, which ensures complete  removal of the antrum. T is is accomplished if the resection includes all of  the stomach distal to the third vein on the lesser curvature and the area on  the greater curvature where the gastroepiploic vessels are nearest the gastric  wall. Some prefer to add vagotomy to the hemigastrectomy. Others pre-  fer to conserve the entire stomach, including the pylorus and a short seg-  ment of the duodenum without vagotomy. T e usual reconstruction after a  pylorus-sparing Whipple procedure is shown in figure loa. An area the  width of the index finger should be cleared on either curvature to prepare  for the anastomosis after the blood supply has been controlled (figure 16).  T e linear cutting stapler is applied adjacent to the traction sutures, which  are left in place to define the areas prepared for anastomosis (figure 16).  T e removal of the antrum greatly assists in the subsequent exposure of  the more difficult portion of the resection. Most surgeons now use a linear  stapling instrument or a cutting linear stapler with deeper gastric staples. A  truncal vagotomy is sometimes performed (Chapter 23).    DETAILS OF PROCEDURE If there is oozing between the sta-  ples, it is controlled by interrupted sutures of 0000 silk. T e upper half of  the approximated gastric outlet is inverted by a layer of interrupted 00 silk  mattress sutures (figure 17). A sufficient length of the gastric outlet near  the greater curvature is retained to provide a stoma approximately two to  three fingers wide. T is portion of the gastric wall should not be excised  until the final steps of the anastomosis, although it may be necessary to  apply several sutures along the line of the clips to control oozing.   A very critical point now involves the identification of the common  hepatic artery and the gastroduodenal artery, which runs downward over  the pancreas behind the duodenum (figure 18a). T e common hepatic  artery may be located by palpation just above the pancreas. T e peritoneum  over it 1s carefully incised and this major artery clearly visualized in order  to avoid its injury. By careful dissection, the surrounding tissue is separated  until the origin of the gastroduodenal artery is visualized. T is vessel must  be identified clearly and doubly ligated (figure 18b). T e lumen of the  common hepatic artery must not be encroached upon. T e tissues about  the right gastric artery also must be freed gently and separated upward, as  shown by the dotted line (figure I8b). Following the ligation of these two  vessels, blunt dissection with a long right-angle clamp may be undertaken  to further free the region of the common duct and portal vein (figure 19).  Since these patients are often rather emaciated, there is relatively little tissue  to be separated away from the portal vein. Great care should be taken gen-  tly to develop a cleavage plane over the portal vein, which will permit the  surgeon to introduce carefully a blunt-nosed clamp, such as a right-angle  clamp, behind the pancreas and to open and close the clamp as the tissues    are separated from the underlying portal vein. It may be safer and easier  for the surgeon to introduce the index finger directly behind the pancreas  and over the portal vein. Considerable time should be spent in manipulat-  ing the pancreas of the portal vein. T 1s can be done since no vessels enter  from the anterior surface of the portal vein. T e tissues about the inferior  surface of the pancreas may need to be incised so that the finger can be  introduced completely underneath the pancreas and come out inferiorly  near the region of the middle colic vein (figure 20).   Better exposure is gained if the body and tail of the pancreas have  been mobilized to serve as traction for the delicate dissection around the  portal vein. Otherwise, the subsequent technical details of the procedure  can be enhanced if the pancreas is divided at this point. A blunt-nosed  right-angle clamp is passed between the anterior surface of the portal vein  and the neck of the pancreas. T e pancreas is divided with electrocautery  (figure 21). T ere is usually one sizable bleeding point above the pancre-  atic duct (figure 22) and at least two other vessels below the pancreatic  duct. T ese are controlled with suture ligatures of fine silk or electrocautery,  making certain not to occlude the pancreatic duct. Although there is debate  about the value of obtaining a negative microscopic margin at the neck,  some surgeons continue to obtain a tissue sample for frozen section. In this  case a knife is used to take a 2-mm cross section of the divided pancreas for  frozen section to ensure negative margins. If the margin is positive, addi-  tional pancreas may be removed. T e duodenum and head of the pancreas  to be excised are grasped primarily with the surgeon’ left hand as the fri-  able vessels entering the head of the pancreas from the right side of the  portal vein are identified.    DETAILS OF PROCEDURE With the index finger of the  left hand above and the thumb below compressing the specimen to be  excised, the surgeon applies right-angle clamps in pairs to the strand of  tissue that extends from the portal vein into the pancreas (figure 23).  Within this strand of tissue, there are a number of small veins that must  be ligated very carefully lest troublesome bleeding occur. All areas should  be ligated to keep the specimen as free of clamps as possible while the  third portion of the duodenum is freed from the region of the ligament of  Treitz and the superior mesenteric vein and artery (figure 24). T is can  be one of the most difficult steps in the procedure. An incision into the  peritoneum about the third portion of the duodenum produces an open-  ing directly into the general peritoneal cavity, through which the upper  jejunum eventually will be pulled for the anastomosis (figure 24). T e  blood supply in the mesentery to the third part of the duodenum and  adjacent jejunum is very short, and it is often difficult to mobilize the    area about the ligament of Treitz with a minimal loss of blood. Small bits  of the mesentery near the duodenal wall are incorporated between pairs  of small curved clamps, and the contents are ligated as this area of the  duodenum is further freed (figure 25).T e attachment of the duodenum  that tends to fix the duodenum beneath the inferior mesenteric vein may  be identified more easily and clamped if a portion of the upper jejunum  is pulled through the opening made in the transverse mesocolon in the  region of the ligament of Treitz (figure 26). T e remaining short mes-  enteric attachments, including arterial branches going into the inferior  mesenteric artery, can then be clamped carefully with curved clamps if a  portion of the upper jejunum is pulled through the opening made in the  mesocolon (figure 27). Alternatively, the surgeon may choose to dissect  the ligament of Treitz and proximal jeyunum from the left side of the mes-  entery. T is approach is preferred in obese patients in whom exposure in    DETAILS OF PROCEDURE Since the gallbladder is often quite  large and distended, it should be removed to provide additional room and  prevent late complication from gallstone formation (figure 28). Many sur-  geons prefer to remove the gallbladder prior to dissection of the porta hepatis  and identification of the common bile duct. Attention 1s now directed toward  further mobilization of the upper jeyunum in the region of the ligament of  Treitz (figure 29). Usually, the peritoneum has been opened from above  the colon, just about where the dotted line is shown. T e upper jeyunum 1s  grasped with Babcock forceps and the bowel held up in order to enhance  the visualization of the arcades providing the rich blood supply to the jeju-  num. Incisions are made through the avascular portion of these arcades, so  that two or three of the basic arcades can be divided and double ligated to  enhance the mobilization of the upper jejunum (figure 30). T e final result  is Shown in figure 30; whereas figure 12, Chapter 89 provides additional    guidance as to the area of mesenteric division below the proximal jejunal  vascular arcade. T e arcade to be divided must be identified very carefully,  and no vessels should be ligated in the mesentery near the mesenteric border  of the bowel, since the blood supply to that segment may be compromised.  When a segment of the mesentery of the upper jejunum has been divided, the  jeyunum is brought up through the opening in the mesocolon (figure 30).  A point to divide the bowel is selected where the mesenteric blood supply 1s  obviously good (figure 30). About 1cm of the mesenteric border is freed of  blood supply and the jejunum divided with a cutting linear stapler (GIA). T e  specimen is removed and the jejunal arm is brought up through the opening  in the mesocolon. It must be long enough to reach well up into the gallblad-  der fossa without undue tension or compromise of the blood supply. If there  appears to be considerable tension, the bowel should be returned below the  colon and additional mesentery divided.    DETAILS OF PROCEDURE T e diagrams in figures 31 and  32 outline two of the many variations of reconstruction after removal of the  duodenum and head of the pancreas that have been developed. When total  pancreatectomy is performed, only the common duct and end of the stom-  ach, or the first portion of the duodenum if the entire stomach 1s preserved,  are anastomosed to the jejunum. T e bile and pancreatic ducts are arranged  to empty their alkaline juices into the jejunum before the acid gastric juice  as a measure of protection against peptic ulceration. T e mobilized jeju-  num can be used safely in a variety of ways for the several anastomoses  required. T e end of the jejunum should come to rest without tension in  the right upper quadrant after being passed through a rent in the transverse  mesocolon to the right of the middle colic vessels. Alternatively, this limb  can be passed through the retroperitoneal space vacated by the duodenum  behind the mesenteric vessels. T e jejunal limb is oriented such that the  cut end lies near the cut edge of the pancreas. T e limb then makes a gentle  counterclockwise bend to abut the bile duct downstream from the pancreas  anastomosis. T e jejunum is then anastomosed to the partly closed end of  the gastric pouch (figure 31). Some prefer to implant the open end of the  pancreas directly into the open end of the jejunum (figure 32). Alterna-  tively, a pancreaticogastrostomy may be performed in the case of a small  pancreatic duct. With this configuration, the common hepatic duct then is  anastomosed to the jejunum and, at an easy point of approximation, to the  stomach. figures 33 and 34 demonstrate details of the technique shown  in figure 31. T e jejunal loop is positioned without tension near the cut  end of the pancreas and the bile duct. T e posterior capsule of the pan-  creas is anchored with interrupted 000 sutures to the serosa of the jesunum    (figure 34). T ere should be no tension and preferably some redundancy  of the jeyunum between the several sites of anastomosis. T e patency and  size of the pancreatic duct are determined by inserting a soft rubber cath-  eter. With the catheter in place to serve as a stent, the margins of the duct  are freed for a short distance to facilitate an accurate anastomosis to the  jejunal mucosa (figure 35).   Some prefer to insert the open end of the pancreas into the open end of  the jejunum, especially when the pancreatic duct is quite small (figur e 36a).  T is alternative technique is schematically shown in figure 32. T e open  end of the pancreas is placed into open end of the jejunum as shown in  figure 36a and b. T e margins near the cut end of the pancreas should be  freed for several centimeters in preparation for telescoping the end of the  jeyunum over it, and all bleeding points should be ligated carefully. T e end  of the jejunum is usually large enough to admit the end of the pancreas. If  not, it may be necessary to incise the full thickness of the jejunum along  the antimesenteric border to make the opening large enough to match eas-  ily the size of the end of the pancreas. After all bleeding is controlled, the  mucosa of the jejunum is sewed to the capsule of the pancreas in a manner  similar to an end-to-end anastomosis. A small, soft rubber catheter can be  inserted into the lumen of the pancreatic duct to ensure its patency dur-  ing the completion of the anastomosis. It is subsequently removed before  closure of the gastrojeyunostomy. An additional one or two layers of inter-  rupted nonabsorbable sutures are placed to pull the jeyunal wall up over  the capsule of the pancreas for approximately lcm (figure 36b). Next the  choledochojeyunostomy is created as shown in figure 37 and described in  further detail on the next page.    DETAILS OF PROCEDURE T e choledochojeyunostomy is a  single-layer anastomosis. T e end of the jeyunum then should be anchored  to the tissues medial to the common duct or even up into the lower portion  of the closed liver bed. Great care should be taken, however, that sutures  do not include the right hepatic artery, which may curve upward into this  area. An incision is made into the adjacent jejunal wall a little shorter than  the diameter of the lumen of the common duct. Sutures of 0000 size are  used to fix either side of the end of the common duct to maintain the wall  under slight tension. T e posterior row of the anastomosis between the bile  duct and jejunum is completed (figure 38). A series of interrupted 4-0  or 5-0 absorbable sutures is used to accurately approximate the mucosa of  the jeysunum to the common duct (figure 38). T e fixed angle sutures are  allowed to remain for traction (figure 38). Placement of the interrupted  sutures in the closure of the anterior layer is then performed (figure 39).  T e peritoneum, which tends to be thickened over the region of the com-  mon duct, is anchored with interrupted sutures to the serosa of the jejunum,  starting beyond the angles of the anastomosis and extending anteriorly par-  allel with the anastomosis (figure 40), which holds the divided end of  the pancreas.   T e gastrojeyunal anastomosis may be made over the entire length of the  gastric outlet, or the outlet may be partly closed and the stoma limited in  size. T e full thickness of the gastric wall, including the staples, is excised to  provide a stoma three to four fingers wide (figur e 41). Anyretained gastric  contents are aspirated, and all bleeding points in the mucosa of the gastric  wall are controlled. T e serosa of the jejunum near the mesenteric border  then is anchored to the posterior wall of the stomach from one curvature  to the other with 000 silk. T e jesunum should be approximated loosely  so that there is some laxity between the anastomosis of the pancreas and  the gastric wall in the region of the lesser curvature. An opening about  two fingers wide is made in the jejunum, and the gastrojejunal mucosa    is approximated with interrupted 0000 absorbable sutures (figure 42).  T e gastrojeyunal anastomosis 1s then completed with a layer of interrupted  0000 nonabsorbable sutures, with the knots buried on the inside. T e sec-  ond layer of the gastrojejunal anastomosis is then completed with a layer  of interrupted 000 sutures from one curvature to the other. T e opening  in the mesocolon should be approximated to the jejunal wall (figure 43)  to prevent prolapse of small bowel up through this opening. T e opening  about the region of the ligament of Treitz should be closed with 000 silk.  A gastrostomy tube and feeding jeyunostomy may be indicated in the mal-  nourished patient. Closed-suction drains are placed adjacent to the cho-  ledochojeyunostomy and pancreaticojeyunostomy.    CLOSURE T e abdominal wall is closed in the routine manner, recogniz-  ing the potential for poor wound healing in an emaciated patient.    POSTOPERATIVE CARE It is of paramount importance, especially in the  jaundiced patient, to make certain that the blood volume is restored at all  times. Fluid balance is sustained by administration of 5% Ringer’ lactate  solution. Blood sugar levels should be tightly regulated, often requiring  insulin in the early postoperative period. T e hourly urine output should be  watched carefully and should be maintained at 30 to 40 mL/h. T e admin-  istration of intravenous fluids should be balanced throughout the 24-hour  period. Urinary output and the replacement of gastric drainage will deter-  mine the amount of fluids required.   T e patient’ weight must be watched carefully, and an adequate daily  caloric and vitamin intake assured. If a feeding jejunostomy tube has been  inserted, tube feedings by continuous infusion may be started 24 to 48 hours  after surgery. Initial infusion rate should be slow and gradually increased.  T e output from the closed suction drains should be monitored and may  be removed early after surgery if there is no bile in the drain fluid and if the  amylase is similar to that of serum. m    INDICATIONS Total pancreatectomy may be indicated in the treatment of  neoplasms of the pancreas as well as for incapacitating, chronic, recurrent  pancreatitis. Excision of the entire gland ensures more complete removal  of neoplasms but adds little to the average long-term survival. Multicen-  tric tumor locations are excised and cellular implantations are obliterated  within the remaining ductal system, and intimately attached lymph nodes  are excised. Removal of the pancreas simplifies the reconstruction of the  upper gastrointestinal tract and minimizes the complications from pancre-  atic duct implantation, postoperative pancreatitis, hemorrhage, and sepsis.  T e diabetes associated with total pancreatectomy is difficult to manage  because of hypoglycemia and requires careful and frequent evaluation of insu-  lin requirements. T e indications for this procedure are related not only to the  clinical history but also to the findings at the time of the surgical exploration.    PREOPERATIVE PREPARATION T ese patients are frequently poor surgi-  cal risks who have lost considerable weight and may be diabetic. T e blood  volume should be restored and blood sugar levels monitored. In the pres-  ence of deep jaundice, the biliary tree is decompressed by percutaneous  transhepatic intubation or stenting at the time of endoscopic retrograde  cholangiopancreatography. Vitamins are given along with pancreatic  replacement if floating stools are present. Several units of blood should  be available. Systemic antibiotics are given. Constant gastric suction is  instituted.    POSITION T e patient is placed in a comfortable supine position.    OPERATIVE PREPARATION T e¢ skin of the lower thorax as well as of the  entire abdomen is prepared in a routine manner.    INCISION AND EXPOSURE A liberal midline incision extending from  over the xiphoid process down to or below the left of the umbilicus is made  (figure 1). Some prefer an inverted U incision that parallels the costal  margins and crosses the midline near the top of the xiphoid process. All  bleeding points are carefully controlled. T e first decision involves estab-  lishing the diagnosis, ascertaining the presence or absence of metastases,  and finally, establishing the mobility of the pancreas with special reference  to the portal vein. Any evidence of distant metastasis to the omentum, the  base of the mesentery of the transverse colon, or to the liver or adjacent  lymph nodes makes any procedure palliative. In the absence of metasta-  sis, and in the presence of a freely movable pancreas, further exploration  is warranted. T e removal of the entire pancreas does simplify the recon-  struction of the gastrointestinal tract by a variety of methods (figures 2  and 3). Only the common duct and the remaining hemigastrectomy remain  to be anastomosed to the jejunum.    DETAILS OF PROCEDURE T e omentum is detached from the transverse  colon and the lesser sac inspected after the right gastroepiploic vessels are  divided. A Kocher maneuver is carried out to mobilize the duodenum and  head of the pancreas (figure 4).   T e duodenum and head of the pancreas can be mobilized as for the  Whipple procedure (Chapter 88). When it has been decided to remove  the body and tail of the pancreas as well as the head, the peritoneum along  the inferior border of the pancreas is incised in preparation for mobilization  by blunt finger dissection (figure 5). T e splenic artery is ligated near its  point of origin. After the peritoneum over the portal vein has been incised,  it is possible to insert the finger between the pancreas and the portal vein  (figure 6). T ere should be no communicating veins anteriorly. T e pan-  creas can be divided with electrocautery in this area, and the two segments  of the pancreas resected separately if preferred.    DETAILS OF PROCEDURE Although antrectomy with gastroje-  junostomy is the usual technique for reconstruction, some preserve the entire  stomach and pylorus plus several centimeters of duodenal bulb for end-to-  side anastomosis to the jejunal limb according to the method of Longmire. In  the usual reconstruction, however, better exposure is obtained for the subse-  quent steps of the procedure if the stomach 1s divided at a level that ensures  complete removal of the antrum (figure 7). Truncal vagotomy (Chapter 23)  also 1s performed to decrease the incidence of late postoperative gastrojeyunal  stomal ulceration, unless lifetime treatment with proton pump inhibitors or  other acid suppressing medication 1s determined to be preferable.    T e spleen is freed up and all gastrosplenic vessels are divided and  ligated. T e spleen and left half of the pancreas are reflected to the right,  providing good exposure for maximal ligation and division of the splenic  artery and vein at their origins (figure 8). Any arterial branches to the  superior mesenteric artery are carefully isolated and ligated (figure 9).  T emost difficult part of the procedure may be the isolation and ligation of  the several short veins entering between the portal vein and the pancreas  (figure 10). T e ligated right gastric artery and the pancreaticoduodenal  artery are shown in figure 10.    DETAILS OF PROCEDURE T e gallbladder is removed in a  routine manner and the common duct 1s divided (figure Il). T enext step  is to excise the rest of the duodenum down to and slightly beyond the liga-  ment of Treitz (Chapter 88, figures 27 and 28).   A long arm of the jejunum is prepared by dividing several vascular  arcades (figure 12). T e mobilized jejunum is brought through an open-  ing made in the mesentery of the transverse colon (figure 12). T 1s open-  ing is made at either side of the middle colic vessels, depending upon how  easily the jejunal loop can be brought up to the region of the common duct.  T ejeyunum is closed with a running 00 absorbable suture or a stapler, and  this layer is inverted with a layer of 00 silk mattress or interrupted sutures.  Following a gastrojejunal anastomosis, the jejunal loop is anastomosed  without tension to the common duct (figure 2). Alternatively, some prefer  to anastomose the biliary duct to the jejunum, followed by an anastomosis  with the gastric pouch (figure 3). It 1s not necessary to make the stoma  the full width of the stomach. A stoma of 3 to 5cm can be made at the  greater curvature end (figure 13). T e jejunum should be anchored to the    entire gastric outlet, regardless of how much has been closed of by sutures.  T e jejunum between the stomach and the common duct should be quite  loose and free of tension (figure 14). All openings in the mesocolon about  the arm of the jejunum should be closed with interrupted sutures to avoid  angulation of the arm of jejunum or the possibility of an internal hernia.  Closed-system suction catheters are commonly used.    CLOSURE T e incision is closed in the routine manner. A subcuticular  closure of the skin may be used, or the skin may be approximated with  interrupted sutures or clips.    POSTOPERATIVE CARE Constant gastric suction is maintained but may  be discontinued in the early postoperative period. Blood sugar levels are  monitored closely. T e amount of insulin may not exceed 25 to 30 units  daily in some patients. An insulin drip may be necessary in the initial days  after surgery. Blood losses must be replaced. Oral pancreatic replacement  therapy is started as soon as tolerated. Frequent nutritional evaluation 1s  essential in postoperative care. m    INDICATIONS T e most common indications for splenectomy are irrepara-  ble traumatic rupture and hematologic disorders. In splenic injury, nonoper-  ative protocols result in a significant improvement in splenic salvage in both  children and adults. However, in severe splenic injury, particularly in severe  multisystem trauma, splenectomy is indicated. In some cases, splenic salvage  is warranted. T e most common hematologic disorders requiring splenec-  tomy include immune (idiopathic) thrombocytopenic purpura, thrombotic  thrombocytopenic purpura, and hereditary spherocytosis. Prior to splenec-  tomy, clinical evaluation should be performed by an experienced hematolo-  gist and a bone marrow biopsy may be necessary to exclude unexpected bone  marrow disorders not improved by splenectomy. Whereas in the past emer-  gency splenectomy may have been occasionally needed in severe thrombo-  cytopenia associated with hemorrhagic complications, today this is almost  never needed, as nearly all patients will have improvement in platelet counts  in response to steroids, intravenous immune globulin or Rho D immune  globulin (winrho). Splenectomy may be indicated in cysts and tumors. Symp-  tomatic benefit may follow splenectomy in certain other conditions, such as  secondary hypersplenism, FeltyS syndrome, Bantis syndrome, Boeck’ sar-  coid, or Gaucher’ disease. In these latter patients, the surgeon should work in  consultation with an experienced hematologist and medical specialists. In the  past either total or partial splenectomy was indicated as part of the procedure  of “staging” to determine the extent of Hodgkin’ disease. Historically stage  I and IT Hodgkin’ disease, traditionally, those patients who are considered  candidates for primary radiation therapy, would undergo staging laparotomy  (pathologic staging) to rule out definitively the presence of occult subdia-  phragmatic disease. An appreciation of the risks of laparotomy and a recogni-  tion of the effectiveness of salvage chemotherapy in patients who fail primary  radiation therapy have permitted the increased use of clinical staging as the  basis for treatment of these patients.   Laparoscopic splenectomy is clearly the procedure of choice when tech-  nically feasible for elective splenectomy. It should be considered in all elec-  tive splenectomy cases. Relative contraindications may be considered in  certain cases of previous surgery or a large spleen. Coagulopathy is not a  contraindication and may actually do better with the laparoscopic approach.    PREOPERATIVE PREPARATION It is necessary to consider the nature of  the disease for which splenectomy is indicated in order to give the proper  preoperative treatment. In congenital hemolytic icterus, preoperative  transfusion is contraindicated, even in the presence of the most severe ane-  mia, because of the likelihood of precipitating a hemolytic crisis. In cases of  thrombocytopenic purpura, platelet transfusions may be given the morn-  ing of operation if indicated. T e patient with primary splenic neutropenia,  pancytopenia, or other types of hypersplenism 1s transfused as indicated by  his general condition and the information gained from the clinical studies.  Antibiotic therapy is given in the presence of neutropenia. Large amounts  of blood should be available in cases of suspected traumatic rupture of the  spleen, and the patient should be operated on as soon as his condition per-  mits. Prompt splenectomy may be a lifesaving procedure in some patients  with a blood dyscrasia, especially those with primary thrombocytopenic  purpura. Previous steroid therapy should be continued preoperatively and  during the early postoperative period.    ANESTHESIA. General anesthesia is usually satisfactory and may be sup-  plemented with muscle relaxants. Patients who have severe anemia should  receive little premedication, and ample oxygen should be administered  with the anesthetic. In the presence of a low platelet count, great care is  taken to avoid trauma to the mouth and upper respiratory passages, since  hemorrhage may occur.    POSITION T e patient is placed in a supine position. T e spleen is made  more accessible by tilting the table to lower the feet.    OPERATIVE PREPARATION T e skin is prepared in the routine manner.  Gastric intubation 1s avoided in portal hypertension or in the presence of a  low platelet count, that is, thrombocytopenic purpura, in order to avoid ini-  tiating hemorrhage. However, in other indications it can be used to ensure  a collapsed stomach and an improved exposure.    INCISION AND EXPOSURE Two types of incision are commonly used: a  liberal incision midline from the xiphoid down to the level of the umbilicus  (figure la), or a left oblique subcostal incision (figure Ib). T e verti-  cal incision is usually employed as it avoids division of muscle fibers in a  patient who may have compromised coagulation profile.   If a bleeding tendency exists in the presence of blood dyscrasias, it is  necessary to exercise rigid control of all bleeding points. In the very ill and  anemic patient the general oozing may be controlled by pressure with warm,  moist gauze pads, so that the abdomen may be opened and the splenic  artery ligated as soon as possible. T is will often affect a marked decrease  in the bleeding tendency as soon as the artery is clamped. In the absence  of acute intra-abdominal hemorrhage or an acute hemolytic blood crisis,  the abdomen is explored. T e gallbladder should be carefully palpated if  the splenectomy has been indicated for hemolytic jaundice, since gallstones  frequently occur in such patients and can be addressed at the conclusion of  splenectomy if the patient’ status permits. T e pelvic organs in the female  are palpated carefully for evidence of other pathology that might be respon-  sible for excessive blood loss from the reproductive system. Enlarged lymph  nodes should be biopsied and any accessory spleens removed.   T e colon is packed downward out of the field of operation by warm,  moist gauze, and the first assistant maintains downward traction with a  large S retractor. A Babcock forceps is applied to the stomach, and a retrac-  tor is placed under the rib margin on the left to facilitate the exposure of  the spleen.    DETAILS OF PROCEDURE T e exact procedure depends upon many  factors: the size and mobility of the spleen, the presence of extensive adhe-  sions between the spleen and the parietal peritoneum, the length of the  splenic pedicle, the presence of active bleeding from a ruptured spleen,  or the patient’ poor general condition as a result of blood dyscrasia. T e  approach to the immobilization and control of the blood supply of the  spleen must be individualized in each case. A thorough understanding of  the attachments and blood supply of the spleen is essential (figure 2). In  general, it is best to devascularize the spleen prior to mobilizing to mini-  mize capsular trauma.   When splenectomy is indicated for blood dyscrasias, a careful search  should be made for an accessory spleen both before and after the spleen  is removed and hemostasis is effected. A routine search is made in the  following order: the hilar region, the splenorenal ligament, the greater  omentum, the retroperitoneal region surrounding the tail of the pancreas,  the splenocolic ligament, and the mesentery of the large and small intes-  tines. If accessory spleens are found in two or more locations, one is usu-  ally in the hilus. In some cases of blood dyscrasias the clinical course of  the patient may suggest recurrence of the disease because of a retained  accessory spleen. In such instances not only should the sites mentioned  above be searched but the search should also be extended to the adnexa in  the pelvis. T e spleen must not be lacerated, nor should remnants be left  within the abdomen because of the danger of seeding, which may result in    DETAILS OF PROCEDURE T e diagram in figure 2 illus-  trates the anatomic relationships of the spleen. As traction is exerted on  the stomach medially, an avascular area in the gastrosplenic ligament  may be incised, giving direct entrance to the lesser sac. Several blood  vessels in the gastrosplenic ligament are divided and ligated to pro-  vide adequate exposure of the splenic artery. Along the upper margin of  the pancreas, the tortuous course of the splenic artery can be palpated.  T e peritoneum over the vessel is incised carefully, and a long right-  angle clamp is introduced beneath the artery to isolate it and to facili-  tate its ligation. T e splenic vein is immediately beneath the artery. One  or more 00 silk sutures are drawn beneath the artery and carefully tied  (figure 3). Alternatively it may be divided with a vascular stapler at this  point. Preliminary ligation of the splenic artery has many advantages. It  allows blood to drain from the spleen, providing an autotransfusion. T e  spleen tends to shrink, making its removal easier and with less blood loss.  Finally, blood transfusions can be given immediately to the patient with  hemolytic anemia. T is preliminary step does not prolong the procedure  and tends to ensure a safer splenectomy with minimal blood loss.   After the splenic artery has been secured, the remainder of the gastro-  splenic ligament is divided between small curved clamps or with an energy  device (figure 4). Great care 1s exercised, especially toward the upper mar-  gin of the spleen, to avoid injuring the gastric wall during the application of  clamps, for in this area the gastrosplenic ligament is sometimes extremely  short. T is is especially true when the spleen is very large or in the presence of  portal hypertension. Failure to secure the uppermost vein in the gastrosplenic  ligament can result in serious blood loss. Because of the danger of postopera-  tive bleeding following gastric dilatation, the vessels along the greater cur-  vature should be ligated with a transfixing suture that includes a bite of the  gastric wall. In addition, in this area several vessels commonly extend from    the hilus of the spleen over to the posterior wall near the greater curvature  high on the fundus. At the inferior margin of the spleen, fairly sizable vessels,  the left gastroepiploic artery and vein, commonly will be encountered in the  gastrosplenic ligament (figure 4). T e contents of the clamps are ligated on  both the gastric and splenic sides, since the division of the gastrosplenic liga-  ment will leave a large opening directly into the lesser sac.   T e early ligation of the major splenic artery makes mobilization of the  spleen easier and safer. T e surgeon passes the left hand over the spleen in  an effort to deliver it into the wound (figure 5). Dense adhesions may be  present between the spleen and the peritoneum of the abdominal wall or  the left diaphragm; however, the spleen can usually be mobilized after a  few avascular adhesions and the gastrosplenic ligament have been divided.   As the spleen is mobilized, the surgeon passes the fingers over its mar-  gin to expose the splenorenal ligament, which should be incised carefully  (figure 6). T e peritoneal ref ection in this area is usually rather avascu-  lar; however, it is necessary to ligate many bleeding points in the presence  of portal hypertension. Usually, the index finger can be inserted into the  peritoneal opening, and by blunt dissection with the index finger of the left  hand, which extends over the surface of the spleen, the margin of the spleen  can be freed easily (figure 7). T is must be done gently since the capsule  may be torn, resulting in troublesome bleeding or seeding of splenic tissue.   After the posterior margin of the spleen has been mobilized, the spleen  may be brought well outside the abdomen; however, if dense adhesions  between the spleen and the parietal peritoneum are encountered, it is easier  to incise the overlying peritoneum and carry out a subperitoneal resection,  which leaves a large, raw space. T is may be safer than attempting to free  the spleen with sharp dissection. Warm, moist packs may be introduced  into the splenic bed to control oozing. Active bleeding points should be  controlled with electrocautery.    DETAILS OF PROCEDURE When the spleen is mobilized out-  side the wound, the splenocolic ligament is divided between curved clamps  (figure 8). T 1s procedure is carried out carefully in order to avoid any  possibility of damage to the colon. T e contents of these clamps are ligated  with a transfixing suture of 00 silk or absorbable suture. In the presence  of portal hypertension, many large veins may be present in this area. T e  spleen is then retracted medially by the surgeon’ left hand, while the tail  of the pancreas, if it extends up to the splenic hilus, is separated by blunt  dissection from the splenic vessels in order to avoid damage to it by the  subsequent ligation of the pedicle (figures 9 and 10). T e surgeon should  keep in mind the possibility of accessory spleens in this location. T e spleen  is held upward and laterally by an assistant, while the large vessels in the  pedicle are separated from the adjacent tissues to permit the application of  several curved clamps to the individual vessels (figure 11). T ese vessels  should be ligated at the base of the pedicle proximal to the bifurcation of  the splenic vessels. Despite the fact that the splenic artery has been ligated  previously, it 1s tied again proximally and transfixed distally (figure 12).  T e same principle of double ligature for the splenic vein is also carried  out. Alternatively, vascular stapler may be liberally applied in this region. In  those instances where preoperative transfusions have been contraindicated,  they may be started as soon as the splenic artery has been divided. T e  operative site is searched for evidence of persistent oozing. Warm, moist  packs or a coagulant matrix may be introduced to control the small bleed-  ing points. Following this, a final careful search is made for any existing  accessory spleens that must be resected.    AITERNATIVE METHOD When the spleen is quite mobile and the ped-  icle is long, which is apt to be the case in the presence of long-standing  splenomegaly, splenectomy may be facilitated if the splenorenal ligament  is incised first without an attempt to divide the gastrosplenic ligament  (figure 13). T e spleen is pulled gently upward and medially, providing  exposure of the vessels in the pedicle from the lateral side (figure 14). It  may be necessary to divide the splenocolic ligament first in order to better  expose the contents of the splenic pedicle. In the presence of a ruptured  spleen the urgency of the situation may require mass clamping or stapling  of the splenic pedicle; however, individual ligation of the major vessels is  safer and more desirable. T 1s may be accomplished by ascertaining the  position of the splenic artery by palpation followed by blunt dissection, in  an effort to isolate the splenic artery (figure 14). When the splenic artery  has been divided, the spleen should be compressed to ensure an autotrans-  fusion through the intact splenic vein. Since the gastrosplenic ligament has  not been previously divided, it may be included in the clamps applied to  the splenic pedicle, thereby sealing off the lesser omental sac (figure 15).  If the gastrosplenic ligament is to be included in these clamps, great care  is necessary to avoid including a portion of the greater curvature of the  stomach, especially when the gastrosplenic ligament is very short. T is is  more likely to occur high in the region of the fundus of the stomach. T e  inclusion of the gastrosplenic ligament in the clamps applied to the splenic  pedicle should not be attempted unless the pedicle 1s long and all structures  may be identified easily and clearly (figure 16). T econtents of the clamps  applied to the splenic pedicle are doubly ligated. T e most superficial of  these ligatures should be of the transfixing type. Deep transfixing sutures  should not be taken, since troublesome hemorrhage may result, especially  from the splenic vein.   In good-risk patients cholecystectomy is performed if gallstones are  found, especially in association with congenital hemolytic anemia. A rou-  tine cholangiogram also is carried out if choledocholithiasis is suggested. In  the younger age groups with primary hypersplenism the appendix may be  removed if the cecum is easily mobilized.    SPLENIC PRESERVATION Recognition that splenectomy increases sus-  ceptibility to infection by encapsulated bacterial organisms necessitates a  conservative approach to splenic injuries. Special effort should be made to  conserve spleen tissue with its attached blood supply, especially in the very  young. Every effort is made to avoid splenectomy in children by follow-  ing a conservative routine of close observation, nasogastric suction, fre-  quent recordings of pulse and blood pressure, repeated blood counts and  radionuclide, or computed tomography (CT) scans. If the scan shows only  a single linear laceration, a non-operative regimen is followed. When the  scan shows a fragmented spleen or evidence of devascularization, surgical  repair is required.   Tears of the splenic capsule during upper abdominal operations are min-  imized by avoiding undue traction on the greater omentum of the stomach  or the left transverse colon, or by dividing peritoneal strands attached to  the splenic capsule. Mobilization of the spleen with temporary control of  the major blood supply permits evaluation of the feasibility of repair of the  capsule or, alternatively, segmental resection with ligation of the segmental  vasculature in the hilum, as well as in the small intrahepatic vessels, com-  bined with liberal use of a hemostatic agent and possible fixation of the  omentum to the area of repair. Locally applied hemostatic agents, compres-  sion of splenic tissue by mattress sutures on atraumatic needles, or ligation  of one or more major vessels in the splenic hilus may control the bleeding  and avoid splenectomy.    CLOSURE T e wound edges can be approximated more easily by return-  ing the table to its original horizontal position, thus facilitating return of  the abdominal contents to their anatomic location. A routine closure 1s  done without drainage. On occasion, a closed-suction Silastic drain may  be placed near the tail of the pancreas if there has been extensive dissection  in this region.    POSTOPERATIVE CARE T is will vary, depending upon the requirement  for whole blood replacement. Within a short time after splenectomy for  a blood dyscrasia involving a bleeding tendency, it 1s usually noted that  the platelet count rises rapidly; thus, transfusion may be unnecessary for  this purpose. It is good practice to monitor platelet counts postoperatively,  even in elective procedures, because of the marked thrombocytosis that  is occasionally seen. In patients with markedly elevated platelet counts  or abnormal platelet function, anticoagulants, such as acetylsalicylic acid  and dipyridamole, may be indicated. Anticoagulants are rarely necessary  in routine splenectomy. A marked leukocytosis commonly follows sple-  nectomy and should not be interpreted as indicative of infection. Constant  gastric suction for a day or so is often advisable. T e patient is permitted out  of bed on the first postoperative day. Fluid balance is carefully maintained  according to the patient’ general condition. Any steroid therapy given pre-  operatively is continued during the postoperative period. Further steroid  therapy will be regulated by the hematologist, who will be guided by the  response of the patient’ blood picture to splenectomy. In patients with sec-  ondary hypersplenism, their primary disease will not be altered, although  the patient’s life has been saved or prolonged by removal of the overactive  spleen. T e incidence of venous thrombosis 1s increased when the splenec-  tomy is performed for myeloproliferative disorders or lymphomas. Anti-  coagulant prophylaxis should be considered in such patients. Atelectasis  of the left basal lobe is one of the common complications after splenec-  tomy. When complete splenectomy has been performed, patients should be  informed and urged to seek immediate medical attention at the first sign or  symptom of infection. Polyvalent vaccines for pneumococcus, Haemophi-  lus infuenzae, and Neisseria meningitidis are also suggested except for  pregnant women. &    IndIcatlIons Laparoscopic splenectomy is most commonly performed  for immune (idiopathic) thrombocytopenic purpura (ITP) or other splenic  conditions causing anemia or neutropenia. Massive trauma to the spleen  as well as overly large spleens are still best approached with an open lapa-  rotomy. However, virtually all other indications for splenectomy listed in  Chapter 90 apply for laparoscopic splenectomy. A complete hematologic  evaluation, including bone marrow studies, 1s essential. T e patient must  be informed of the lifelong consequences of increased susceptibility to bac-  terial infection. Ideally, the patient should receive polyvalent pneumococ-  cal, Haemophilus infuenzae, and Neisseria meningitidis vaccination prior  to surgery.    Preo PeratIve PreParatlon Patients for elective splenectomy are  usually referred to the surgeon by hematologists or oncologists, because  their treatment with blood products, corticosteroids, plasmaphoresis,  gamma globulins, or chemotherapy can no longer safely control the pri-  mary disease. Accordingly, the patient may require transfusion of blood  products to raise the hematocrit or platelet counts to safe levels for general  anesthesia and coagulation during surgery. Packed red cells may be given  in advance of planned surgery, whereas platelets, with their short life span,  may be infused just prior to and during the procedure. When platelet trans-  fusions are contraindicated, endogenous platelet counts are often tempo-  rarily boosted with a few days of increased corticosteroid therapy, immune  globulin or Rho D immune globulin (winrho) prior to surgery. If steroids  are used, then they must be continued during and immediately after sur-  gery. T e patient should have a type and screening blood test, and blood  products must be available for infusion. T e size of the spleen should be  determined by physical examination or imaging studies, as massive spleens  are usually more safely approached by open splenectomy.    anestheslIa General anesthesia with endotracheal intubation is  required. Two large, well-secured intravenous catheters are placed for easy  access by the anesthesiologist. T e intravenous sites and any finger pulse  oximeters should not be positioned distal to an arm blood pressure cuff.  A Foley catheter and an orogastric (OG) tube are passed and pneumatic  sequential compression stockings are applied to the lower legs. Care must  be taken in the placement of the endotracheal, OG, and Foley tubes in  patients with marked thrombocytopenia lest bleeding occur.    PoslItlIon T e patient is placed in a lateral position with the left arm  crossing the chest and lying on top of the right arm. Liberal padding is used  between and around both arms. T e left hip and chest are elevated with pil-  lows, leaving the flank area open and the left knee flexed, with a padding of  blankets between the legs. T e patient is secured across the chest and hips to  the table with wide adhesive tape, as the operating room table will be tilted.    o Perat Ive PreParatlon T eskin is prepared from the lower chest to  the pubis in a routine manner.    IncIslon and exPosure A 5-mm videoscope port is placed either  through the umbilicus or in the lateral midsubcostal position using the  open technique of Hasson as described in Chapter Il. T e videoscope  is introduced and all four quadrants of the abdomen are examined. T e  size and location of the spleen and the presence of accessory spleens are  noted. A second 10-mm port is placed in the left lateral subcostal posi-  tion and a 12-mm port is placed just to the left of the midline. T ese ports  are in a line about two fingerbreadths or so below the edge of the costal  margin for a normal-sized spleen. Additional locations or ports may be  placed according to the preference of the surgeon, the size of the spleen,  and the shape of the patient’ body. In general, larger spleens require a  lower (more caudal) and more medial placement of ports. T e patient is  positioned with the left side up and then placed in a reversed Trendelen-  burg position.    detalls of Procedure T e general anatomy of the spleen, stomach,  colon, and omentum is shown in figure 1, which complements the cross-  sectional anatomy of this region shown in Chapter 90. T e splenocolic liga-  ment is visualized along with the greater omentum in its attachment to the  transverse colon is visualized. T e splenic end of this ligament is elevated  with traction (figure 2) and a suitable zone just above the splenic flexure  of the colon is entered with the energy device. T is elevation is done with  grasping and gentle traction using a dissecting instrument. T e dissection  proceeds medially around the tip of the spleen, where the gastrosplenic lig-  ament containing the short gastric vessels is identified. Using blunt dissec-  tion, the lesser sac is entered and the short gastric vessels are sequentially  divided about 1 cm away from the gastric wall (figure 3). T 1s cuff mini-  mizes potential thermal damage to the stomach. As the dissection proceeds  toward the gastroesophageal junction, care is taken to visualize each short  gastric vessel within the jaws of the energy device before it is activated.  Partial transection of the next short gastric vessel will result in bleeding  that is dif cult to control. Exposure for this dissection within the gastro-  splenic ligament is improved by gentle retraction of the greater curvature  of the stomach, using the dissecting instrument to lift the greater curvature  forward and medially. T e pancreas, with the splenic artery and vein run-  ning along its superior or cephalad border, is seen in the base of the lesser  sac. T e short gastrics are divided almost to the gastroesophageal junction  (figure 4).   T esplenorenal ligament is opened by gently elevating the spleen medi-  ally with the dissecting instrument (figure 5). T 1s thin peritoneal layer is  easily seen in the left gutter behind the spleen. T e ligament has few vessels,  but it must be transected with coagulation in a cephalad direction until  the top of the spleen is free. T e splenic pedicle is inspected in all areas  by lifting the spleen from side to side to make certain that no ligamentous  attachments remain. T e spleen should be completely mobile on its vascu-    detalls of Procedure T e area chosen should be distal  to the tail of the pancreas but proximal to the trifurcation of the splenic  vessels. Dissection is performed until the vessels can be safely encom-  passed within the jaws of an endoscopic vascular stapler. T is instrument  currently requires a 12-mm port. It is common practice to use a vascular  stapling device to occlude and divide the entire splenic pedicle together. In  some cases it is preferable to individually ligate the splenic artery and vein  using the endovascular stapler. When this technique is employed the artery  should be divided first. If either splenic vessel is entered during the dissec-  tion, emergency control of the hemorrhage is obtained by cross-clamping  both the splenic artery and vein with the dissecting instrument (figure 7).  As all collateral vessels to the spleen have been transected, only temporary  back bleeding should occur. T 1s maneuver allows the surgeon to place  another operating port for further proximal dissection and stapling of the  splenic artery and vein or to control the hemorrhage during conversion to  an open procedure.   When the tail of the pancreatic tissue extends into the hilum of the  spleen, the zone for transection of the splenic vessels is quite short. Dissec-  tion is more dif cult, as the vessels may have divided into their branches.  In this case, the pedicle may be taken in serial transections, as opposed to  stapling of the vascular pedicle en bloc (figure 8). In reality, the splenic  artery and vein are rarely skeletonized as cleanly as shown in these illus-  trations, but the general principle is that the tissue to be stapled must be  contained well within the span of the stapling instrument’ jaws. A useful  maneuver is a 180-degree rotation of the stapler to ensure that no tissue or  vessels extend beyond the staple zone within the instrument’ jaws.   A reinforced oversized plastic bag is placed through a large port site.  T is special bag comes in an extra-large instrument that usually requires  removal of a 10-mm port and finger dilation of this site to approximately  12 mm. T e videoscope is used for visualization as the collapsed bag and  instrument are passed through the abdominal wall. T e bag is opened,    noting the arrow orientation on its rim. T e spleen is placed into the bag  (figure 9), which is closed. T is reinforced bag is then partially withdrawn  through the abdominal wall until the open rim of the bag is under control  outside of the abdomen. T e bag is cut free from the carrier using the draw-  string in the end of the instrument handle. T e spleen is morcellized with  either finger fracture within the bag or, most often, with a ringed forceps,  which then extracts the spleen in pieces (figure 10). Care must be taken  not to pinch or tear the bag with the ringed forceps.   Following complete extraction of the spleen and bag, the right upper  quadrant of the abdomen is lavaged with the suction irrigator and a careful  inspection is made of all cut surfaces and vessels. T e tail of the pancreas is  examined for possible injury that might necessitate placement of a closed-  suction Silastic catheter drain. A final search for accessory spleens is made in  the usual locations and they are simply excised using the ultrasonic dissector.    closure Each of the ports is removed under direct vision of the vid-  eoscope and the enlarged Hasson and 10-mm port sites are closed with  interrupted delayed absorbable 00 sutures. T e skin is approximated with  00000 absorbable subcuticular sutures. Adhesive skin strips and dry sterile  dressings complete the procedure.    Posto PeratIvecare T eOGtubeisremoved before the patient awak-  ens and the Foley catheter is discontinued when the patient is alert enough  to void. Intake of clear liquid is begun within a day and the diet 1s advanced  as tolerated. Corticosteroid coverage 1s tapered to the preoperative basal lev-  els and serial blood counts are performed. Additional medical consultation  may be needed with the hematologist or oncologist to regulate medications  in complex cases. Recurrence of left-upper-quadrant and shoulder pain  along with the appearance of a left pleural effusion may signal either a pan-  creatic leak or an abscess if signs of infection are present. Either may require  placement of a subdiaphragmatic closed drain using imaging study guid-  ance. Prolonged follow-up by the hematologist or oncologist is necessary. m    IndIcatIons Injury to the spleen is one of the more serious problems  associated with trauma. Emergently there is the possibility of exsangu1-  nation. However, for the remainder of the patient’s life after splenectomy,  there is the possibility of catastrophic bacterial infection with encapsu-  lated organisms, such as pneumococci, especially in the very young. T is  has stimulated clinicians to conserve the spleen with or without operation.  Nonoperative treatment in children is often successful if careful monitoring  is provided in-hospital and thereafter at home until full healing is docu-  mented. In addition, in adults as well as in children, splenorrhaphy is often  possible, as it is desirable to salvage as much of the traumatized spleen as  possible. It is uncertain how much retained spleen is essential to provide  normal protection for the patient, but many recommend preservation of  half or more if possible. T e surgeon must appreciate that it is essential to  control exsanguination and that total splenectomy should be performed for  splenic fractures that are massive or that cannot be easily controlled in the  presence of continued major hemorrhage.   Rib fractures (especially those in the left lower and posterior region)  and an elevated left diaphragm on roentgenograms of the chest are sugges-  tive of splenic injury. Abdominal CT scans are invaluable in demonstrat-  ing splenic injury and their findings may support a decision for or against  immediate splenectomy. Early operation should be considered when the  scan shows a fracture that extends into the hilum of the spleen. T e patient  with splenic injury who is managed with observation must be evaluated  frequently as occult hemorrhage may result in sudden hypotension and  shock. T e decision for or against nonsurgical treatment of a splenic injury  should be based upon clinical judgment rather than solely on radiographic  findings. If the diagnosis is not clear, a peritoneal tap or lavage yielding an  obviously bloody return can be helpful in supporting surgical intervention  as this indicates a free or noncontained rupture of the spleen.   Familiarity with the major blood supply of the spleen is required if sal-  vage of the portion of the spleen is to be successful (figure 1). T e major  splenic artery and vein run just under the peritoneum along the top of the  pancreas. T e easiest accessibility to the vessels occurs through an open-  ing in the gastrocolic omentum (Chapter 90). A bulldog clamp can be  applied temporarily to the splenic artery and this will lessen the massive  bleeding as the surgeon mobilizes up the extensively damaged spleen. T e  clamp is applied proximally as the splenic artery within the hilum divides  into three terminal vessels, each supplying approximately one-third of  the spleen. It is important to remember that the spleen has a dual blood  supply—namely, the short gastric vessels from the greater curve of the  stomach in the gastrosplenic ligament as well as the retroperitoneal  splenic artery and vein.    Preo PeratIve PreParatlon Evidence of shock associated with a  falling hematocrit or hemoglobin should be viewed with alarm and result  in early surgical intervention. T e patient with a potential splenic injury  should be typed and cross-matched while reserving several units of packed  red cells or blood at all times. T e importance of sustained observation day    and night in a patient treated nonsurgically cannot be overemphasized,  since the decision for surgical intervention can come at any time!   Hypotension and shock must be treated with adequate volumes of fluid  and blood. A tendency to recurrent hypotension after resuscitation should  be viewed with alarm and early surgical intervention undertaken. CT scans  of the spleen in a stable patient can provide significant help in establishing  the location, extent, and progress of the injury.    anesthesIa A general anesthesia is required. Large-bore venous access  catheters are placed in both arms for rapid administration of blood, fluids,  and medications.    Po sIt Ion Because of associated injury, the supine position may need to  be altered. T e patient is usually placed flat upon the table, thus preserving  the option to accomplish a Trendelenburg position if shock develops.    o Perat Ive PreParatlon Nasogastric intubation is useful in improv-  ing exposure by lessening gastric dilatation. Antibiotics are given, and a  routine preparation of the skin of the upper abdomen and left side of the  lower chest is rapidly performed.    IncIslon and exPosure A midline or left subcostal incision is made.  T e latter may provide a better exposure when the splenic trauma is severe,  whereas the midline incision may be useful if other associated intra-  abdominal injuries are suspect.   One of the more common minor injuries to the spleen may occur  during an upper abdominal procedure when traction is placed upon adja-  cent structures which have attachments to the surface of the spleen. T e  resultant tear in the capsule of the spleen can lead to a slow loss of blood  (figure 2). Such superficial injuries should be recognized early. Compres-  sion with a gauze sponge is applied to the denuded area for several minutes,  remembering that clotting times are usually in the range of 6 to 8 minutes.  If the bleeding persists, microfibrillar collagen is applied directly to the  spleen and further gauze compression is given.   In the presence of major fracture of the spleen, a large gauze pad or towel  is placed over the spleen to enable medial traction by the surgeon’ left hand  (figure 3). T 1s left hand also compresses the spleen so as to provide some  control over the bleeding. Blood in the left lumbar gutter is aspirated by  suction and an incision is made in the splenorenal ligament several cen-  timeters away from the capsule of the spleen (figure 4). T is incision is  extended upward to free the spleen from the base of the diaphragm. T e  spleen and tail of the pancreas are mobilized and lifted anteriorly and medi-  ally, as shown in Chapter 90. If splenic preservation rather than splenec-  tomy 1s to be attempted, temporary control of the splenic artery is obtained  with a bulldog or vascular clamp. Finger compression of the splenic pedicle  may be utilized until the clamp is applied through either an anterior or  posterior (Chapter 90) approach. Salvage of the spleen that appears to be  badly injured may become feasible after control of the arterial inflow slows  the bleeding such that a more thorough evaluation of the spleen and its  vascular pedicle can be made.    IncIslon and exPosure T esuccess of saving the spleen  depends first upon the extent of damage from the trauma and second upon  the ef ective compression of the lacerated splenic tissue with interrupted  sutures. T e splenic tissue is quite friable and some prefer to fill the crevice  of the injury with hemostatic material such as microfibrillar collagen and  then hold the cavity material in place with a series of carefully placed inter-  rupted sutures which gently compress the spleen (figur e 5). Alternatively,  the adjacent omentum may be mobilized on a viable vascular pedicle so as  to fill the cavity created by the laceration. Again mattress sutures are used to  hold the omentum in place so as to approximate the margins of the lacera-  tion and minimize further bleeding.   Laceration of the midportion of the spleen with extension into the hilum  is usually considered an indication against splenic conservation. However,  laceration involving either pole of the spleen may be controlled by isolat-  ing the appropriate artery and vein within the hilus that supplies the polar  region of the organ. After dividing the gastrosplenic ligament and securely  ligating the short gastric blood vessels, control of bleeding is enhanced by  freeing up a segment of the splenic artery for the application of a bulldog  clamp. T e major arterial and venous vessels heading to the lower pole of  the spleen are dissected free, ligated, and divided (figure 6).   T e devascularized section of the lower pole of the spleen is demarcated  by its change in color and this ischemic damaged section is excised using  cautery (figure 7). T e bulldog clamp on the splenic artery can be released  after the polar splenic artery and vein branches of the major splenic vessels  are divided and ligated. Active bleeding points are ligated by fine absorbable  or silk sutures. Mattress sutures tied over Gelfoam pledgets may be required  to control the bleeding (figure 8). Additional hemostasis can be obtained  using the argon-beam electrocoagulation system. It is desirable to have the  raw splenic surface as dry as possible before microfibrillar collagen 1s applied.   T e surface is compressed with a dry gauze sponge. If no active bleeding  occurs after 5to 10 minutes, the spleen is returned to the left upper quadrant  after inspecting the cut edge of the splenorenal ligament for hemostasis.    closure Closure is delayed if there is any uncertainty about continued  slow bleeding. Accessory spleens need not be excised, but all free splenic  tissue should be removed to avoid subsequent splenosis. T e tail of the  pancreas is inspected to determine if pancreatic tissue has been injured.  If disruption of the pancreatic tail is found, the pancreatic duct should be  ligated if it is visible. Mattress sutures may be placed through the anterior  and posterior capsules of the pancreas so as to compress the cut end. Alter-  natively, the pancreas may be divided with a stapling instrument. A Silastic  closed-suction catheter may be placed in this region although, in general,  catheter drainage in a splenectomy site is to be avoided as it may increase  the hazard of subphrenic abscess.   It is important to evaluate the liver and other intra-abdominal organs  that also may have been injured. After a final look at the spleen to verify  viability and hemostasis, the abdominal incision is closed. T is is done in a  routine manner after all bleeding points have been ligated. Skin staples or  subcuticular closure may be used for skin approximation.    Posto PeratIvecare Frequent monitoring is required for several days  and additional transfusions may be needed. Many surgeons maintain naso-  gastric decompression for a few days until gastrointestinal function resumes.  T is lessens the chance of gastric dilation, which may dislodge ligatures on  the short gastric vessels along the greater curvature of the stomach. Vigorous  pulmonary toilet may be necessary to avoid atelectasis and pneumonia,  especially if rib fractures are present. T e patient should be observed for  signs and symptoms of a subphrenic abscess or an unrecognized pancreatic  leak. If the injured spleen is removed, polyvalent vaccines for pneumococ-  cus, Haemophilus inf uenzae, and Neisseria meningitidis are given except to  pregnant patients and children below 2 years of age. Antibiotics may be  given prophylactically to the very young patient after splenectomy. Both  children and adults should be advised to seek medical attention without  delay if signs of infection develop at any time for the remainder of their  lives. =    GynecoloGic SySt em—Ro utine fo Ro pen Abdo minAl pRo-  ceduReS Gynecologic procedures, in general, carry less risk than other  abdominal surgical procedures because of the minimal amount of manip-  ulative trauma to the alimentary tract and the patient’ generally good con-  dition. However, the same general principles apply here as in any major  surgical operation, and the patient’ condition must be appraised carefully.    pReo peRAtive pRepARAtion T e obese patient should diet suf-  ficiently to obtain a more normal weight before elective procedures are  done. Secondary anemia is corrected preoperatively. Urinary complaints  are investigated by analysis of the catheterized specimen of urine and endo-  scopic and roentgenographic studies when indicated. Bowel preparation,  including enemas, is individualized. Antibiotics are given when sepsis 1s  suspected. A cleansing enema is given and may be followed by an antiseptic  vaginal douche. Prophylactic antibiotics are indicated for major vaginal and  abdominal procedures.    inciSion And expoSuRe Many major gynecologic procedures can  now be performed via minimally invasive techniques, which include lapa-  roscopic and robotic approaches. A lower midline incision is made, and the  lower angle of the wound 1s held open with a superficial retractor to permit  a free dissection of the fascia until the location of the midline is absolutely  ascertained.   Some operators prefer the transverse incision (Pfannenstiel), which is  a convex incision following the lines of skin cleavage just above the sym-  physis. T e upper skin flap may be dissected from the underlying rectus  muscles, and the usual midline incision of the muscles and peritoneum 1s  made. When an extensive exposure is required, it 1s better to use a Mallard  incision which cuts across the recti muscles or a Cherney incision which  detaches these muscles from the symphysis. An increased number of blood  vessels require ligation by this approach in comparison to the midline inci-  sion, most notably, the inferior epigastric vessels.   T e fascia is incised, scissors being employed at the lower angle of the  wound to open the fascia down to the symphysis. T e medial edge of pre-  senting rectus muscles 1s freed and pushed laterally with the scalpel handle.  Although few bleeding points are encountered in the midline, all must be  clamped and tied or controlled by electrocoagulation. As the incision pro-  gresses, its margins are protected with gauze pads. T e peritoneum, before  being incised, is picked up to one side of the urachus with toothed forceps  alternately by the operator and first assistant as in any abdominal proce-  dure. T e urachus, which can be seen through the peritoneum as a thick-  ened cord, should be left intact, since it is not only vascular but also exerts  traction on the bladder, inviting its accidental opening.   A self-retaining retractor is substituted for the superficial ones, although  deep individual retractors may be used if a shifting of the retraction is desired  to procure the maximum exposure as the operation progresses. Careful  inspection is made to ensure that no intestine is caught in the retractor. When  a self-retaining retractor is used, the smooth blade is inserted and the whole  apparatus is adjusted.   Unless contraindicated by infection in the pelvis, a general abdominal  exploration is carried out. T e surgeon moistens his or her hands in saline  and systematically explores the abdomen and finally the pelvis. T e surgeon’    operative note should contain a description of the findings, especially the  presence or absence of gallstones. If a large uterus with extensive involve-  ment by fibromyomata is encountered, it may be advantageous to deliver the  uterus through the abdominal opening before the introduction of the self-  retaining retractor. Large ovarian cysts, if benign and not grossly adherent,  may be reduced in size by aspirating their contents through a trocar, great  caution being used to avoid contamination from their contents. If the sur-  geon suspects ovarian malignancy, the organ is removed intact and a frozen  section is performed. In addition, the surgeon should perform a saline per1-  toneal lavage for cytology and biopsy of the pelvic, lateral abdominal, and  diaphragmatic peritoneal surface. Comprehensive staging of ovarian can-  cer also includes a pelvic periaortic lymph node dissection, infracolic node  removal, and sampling of the iliac and preaortic lymph nodes. A tenaculum  is applied to the fundus of the uterus to maintain traction while the intes-  tines are walled of completely with several moist gauze pads. To accom-  plish this, the intestines are retracted upward by the left hand as the gauze  pads are directed inward and upward by long, smooth dressing forceps,  the packing being continued until the pelvis is free of small intestine. T e  pouch of Douglas is emptied of intestines, other than the rectosigmoid, and  is likewise protected by a gauze pack. To maintain these packs in position, a  moderate-sized smooth retractor is sometimes placed in the midline at the  umbilical end of the wound.    clo SuRe Before the abdominal closure is started, the site of operation  is finally inspected for evidence of bleeding, and the appendix may be  removed. A search is made for needles, instruments, and sponges, and a  correct count is reported before closure is started. T e sigmoid and omen-  tum are returned to the pelvis. After the peritoneum has been closed, the  patient is gradually returned from the Trendelenburg position to horizontal  to release tension on the wound and to permit stabilization of the blood  pressure while the patient is under the surgeon’ direct supervision. A rou-  tine abdominal wall closure is done (Chapter 10). T e surgeon inspects as  well as palpates the fascial suture line to ensure a secure closure.    po Sto peRAt ive c ARe When conscious, the patient is placed in a com-  fortable position. T e fluid balance is maintained with 2 L of glucose in  lactated Ringer’ solution the day of operation and each day thereafter until  fluids and food are tolerated by mouth. If constant gastric suction is neces-  sary, Saline and potassium are added after the first day to accurately replace  the losses by gastric intubation. T e measured blood loss during surgery  may be replaced if it exceeds 700 mL and the patient is hemodynamically  unstable. Significant anemia can be tolerated in a healthy patient given the  additional support of supplemental oxygen, colloid expansion (Hespan),  and bed rest. In addition to surgical site infection prophylaxis, additional  antibiotics are not routinely administered.   T e patient should be ambulated at the earliest possible time. Ambu-  lation in contrast to dangling is advisable. T e inlying Foley catheter is  removed in 24 to 72 hours, depending upon the extent of the surgical pro-  cedure and the patient’ general condition. If repeated catheterizations are  necessary, the amount of residual urine should be recorded and the cathe-  terized specimens examined for evidence of infection. If infection is found,  the appropriate antibiotics are given. Sterile perineal care is observed. Elas-  tic stockings may be worn, especially if varicose veins are prominent or  there has been a history of phlebitis. m=    IndIcatIons A total abdominal hysterectomy is most commonly per-  formed for benign conditions of the uterus including leiomyoma, adeno-  myosis, endometriosis, pelvic inflammatory disease, and dysfunctional  uterine bleeding. Other indications include malignancies of the cervix,  uterus, and ovaries.    o PeratIve PreParatlIon Routine vaginal and abdominal preparation  is given. T e patient is catheterized, and an indwelling Foley catheter, No.  16—18 French, is inserted with inflation of the balloon and then anchored  to the inner thigh. If access to the vagina and or anus is required, then the  patient should be places in the low lithotomy position.    detalls of Procedure Whenever conditions will permit, the uterus  is retracted upward toward the umbilicus, exposing the anterior uterine  surface and allowing incision of the peritoneum at the cervicovesical fold  (figure 1). T e surgeon should anticipate the course of the ureters. T e  round ligaments are ligated or incised with an electrosurgical unit (ESU)  which enhances the surgeon’ ability to dissect the retroperitoneal tissue  planes. T e loose layer of peritoneum 1s picked up with atraumatic forceps  and incised transversely with scissors, or the ESU, close to its attachment to  the uterus (figure 2). If there are indications to remove the tubes and ova-  ries, the ovarian vessels are clamped proximal to the ovaries with a Heaney  or curved Zeppelin clamp and doubly ligated with 2-0 delayed absorbable  suture. Prior to applying the clamp the surgeon should insure that the ureter  is out of the field of dissection. T e ureters are identified along the medial  leaf of the broad ligament to insure that they are out of the field of dis-  section. T e adnexa is mobilized away from the pelvic sidewall structures  (figure 3). If the adnexa are to be spared, the uterine-ovarian ligament    is clamped and ligated (figure 3). T e operator uses sharp dissection to  open the cervicovesical space and to dissect the areolar tissue between the  bladder and the lower uterine segment. Blunt dissection should be used.  After the ovarian vessels have been ligated, the surgeon can palpate the  region of the cervix with two fingers to determine its length and the posi-  tion of the bladder. T e bladder is sharply dissected off of the lower uterine  segment and cervix (figure 4). It is advantageous to divide the tissue over  the cervix with sharp dissection until a definite avascular cleavage plane  is established. Blunt dissection should be used sparingly and only in the  midline directly over the cervix, or troublesome bleeding will be induced  from tearing vessels in the broad ligament. Sharp dissection will permit the  bladder to be directed forward and downward until the operator’ thumb  and index finger can compress the vaginal wall below the cervix (figur e 5).    detalls of Procedure For supravaginal hysterectomy, the opera-  tion proceeds as in total abdominal hysterectomy except that the uterine  arteries may be ligated higher on the cervix. T 1s procedure is shown in  figure 6. Technically, this is an easier and safer operation to perform, as  the uterine artery suture ligatures are placed further away from the ureters.  It requires, however, that the patient be compliant with lifelong gyneco-  logic examinations that include cervical Pap tests. T e posterior leaf of the  broad ligament is incised down the level of the lower uterine segment and  then the uterine vessels are skeletonized. T e cervix is kept in position by  Teale or similar forceps at the lateral margins and is divided at the level of  the internal os, or lower uterine segment (figure 6). T e cervical stump  then is closed transversely by placing several figure-of-eight sutures of 0  absorbable suture, one in each lateral angle and one or more in the central  portion. T ese sutures must be placed suf ciently deep to secure complete    detalls of Procedure T e surgeon then holds the  uterus forward and makes certain that the rectum is not adherent to the  upper portion of the vagina. Should the rectum be adherent to the vagina,  it is sharply dissected free to avoid possible injury. A moist gauze sponge  or malleable retractor is loosely introduced into the pouch of Douglas to  prevent any intestine from coming into the field of operation. T e uterus 1s  rotated slightly to the right in preparation for the application of a Heaney or  Zeppelin clamp (figure 7). T e ureter is mobilized out of the field of dis-  section by mobilizing the bladder off of the lower uterine segment and  cervix, and skeletonizing the uterine vessels. T e surgeon can also skeleton-  ize the anterior bladder pillars when necessary. Once the relative position  of the ureter is established, the slightly curved clamp is applied from the  side at a 90-degree angle to the cervix (figure 7a). It is not necessary to  include cervical tissue in the clamp. Now the uterine vessels are divided with  curved scissors (figure 7). If the uterus is quite large, a half-length clamp  may be af xed to the vessels higher up along its wall to prevent troublesome  backbleeding as the uterine vessels are divided. T e paracervical tissue is  divided with scissors to a point just below the level of the clamp to develop  a free pedicle that can be tied easily (figure 8). Failure to carry the incision  beyond the tip of the distal clamp hinders accurate ligation of the uterine  vessel pedicle, and troublesome bleeding results. A transfixing suture, a,  of 2-0 delayed absorbable suture is tied as the clamp is slowly withdrawn  (figure 8). T edevelopment of an easily tied pedicle that includes the uter-  ine artery is one of the most important steps in abdominal hysterectomy.    After a similar procedure has been concluded on the opposite side, a series  of straight clamps are applied to the paracervical tissue and the uterosacral  ligaments between the cervix and the uterine vessels (figure 9). Modest-  sized pedicles are taken with the straight clamps until the surgeon reaches  the lower portion of the cervix which can be confirmed by palpation. At  this point curved clamps are placed at each angle of the vagina just below  the level of the cervix and then the tissue is cut with curved scissors. Any  remaining attachments of the vagina to the cervix are incised with the scis-  sors. (figure 10). As the cervix is freed from the vaginal vault, the anterior  and posterior vaginal walls are approximated with Teale forceps to include  the full thickness of the vaginal wall as well as its posterior peritoneal sur-  face (figure ll). T e lateral angles of the vaginal vault are first closed with  transfixing sutures of 2-0 absorbable suture (figure 12), following which  one or more sutures are placed at the middle portion to ensure complete  closure and hemostasis. T e most likely place for troublesome bleeding 1s at  the outer angles of the vagina near the ligated uterine vessels. Accurate and  firm closure of the angles is imperative (figure 12). Upward traction on the  vaginal vault 1s released to determine whether any bleeding occurs.    closure T esigmoid and omentum are returned to the pouch of Doug-  las. It is not necessary to close the peritoneum. T e patient is returned to the  horizontal position while the fascia and skin are being closed. Only in rare  instances 1s drainage instituted either through the vagina or abdominal wall.    IndIcat Ions Removal of the fallopian tubes and/or ovaries is indicated for  inflammatory involvement of the adnexa that cannot be relieved by the use  of conservative measures including antibiotics, for ovarian cysts, neoplasms,  ectopic pregnancies, and endometriosis. Bilateral oophorectomy is advised by  some as a desirable procedure in extensive carcinoma of the rectum because  of the susceptibility of the ovaries to tumor transplantation from lesions of  the gastrointestinal tract. In the absence of malignancy every effort should be  made to conserve even remnants of functioning ovarian tissue especially in  the younger patients, but recently conservation has also been recommended  for menopausal patients without other indications for ovarian removal.    IncIsIon and exPosure See Chapter 93. In the presence of extensive  pelvic inflammation, the intestines are often attached to the adnexa by adhe-  sions that must be separated by sharp dissection. Meticulous dissection and  careful handling of the tissue 1s important in order to avoid unintentional  injury to the bowel. By placing the adhesions on tension as they are cut, the  cautious surgeon can almost always develop a cleavage plane between the  diseased adnexa and the other structures. In minimally invasive surgery, the  bowel (except for the pelvic sigmoid colon) will usually fall out of the pelvis  secondary to placing the patient in Trendelenburg position, but loops of  small bowel may be needed to be carefully flipped into the upper abdomen  with blunt atraumatic instruments. During a laparotomy, the intestines are  carefully packed away with warm, moist gauze pads, or placed in a plastic  bag and moistened with warm saline. T e free adnexa are then held upward  with a half-length clamp (figure 1).    detalls of Procedure T e uterus is held forward by placing a  Kelly clamp to the round ligament adjacent to the uterus (figure 1).    T e mesosalpinx is clamped with a sufficient number of half-length clamps,  usually three pairs, to include its entire length (figures | and 2). To avoid  possible interference with the blood supply of the ovary, the line of inci-  sion is kept near the fallopian tube (figure 1). T e clamps are then ligated  with transf xing sutures using 2-0 absorbable suture. Alternatively, a bipolar  electrosurgical unit (ESU) can be applied in sequential bites along the  mesosalpinx to the level of the cornu of the uterus (figure 3). T e proxi-  mal aspect of the fallopian tube is then excised from the cornu (figure 4)  and ligated at the level of the uterine fundus with a transf xing suture  (figure 5) or with the bipolar ESU.    detalls of Procedure When both the tube and ovary are to be  removed, a peritoneal incision is made parallel and lateral to the fallo-  pian tube and the ovarian vessels as shown in figure 6. Prior to ligating  the ovarian vessels the pararectal space should be opened and the ure-  ter identifed at the level of the bifurcation of the common iliac artery  (figure 6). After establishing that the ureter is out of the feld of dissec-  tion, curved Heaney clamps are applied to the infundibulopelvic ligament,  which includes the ovarian vessels (figure 6). T e vessels are divided and  doubly tied with 2-0 delayed-absorbable sutures. T e medial leaf of the  broad ligament is then incised with scissors or the ESU down to the level  of the uterine vessels while staying above the level of the ureter. Next the  proximal portion of the fallopian tube is ligated as shown in figure 5.T e  peritoneal surfaces may be approximated (figure 7) and a possible, but  not necessary, partial suspension is shown (figure 8). Anti-adhesive bar-  riers may be applied, when indicated, in cases where fertility preservation  is a concern.    Preo Perative PreParation In the majority of instances, no preop-  erative douches are used. T e symphysis, perineum, and adjacent surfaces  are not shaved but may be clipped carefully before operation. A preopera-  tive cleansing enema is optional. Prophylactic antibiotics are administered.    Position Vaginal procedures are carried out in the lithotomy position.  After the induction of anesthesia, the patient’ buttocks are brought to the  edge of the table. T e legs are raised simultaneously to avoid straining the  sacroiliac joints and are fixed in stirrups with the knees f exed. Whenever  possible, the legs are elevated upward and backward to permit the assistant  to be nearer the field of operation. Excessive hip fexion, abduction, and  external rotation should be avoided. T e buttocks are brought to the edge  of the table. T e operating table is turned so that the light falls on the field  and is focused on the introitus.    oPerative PreParation T e vulva and adjacent skin areas are  scrubbed from above downward with pairs of prepping sponges held in  gloved hands. T e sponges are saturated with a solution of water and a  detergent with germicidal action, such as a povidone-iodine—containing  scrub. In all, approximately five pairs of sponges are used, each being dis-  carded as it comes in contact with the anus. T e vaginal vault is cleaned  with approximately five saturated sponges which are attached to a prep-  ping stick. Dry sponges are used to remove excess solution from the vagi-  nal vault and the cleaned skin is blotted dry with a sterile towel. T e anus  may be excluded from the operative area by the use of a spray-on adhesive  compound and the application of a piece of sterile, transparent plastic film.  T e footboard of the operating table can be raised to a convenient level and  serves as an instrument table for the surgeon. A sterile, fenestrated perineal  drape is applied, and the bladder is emptied by catheterization.    exPosure Adequate exposure is obtained by introducing into the vagina  either a weighted vaginal speculum, hand held retractors or a self-retaining  retractor, depending on the type and location of the operation to follow.  A thorough pelvic examination is made as a preliminary to the technical  procedures.    Posto Perative Care After the completion of the operation, the  vagina and perineum are cleaned with sponges moistened with saline or a  mild antiseptic solution. A sterile perineal pad 1s then applied and held in  position by a T binder. When constant bladder drainage is desired, a Foley  catheter is inserted and held by adhesive tape anchored to the thigh. T e  drapes are removed, and the legs are withdrawn slowly and simultaneously  from the stirrups to prevent disturbances in blood pressure and straining  of the sacroiliac joints.   T e immediate postoperative care is similar to that following abdomi-  nal procedures, with certain added perineal precautions. Indwelling cath-  eters are not necessary. T e patient may be catheterized every 4 to 6 hours,  depending on the f uid intake, until she voids voluntarily. Postvoiding resid-  uals should be checked. Values less than 50 mL usually indicate satisfactory  emptying. T ese patients should take in extra oral liquids to ensure a liberal  urine output. Antibiotics may be given if a urinary tract infection occurs.  T e daily intake and output are recorded during the hospital admission.   T e perineum is kept clean and dry with a peri-pad and is rinsed with  clean water after urination and defecation. Warm, moist applications or  dry heat to the perineum may be used to relieve pain. Sitz baths promote  comfort and stimulate voiding. A stool-softening preparation is given  starting either on the evening of surgery or the first postoperative morn-  ing. After procedures requiring extensive tissue dissection, bowel move-  ments are often delayed for 3 to 5 days. T e principle of early ambulation  is followed. m    IndIcat Ions Cervical conization is indicated for suspicious lesions of  the uterine cervix to confirm or exclude the diagnosis of cervical cancer.  It is also a therapeutic procedure for preinvasive lesions of the cervix. Cer-  tain outpatient procedures, such as colposcopy, usually precede conization  and are useful in the investigation of cervical lesions and/or an abnor-  mal pap smear. A grossly apparent lesion that 1s suspicious for neoplasia  should be biopsied regardless of Pap smear results. A punch biopsy is the  usual approach in this situation (figure 1). After exposure of the cervix,  the punch biopsy forceps is introduced, and a piece of cervical tissue 1s  removed with inclusion of a small bite of surrounding healthy tissue. Alter-  natively, many surgeons now stain the cervix with acetic acid and perform  the biopsies via colposcopic guidance.   A suspicious or positive Papanicolaou smear and/or positive punch  biopsy may necessitate operation with cold knife conization, the definitive  diagnostic procedure for malignant lesions of the cervix. Alternatively, a loop  electrical excisional procedure (LEEP) can be performed in the of ce setting.    o Perat Ive Procedure T e usual preparation of the perineum and  vagina is carried out. Following a pelvic examination under anesthesia, a  speculum is inserted into the vagina and the anterior lip of the cervix is  grasped with a single-toothed tenaculum. Dilatation and curettage is not  performed before conization because it interferes with the lining of the  endocervical canal and the squamocolumnar junction, making a patho-  logic diagnosis more dif cult.    detalls of Procedure T e cervix may be sprayed with a 7% iodine  solution for evidence of possible carcinoma. T e cervix is circumferen-  tially injected with a vasoconstrictive solution such as diluted Pitressin  or lidocaine with epinephrine. T e surgeon maintains traction on the  tenaculum as an incision is made with a No. 11 triangular-shaped blade at a  45-degree angle toward the endocervical canal. T e involved portion of the  cervix is excised (figure 3A). T e proximal 15 to 2.5cm of the endocervix    is also removed (figure 4). T e removed tissue, which appears as a cone,  is immediately placed in a fixative to avoid loss of diagnostic epithelium  through contact with gauze and so forth. T e length and width of the con-  ization procedure can be tailored to the size and location of the lesion, and  to the age of the patient. Alternatively, a CO, laser or electrocautery wire  (LEEP) may be used in place of the cold knife (figur e 2 and 3).   After the cone is removed, the conization bed may be coagulated with  the electrosurgical unit to maintain hemostasis. Individual points of hem-  orrhage are coagulated if necessary (figure 4). T e patency of the canal  is verified with a dilator (figure 5) and usually figure of eight sutures are  placed on each lateral aspect of the cervix to achieve hemostasis (figure 6).  Occasionally, additional anterior and posterior figure-of-eight sutures are  required.   T e patency and direction of the cervical canal are determined by the  passage of a uterine sound. T e cervix 1s dilated gently with a series of lubri-  cated, graduated Hegar dilators, and a systematic curettage is carried out  (figures 7 and 8). For diagnostic curettage dilatation up to a No. 8 or 10  Hegar dilator is adequate. T e largest sharp curette than can pass through  the dilated cervix is gently inserted and passed to the fundus. It is impor-  tant to maintain counter-traction on the cervix with a tenaculum while  placing dilators and performing the curettage. T e anterior wall is scraped  until all endometrium is removed, then the posterior wall. Curettage 1s  then repeated on the right and left walls, the fundus, and finally the uterine  cornu. Following curettage of the uterus, persistent bleeding from the cold-  knife conization is controlled with figure-of-eight sutures.    Posto PeratlIve care Postoperative care in a cervical conization  is most important. Wide and deep conizations of the internal os may be  the source of cervical stenosis. Postconization stenosis may be associated  with the development of dysmenorrhea as well as sterility, early pregnancy  loss and/or pre-term labor. Postconization patients should be seen in the  of ce in 6 weeks for dilatation of the cervix if necessary. Under no circum-  stances should a stem pessary be left in the cervix at the time of coniza-  tion, since infection may supervene in the presence of a foreign body. On  occasion, patients develop a perimetritis. T 1s usually responds very well to  antibiotics. m    IndIcatlIons T e left ureter is at risk for injury during hysterectomy,  hemicolectomy, and any procedure performed in the pelvis. Recognition  and repair of the injury limits post-operative morbidity. Once the injury  is recognized, a number of repairs are possible. In all repairs, a water-tight  closure and mucosa-to-mucosa apposition of the anastomosis is necessary.  T e location of the injury often determines the type of repair utilized.   More commonly, injuries occur outside the pelvis. In these cases, a  ureteroureterostomy can be performed to restore continuity of the urinary  tract. For injuries in the pelvis, commonly a simple ureteral reimplantation  into the bladder is the most effective option. T e ureter is spatulated and a  new opening created in the bladder wall. T e ureter is anastomosed to the  bladder mucosa with 4-0 or 5-0 absorbable suture, and potential tension on  the anastomoses is lessened with a psoas hitch.    detalls of Procedure Injuries in the middle to proximal third of the  ureter are often repaired with ureteroureterostomy (figure 1). T e proxi-  mal ureter around the injury is mobilized for a short segment. T is can  often be performed with blunt dissection that preserves the periureteral  vascular supply. T e same is then completed for the distal segment. T e two  ends should meet, excluding the injured portion, without tension. A healthy  portion of the ureter needs to be identified and used for the anastomosis on  each end. T e injured portion of the ureter can often be removed. Once the  two ends are able to reach without tension, spatulation longitudinally 1s  performed to widen the region of anastomosis (figure 2a and b). T is will  allow minor contraction without narrowing the lumen. A stay stitch may  be used in each end to minimize tissue handling. T e mucosa should not be  manipulated with forceps. Using a 4-0 or 5-0 synthetic absorbable suture,  the apex of one end is anastomosed to the spatulated portion of the other  (figure 2c). A full thickness suture is placed with the knot on the outside  of the mucosal apposition. Interrupted sutures are placed approximately  every 2 to 3mm to ensure a water tight closure. Once half the anastomo-  sis 1s completed, a ureteral stent may be placed to facilitate drainage while  the injury heals. T e ureteral anastomosis is then completed. Post-opera-  tively, a closed suction drain should not be left adjacent to the repair as this  may promote further urine leak and fistula formation. If a ureteral stent 1s  placed, it should be removed in 4 to 6 weeks (figure 3).   Injuries occurring in the lower third of the ureter can be repaired with  primary ureteral reimplantation with or without a psoas hitch. To prepare  the proximal ureteral segment, gentle mobilization of the peritoneum  medially is accomplished using a vessel loop around the ureter and bluntly  dissecting proximally. T e ureteral segment is transected at 90 degrees, fol-  lowed by a longitudinal spatulation of approximately 5mm (figure 4). A  stay stitch is placed in the apex to allow manipulation of the ureter. T e  bladder is then filled with saline through a sterile Foley catheter. T is allows  the surgeon to assess overall bladder volume and if the ureter will reach  without tension. If it does not, a psoas hitch (figure 4) is performed to  gain additional length to reach the proximal ureter.   A psoas hitch brings the bladder to the ureter and anchors it to the psoas  muscle. T e peritoneum over the dome of the bladder is ref ected. In men,    the vas may need to be ligated and the round ligament may need to be  divided in women. T e bladder is opened horizontally in the middle of the  anterior bladder wall (figure 5). T 1s can be made with the cutting cautery  current and stay sutures placed on either side of the incision facilitate a  clean incision. T is incision will ultimately be closed vertically and can be  opened to approximately half of the bladder equator for maximal length.  T e superior portion of the bladder is then elevated toward the psoas ten-  don. T is often allows elevation above the iliac vessels. An overlap of the  ureter and bladder dome ensures there is no tension on the closure. If fur-  ther distance is needed, the contralateral superior vesical artery and vein  may be ligated. T 1s may be done with a vascular stapler or suture ligation.  In additiona, the contralateral endopelvic fascia can be incised to allow a  few extra centimeters elevation. Once the necessary distance is attained, the  psoas muscle and tendon are exposed. T e bladder is held along this region  and two 0 or 2-0 nonabsorbable sutures are placed into the detrusor muscle  and tied to the psoas tendon (figure 4). More sutures can be placed if  needed. Care should be taken to place the sutures in the psoas tendon in a  longitudinal fashion to ensure the genitofemoral nerve is not entrapped. T e  anastomosis is ready at this point. A small opening 1s created in the blad-  der wall with cutting current electrocautery and a small hemostat creates  a direct entrance into the bladder lumen at 90 degrees (figure 6a). From  within the bladder a narrow hemostat is passed in an inferior direction to  create a submucosal tunnel from opening A to Bas in figure 6b. T epre-  viously placed stay suture on the ureter is used to pass the ureter through  the superior/posterior bladder wall into opening A (figure 6a) and the  stay suture is used to bring the ureter through the submucosal tunnel exit-  ing through opening B into the bladder lumen (figure 6c). T e ureter is  then sewn to the bladder mucosa with visualization through the previously  created cystotomy incision. A full thickness 4-0 or 5-0 synthetic absorbable  suture is placed through the ureteral wall and placed deep into the blad-  der wall so the mucosa is approximated. Intermittent sutures are placed  in this fashion until the ureter anastomosis is completed (figure 6d).  T is creates a fap valve to lessen ref ux as shown in figure 6e. It is gen-  erally recommended a ureteral stent be left in place. T e ureteral stent is  placed prior to closing the bladder wall. T e mucosal opening A is closed  with absorbable sutures. T e anterior bladder incision is closed with 3-0  chromic suture in a running layer incorporating mainly mucosa. A second  layer is closed with 3-0 synthetic absorbable suture to include the muscu-  laris and serosal layers (figure 7). If possible, a third layer can be closed  with 3-0 suture along the serosa. T e previous created f ap of peritoneum is  then replaced. A drain may be left in place; however, a closed suction drain  should not be placed over the anastomosis or bladder closure. A Foley cath-  eter should be left in place to straight drain.    Posto Perat Ive care Post-operatively the bladder is drained with the  Foley catheter for 1 week. A cystogram is performed to ensure no urine  leak exists prior to catheter removal. If a leak exists, the catheter should  be left another two weeks prior to the next cystogram. T e ureteral stent is  removed after 4 to 6 weeks. m    IndIcatIons Only persons who have voluntarily referred themselves as  willing kidney donors are considered for this operation. Donor candidates  undergo psychosocial and medical evaluation to determine their suitability  for donation. In general these donor candidates must be of sound mind and  in good health, nondiabetic, normotensive, nonobese, and with preserved  renal function.    Preo PeratIve PreParatlIon Candidates that have been deemed  suitable for donation undergo abdominal imaging with CAT scan angi-  ography, magnetic resonant angiography, or less commonly bilateral renal  artery arteriography. Imaging must verify the presence of two kidneys. In  patients with multiple renal arteries, determination of kidney suitability for  donation is based upon the experience and comfort of the donor, as well as  the recipient and surgeon.   Intravenous access is obtained prior to administration of general anes-  thesia and endotracheal intubation. Antibiotics are administered intra-  venously within | hour prior to procedure commencement. Intravenous  volume loading with crystalloid (25-50 cc/kg) is given prior to incision.  T is obviates compromised renal blood flow during abdominal insufflation  which can result in acute tubular necrosis of the donated kidney after reper-  fusion in the recipient. Following intubation a urinary catheter is placed for  bladder decompression and continuous urine output monitoring. An oral  gastric tube is placed and kept on suction to evacuate and decompress the  stomach. Deep venous thrombosis prophylaxis should be employed.    PosIt Ion T e patient is placed in the lateral decubitus position with the  left side up for left-sided nephrectomy and right side up for right donor  nephrectomy. A kidney rest 1s centered under the patient’s flank and axillary  roll under the dependent axilla. A bean bag may be used for holding the  patient in place. T e lower arm is placed on an arm board and the upper arm  is supported on stacked padding or an elevated arm rest. T e dependent leg  is flexed at the knee and hip while the upper leg 1s kept straight. Padding is  placed between the legs. T e trunk is kept at right angle to the table and the  pelvis and chest are strapped to the table to prevent movement during the  procedure. T e table is flexed 20 degrees and placed in slight Trendelenburg.  T e head should be supported to avoid lateral cervical flexion (figure la).    o PeratIve PreParatlon Hair within the surgical field is removed with  clippers immediately prior to positioning the patient in the lateral decu-  bitus position. T e midline of the lower abdomen is also marked prior to  lateral decubitus positioning, especially for obese patients. T e abdomen is  prepped from the xiphoid process to symphysis pubis and laterally from the  table dependently to the midaxillary line. T e surgeon and assistant stand  facing the patient’ abdomen with video monitors placed behind the patient  facing the surgeon and behind the surgeon and the surgeon’ assistant.    IncIsIon and exPosure A 10-mm port site incision 1s placed in the  skin at the anterior axillary line below the costal margin on the left or right  side ipsilateral to the kidney which is being removed (figure lb). A Veress  needle is used to inflate the abdomen up to a pressure of 15 cm of water that  will be maintained during the operation. T e Veress needle is replaced with  the 10-mm port that will serve as the port for the camera. T e laparoscope  can be inserted to examine the abdomen for adhesions, especially for patients  with previous abdominal operations. Another 10-mm camera port is placed  below the costal margin just lateral to the midline. For hand-assisted pro-  cedures an 8-cm hand port is generally placed either as an infraumbilical  midline incision or a transverse Pfannenstiel incision (figure 2). For the  totally laparoscopic approach the extraction incision is created at the end of  the procedure and can be placed either as described for the hand port site or  as a muscle splitting incision lateral to the rectus muscle on the left or right  side. T e camera operator will stand towards the head of the patient and the  surgeon towards the patient’s feet. Additional ports are placed as needed.    detalls of Procedure T e descending colon is mobilized from the  spleen to its transition to the sigmoid colon (left-sided nephrectomy) or  ascending colon from the hepatic flexure down to and including the cecum  (right-sided nephrectomy). On the left side, the surgeon or assistant’s hand  pulls the colon gently away from its attachments which are divided along  the white line of Toldt with an ultrasonic shears or alternate energy device.  T esuperficial peritoneal attachments are released. T e lateral renal attach-  ments are not released in order to prevent medial rotation of the kidney.  Gravity will allow the colon to remain deep or medial to the operative   T e ureter is next identified. T e ureter will be found 8 to 10 cm caudal  to the tip of the inferior pole of the kidney anterior to the psoas muscle and  lateral to the aorta (left side) or vena cava (right side) in close proximity  and posterior to the gonadal vein (figure 4). T e gonadal vein is a good  anatomic landmark to help identify the ureter. T e ureter is mobilized away  from the gonadal vein leaving adequate soft tissue around the ureter to avoid  stripping of its blood supply, resulting in ureteral ischemia which could lead  to urine leakage in the recipient. Alternatively, the gonadal vein and ureter  can be mobilized and removed together to ensure integrity of the ureteral  blood supply. Dissection proceeds in a cephalad direction along the gonadal  vein until reaching the renal vein (left side) or the vena cava (right side).   On the left side, the gonadal vein is secured with titanium vascular clips  adjacent to the renal vein and sharply divided (figure 6). A bipolar energy  device may also be used to transect the gonadal vein. If the gonadal vein is  removed with the ureter, the vein will be similarly clipped more caudally, at  the same level that the ureter is eventually divided. On the right side, the  gonadal vein is kept intact unless it 1s removed with the ureter, in which case  it is secured with vascular clips and sharply divided adjacent to its termina-  tion at the vena cava as well as at the level that the ureter 1s eventually divided.   T e kidney is next mobilized. Mobilization may begin inferiorly, as shown  in the accompanying figures or superiorly. Gerota’ fascia is entered along the  anterior aspect of the lower pole of the kidney (figure 4). T en the upper pole  of the kidney is dissected (figur e 5) and the adrenal gland is retracted medially  and dissected away with a bipolar energy device from the upper pole as shown  in Chapter 118 (figur e 7). In this dissection renal artery branches to the upper  pole may be identified and care should be taken not to injure them. After the  upper pole of the kidney is released then the lateral and posterior attachments  are divided. T e kidney may be rotated in the medial direction to facilitate dis-  section and identify any posterior attachments to the renal artery and vein.   It is preferable to divide all the branches of the left renal vein prior to com-  plete mobilization of the kidney for ease of exposure during their dissection.  On the left side, the adrenal vein is dissected at its insertion into the renal  vein. It is divided with clips or a bipolar energy device. T e left renal lumbar  vein should be identified. If present it should enter the renal vein on its poste-  rior aspect. T e left renal lumbar vein is found joining the inferior/posterior  aspect of the left renal vein anterior to the renal artery. It then courses poste-  riorly and just lateral to the aorta, inferior to the renal artery, and posterior to  the gonadal vein (figure 6). T is vein must be divided in order to identify  the renal artery that lies immediately posterior. T e left renal lumbar vein  is carefully dissected, clipped, and sharply divided (figur e 6). Occasionally  the lumbar vein will be absent and occasionally the predominant venous  drainage to the vena cava will be the via lumbar vein posterior to the aorta  (retroaortic renal vein). Note that there are no lumbar branches arising from  the the right renal vein if the right kidney is being donated. In order to pro-  vide adequate length for the anastomosis the renal vein is dissected from all  surrounding perivascular attachments to a point medial to the adrenal vein.   T erenal artery is identified posterior to the renal vein and bluntly dis-  sected from the surrounding tissues using an ultrasonic device to minimize  blood loss. On the left side, an adrenal artery originating from the cepha-  lad aspect of the renal artery is usually encountered and must be clipped  and divided or divided with a bipolar vessel sealing device (figure 6). T e  renal artery is dissected proximately to the aorta (left side) or well posterior  of the inferior vena cava (right side). T e renal vein should be dissected  about 2 cm proximal to the adrenal vein (left side) or to the vena cava (right  side) to allow adequate length for the anastomosis. During the renal ves-  sel dissection it is important to maintain the soft tissue lying between the  ureter and the inferior pole of the kidney to avoid disrupting ureteral blood  supply in this area. Once the artery is circumferentially dissected, the renal  vessels are the only intact structures within the renal hilum.   On the right side, the artery is best approached by reflecting the kidney  medially and dissecting directly over the renal artery behind the inferior  vena cava. T ere are no renal vein branches to divide. Once the renal artery  is dissected, the remaining tissue lying between the artery and the vena cava  is dissected. Upon completion the renal vessels are the only intact struc-  tures within the renal hilum.   After the kidney is mobilized the patient is administered intravenous  furosemide and mannitol. One should avoid administration of these diuret-  ics before the kidney is mobilized as the kidney swells, making the dissection    detalls of Procedure Finally the ureter, with or with-  out the gonadal vein, is dissected caudally until the common iliac vessels  are encountered deep to the ureter. T e kidney is now ready for removal.  T e patient 1s systemically heparinized as the ureter is clipped with vas-  cular clips at the caudal limit of the dissection and sharply divided leav-  ing the proximal ureter open. T is preserves adequate length of the ureter  (figure 7a and b). T e renal artery is stapled close to the aorta (left side)  or behind the inferior vena cava (right side) (figure 8). T e renal vein is  stapled > 2 cm proximal to the adrenal vein stump (left side, figure 9) or  at the vena cava (right side). T e kidney is extracted through the hand port.  T e heparin is reversed with protamine.    T e surgical site is inspected to assure hemostasis (figure 10). T e pre-  viously mobilized colon is placed back in its in situ position and port sites  are closed in standard fashion and sterile dressing applied.    Posto PeratIvecare T coral gastric tube is removed by the anesthe-  siologist. Oral fluids are begun the day of surgery and the diet 1s advanced  as tolerated. Cough and deep breathing are encouraged immediately. T e  patient is ambulated on the first day after surgery, and the sterile dressing is  changed on the second day. m=    IndIcatlIons T is procedure is for patients with end-stage chronic  kidney disease with a glomerular filtration rate < 20 mL/min who possess  adequate cardiopulmonary reserve to undergo surgery. In addition, the  patient cannot have an active infection or malignancy that would be exac-  erbated after the transplant due to the necessity of ongoing 1immunosup-  pression therapy following engraftment.    Preo Perat Ive PreParat Ion Candidates are evaluated prior to trans-  plantation for suitability based on the above indications as well as other  psychosocial factors. Candidates found to have pre-existing comorbidities  will receive additional evaluation and testing at this time as needed to aid in  determining suitability. Once the candidate has been deemed suitable, the  patient is ready for transplantation with a living donor kidney, if available,  or listed for a deceased donor kidney.   Intravenous access is obtained prior to administration of general anes-  thesia and endotracheal intubation. Central venous access 1s preferable as  it allows for intravascular volume assessment during the procedure. Anti-  biotics are administered intravenously within 1 hour prior to procedure  commencement. Following intubation, a urinary catheter is placed and the  bladder is irrigated with antibiotic-containing saline. If the patient is oligu-  ric or anuric saline is left in the bladder after irrigation to distend it, aiding  intraoperative identification. T e Foley drainage bag is clamped to keep the  bladder distended until the neoureterocystostomy is performed. An oral  gastric tube is placed and kept on suction to evacuate and decompress the  stomach. Deep venous thrombosis prophylaxis should be employed.    PosItIon T epatientis placed in the supine position. T elegs are secured  to the table with a strap with slight laxity. T e lower extremities should be  exposed enough to allow surgical access to the infrainguinal femoral vessels  for the rare case where arterial reconstruction is necessary. If the patient has  a peritoneal dialysis catheter every attempt should be made to position and  drape it out of the surgical field. T e ipsilateral femoral artery is palpated  to verify iliac artery patency.    oPeratIve PreParatlon Te hair overlying the surgical field is  removed with hair clippers. T e abdomen is prepped from the midaxillary  line on the side chosen for implantation to well beyond the midline, or if  desired to the opposite midaxillary line. Caudally the abdomen is prepped  below the symphysis pubis, and includes the femoral region on the implan-  tation side. T e prep extends cephalad to at least 5cm above the umbilicus.    IncIslon and exPosure T e straight or curvilinear skin incision is  made on the left or right side of the lower abdomen from the symphysis  pubis at the midline laterally and cephalad far enough to provide ade-  quate exposure of the external iliac vessels and to perform the vascular  anastomoses (figure 1). T e external and internal oblique aponeuro-  ses are divided just lateral to the rectus muscle, exposing the superficial  inferior epigastric artery and vein. T ese vessels are ligated and divided.  T e round ligament (females) or spermatic cord is encountered as the  peritoneum is swept medially exposing the contents of the iliac fossa.  T e round ligament is ligated and divided. T e spermatic cord 1s encir-  cled with a vessel loop and retracted medially and inferiorly to aid in  exposure of the iliac fossa. Exposure is maintained with a Balfour self-  retaining retractor.    detalls of Procedure T e external iliac artery and vein are dis-  sected free from surrounding tissues from the inguinal ligament distally  to its origin proximately and encircled with vessel loops (figure 2). T e  genitofemoral nerve is found lateral to the artery and can lie quite close to  it. T is nerve should be identified and spared. Lymphatics are ligated with  permanent 2-0 suture to prevent postoperative lymph leakage. T e donor  kidney is now prepared on a back table for implantation.   T edonor kidney is placed in a bowl filled with iced saline. T e configu-  ration of right and left deceased donor kidneys 1s shown in figure 3a andb.  T e configuration of the right and left living related kidneys is shown in    figure 3c and d. Deceased donor kidneys will have a cuff of aorta and on  the right side a segment of inferior vena cava.   T e renal artery and vein are dissected free from surrounding tissues,  without over dissecting too close to the renal hilum. T e gonadal, adrenal,  and lumbar veins need to be ligated with 2-0 permanent suture and divided  for a left kidney. For the right kidney the inferior vena cava is stapled (or  over sewn with 4-0 nonabsorbable monofilament suture) both cephalad  and caudal to the renal vein orifice and the left lateral edge of the inferior  vena cava is opened, thereby creating a longer vein. T us the cava and renal  vein are dissected free from surrounding tissues with ligation of any venous  branches, including lumbar veins, with 2-0 and 4-0 silk sutures. T e extra  cava is then removed. For deceased donor kidneys a cuff of aorta is included  with the renal artery (figure 3a and b). For living donor kidneys this can-  not be done. If multiple arteries exist they can be anastomosed together on  the back table to reduce the number of anastomoses needed during implan-  tation or they can be implanted separately, depending on surgeon prefer-  ence. Any extra tissue adherent to the kidney capsule is removed as well as  extra retroperitoneal tissue associated with the ureter. T e triangle of soft  tissue between the ureter and inferior pole of the kidney is left in place to  assure adequate blood supply to the ureter. T e kidney is brought to the  operative field.   A left living related donor kidney transplant is illustrated. T e external  iliac artery and vein are clamped with vascular clamps proximal and distal  to the intended anastomotic site. T e patient is heparinized prior to clamp-  ing if not yet dialyzing. A venotomy is created in the external iliac vein,  appropriately sized to the renal vein orifice (left kidney) or inferior vena  cava orifice (right kidney). Four 5-0 nonabsorbable double-armed mono-  filament sutures are placed one each at the proximal and distal ends of the  external iliac vein venotomy and one each at the midpoint of the medial  and lateral sides, and then brought through the appropriate, correspond-  ing area on the renal vein (or inferior vena cava) (figure 4). T e proximal  and distal “corner” sutures are tied and the medial and lateral sutures are  clamped with nontraumatic clamps and placed on tension to hold the walls  of the external iliac vein apart. One of the two ends of a “corner” suture is  then run down one side of the anastomosis to the opposing “corner” pro-  ceeding outside to inside the renal vein and inside to outside of the external  iliac vein, approximating the renal vein (or inferior vena cava) to the exter-  nal iliac vein, then tied to one of the ends of the opposite “corner” suture.  T is maneuver is then repeated on the opposite side, completing the anas-  tomosis. An arteriotomy is created in the external iliac artery either with  mucosal scissors or an #11 scalpel blade followed by an appropriately sized  aortic punch. T e arteriotomy site is selected to avoid kinking of the renal  artery once the kidney is placed into the iliac fossa and to avoid (as much as  feasible) areas involving severe atherosclerotic disease or calcification. Four  5-0 nonabsorbable double-armed monofilament sutures are placed as was  done for the venous anastomosis (figure 5). T e medial and lateral sutures  are clamped and placed under tension and the “corner” sutures are tied  with one arm of the suture run to the opposite “corner” proceeding outside  to inside the renal artery and inside to outside of the external iliac artery, as  was done for the venous anastomosis. If accessory arteries are present and  require implantation then the arterial anastomosis is repeated as necessary.   T erenal artery and vein are then clamped with bulldog clamps prior to  sequentially removing the iliac vessel clamps; proximal iliac vein, distal vein,  distal iliac artery, and proximal iliac artery. Clamping the renal vessels allows  for inspection of the vascular anastomoses and placement of repair stitches  if necessary prior to reperfusion of the kidney. When the anastomoses are  hemostatic, sponges are placed adjacent to the anastomoses to promote seal-  ing of the suture line with platelet thrombi, and the renal vessel bulldogs are  removed and the kidney reperfused. A small bulldog clamp is placed near the  end of the ureter so it will distend with urine. T e kidney will become pink,  firm, and often pulsatile to palpation. Bleeding from the kidney surface and  small vessels is controlled with vascular clips and electrocautery. T e sponges  are removed and the kidney 1s positioned in the iliac fossa and the renal ves-  sels are inspected to assure they are not kinked or twisted.    detalls of Procedure T e Balfour self-retaining retrac-  tor is removed and an Adson—Beckman self-retaining retractor is placed at  the medial-caudal end of the incision to expose the bladder. A 1.5- to 2.0- cm  incision 1s made in the bladder using electrocautery, oriented parallel to the  long axis of the ureter (figure 6a). T ree 4-0 absorbable retention sutures  are placed full thickness into the bladder, clamped and placed on tension.  T eureter is passed underneath the spermatic cord in male patients assur-  ing it is not kinked or twisted. T e ureter is spatulated an appropriate length  and an 8-French red rubber catheter placed into it to divert urine away from  the operative field and to stent the ureter during the creation of the anasto-  mosis. A ureter that is too long will result in unwanted redundancy and too  short will not allow the kidney to rest in the intended location within the  iliac fossa. T e ureter-to-bladder anastomosis is begun using a 5-0 double-  armed absorbable monofilament suture placing one arm inside out in the  end of the bladder incision closest to the kidney and the other arm inside  out in the proximal corner of the spatulated ureter (figure 6b).T is suture  is tied. Each arm of the suture is used to run the two sides of the anasto-  mosis, proceeding from outside to inside on the bladder wall and inside to  outside on the ureter. Prior to completing the anastomosis the red rubber  catheter is removed and any extra length of ureter is removed with mucosal  scissors. T e anastomosis is completed and the two arms of the suture tied  together (figure 6c). An indwelling 6-French, 12-cm double-J stent (not  shown) may be placed into the ureter based on surgeon preference. If used,  this stent is placed in the ureter instead of the red rubber catheter and the  bladder end of the catheter is “dunked” into the bladder prior to completing  the anastomosis. Once the anastomosis is completed the retention sutures    are removed. T e bladder muscularis is imbricated over the anastomosis  with two or three 4-0 absorbable sutures to create a tunnel for the ureter  to prevent urine reflux into the ureter (figure 6d). T ese sutures must be  carefully placed to avoid constricting the ureter, causing obstruction.   T e kidney, renal vessels, and iliac vessels proximal and distal to the  vascular anastomoses are inspected to assure adequate blood flow and no  thrombosis (figure 7). T e anesthesia team is queried to determine the  quantity of urine output. If the kidney appears adequately perfused and  the urine output is satisfactory the retractor and sponges, if present, are  removed. T e iliac fossa is irrigated with antibiotic-containing saline. T e  fascia and skin are reapproximated. An ipsilateral femoral pulse is palpated  and confirmed.    Posto PeratIvecare Hourlyurine output should be measured for the  first postoperative 24-hour period. Any sudden and unexpected decrease in  output should be immediately investigated. An ipsilateral femoral pulse is  confirmed. Loss of a femoral pulse indicates arterial thrombosis or dissec-  tion, requiring immediate reoperation. T e bladder can be gently flushed  through the Foley catheter to dislodge any obstructing clots that may be  present. Recipient intravascular volume status is assessed and postopera-  tive hemorrhage considered. A renal ultrasound can be performed to verify  blood flow to the kidney. If concern persists, a timely return to the oper-  ating room is warranted for visual inspection of the transplanted kidney.  Laboratory studies are obtained every 6 hours to monitor renal function  and blood loss. Electrolyte values are obtained and abnormalities that may  develop due to renal insuf ciency or large volume diuresis are corrected. m    IndIcatIons Ventral hernias in the anterior abdominal wall include  both spontaneous or primary hernias (e.g., umbilical, epigastric, and  spigelian) and, most commonly, incisional hernias after an abdominal  operation. Small primary ventral hernias less than 2’4 cm in diameter are  often successfully closed with primary tissue repairs. However, larger ones  have a recurrence rate of up to 30% or 40% when a tissue repair alone 1s  performed. It is estimated that 2%to 10% of all abdominal operations result  in an incisional hernia. T is explains the predominance of such hernias.  Fortunately, the use of mesh has revolutionized the repair of abdominal  wall hernias. Anterior placement of polypropylene mesh as an onlay to the  primary repair is helpful and a retrorectus muscle placement is even better.  However, the development of dual-sided mesh has allowed for an improved  placement of mesh behind the abdominal wall and hernial defect. T ese  meshes present an intraperitoneal nonadherent surface to the bowel and  an open synthetic mesh grid or screen for adherence and incorporation  into the peritoneum and posterior abdominal wall fascia. T e dual-sided  meshes can be placed laparoscopically for almost any ventral hernia, but  extremely large hernias with loss of abdominal domain or those associated  with extensive, dense intra-abdominal adhesions (e.g., peritoneal dialy-  sis, prior peritonitis) are relative contraindications. T e meshes are very  expensive; however, operating room time and hospital length of stay are  shortened. T e laparoscopic incisions cause less pain and there is a faster  return to normal activities or work. Finally, laparoscopic repair enables the  detection and repair of multiple defects—a common finding in midline  incisional hernias.    Preo Perat Ive PreParatlon T e patient must be free of infections,  especially in the skin. Respiratory function should be optimized with cessa-  tion of smoking and appropriate pulmonary function evaluation. If bowel  is contained with the hernia, endoscopic visualization, contrast studies, or  imaging may be performed and the patient may be given a bowel prepara-  tion with a liquid diet and cathartics for 1 or 2 days prior to surgery. T e  major factors in the occurrence of this hernia, as well as the preceding oper-  ative note, should be reviewed.    PoslItIon T e patient is placed in a supine position with a pillow placed  to produce mild flexion of the hips and knees. T is helps to relax the  abdominal wall. For ventral hernias that are not midline, the patient may  be positioned with pillows for some lateral elevation of the chest, flank, and  hips.    o PeratIve PreParatlon T e patient is given perioperative antibiot-  ics. An orogastric tube is passed for gastric decompression. A Foley catheter  is placed and pneumatic sequential stockings are applied. T e skin is pre-  pared in the routine manner.    IncIslon and exPosure T e 10-mm videoscope port (0) and the  5-mm operating ports (X) are a function of the position of the hernial  defect and the preference of the surgeon (figure la). T e general prin-  ciple is that of triangulation. T e ports should be about a hand’ breadth or  more apart from each other and the two operating ports should be placed  as widely apart as possible. Typical hernias and the placement of ports are  shown (figure lb toe). One of the operating ports should be 10 mm in size  if a 5-mm videoscope is not available.   T e videoscope port is placed first, using the open Hasson technique  (Chapter 11) or an optical trocar may be used after preinsufflation of the  abdomen using a Veress needle when accessing the abdominal cavity lat-  erally. After the abdomen is entered safely and the port secured with stay  sutures, the intraperitoneal space is inflated with carbon dioxide. T e sur-  geon sets the gas flow rate and the maximum pressure (< 15 mm Hg). T e  rising intra-abdominal pressure and total volume of gas infused is observed  as the abdomen and hernia distend. T e videoscope is white-balanced and  focused. T e optical end, usually a 30-degree angle, is coated with antifog  solution and the scope is advanced down the port into the abdomen under  direct vision. All four quadrants of the abdomen are explored visually. T e  hernia and its contents are evaluated and additional unrecognized inci-  sional hernial defects may be found, especially in long midline incisions.  Omental and other adhesions to the abdominal and anterior abdominal    wall about the hernial defect are visualized. A zone of about 4 to 6 cm must  be made clear about the rim of the hernial defect for the wide attachment of  the mesh beyond the borders of the actual defect.   Placement of the operating ports begins with the infiltration of the skin  with a long-acting local anesthetic. T e local needle may be passed perpen-  dicularly full thickness through the abdominal wall and its entry site veri-  fied with the videoscope. T e skin is incised and the subcutaneous tissues  are dilated with a small hemostat. T e abdominal wall is transilluminated  with the videoscope to show any regional vessels within the abdominal  musculature. T e 5-mm operating ports are placed, with visualization of  their clean entry into the intraperitoneal space.    detalls of Procedure In the typical ventral or incisional hernia,  the omentum will have formed some adhesions to the sac of the hernia.  T e omentum is grasped near the abdominal wall with the forceps or the  dissecting instrument and gentle traction is applied. Using laparoscopic  scissors, the surgeon sharply incises the junction of the omentum with the  peritoneum of the abdominal wall (figure 2). After each cut, a sweeping  motion in the same area will open up the next zone for cutting. Minimal  bleeding occurs. Electrocautery or other heat-generating coagulating sys-  tems should be used sparingly and only with full visualization so as to mini-  mize the chance of thermal injury to the bowel. Extensive dense adhesions,  inability to reduce the hernial contents from the sac, or an enterotomy that  is not easily repaired all require conversion to an open laparotomy and  repair. After the abdominal wall adhesions are taken down, the omentum  is removed from the hernial sac, which is left intact. A useful maneuver is  the inversion of the hernial sac using several fingers externally (figure 3).  T is allows the sharp cutting to continue with the best visualization of the  junction of the omentum with the peritoneal sac. Again, gentle traction  is applied to the omentum while the surgeon spreads, cuts, and sweeps.  T roughout this dissection, the surgeon must be vigilant for the appearance  of a loop of bowel hidden within these adhesions. Small and large bowel  may also be cautiously cut away from the abdominal wall and hernia sac,  but less sweeping and traction is applied lest an enterostomy occur. T e  appearance of bile or succus demands a search for the source, which may  be repaired laparoscopically or after conversion to and open laparotomy.  Some surgeons regard this complication as a contraindication to the  placement of mesh, which is porous and may harbor a chronic infection,  requiring eventual removal of the mesh.   After careful inspection of the omentum and other adhesions that  have been removed from the abdominal wall, the surgeon makes a visual  measurement about the perimeter of the defect to be certain there is an  adequately clear zone for attachment of the mesh and its sutures. In gen-  eral, 4 to 6 cm is suf cient. An important next step is to lower the intra-  abdominal CO, gas pressure to about 6 or 8 mm Hg, which minimizes  the stretching of the abdominal wall and hernia. If measurements of the  defect are made with the abdomen fully inflated at 15 mm Hg, the mesh  will be too large. It will become very wrinkled and loose when the CO, 1s  removed at the end of the operation. T e size of the defect is measured.  Some surgeons use an internal measurement based upon a 2-cm spread,  tip to tip, of the opened dissecting instrument. Most perform an external  measurement and marking maneuver (figure 4). A long needle is passed  perpendicularly at the edge of the fascial defect in each of the four quad-  rants. T e entrance site at the internal edge of the hernial defect is verified  with the videoscope and the external sites are marked with indelible ink.  T e pattern of the defect is outlined so as to determine the size and shape  of the mesh. A 3- to 4-cm margin is drawn out from this defect. T is is  marked and measured for choosing the mesh’ size and shape (figure 4).  T e dual-sided mesh is prepared with placement of four sutures, one in  each quadrant (figure 5). T e sutures are nonabsorbable 00 in size and  may be placed with parallel or perpendicular to the edge of the mesh. A  useful maneuver is to use a pair of parallel sutures in one axis (12 and  6 oclock) and perpendicular sutures in the other axis (3 and 9 oclock). In  this manner, the axis for internal attachment is identified when the mesh is  not round in shape. Each suture is tied in its midpoint and the long tails are  left intact. T e mesh is rolled snugly with the nonadherent surface inside  and synthetic mesh outside, so as not to create tension that may peel the  two layers apart (figure 6).    detalls of Procedure In the hernia illustrated, the  10-mm Hasson port for the videoscope was placed in the left lateral abdom-  inal position. T is large port site is needed for the dif cult passage of the  rolled up mesh through the abdominal wall. A useful technique is to pass a  grasping forceps through an operating port and then out through the Has-  son port (figure 7). T e port tube is removed and the rolled up mesh is  grasped with the forceps (figure 8) and drawn back into the abdomen.  T e mesh is unrolled and oriented with the smooth nonadherent surface  down toward the bowel. Getting the mesh into the abdomen and unrolling  it in the correct orientation can be quite tedious. T e mesh 1s first secured  with one of the preattached sutures at the four quadrants. Most surgeons  begin with the 12 or 6 oclock sutures. T e four previously marked skin sites  are incised with a No. 11 scalpel blade, which makes a 3-mm skin opening  (figure 9). A special suturing needle is passed perpendicularly through  the abdominal wall. T e needle tip is opened and one of the suture ends  is grasped as it closes. T e loose suture end is brought out through the  abdominal wall and secured with a hemostat. A special suturing needle is  passed again through the abdominal incision, but this time it is armed to  enter the abdominal space about 1 cm away from the first site. T e other  half of the tied suture is grasped and brought out. T e suture is tied down  through the skin incision, setting the knot deeply. T is secures the mesh to  the abdominal wall fascia (figure 10). T is transabdominal suturing con-  tinues with placement of the two lateral sutures and then, last, the opposite  (6 oclock) suture. A minimum of four transfascial sutures should be placed  to secure the mesh to the anterior abdominal wall. Larger pieces of mesh  may require eight transfascial sutures to appropriately fix the mesh to the  anterior abdominal wall. In general, the mesh should be slightly loose but  not wrinkled rather than precisely tight. T e exposed perimeter of the mesh    is now secured with an endoscopic stapling device. Spiral screws or tacks  are preferred.   T ese are placed 1cm apart. It is important that the perimeter be securely  attached with closely spaced tacks such that no bowel or omentum can get  under the edge of the mesh. Placement of the tacks is facilitated by hav-  ing the surgeon apply external counterpressure with the hand while the  tacking instrument spreads out the mesh in a radial manner (figure 11).  T ese two actions provide a little lip to the edge of the mesh, thus allowing  a more precise placement of each tack. Upon completion of the procedure,  the abdomen is lavaged with the suction irrigator. Careful inspection is  made for any bleeding sites and bile or succus. Each of the operating ports  is removed under direct vision to be certain that there are no bleeding sites  in the abdominal wall. As intra-abdominal gas is vented, the final view of  the loosely applied mesh is seen (figure 12). T e fascia of any 10-mm port  site is closed with 00 delayed absorbable sutures. T e skin is approximated  with fine subcuticular sutures. Adhesive skin strips and dry sterile dressings  are applied.    Posto PeratlIve care T e orogastric tube is removed before the  patient awakens and the Foley catheter is discontinued when the patient  is alert enough to void. He or she may experience a moderate amount of  pain for a day or so. Clear liquids are resumed within | day and the diet is  advanced as tolerated. Some surgeons recommend the use of an abdomi-  nal binder for 1 month after surgery. Hematomas and surgical-site infec-  tions can occur. T e latter may require eventual removal of the mesh if  the infection becomes chronic. Accumulation of serum in the old hernial  sac occurs frequently and may require aspiration. Finally, some patients  may experience chronic pain at the sites of transfascial suture fixation. m    IndIcatIons Ventral hernias in the anterior abdominal wall include  both spontaneous or primary hernias (e.g., umbilical, epigastric, and spige-  lian) and, most commonly, incisional hernias that occur after an abdomi-  nal operation. It is estimated that 2% to 13% of all abdominal operations  result in an incisional hernia. Risk factors for the development of an inci-  sional hernia include obesity, multiple abdominal procedures, diabetes,  wound infections, and the use of immunosuppressive medication(s). Small  primary ventral hernias are often successfully closed with primary tissue  repairs. Repair of incisional hernias often utilizes synthetic or biologic  mesh to decrease recurrence rates. In some patients, the use of mesh 1s con-  traindicated or not desired and the hernia defect is too large or extensive to  allow for appropriate primary closure. In the event of real or potential con-  tamination, the use of synthetic mesh may be contraindicated. In addition,  patients may request or require a more cosmetic repair of their abdominal  wall as part of their treatment with “medialization” of their abdominal wall  musculature that was previously displaced due to the ventral/incisional  hernia. In patients whom synthetic mesh cannot be utilized, native abdom-  inal wall fascia and musculature must be used to close the hernia defect  and reapproximate the abdominal wall components while minimizing the  potential for hernia recurrence. Open component separation is used almost  exclusively for midline ventral hernia defects, whether they are single or  multiple, when the use of synthetic or biologic mesh is not an option for  repair. Component separation enables the detection and repair of multiple  defects—a common finding in midline incisional hernias.    Preo Perat Ive PreParatlon T e patient must be free of active infec-  tions, especially in the skin. Respiratory function should be optimized with  cessation of smoking and appropriate pulmonary function evaluation. If  bowel is contained with the hernia, endoscopic visualization, contrast stud-  les, or imaging may be performed preoperatively and the patient may be  given a bowel preparation with a liquid diet and cathartics for 1 or 2 days  prior to surgery. T e major factors in the occurrence of this hernia, as well  as the preceding operative note(s), should be reviewed.    PoslItIon T e patient is placed in a supine position with a pillow placed  to produce mild flexion of the hips and knees. T is helps to relax the  abdominal wall and take some tension of of any repair performed.    o PeratIve PreParatlon T e patient is given perioperative antibiot-  ics. An orogastric tube is passed for gastric decompression. If significant  dissection is anticipated, a nasogastric tube may be placed for postopera-  tive decompression of the stomach in the event of an ileus. A Foley catheter  may be placed and pneumatic sequential stockings are applied. T e skin  is prepared in the routine manner with attention to prepping the patient’    abdominal wall laterally as this may be accessed as part of the operative  procedure.    IncIslon and exPosure A component separation technique is most  ef ectively utilized for midline abdominal hernias when synthetic or bio-  logic mesh is unavailable or contraindicated and a midline primary closure  is desired but unattainable due to the “space” created in the midline by the  fascial defect. T is technique may also be used in conjunction with a ret-  romuscular piece of synthetic or biologic mesh to “bolster” the repair. For  this reason, typically a midline abdominal incision is made overlying the  hernia (figure 1). T e incision may extend from the xiphoid to the pubis  or be shorter and tailored to the size of the defect undergoing repair. Ade-  quate length of the incision is necessary to insure appropriate exposure of  the abdominal wall musculature above and below the hernia. T e incision  is carried down through the subcutaneous tissue onto the hernia sac in the  midline and the unadulterated fascia. Exposure is facilitated by elevation  of subcutaneous flaps laterally overlying the abdominal wall musculature.  T ese flaps extend to the anterior axillary line just lateral to the insertion of  the external oblique fascia onto the more medial rectus sheath (figure 2).    detalls of Procedure Once the incision and subcutaneous flaps  are complete exposing the insertion of the external oblique on the rectus  sheath, the external oblique fascia 1s incised on its anterior border just later-  ally to its insertion on the rectus sheath (figure 3). T e length of the inci-  sion may be tailored to the hernia defect but can extend the entire length of  the abdominal wall. Once the external oblique is incised a plane is created  laterally between the external oblique aponeurosis and internal oblique  aponeurosis ef ectively lifting the external oblique musculature of of the  internal oblique aponeurosis and allowing for advancement or “medial-  ization” of the rectus sheath into the midline for primary closure. Release  of the external oblique fully along its course from xiphoid to pubis may  allow for primary closure of small to moderate sized defects. Tension on  closure should be evaluated by the surgeon after mobilization of both sides.  If tension is considered to be too high, consideration of further mobiliza-  tion is undertaken. Incision of the posterior rectus sheath along its course  (figure 4) and dissection of the posterior rectus sheath of of the poste-  rior elements of the rectus abdominis muscle further mobilize the abdomi-  nal wall musculature to allow for midline closure. Full mobilization of  the external oblique aponeurosis and the posterior rectus sheath can be  expected to allow for 3 to 5cm advancement in the upper and lower abdo-  men and 8 to 10 cm of advancement at the waist (figure 5). T is technique  insures at least two layers of abdominal wall envelope the intra-abdominal  organs except in the midline which is closed in a single layer. Primary clo-  sure of the midline wound is often performed with interrupted nonabsorb-  able sutures (figure 6).    detalls of ProcedurecontInued In an ef ort to pre-  vent midline recurrences, many surgeons place an underlay of synthetic or  biologic mesh to prevent a recurrence in the suture line (figure 7). T e  mesh should overlap the fascial edges by 4 to 5 cm. Heavy number 0 or 1  nonabsorbable sutures are placed laterally about 2 to 4 cm from the fas-  cial edge with the knots on top (figure 7). If the posterior rectus sheath  is missing (as in inferior to the level of the semilunaris line in the supra-  pubic region) then the sutures are passed through the confluence of the  fascia of the oblique muscles. If the mesh will be in contact with the intra-  abdominal organs, a mesh coated with an antiadhesive surface should be  employed to prevent adhesions from forming between the mesh and intra-  abdominal organs/bowel. With the fascia closed, attempts should be made  to reapproximate the subcutaneous tissue elevated of of the abdominal  wall musculature in an attempt to eliminate the “dead-space.’ T e use of  2-0 absorbable interrupted suture is desired. Often, the subcutaneous flaps  create an opportunity for blood and/or fluid to accumulate and placement  of two closed suction drains within the flaps collect fluid/blood and prevent  a postoperative seroma or hematoma from developing (figure 8). T ese  drains are not in contact with and must be excluded from mesh that may  be placed retromuscularly so as to pose no additional risk to “seeding” or  infecting mesh. T eskin may be close with staples or an absorbable running  suture. A sterile dressing is applied. Overtop the dressing, many surgeons  will wrap the abdominal wall in a binder in an ef ort to provide additional  support to the abdominal wall in the postoperative period.   If the surgeon does not believe mesh should be used because of patient  factors, then it may be possible to achieve closure with the extended    separation shown in figure 9. T eanterior rectus sheath from points A to  C is freed (figure 9a) and the insertion of the internal oblique and trans-  versus fascia along with remaining posterior rectus sheath (figure 9b) 1s  secured anteriorly to the lateral edge of the anterior rectus sheath at point  C (figure 9c). T e external oblique muscle with fascial cuts (point C) is  allowed to retract laterally and thus provide the needed slack for the points  Bto C closure in front of the rectus muscle.    Posto PeratlIve care Te orogastric tube is removed before the  patient awakens if it is anticipated that the patient will not have a significant  ileus. If an ileus is anticipated due to bowel manipulation or extensive dis-  section, a nasogastric tube should remain until return of bowel function.  T e Foley catheter is discontinued when the patient is alert enough to void.  He or she may experience a moderate amount of pain for a few days. Clear  liquids are resumed within | day and the diet is advanced as tolerated. Some  surgeons recommend the use of an abdominal binder for up to 6 weeks  after surgery. Hematomas and surgical-site infections can occur. Accumu-  lation of serum in the old hernia sac may occur and require aspiration. If  a subcutaneous drain was placed in the subcutaneous flaps, it 1s removed  once the drainage is serous and minimal to prevent accumulation of fluid  in this space. T e patient is asked to refrain from strenuous physical activity  and lifting heavy weight for 6 weeks postoperatively in an attempt to allow  fascial healing until the wound strength is such that strenuous activity will  not compromise the repair. An abdominal binder is continued at home for  several weeks and the patient is asked to wear the binder as much as pos-  sible. Removal of the binder during sleep is necessary in some patients. m    IndIcatlIons Anumbilical hernia is usually a congenital defect, although  a variation may follow surgery such as the placement of an incision or lapa-  roscopic port in this region. T e increased susceptibility to strangulation of  an umbilical hernia in an adult necessitates repair as the patient’s condition  permits.   Repair of an umbilical hernia in the very young child is rarely indicated,  since 80% of these fascial defects will close by the age of 2 years. In addi-  tion, the incidence of incarceration and strangulation within an umbilical  hernia in this age group 1s extremely low. However, if supportive measures  such as the “keystone” type of strapping during infancy have failed and the  fascial ring is sufficiently large to admit the index finger, the hernia should  be repaired before school age.    Preo Peratlve PreParatlon T is defect is usually seen in either chil-  dren or obese adults, and the preoperative preparation depends entirely upon  the patient’ general condition and age. Obese patients are placed on a diet. A  general medical assessment is indicated. T e patient may be placed on a low-  residue diet for a day or two and the bowels emptied with a mild cathartic.  Repair 1s delayed in the presence of acute respiratory infection, chronic cough,  or infection about the navel. Special attention is given to cleaning of the navel.    anesthesIa Spinal anesthesia may be preferred in large hernias because  of the excellent relaxation it provides; however, inhalation anesthesia can be  used if not contraindicated. Inhalation anesthesia is the method of choice  for children.    o PeratIve PreParatlon T e skin is prepared in the usual manner  after the umbilicus has been carefully cleaned. T 1s may require cotton  applicators saturated with antiseptic to reach any deep crevices.    IncIslon and exPosure A curved incision placed superiorly or infe-  riorly about the umbilicus is most commonly used (figure 1). A vertical  incision that curves around the umbilicus may be necessary for very large  hernias. T e umbilicus proper should be retained in the skin fap. T e inci-  sion is made to the hernia sac. T e sac is easily mobilized except for its  attachment to the back of the umbilical skin. T is is dissected carefully so as  not to create a buttonhole that may put the repair at risk for infection. T e  neck of the herniated sac is then dissected from adjacent tissues by a com-  bination of blunt and sharp dissection, which 1s carried down to the level of  the linea alba and anterior sheaths of the rectus muscle.    detalls of Procedure Most commonly, omentum is contained  within the sac, but small and large bowel may also be present. Frequently  the omentum will have formed adhesions to various areas of the sac, thus  preventing reduction of the hernia. Sharp dissection is required to detach  hernial contents from the sac as well as from the peritoneum around the  neck of the sac as it joins the peritoneum. When there is a strong susp1-  cion of gangrenous intestine within the sac, the abdominal cavity should be  entered through an extended midline incision that enters either above or  below the umbilicus. T is incision is extended to the fascial defect and up  the side of the sac so as to allow complete mobilization of the incarcerated  bowel. T e intestine is either reduced or resected as indicated. In the major-  ity of cases, omentum is incarcerated within the sac.   In these patients, the sac may be opened (figure 2). If the omentum  cannot easily be freed and/or reduced, it is wise to resect it with sequential  clamping and suture ligature placement. When the contents of the sac have  been reduced and its neck has been well defined, a decision is made as to  how to repair the fascial defect.   In general, when the defect is less than 2 cm in diameter, the peritoneum  is closed and the excess sac excised. T e perimeter of the fascial defect is  cleaned of fat both anteriorly and posteriorly, and a primary repair is per-  formed using interrupted 00 sutures that may be of a delayed absorbable or  nonabsorbable nature (figure 3). T is primary repair is performed only  for small defects of 2.5 cm or less.   If an intermediate-sized defect in the range of 2 to 4 cm is found, many  surgeons prefer to repair it with the two-layer “vest-over-trousers” (Mayo)    technique (figures 4 to 6). T e upper fascia is imbricated over the lower  fascia with a row of interrupted 00 sutures. T ese begin and end high on the  vest, while the trousers are secured in a horizontal manner at the belt line  (figure 4). When these sutures are secured, the free superior edge (vest)  overhangs the inferior fascia (trousers) and a second layer of interrupted 00  sutures is used to secure the free edge (figure Sand 5a). T e technique is  illustrated schematically in the cross-sectional view illustrated in figure 6.   Many surgeons believe that a medium to large defect should be repaired  with mesh, as primary tissue repairs in large hernias have a significant  recurrence rate. T e preferred site for placement of the mesh is posterior to  the defect and posterior rectus sheath. If the zone between the peritoneum  and posterior rectus sheath can be freely dissected, some surgeons use a  synthetic mesh after first being certain that the omentum is directly behind  this region when the umbilical hernia sac is closed. Alternatively, if this  plane cannot be developed and the mesh must be placed in an intraperito-  neal position, a dual-sided mesh is used wherein the smooth, nonadherent  surface is posterior toward the omentum and bowel, while the unprotected  screen-like synthetic mesh 1s anterior against the peritoneum and posterior  fascia (figure 6). T emesh should be sized to extend 3 to 5cm beyond the  anticipated edges of the closed defect. T 1s mesh is secured with nonab-  sorbable 00 mattress sutures that are placed full thickness through the linea  alba at the 12 and 6 oclock positions and through the rectus sheaths and  muscle at the 3 and 9 oclock positions (figure 6a). T ese sutures should  secure only the unprotected side of the synthetic mesh and should not go  full thickness as this may create a free intra-abdominal loop that may catch  a loop of bowel. T e anchoring sutures are tied and the defect is closed  either vertically or transversely using interrupted 00 sutures.    closure After careful hemostasis is obtained, the apex of the subcuta-  neous tissue beneath the umbilicus is sutured down to the linea alba with  00 absorbable sutures. T is produces the desirable ingoing bellybutton.  Further absorbable sutures are used to obliterate the subcutaneous dead  space. A triple-bite suture that secures Scarpa’ fascia to the deep fascia and  then the Scarpa’ fascia on the other side of the incision minimizes the space  for a potential accumulation of serum or a hematoma. When the hernia is  quite large, a closed-system Silastic suction catheter may be placed through  an adjacent stab wound such that it does not communicate or come in con-  tact with the mesh placed as part of the hernia repair.    Posto PeratlIve care Special attention is given to the avoidance of  abdominal distention. An adhesive tape strip 3-1in wide is liberally applied  across the abdomen, and the patient may use an abdominal binder for  approximately | month. T e patient is warned to avoid overly heavy lifting  and straining for a minimum of 6 weeks.    detalls of Procedure A curved incision around the superior half  of the umbilical depression is made and the hernia sac is freed down to  the linea alba. T is dissection extends laterally onto either rectus sheath.  T e hernia sac is dissected free from the back of the umbilical skin, using  countertraction with skin hooks. T e fascia is cleaned for a few centimeters  in all directions. In most patients, the sac can be reduced without being  opened. T e edges of the fascial ring are grasped with Kocher clamps and  the posterior aspect of the fascia is cleaned for 1 or 2 cm. As most of these  fascial defects are small, a primary repair using 00 interrupted sutures can  be performed in either a vertical or horizontal manner, depending upon the  shape of the defect.    Posto PeratIve care T e routine postoperative care is performed.  Most patients are able to tolerate fuid within a few hours and are dis-  charged home within a day on a soft diet. T e skin of the umbilicus should  be observed for viability if an extensive dissection has been performed. In  most patients, the curved periumbilical incision becomes minimally visible  as the area heals. m=    IndIcatIons Any indirect inguinal hernia should be repaired electively  unless contraindicated by the large size of the hernia or by the age or poor  physical condition of the patient. T e appearance of indirect inguinal  hernia in middle-aged or elderly patients requires thorough medical inves-  tigation. Before repair is advised, it is wise to rule out any other source of  pathology as a cause for the patient’s complaint rather than ascribe it to the  presence of an indirect inguinal hernia. Patients who have straining from  symptomatic gastrointestinal tract obstruction, chronic pulmonary disease,  or prostatism need appropriate diagnostic studies.   Repair of an inguinal hernia in an infant or child is indicated as soon  as practical after the diagnosis 1s made. In the presence of an undescended  testicle, the repair, which includes an orchiopexy, should be delayed until  3 to 5 years of age to permit maximum spontaneous descent. T e orchio-  pexy is indicated at any age if there is strong indication for repairing the  hernia due to incarceration.    Preo Perat Ive PreParat Ion Obese persons should be refused repair  until their weight has been substantially reduced to a point within the  range of their calculated ideal weight in order to ensure a low recurrence  rate. Repair should also be delayed in patients with acute upper respiratory  infections or a chronic cough until these conditions have been remedied.  Smoking is curtailed or stopped and frequent intermittent positive pressure  breathing, with appropriate drugs added, should be instituted several days  before surgery.   In the presence of strangulation, the operation is delayed only long  enough for fluid and electrolyte balance to be established by the intrave-  nous administration of Ringer’ lactate solution. Systemic antibiotic therapy  is instituted. Colloid solutions or blood products may be needed, especially  if gangrenous bowel is suspected. A small nasogastric tube is passed, and  constant gastric suction is maintained before, during, and for several days  after operation. Sufficient time must be taken to ensure a satisfactory urine  output of at least 30 to 50 mL per hour, a pulse under 100 per minute, and an  appropriate blood pressure with a normal central venous pressure. Repeated  electrolyte values should be approaching normal. Adequate resuscitation  may require from several hours to a much longer period for the adminis-  tration of several liters of fluids and electrolytes, especially potasstum and  blood, in the patient who has had intestinal obstruction for several days.  Operative intervention before stabilization may have disastrous results.   A child 2 years or older should be prepared psychologically in advance  for the hospital experience. Booklets that describe in simple narrative style  the various details of hospitalization and operation can be read to the child  before operation. Such preparation undoubtedly serves to diminish the  incidence of emotional trauma as a complication of elective surgery.   Uncomplicated inguinal hernias in patients of any age may be repaired as  ambulatory surgical procedures using local, regional, or general anesthesia.    anesthesIa Intravenous sedation plus local infiltration should be con-  sidered in low risk patients who are suitable for repair in an ambulatory  surgical setting. Local anesthesia allows approximation of the tissues at a  more normal tension and also makes it possible for the patient to increase  the intra-abdominal pressure by coughing, which will aid in identifying the  sac and in testing the adequacy of the repair. Note the position of the nerves  for local anesthesia (figure 1). If obstruction is present, general anesthe-  sia with an endotracheal tube and cuf 1s recommended to avoid the ever-  present threat of tracheal aspiration.   Inhalation anesthesia is the method of choice in children and anxious  adults.    PosItIon T e patient is placed in a supine position with a pillow beneath  the knees so that slight relaxation at the groin is achieved. T e table 1s tilted  with the head down slightly to aid in reducing the contents of the hernia sac  and in retracting a thick abdominal wall by gravity.    IncIslon and exPosure A skin incision, extending from just below  and medial to the anterosuperior iliac spine to the pubic spine, is made  2 to 3 cm above and parallel to Poupart’ ligament (figure la). A more  comfortable and cosmetic incision results if the major crease in the lines of  skin cleavage is followed (figure |b). T is may be defined by gentle down-  ward traction on the abdominal wall, which demarcates the natural crease  in the skin beneath the plastic drape. Either incision is carried down to  the external oblique fascia. Several blood vessels, especially the superficial  epigastric vein and the external pudendal vein, are usually encountered in  the subcutaneous tissue in the lower portion of the incision. T ese must be  clamped and tied (figure 2).    detalls of Procedure T e external oblique is carefully cleaned of  all fat by sharp dissection throughout the length of the wound, and the  external ring is visualized (figure 2). After the margins of the wound have  been covered with gauze moistened in isotonic saline, a small incision is  made in the direction of the fibers of the external oblique, which extend  into the medial side of the external inguinal ring (figure 2). T e edges  of the external oblique are held away from the internal oblique muscle to  avoid injury to the underlying nerves as the incision is continued through  the medial side of the external ring (figure 3). T e nerves are most com-  monly injured at the external ring. T e lower side of the external oblique  is freed by blunt dissection down to include Poupart’ ligament. T e upper  margin is similarly freed for some distance. As the ilioinguinal nerve is  dissected free from the adjacent structures, a bleeding point is commonly  encountered as it passes over the internal oblique (figure 4). T 1s bleed-  ing vessel, if encountered, must be tied carefully; otherwise a hematoma  may develop in the wound. When the ilioinguinal nerve has been carefully  dissected free, it is pulled to one side over a hemostat placed at the edge of  the incision (figure 5). T e cremasteric fibers are grasped with toothed  forceps and divided in order to approach the sac (figure 6). T esac itself  is seen as a definite white membrane that lies in front and toward the inner  side of the cord; it is usually easily dif erentiated from surrounding tissues.  If the hernia is small, the sac lies high in the canal. T e vas deferens can  be recognized by palpation because it is firmer than the other structures  of the cord. T e wall of the sac 1s lifted up gently and opened with care to  avoid possible injury to its contents (figure 7). While the margins of the  opened sac are grasped with hemostats, the contents are replaced within  the peritoneal cavity. With the index finger of the left hand introduced into  the sac to give counter-resistance, the surgeon frees the sac with the right  hand by either blunt or sharp dissection (figur e 8). If the dissection is kept  close to the sac, an avascular cleavage plane will be found. Sharp dissection  is advisable to separate the vas deferens and adjacent vessels from the sac  (figure 9). If this is done carefully, fewer bleeding points will be encoun-  tered than if an ef ort is made to sweep these structures away from the sac  by means of blunt dissection with gauze. T e dissection is then continued  until the properitoneal fat is displaced and the peritoneum beyond the nar-  row neck of the sac is visualized.    detalls of Procedure T esacis opened within 2to 3cm  of its neck, and exploration is carried out with the index finger to rule  out the presence of a “pantaloon” or secondary direct or femoral hernia  (figure 10). To ensure obliteration of the sac, a purse-string suture is placed  at the inner side of the neck (figure 11), or several transfixing sutures may  be used if preferred. T e lumen of the neck of the sac must be visualized as  sutures are placed or tied to avoid possible injury to omentum or intestine.  T is suture should include the transversalis fascia with the peritoneum. T e  neck of the sac can sometimes be identified as a slightly thickened white  ring. T esac should be ligated proximal to this ring. After the purse-string  suture 1s tied, the excess sac is amputated with scissors (figure 12).   If desired, the ligated sac may be anchored to the overlying muscle. In  this instance the long ends of the suture used to close the neck of the sac  are rethreaded. T e needle is inserted beneath the transversalis fascia and  brought up in the edge of the internal oblique muscle, the two ends being  brought through separately and tied (figure 13). Care should be taken to  avoid injuring the inferior deep epigastric vessels.    alternatetechnIques forsac Although the classic inguinal hernia  operations utilize high ligation with division of the hernia sac, two alternate  methods have gained popularity with mesh repair. In small to medium-sized  indirect hernias, the sac is left intact as it is dissected from the posterior cord  structures. Electrocautery is used along the edge of the sac while gentle trac-  tion is applied. T is minimizes bleedsing and ecchymosis after surgery. Any  entry into the sac is used for finger exploration and guidance of further dis-  section well up into the internal ring. Any opening in the sac 1s closed using  00 absorbable suture, and the entire sac, along with any lipoma of the cord,  is returned to the preperitoneal space behind the abdominal muscular wall.  In very large inguinoscrotal hernias, the indirect sac is transected and  suture ligated near the internal ring. Only the proximal sac is dissected    free into the internal ring. T e distal very large sac is left untouched, as the  extensive dissection from the cord vessels and the mobilization of the tes-  ticle up and out of the scrotum may result in venous thrombosis or possible  ischemic orchiditis. A residual hydrocele rarely occurs.    closure T ere are various methods of repair after the sac has been  removed. Large or recurrent hernias in older persons or hernias in patients  doing very heavy work may be corrected by a method that either partially  or completely transplants the cord or narrows the internal ring.    nontransPlantatlon of cord (ferguson rePalr) T ecrem-  asteric fibers, which may or may not be well developed, are approximated  with interrupted 00 silk sutures (figure 14). T 1s covers the raw surface  remaining after removal of the sac and restores the structures to a normal  appearance. T e cremaster muscle is pulled beneath the conjoined ten-  don to relieve strain on the next layer of sutures and to increase the effi-  ciency of the repair (figure 15). Sutures are then placed to approximate the  conjoined tendon and internal oblique muscle to Poupart’s ligament, the  sutures being tied anterior to the cord (figure 16). T e sutures in Poupart’  ligament are placed from below upward, unequal portions of the ligament  being taken to avoid fraying. T e first suture should be tied loosely enough  so that the cord is not constricted and there is sufficient space about the cord  to permit an instrument tip to pass; moreover, care should be taken to avoid  injury or inclusion of the ilioinguinal nerve by the sutures. T e external  oblique fascia is approximated with interrupted sutures (figure 17). Here  again, the external ring should not constrict the cord (figure 18). T esub-  cutaneous tissue is carefully approximated with interrupted 0000 absorb-  able sutures to (figure 19). Alternatively a continuous subcutaneous clo-  sure with absorbable suture may be used, followed by adhesive skin strips  and a dry sterile dressing.    rePalr n children A short (3 cm) skin incision is made  in the suprapubic crease above the inguinal ligament and centered over the  internal inguinal ring.   After the incision has been made through the skin, a small curved  mosquito hemostat is placed in the subcutaneous tissue on either side of  the midportion of the incision for traction. Scarpa’ fascia is exposed and  divided. T e underlying aponeurosis of the external oblique is cleared  down to the external inguinal ring. T e aponeurosis of the external oblique  is then opened upward from the external inguinal ring. If there is no associ-  ated scrotal hydrocele, the incision through the external oblique aponeuro-  sis may be placed just above rather than through the external ring. Superior  and inferior flaps of the aponeurosis of the external oblique are developed  with the scalpel handle, and a small right angle retractor is placed under  the superior flap to expose the inguinal canal. T e cremasteric muscle fibers  are separated by blunt dissection. T e hernia sac is identified on the antero-  medial aspect of the cord structures, lifted up, and gently separated in the  midportion of the inguinal canal from the vas and vessels. T e cord struc-  tures themselves should not be mobilized from the inguinal canal. T e sac  is divided between two straight mosquito hemostats in the midportion of  the inguinal canal, and the proximal portion 1s freed well above the level of  the internal ring. T e neck of the sac then is closed with a suture ligature  of fine silk and the sac amputated. Ordinarily, it is not necessary to open  the sac during this process. However, if omentum or a loop of intestine is  within the sac, the sac is opened, and these structures are returned to the  peritoneal cavity before the neck of the hernia sac is closed. T e distal por-  tion of the sac is freed below the level of the external ring and excised.   T e testis and cord structures are repositioned into their normal ana-  tomic bed if they have been disturbed, and an anatomic closure is per-  formed. T e aponeurosis of the external oblique and Scarpa’ fascia are  closed with interrupted sutures of fine silk. A subcuticular closure with fine  absorbable suture is used in children. Because of the high incidence of a  patent processus vaginalis on the opposite side in instances of a clinical  inguinal hernia in infants, it is common practice to perform an inguinal  exploration on the opposite side in infants but not older children.   In female children, the incision and initial stages of the procedure are as  described above. However, in a high proportion of cases a congenital indi-  rect hernia in a female 1s a sliding type of hernia, with the fallopian tube and  its mesenteric attachments making up a portion of the hernia sac. In such  instances the hernia sac and round ligament are closed with a suture liga-  ture of fine silk distal to the attachment of the mesosalpinx. T e remainder  of the procedure is identical with that done in the male.    rePalr In adult females T e round ligament is usually closely  attached to the sac, making sharp dissection necessary for separation. After  the neck of the sac is freed and ligated, the repair proceeds as in the opera-  tion on the male, except that the round ligament may be included in the  sutures that bring the conjoined tendon to Poupart’s ligament. If the round  ligament is divided, it must be ligated, since it contains a small artery, and  the proximal end must be anchored in order to give support to the uterus.    Posto PeratIve care Adult T e patient is placed flat in bed with the  thighs somewhat flexed either by a pillow beneath the knees or, if in an  adjustable bed, with the lower part of the bed somewhat elevated in order  to prevent undue tension upon the sutures in the wound. Support to the  scrotum may be furnished by suspensory. An ice pack may be applied  to the scrotum. Coughing must be controlled by sedation. Laxatives are  given in sufficient dosage to avoid undue straining at stool. Patients should    ambulate and void as soon as possible. Normal activities are resumed as  tolerated. However, several weeks should elapse before the patient is per-  mitted to perform heavy physical work. Special abdominal supports usually  are not necessary.   Child T e infant or child is fed 4 to 6 hours after operation and, by the  evening of operation, should be taking a normal diet.    detalls of Procedure Te cord is visualized by the approach  described earlier in this Chapter. Since the structures of the cord are to be  transplanted, it may be easier to separate the cord from the surrounding  structures before the hernia sac is identified and opened. T e index finger  may be inserted beneath the cord from the medial side just above the pubic  tubercle in order to assist in the blunt dissection and freeing of the cord from  the underlying Poupart’ ligament (figure 20). A curved half-length clamp  directed over Poupart’ ligament and toward the pubic spine is then passed  beneath the cord and guided by the index finger (figure 21). A tube of  soft rubber (Penrose drain) is drawn through beneath the cord for traction  (figure 22). Many times blood vessels that course downward beneath the  cord must be clamped and tied to ensure a dry field. T e cremaster muscle  is divided, and the hernial sac is grasped with toothed forceps preliminary  to opening it (figure 23). Some prefer to completely divide the cremaster  muscle near the internal oblique muscle, leaving the vas and its accompany-  ing vessels exposed. T e sacrifice of the cremaster muscle at this level per-  mits a more accurate closure of the internal ring. T e hernia sac is opened,  and traction 1s maintained by curved or straight hemostats applied to its  margin. With the surgeon’ index finger in the hernia sac, the vas deferens  and accompanying vessels are dissected free by sharp and blunt dissection  (figure 24). With the surgeon’ finger in the neck of the hernia sac to ensure  that all abdominal contents are completely reduced, a purse-string suture 1s  placed at the inner side proximal to the neck of the sac or several transfixing  mattress sutures are used, as preferred (figure 25). Care must be taken that  the adjacent epigastric vessels are not injured.    closure (transPlantatlon of cord, BassInJ T e first step  in the closure is to provide adequate retraction of the cord as well as the  internal oblique muscle, so that the deep-lying aponeurosis of the trans-  versus abdominis and transversalis fascia can be identified (figure 26).  It is important to reinforce the weakened area over the ligated hernia sac  by approximating the thickened fascia just below the free edge of Poupart’s  ligament, the so-called iliopubic tract, and the edge of the aponeurosis of  the transverse abdominal muscle (figure 26, Suture X). T e remaining  opening in the cremaster muscle is closed with interrupted sutures unless  it has been completely divided adjacent to the internal oblique muscle. T e  transversalis fascia may appear to be very thinned out adjacent to Poup-  art’ ligament, but an aponeurosis, the strong white membrane forming  the inferior margin of the transversus abdominis, is exposed (figure 26)  by retracting the internal oblique sharply upward. T e hernial repair 1s  strengthened if an ef ort 1s made to approximate the latter structure to the  iliopubic tract beyond the margins of Poupart’ ligament. T e conjoined  tendon is retracted upward so that each bite of the needle includes a good  portion of the aponeurosis of the transversus muscle (figure 27) and  the thickened fascia adjacent to the margin of Poupart’ ligament. Several  sutures between the iliopubic tract and the aponeurosis of the transversus  muscle are taken lateral to the cord to close the redundancy of the internal    closure (transPlantatlon of cord, Bassin} A  second layer of 00 nonabsorbable sutures includes unequal portions of the  shelving edge of Poupart’s ligament and a bite of the conjoined tendon. T is  suture line extends from the pubic tubercle outward over the deep epigas-  tric vessels until the cord appears to be angulated laterally. Before these  sutures are placed, the mobility and composition of the tendon should be  determined. In many instances the conjoined tendon cannot be brought  down to Poupart’s ligament except under a great deal of tension. A prelimi-  nary trial should be carried out by attempting to approximate the conjoined  tendon to Poupart’ ligament at the proposed suture line to determine the  amount of tension that will be present (figure 29). T e medial leaf of  the external oblique fascia is retracted medially, and by blunt dissection  the underlying sheath of the rectus is exposed (figure 30). If the tension  appears to be excessive, relaxation of the fascia with retained support of  the underlying rectus muscle is achieved by multiple incisions in the rectus  sheath (figure 31). T e relaxing incisions can be made about | cm apart  and Icm in length. Eight or ten or even more may be required to produce  the desired relaxation (figures 31 and 32). T e number required can be  judged by the spread of the tissues as the incisions are made and as traction  on the fascia is maintained. T e conjoined tendon is sutured to the lower  edge of Poupart’s ligament adjacent to the suture line that has approximated  the aponeurosis of the transverse abdominal muscle to the iliopubic tract.  T e initial suture should include the periosteum of the pubic spine and  the medial portion of the conjoined tendon. Several sutures are taken to    approximate the muscle to Poupart’s ligament above the point of exit of the  cord, but these must not constrict the cord, especially if its size has been  decreased markedly by the excision of some of the dilated veins and the  cremaster muscle (figure 33). T e ilioinguinal nerve is replaced, and the  external oblique aponeurosis is closed over the cord, either by imbricating  the mesial flap of the external oblique muscle over the lower flap by two  rows of mattress sutures (figur es 34 and 35) or bya simple approximation  of the edges of the external oblique with a running 00 suture. T e newly  constructed external ring should be tested to make certain that the cord is  not unduly constricted.    transPlantatlon of cord (halsted) Some surgeons prefer the  method of transplanting the cord to the subcutaneous fatty layer (figur e 36).  Here, the cord is brought out through the upper third of the incision in  the external oblique fascia (figure 36) and the fascia is closed beneath  the cord, leaving it entirely in the superficial fatty tissue (figure 37). T e  size of the cord is usually decreased by the excision of many of the sper-  matic veins as well as the cremaster muscle; however, sufficient blood sup-  ply to the testicle must be retained. T e cord must not be constricted, or  atrophy of the testicle may occur. T e size of the external ring is tested with  a curved clamp, and, if necessary, a small incision is made just through the  margin to release the constriction about the cord (figure 36).    IndIcatlons Herniorrhaphy has become an outpatient surgical proce-  dure, regardless of the age of the patient. T e Shouldice repair has been  advocated for some years as the procedure of choice for adults with inguinal  hernias.    Preo Perat Ive PreParatlon T e obese patient should be required  to lose weight, preferably to within 10% of calculated ideal weight. T is  may delay the operation for a considerable time. Any infections of the skin  should be cleared up before operation. A productive cough or an upper  respiratory infection delays the procedure. Chronic smokers should be  encouraged to curtail their smoking. Evidence of prostatic obstruction  should be sought in older men. All patients should be taught how to get out  of bed with a minimum of discomfort and advised to practice this. Sensi-  tivity to drugs, including local anesthetics, should be ascertained. A mild  cathartic should be given a day before the operation to ensure an empty  colon. A mild laxative or mineral oil may be given to ensure bowel action  without excessive straining after operation. A thorough medical evaluation  is essential in older patients. A hernia should be relatively asymptomatic  unless it becomes incarcerated. Any other symptoms must be evaluated,  because they may be due to causes other than hernia.    anesthesIa Deep sedation plus local anesthesia is commonly used.  T e type of sedation will vary, but may include midazolam, fentanyl or  meperidine, and propofol. Local anesthesia is limited to 30 mL of 1% lido-  caine without epinephrine (total lidocaine dose < 300 mg). T e amount is  reduced in elderly patients.    skIn PreParatlon T e skin is carefully inspected for any evidence of  localized infection. All hair of the lower abdomen and pubis is removed  with an electric hair clipper. In patients with scrotal hernias, the skin of  the scrotum should be included in the usual skin preparation with topical  antiseptics.    PosIt Ion T e legs should be slightly flexed, with pillows under the  knees, and the patient placed in a modified Trendelenburg position to assist  in the reduction of the hernia sac. Following the draping of the patient, the  local anesthetic is injected. Keeping in mind the location of the ilioingui-  nal and iliohypogastric nerves, the original injection of a few milliliters of  anesthetic agent is made, using a fine needle (No. 25), just medial to the  anterosuperior spine. Approximately 10 mL of (lidocaine) anesthetic solu-  tion is injected subcutaneously with a No. 25 needle above and parallel to  the inguinal ligament. About 5 mL is injected medial to the anterosuperior  spine deep into the external oblique aponeurosis to anesthetize the ilioin-  guinal nerve. Another 5 mL 1s injected about the internal ring to eliminate  painful impulses from the peritoneum and from the genital branch of the  genitofemoral nerve. In elderly patients, less anesthetic solution is used.  Epinephrine 1s not used in the elderly or in patients with cardiovascular  disease.    IncIslon and exPosure A 10-cm incision is made parallel to the  inguinal ligament, although some prefer a more transverse or skinfold  incision. T e external pudendal vessels are spared, especially in bilateral  repairs, in an ef ort to minimize postoperative edema.    detalls of Procedure T e external oblique aponeurosis 1s divided  along the line of its fibers. Great care is exercised to avoid possible injury to  the underlying ilioinguinal nerve. T e aponeurosis of the external oblique  is divided from the level of the internal ring down through the external  ring, and both flaps are mobilized (figure 1). Mobilization of the lower  flap should involve some division in the superficial fascia of the thigh to  allow inspection of the femoral area for evidence of a femoral hernia. T e  cremaster muscle is carefully divided longitudinally, with the lateral side  being made the larger, since it contains the cremaster vessels and the genital  branch of the genitofemoral nerve in its base.   T e internal ring is freed from attachments, and evidence of a hernial  sac 1s sought. If no indirect hernial sac is found, a small crescent reflection  of peritoneum (processus vaginalis) is visible proximally. When an obvious  hernial sac is found, it is freed by blunt and sharp dissection. When the  sac 1s large, it can be filled with gauze sponge to provide counterpressure,  which simplifies the pushing away of other tissues. T e sac is opened and  the index finger inserted medially under the inferior epigastric vessels in an    ef ort to determine the presence or absence of a direct hernial defect. T e  neck of the hernial sac is freed from the surrounding tissue. Following this,  the sac is ligated (figur e 2). Some believe an ef ort for a high ligation of the  sac 1s unnecessary. If a lipoma of the cord is found, it is carefully excised,  but the cord is not stripped of interstitial fat. Even large sliding hernia sacs  can be freed and reduced without opening the sac.   T e two cremaster muscles are excised with double ligation of the  stumps. T e posterior inguinal wall should now be fully visible. T e poste-  rior inguinal wall is palpated for an area of weakness or general bulge. T e  transversalis fascia is divided starting on the medial aspect of the internal  ring but avoiding the inferior epigastric vessels and proceeding to the pubic  tubercle (figure 2). T e femoral ring is evaluated for evidence of a femoral  hernia.   If the transversalis fascia has been stretched by the dif use bulge of a  direct hernia, the excess from each flap is excised. T e upper flap (A) 1s usu-  ally narrower than the lower flap (B). It is extremely important to develop  an adequate lower flap if the repair is to have the best chance of success.  T e latter tends to be 1 to 2 cm wide and somewhat stronger. T e lower  flap is completely freed by careful dissection. T e development of the flaps  of the transversalis is very important in the subsequent steps of the Shoul-  dice repair (figure 2). T e subsequent repair involves the development  of a four-layered closure, using either two dif erent continuous sutures of  34-gauge monofilament stainless steel wire or a nonabsorbable suture mate-  rial. Absorbable suture or mesh is not used. Continuous sutures are pre-  ferred for distributing the stresses evenly.   T e repair of the posterior inguinal wall must be carefully performed,  using small, even bites without tension on the suture. Retaining sutures are  not used. T e first suture anchors the free edge of the lower flap (B) of the  transversalis to the posterior aspect of the lateral edge of the rectus close to  its insertion (figure 2a). T e placement of the suture must be accurate,  and the knot securely tied without leaving a defect in this area. Only a short  distance from the edge of the rectus sheath is included before the suture  is continued laterally to include the deep underneath surface of the upper  flap (A) of the transversalis and the internal oblique (figure 3). T e infe-  rior epigastric vessels are carefully avoided as the suture line is extended to  include the upper lateral cremasteric stump. T e suture is now reversed at  the internal inguinal ring (figure 4), extending medially as it unites the  free edge of the upper transversus flap (A) to the edge of Poupart’s ligament.  T esuture is continued down to the pubic bone and tied. T e space medial  to the femoral vein may be obliterated by including the lacunar ligament if  necessary.   Another continuous suture line is used to reinforce the second suture  line just completed. T e third suture line starts at the internal ring and  includes bites of the internal oblique and transversalis muscles as well as  the deep surface of the inguinal ligament as it continues medially to the  pubic bone (figure 5). T e fourth suture line returns from the pubic bone,  bringing together the same structures at a slightly more superficial plane up  to the internal ring, where it is tied (figure 6).   T espermatic cord is tested to determine that it can be freely moved and  the veins are not engorged. T e cord is returned to its normal position and  the external oblique fascia approximated without constricting the vein in  the region of the external inguinal ring (figure 7).   T e subcutaneous tissues are carefully approximated with interrupted  sutures. T e skin can be closed with interrupted or a continuous subcutane-  ous suture of absorbable material reinforced with skin tapes of a “butterfly”  nature. Some prefer metal staples. A small dressing is applied to cover the  wound.    Posto PeratIvecare T epatient mayreturn home several hours after  the operation with full written instructions concerning activities, signs of  bleeding or infection, or any other unusual reaction. Oral narcotic 1s sup-  plied, and an ice pack may be applied locally for several hours. T e patient  should rest in bed except for voiding in the bathroom on the day of surgery.  A suspensory for men is optional. Physical activity is restricted for an addi-  tional few days. Many experience improvement after 3 days, and some may  drive or return to light duty work after 7 to 10 days. Vigorous exertion, as in  sports, is limited for 4 weeks, and extreme exertion should be avoided. See  also Chapter 104. m=    IndIcatlIons A McVay primary tissue repair is infrequently performed  as an initial herniorrhaphy, as it is associated with a high rate of recur-  rence. However in patients where mesh from a previous operation must  be removed (e.g., chronic infection), some form of primary tissue repair 1s  needed. T e McVay procedure may be useful in these cases, especially when  the femoral space must also be obliterated.    detalls of Procedure Instead of approximating the transversalis fas-  cia and the aponeurotic margin of the transverse abdominal muscle to the  iliopubic tract and to Poupart’s ligament to repair either a direct or indi-  rect hernia, the McVay repair attaches these musculotendinous structures to  Cooper’ ligament and the lacunar ligament medially and the inguinal liga-  ment laterally. To accomplish this, it is necessary to retract the conjoined ten-  don upward and the cord downward, while the transversalis fascia adjacent  to the pubic spine is freed from Cooper’ ligament (figure 1). In figure la  direct inguinal hernia sac has been reduced and the floor of traversalis fascia  has been reconstituted with interrupted non absorbable sutures.   By blunt dissection and the use of a curved retractor (figure 2), the  region of Cooper’ ligament can be visualized, and the external iliac vessels  can be identified. As the conjoined tendon or internal oblique muscle is  held upward, a firm aponeurotic margin of transverse abdominal muscle is  exposed in order to facilitate the placement of interrupted sutures. As the  bulge in this region is retracted upward and medially by an appropriate  retractor, Cooper’s ligament is clearly visualized as a white, fibrous ridge,  deep in the wound at the innermost portion of the concavity and closely    applied to the horizontal ramus of the pubis (figure 2). Interrupted 00  silk sutures approximate the aponeurotic margin of the transverse abdom-  inal muscle and the transversalis fascia to Cooper’s ligament. T e iliac  vessels may be protected by the surgeon’ left index finger or a narrow  S retractor as the innermost suture 1s placed. T e sutures are continued  downward until the region of the pubic spine is included in the last one  (figure 3). T ree to five interrupted sutures are usually required. In obese  individuals it may be difficult to obtain an easy exposure in this location,  and constant care must be exercised to avoid injury to the iliac vessels and  to ef ect a complete and solid repair (figure 4). Some operators prefer to  make an incision in Cooper’ ligament before placing the sutures in order  to ensure a better fascial approximation. After the aponeurotic margin of  the transverse abdominal muscle has been anchored as far medially to  Cooper’ ligament as can be done safely, more superficial sutures may be  taken to approximate it to the iliopubic tract (figur es 4 and 5). Some sur-  geons prefer to reinforce the repair to Cooper’s ligament by another row of  sutures approximating Poupart’s ligament to the aponeurosis of the trans-  verse abdominal muscle (figure 6). T e suturing of the internal oblique  muscle to Poupart’s ligament is not considered worthwhile. T e type of  repair should be varied to suit the anatomic conditions encountered. A  combination of the technique described may be advantageous to ensure a  solid repair without tension upon the suture lines and an accurate approxi-  mation of fascia to fascia.    IndIcatIons Adult inguinal hernias are usually repaired in an ambula-  tory surgery setting unless coexisting medical conditions merit hospital-  ization for specialized monitoring or care. T e use of synthetic mesh has  become increasingly popular as it may be used for both direct and indirect  hernias and it results in a lower rate of recurrence.    Preo Perat Ive PreParatlon T e obese patient should be required  to lose weight, preferably to within 10% of calculated ideal weight, which  may delay the operation for a considerable time. Any open-skin infections  must be healed prior to operation. Systemic causes of increased intra-  abdominal pressure or straining should be reviewed. A productive cough  or an upper respiratory infection will delay the procedure until resolution.  Chronic smokers should be encouraged to curtail their smoking. Evidence  of prostatic obstruction should be evaluated in older men and the possibil-  ity of new colon lesions should be evaluated in older men and women. All  patients should be taught how to get out of bed with a minimum of discom-  fort and advised to practice this. Sensitivity to drugs, including local anes-  thetics, should be ascertained. A mild cathartic may be given a day before  the operation to ensure an empty colon. Mineral oil may be given to ensure  bowel action without excessive straining after operation. A thorough medi-  cal evaluation is essential in older patients. A hernia should be relatively  asymptomatic unless it becomes incarcerated. Any other symptoms must  be evaluated, because they may be due to causes other than hernia.    anesthesIa Deep sedation with an anxiolytic, narcotic, and hypnotic  (commonly midazolam, fentanyl, and propofol) is combined with a field  block of local anesthesia. Lidocaine 1% or ‘2% without adrenaline is pre-  ferred and the total dose is limited to less than 300 mg (30 mL of 1% lido-  caine). T is amount may be reduced in elderly patients. No adrenalin is  used during the opening as this may obscure small bleeding vessels that  should be ligated or cauterized thus lessening ecchymosis or hematoma  formation. However, during the closure, when hemostasis is secured, many  surgeons reinfiltrate the operative field with a long-acting local anesthetic  such as bupivacaine. Adrenalin is often added except in patients with heart  disease so as to extend the duration of the local anesthetic.    PoslItIonIng T e patient is placed in a supine position with a pillow  under the knees to lessen tension in the inguinal region.    o PeratlIve PreParatlon T e hair in the planned operative field is  clipped and the skin prepared in a routine manner. In men, the penis and  scrotum should be prepared, especially if the hernia extends into the scro-  tum or if a hydrocele is present.    IncIslon and exPosure After a sterile draping of the region, the local  anesthetic is injected. T e surgeon may perform a selective nerve block of    the ilioinguinal and iliohypogastric nerves, which are just medial to the  anterior superior spine (figure 1). T e incision may be made either par-  allel to the inguinal ligament (figure 2a) or more transversely along a  skinfold line (figure 2b). Most surgeons prefer a field block with multiple  injections along the incision (figure 3) followed by further injections at  each new level of fascial dissection.    detalls of Procedure T e incision is carried down through Scarpa’  fascia to the external oblique aponeurosis. Additional local is infiltrated  beneath this fascia, especially laterally (figure 4). T e external oblique is  opened in a direction parallel to its fibers down through the external ring.  Care is taken to lift this fascia away from the cord and ilioinguinal nerve  during the opening so as to lessen the chance of transection of the nerve.   T e free edges of the external oblique fascia are grasped with a pair of  hemostats medially and laterally. Using blunt dissection, the fascia is sepa-  rated from the internal oblique muscle superiorly and the cord inferiorly. T e  cord is encircled with a soft rubber Penrose drain. Additional local anesthe-  Sia 1s injected along the inguinal ligament and about the pubic tubercle. T e  direct hernial sac is carefully separated from the cord, which is cleaned back  to the level of its exit at the internal ring. It is verified that this is a direct  herniation rather than a medial protrusion of an indirect herniation. T e cre-  master muscle about the cord is opened anteriorly. T e cord structures are  identified and the region of the internal ring inspected for evidence of an  indirect hernia and sac. A direct hernia only is shown (figure 5). T e direct  hernial sac is cleaned with blunt and sharp dissection around to its neck. T 1s  protrudes through a defect in the transversalis fascia of the canal floor. T ese  defects may be discrete, with a finger-sized punched out hole, or may involve  the entire floor as a dif use blowout from the inguinal ligament below to the  conjoint tendon above. Some surgeons prefer to open the direct sac, reduce  the properitoneal fat, and excise the residual sac, as is done with indirect her-  nias. Almost always, however, the sac and fat are easily reduced (figure 5)  and then kept reduced with an instrument as the floor is reconstructed.   A continuous nonabsorbable 00 suture is placed for reconstruction  of the canal floor. T is begins at the pubic tubercle and approximates the  residual transversalis fascia just above the inguinal ligament to the trans-  versalis fascia or muscle just below the conjoint tendon so as to imbricate  the herniation (figure 6). T is suture continues laterally to the level of the  internal ring. Care is taken to avoid the inferior epigastric vessels. After this  suture is tied, the internal ring should be snug about the cord (figure 7).  T e floor of the canal is now solid and the conjoint tendon lies in its normal  position. T e conjoint tendon is not artificially pulled down under tension  to the inguinal ligament as in the classic Bassini repair.    detalls of Procedure Once the continuity of the direct  floor is restored, the repair continues in the same manner as that for an indi-  rect inguinal herniorrhaphy for a Lichtenstein indirect inguinal hernior-  rhaphy. T ecremaster muscle is opened anteriorly. T e vital cord structures  are identified and a concurrent indirect hernia sac is found. T 1s sac is freed  from the cord using electrocautery and gentle traction. T e key landmark  is the vas, which 1s directly posterior to the sac. After the sac is opened and  examined, a transfixing nonabsorbable suture is placed through its neck  and ligated (figure 8). T e excess sac is then excised, as is any significant  lateral lipoma of the cord. Alternatively some surgeons do not open the  hernia sac and merely return it to the preoperational space.   A rectangular piece of synthetic mesh approximately 2’2 to 3 cm by 8 to  10 cm in size is cut with a lateral slit for the cord and a medial blunt oval for  the pubis (figure 9). T e mesh is positioned on the floor of the canal with  the tails overlapping lateral to the internal ring and cord. A nonabsorbable  00 suture anchors the mesh to the pubic tubercle. T is continuous suture  secures the inferior edge of the mesh to the inguinal ligament while inter-  rupted absorbable sutures anchor the superior edge to the internal oblique  muscle (figure 10). Care is taken in the placement of the superior suture  so as to avoid any nerve branches. Additional care is needed in the place-  ment of interrupted sutures laterally so as to avoid the ilioinguinal nerve,  which lies upon the internal oblique muscle just lateral to the cord. T e two  tails of the mesh are overlapped and then sewn together. It is important  that the mesh not be stretched tightly. T e superior suture placements are  chosen such that the mesh 1s not stretched but rather is loose and almost  wrinkles longitudinally. T e importance of this maneuver becomes appar-  ent when the patient is asked to cough or strain (an advantage possible with  the use of local anesthesia). T e wrinkles disappear as the abdominal wall  tightens. If the mesh had been placed without slack, the suture lines would  now be under tension. A few interrupted sutures are placed to further close  the lateral slit and create an appropriate size for the internal ring opening.  Currently, only a few (4 or 5) loops of each continuous suture are placed on  the inferior and superior edges of the mesh by Lichtenstein surgeons.   An alternate pattern for the mesh may be used where the slit is placed  inferior to the cord (figure 11). T e mesh 1s sewn in place with the same    continuous nonabsorbable suture, which begins at the pubic tubercle.  Additional interrupted sutures are used to anchor the superior edge of the  mesh to the internal oblique muscle and to close the inferior slit about  the cord (figure 12). A modification described in the classic Lichtenstein  repair is shown for males in this illustration where the spermatic cord has  been thinned and partitioned. T e superior bundle of cremasteric mus-  cle has been transected and ligated at the internal ring. T e cord is then  partitioned into a major portion containing ilioinguinal nerve, vas, and  major vessels and a minor portion containing the intact inferior cremaster  muscle bundle with the external spermatic vessels and the genital branch  of the genitofemoral nerve. T e major cord exits through the internal ring  and is shown encircled with a soft rubber Penrose drain. T e minor por-  tion is left undisturbed, with minimal dissection or disruption in the floor  of the canal near the internal ring. T is minor portion now exits through a  separate opening left between the inferior edge of the mesh and the ingu1-  nal ligament. It is important to use a double loop or locking stitch on either  side of this opening such that the minor portion of the cord will not be  compressed.   T e external oblique fascia is reapproximated with a running suture,  which may begin at either end of the incision and which creates a snug-  defined external ring (figure 13). Scarpa’ fascia is approximated with  interrupted absorbable sutures and the skin 1s approximated with subcuta-  neous absorbable sutures reinforced with skin paper tapes. A small dressing  is applied to cover the incision.    Posto PeratIve care T e patient may return home several hours  after the operation with written instructions concerning activities, signs  of bleeding or infection, or any other unusual reaction. Oral narcotic is  supplied, and an ice pack may be applied locally for several hours. T e  patient should rest in bed except for voiding in the bathroom on the day  of surgery. A suspensory for men is optional. Physical activity is restricted  for an additional few days. Many experience improvement after 3 days,  and some may drive or return to light duty work after 5 to 7 days. Vigor-  ous exertion, as in sports, is limited for a few weeks, and extreme exertion  should be avoided. m    IndIcatIons T e repair of inguinal hernias in adults has shifted from  pure tissue repairs (e.g., Bassini) to “tension-free” repairs using synthetic  mesh. T e Lichtenstein repair, shown in Chapter 107, represents the first  widely accepted method for repair of an inguinal hernia using mesh. Since  1990, however, multiple new configurations of mesh have been invented.  A frequently used variation is the “plug and patch; popularized by Drs.  Rutkow and Robbins. T is technique has results equivalent to those of the  Lichtenstein method. T e mesh cone or “plug” brings a new approach to  the correction of the actual hernial defect. T is technique may be used for  recurrent as well as primary inguinal hernias.    Preo PeratIve PreParatlon T e patient is evaluated for general  medical and anesthesia risks, as discussed in Chapter 4, Ambulatory Surgery,  and in the preceding chapters concerning hernia repair. As most operations  are elective and performed in an ambulatory setting, sufficient time should  be available to optimize the management of any medical diseases. Chronic  coughing, new constipation with straining, and symptoms of prostatism  require a specialty evaluation prior to surgery. Any active infections, includ-  ing intertrigo, must be controlled. Although synthetic mesh and sutures do  not harbor bacteria, an infection may become established or chronic in the  presence of mesh, thus requiring its removal.    anesthesIa Most patients can be managed effectively with deep seda-  tion plus local anesthesia. T e use of anxiolytic drugs followed by a narcotic  and hypnotic (typically midazolam, fentanyl, and propofol) allows a pleas-  ant induction. Dilute 0.5% lidocaine without adrenaline is placed by intra-  dermal infiltration. T is produces instant skin anesthesia, which lessens the  discomfort of deeper injections. At the same time, the swelling serves as a  marker for the skin incision. Adrenaline is not used with the entry local  anesthetic as it may obscure bleeding points. Later during the closure, when  hemostasis has been fully secured, adrenaline may be added to the long-  acting local anesthetic to prolong its duration of action. Adrenaline is not  used in older patients or in those with cardiovascular disease. Alternatively,  some surgeons prefer epidural anesthesia for their patients, as they believe  there is a significant interval of hyperesthesia during recovery. Finally, gen-  eral anesthesia may be required for the very anxious patient.    PoslItlonIng T e patient is placed in a comfortable supine position. A  pillow is often put under the knees to lessen tension in the inguinal region,  and some older patients may require an additional pillow under the head  and neck.    o PeratIve PreParatlon T e skin hair is clipped and the skin 1s pre-  pared in the usual manner. In men, the penis and scrotum should be prepared,  especially if the hernia extends into the scrotum or if a hydrocele is present.    IncIslon and exPosure T e area is draped in a sterile manner and  local anesthesia 1s injected along the planned 5-cm incision. T e incision 1s  placed directly over the inguinal canal and extends obliquely and laterally  from the external ring. In very obese patients, a more transverse incision  may be required because of a major skinfold crease. In general, these inci-  sions are placed below and parallel to the crease. Alternatively, a recurrent  hernia may be approached through the old or original incision. It may be  prudent to make a longer incision that extends laterally into an area that  has not been scarred from the previous operation, as recurrences are best  approached laterally through new tissue planes. After the skin is opened, the  dissection proceeds down through Scarpa’ fascia to the level of the external  oblique fascia. More local anesthetic is injected deeply beneath the fascia,  especially laterally toward the origin of the nerves. T e external oblique fas-  cia is opened in a direction parallel to its fibers from laterally to the midpor-  tion of the external ring (figure 1). Some surgeons prefer to make a small  lateral opening and lift the external oblique fascia away from the cord and  ilioinguinal nerve. Scissors are inserted into the opening and the fascia is cut  under direct vision from lateral to medial with avoidance of the nerve.    detalls of Procedure T e inferior leaf of the external oblique fascia  is grasped with two hemostats, one lateral and the other at the external ring.  Using blunt dissection with the peanut on a Kelly, the wispy attachments  between the cord and inguinal ligament are swept from lateral to medial,  exposing the clean shelving edge of the inguinal ligament and the pubic  tubercle. Additional local anesthetic is injected along the ligament and at  the pubic tubercle. T e superior leaf of the external oblique fascia is grasped  by two hemostats. T e cord is dissected free, again beginning laterally. T e  pubic tubercle is cleaned. Further extension of this dissection from above,  out along the first centimeter or so of inguinal ligament lateral to the pubic  tubercle, ensures an easy mobilization of the cord. T e surgeon’ finger is  placed around the cord and a soft-rubber Penrose drain is placed around  it for inferior retraction (figure 2). T e cremaster muscle is opened ante-  riorly and longitudinally for a few centimeters in its proximal region. T e  sac 1s identified anterior to the vas deferens and is carefully dissected away  from the vas and blood vessels. T is dissection is performed using electro-  cautery at the edge of the sac while gentle traction is applied to the fat and  vessels. Historically, this dissection was done bluntly with smooth forceps  or with a sweeping motion using a gauze sponge; however, careful dissec-  tion with electrocautery along the edge of the sac minimizes bleeding. T e  sac is freed up well into the internal ring (figure 2). If the sac is entered,  the opening is closed with a 00 absorbable suture. When an extremely large  sac associated with an inguinoscrotal hernia is present, it may be prudent  to perform a high transection and ligation of the proximal sac. T is leaves  the distal sac intact and minimizes potential trauma of the cord veins, with  consequent testicular complications.   T e hernia sac in this example of an indirect hernia is not divided but  rather is invaginated back up through the internal ring with an instrument  (figure 3). T e internal ring may be sized with the surgeon’ finger, which  then guides the polypropylene cone or “plug” into the opening. T e cone 1s  secured to the conjoint tendon (internal oblique muscle) with one or more  00 absorbable sutures. It is important that the cone be positioned behind the  muscle and that a sufficient number of sutures be placed such that the sac or  preperitoneal fat cannot get out around the perimeter of the cone (figure 4).   T e onlay “patch” of synthetic mesh is placed with the pointed or shield  end overlapping the pubic tubercle. T e cord is passed through the lateral slit  and the two tails are joined together with 00 absorbable suture (figure 5). A  suture is placed near the cord, thus determining the diameter of the new inter-  nal ring. Traditionally, this opening has been sized for easy passage of the cord  plus an instrument tip. It is important that the onlay patch be of sufficient size  to overlap the inguinal ligament inferiorly, the pubic tubercle medially, and the  entire f oor centrally, as shown in the cross section (figure 5a). In addition,  the mesh should reach well lateral to the internal ring. T is may require the  custom cutting of a sheet of synthetic mesh for large indirect hernias.   T e perimeter of the incision, both deep and superficial, is infiltrated with  a long-acting local anesthetic. T e external oblique fascia is reapproximated  above the level of the cord using a 00 absorbable suture. T e closure begins  at the external ring with observation of the cord, the ilioinguinal nerve, and  the path of each edge of the oblique fascia. Starting the closure here allows the  surgeon to size the external ring. T e closure is continued laterally as a run-  ning suture (figur e 6). Scarpa’ fascia is approximated with a few 00 or 000  absorbable sutures and the skin is closed in a subcuticular manner with a fine  absorbable suture. Adhesive skin strips and a dry sterile dressing are applied.    Posto PeratIve care Patients operated upon in an ambulatory sur-  gery setting are observed for about an hour until discharge criteria are  met. T ey may take liquids by mouth and are encouraged to void. T e  homegoing instructions detailing activities and the signs of bleeding  or infection are reviewed with the patient and caregiver. Most patients  require pain medications for a day or two. Normal activities are resumed    detalls of Procedure T e incision and exposure is the same as that  utilized for the indirect hernia. T e external oblique fascia is opened and  the superior and inferior edges are grasped with pairs of hemostats. T e  shelving edge of the inguinal ligament is cleared first with blunt dissec-  tion using a peanut on a Kelly. However, as the surgeon begins the supe-  rior exposure, the direct f oor is not apparent as a structure separate from  the cord. It appears as though the cord and hernial process covered both  areas (figure 7). As the cremaster is opened anteriorly, the cord is identi-  fied as separate from the direct herniation. T e cord is dissected free and  isolated for retraction with a soft-rubber Penrose drain. T e direct her-  nial sac, which is often quite large compared to its defect in the foor, is  cleaned carefully back to its junction with the f oor or transversalis fascia  and muscle. A suitable zone approximately 1 cm above the junction of the  direct sac with the f oor is chosen for incision with the electrocautery. As  the sac is cut, the preperitoneal fat literally pops into view (figure 8). T is  circumscription is carried for 360 degrees about the entire neck of the sac.  T is allows the tethered sac and its content of preperitoneal fat to be easily  returned into the preperitoneal space. T e actual size of the direct defect is  often smaller than anticipated. On palpation of the defect, there is usually  a clear-cut rim of transversalis fascia and muscle that persists, although  these layers are often quite thin. T e synthetic mesh cone or “plug” is  placed into the direct opening such that its rim is directly fush with the  transversalis f oor. Multiple interrupted 00 absorbable sutures are used  to secure the perimeter of cone to the transversalis tissues (figure 9).    Usually eight or more sutures are placed such that none of the preperi-  toneal fat can protrude between the edge of the cone and the rim of the  transversalis. T e cremaster is opened anteriorly (figure 10) and a search  is made for any indirect hernia, which may require a second cone for repair.  T e cord structures including the vas are identified and the cremasteric  opening is not closed. T e onlay “patch” of synthetic mesh is placed over  the entire direct foor in the same manner as described in the preceding  chapter for indirect hernia. T e two tails of mesh are joined together pro-  ducing the new internal ring (figure 11). T e same precautions apply—  namely, the mesh must clearly overlap the inguinal ligament inferiorly, the  pubic tubercle medially, the entire direct f oor and cone centrally, and the  internal ring laterally. If this coverage is in doubt, a custom-cut piece of  synthetic mesh is prepared. In their original description, Rutkow and Rob-  bins do not suture down the perimeter of the onlay mesh “patch,” as in the  Lichtenstein repair. However, some surgeons prefer to suture the inferior  edge of the patch to the inguinal ligament and the superior edge to the  internal oblique muscle, thus creating a hybrid procedure that Rutkow has  humorously named the “plugstein-”    Posto PeratlIve care T e perimeter of the incision is infiltrated with  long-acting local anesthetic and the external oblique 1s reapproximated above  the level of the cord using a running 00 absorbable suture that begins at the  external ring. Scarpa’ fascia may be approximated with absorbable sutures.  T e skin is approximated with a fine absorbable subcuticular suture. Adhe-  sive skin strips and a dry sterile dressing are applied. T e postoperative care  is the same as that described earlier for the indirect hernia in Chapter 104. =    Preo Perat Ive PreParatlon T e preoperative preparation is directed  by the patient’ general condition. When the contents of the hernia sac are  strangulated, the fluid and electrolyte balance is restored by Ringer’ lactate  solution administered intravenously. Antibiotics are instituted if the exam1-  nation indicates the possibility of nonviability of the bowel and consequent  necessity for resection of intestine. Sufficient time is taken to fully resuscitate  the patient. Constant gastric suction is instituted. A slowing of the pulse and a  good output of urine are signs favorable to early surgical intervention. Uncom-  plicated femoral hernias may be repaired as ambulatory surgical procedures.    PoslItlIon T e patient is placed in a supine position with the knees  slightly flexed to lessen the tension in the groin. T e entire table is tilted  slightly with the patient’ head down.    o PeratIve PreParatlon T eskin is prepared in the routine manner.  A sterile transparent plastic drape may be used to cover the operative area.    IncIslon and exPosure T e surgeon should have in mind the rela-  tionship of the hernia sac to the deep femoral vessels and Poupart’ liga-  ment (figure 1). T e usual incision for inguinal hernia is made just above  Poupart’s ligament in the line of skin cleavage (figure 2). T e incision  above Poupart’s ligament is preferred because it gives the best exposure of  the neck of the sac and provides better exposure if bowel resection and  anastomosis are necessary. T e incision is made and carried down to the  external oblique fascia. After the fascia has been dissected free of the sub-  cutaneous fat, retractors are inserted in the wound. T e external oblique  fascia 1s divided in the direction of its f bers, as in the incision for inguinal  hernia (Chapter 104). T e round ligament or spermatic cord is retracted  upward along with the margin of the conjoined tendon (figure 3). T e  peritoneum, covered by transversalis fascia, now bulges in the wound. T e  neck of the hernia sac is freed from the surrounding tissues.    detalls of Procedure T e operator must now choose one of two  procedures. If the sac can be pulled upward through the femoral canal to the  surface, it may be unnecessary to open the abdominal cavity until the sac  itself is opened. T 1s is facilitated by retracting the neck of the sac upward  with forceps, while the operator applies counterpressure below Poupart’    ligament through the hernial mass (figur e 4). If the sac cannot be reduced  from beneath Poupart’ ligament by this maneuver, it becomes necessary to  dissect the subcutaneous tissue from the lower leaf of the external oblique  until the hernial sac is exposed as it appears in the femoral canal beneath  Poupart’ ligament (figure 5). Following this procedure, it is frequently  possible to withdraw the hernial sac from the femoral canal, converting the  femoral hernia to a diverticular type of direct hernia (figure 6).   If the contents of the hernial sac appear to be reduced so that it can be  opened without possible injury to incarcerated bowel, the sac is opened  (figure 7). A purse-string suture, which should include transversalis fascia  as well as peritoneum, is placed at the junction of the sac and the perito-  neal cavity so that when it is tied, no residual peritoneal pouch remains  (figures 8 and 9). Great care is taken that the suture closing the neck of the  sac does not include intestine or omentum.    closure T ere are several methods of preventing recurrence of the  hernia. T e transversalis fascia and the aponeurotic margin of the trans-  verse abdominal muscle may be approximated from the spine of the pubis  upward along Cooper’ ligament (figure 10), as in the repair of a direct  inguinal hernia by the McVay technique (Chapter 106, page 416). It is  essential to have adequate exposure of the iliac vessels such that they are  not injured when these interrupted sutures (figures |! and 12) are placed.  Several sutures are taken in Cooper’ ligament and the lacunar ligament on  the inferior edge of Poupart’s ligament in order to close the femoral canal  (figure ll). T e iliac vessels should not be constricted as the transition  suture is placed near the medial wall of the femoral vein. T e repair then  proceeds laterally in the McVay manner, with interrupted sutures securing  the conjoint tendon (internal oblique muscle) to the shelving edge of the  inguinal ligament (figure 12). T e round ligament in the female or the  cord in the male is returned to normal position or transplanted as in other  types of hernia repair. T e external oblique is closed without constriction  about the cord or round ligament, followed by the usual approximation of  the subcutaneous tissue and skin. A continuous subcutaneous absorbable  suture 1s used to approximate the skin. Adhesive strips and a dry sterile  dressing are then applied.    Posto PeratIvecare It is wise to keep the thigh slightly flexed during  the immediate postoperative period. T e patient is encouraged to ambulate  as soon as possible. Heavy manual labor, especially such as which greatly  increases intra-abdominal tension, should be avoided for about |month. mg    IndIcatIons All femoral hernias should be repaired unless contraind1-  cated by the physical or medical condition of the patient. Incarceration with  possible strangulation is a concern, as the femoral opening is small and its  boundaries are unyielding. Ultrasound imaging studies may be useful when  the diagnosis 1s difficult.    Preo PeratIve PreParatlon T e preoperative preparation is deter-  mined by the general condition of the patient. Uncomplicated femoral  hernias may be repaired in an ambulatory surgery setting. Incarcerated fem-  oral hernias without gastrointestinal signs or symptoms should be repaired  expeditiously, while symptomatic hernias are treated urgently. Strangulation  requires hospitalization and resuscitation of the patient with nasogastric  tube decompression, intravenous rehydration, and parenteral antibiotics.  Any general medical conditions are evaluated and sufficient time is allowed  for volume and electrolyte stabilization. Improved vital signs and a good  urine output indicate readiness for surgery.    anesthesla Deep sedation with infiltration of a local anesthetic as a  field block may be used in elective cases, as can spinal or epidural anes-  thetic techniques. Patients with strangulation and obstruction should have  general anesthesia with an endotracheal tube and cuff to lessen the threat  of tracheal aspiration.    PosIt Ion T epatient is placed in a supine position with the knees slightly  flexed by a pillow so as to lessen the tension in the groin.    oPeratIve PreParatlon T e hair in the planned operative site is  clipped and the skin prepared in the routine manner. Parenteral antibiotics  appropriate for prophylaxis against the usual skin bacteria are given immedi-  ately prior to the start of the procedure and in sufficient time to reach thera-  peutic tissue levels.    IncIslon and exPosure It is important that the surgeon under-  stand the regional anatomy of the femoral space. T is opening is approxi-  mately Ito 1’4 cm in diameter and lies directly lateral to the pubic tubercle  but inferior to the inguinal ligament (figure 1). T e fascia overlying the  pectineus muscle forms the posterior wall, whereas the lateral aspect is  bounded by the slightly compressible femoral vein as it emerges under the  inguinal ligament. Clinically, the femoral herniation presents as a mass  that may be confused with superficial inguinal lymphadenopathy. In thin  patients, the line of the inguinal ligament from the anterior superior spine  to the pubic tubercle can be projected and the femoral herniation will  clearly present below this, being immediately lateral to the pubic tubercle  and medial to the pulsation of the femoral vessels. If the surgeon is cer-  tain of this diagnosis, which may be aided by the use of ultrasonography,  then the lower limited oblique incision directly over the mass may be  made (figure 2b). If the diagnosis is in doubt, the patient is obese, or the  possibility of strangulation exists, then the upper incision (figure 2a) 1s  made so as to provide maximum exposure and flexibility. T is incision 1s  slightly lower than that made for the usual inguinal hernia. It is above and    parallel in general to the inguinal ligament with a more transverse medial  extension. T e incision 1s made and carried down to the external oblique  fascia. T e fascia over the canal is cleaned so as to expose the external  ring. T e external oblique fascia is divided in the direction of its fibers in  the manner used for exposure in inguinal hernias. A pair of hemostats are  placed on the superior and inferior leaves of the external oblique, which  is then cleaned by blunt dissection down to the internal oblique muscle  superiorly and the shelving edge of the inguinal ligament inferiorly. T e  round ligament or spermatic cord with attached ilioinguinal nerve 1s dis-  sected free and retracted superiorly either with a rubber Penrose drain or  a Richardson retractor (figure 3). T e transversalis fascia constituting  the floor of the canal is explored to rule out any direct herniation, and  thereaf er the region of the internal ring is explored to rule out the pres-  ence of an indirect herniation.    detalls of Procedure T e inferior leaf of the external oblique is  retracted superiorly and the femoral herniation becomes apparent as it  emerges just under the inguinal ligament lateral to the pubic tubercle. T is  same exposure is obtained if the lower incision is made directly over the  hernia. T e sac is grasped and, using a combination of sharp and blunt dis-  section, it is freed from the surrounding fat of the upper thigh (figure 4).  As the dissection proceeds, the herniation is found to occur through a nar-  row opening that is approximately the size of the surgeon’ fif h finger. Most  of en the sac contains preperitoneal fat or omentum, which can be reduced;  however, should strangulated gangrenous bowel be encountered, the sur-  geon must plan for resection with a synchronous laparotomy.   Af er successful reduction in an uncomplicated case, it is not necessary  to open the sac. T is is usually invaginated back through the femoral open-  ing, which now presents as a defined hole (figure 5). A synthetic plug is  made according to the method of Lichtenstein by rolling up a piece of syn-  thetic mesh approximately 2 by 15cm in length. T is spiral winding creates  a cylinder of mesh that is grasped with a Babcock clamp (figure 6) and  then inserted into the femoral opening such that a few millimeters pro-  trude externally. T ree quadrants of the cylinder are secured with inter-  rupted nonabsorbable sutures of polypropylene or nylon. Each is anchored  to the adjacent fascia with the suture extending well into the center of the  rolled cylinder so as to prevent an intussusception of the mesh. T e supe-  rior suture attaches to the inguinal ligament, the medial one to the lacunar  ligament and fascia investing the pubic tubercle, and the inferior one to the  fascia over the pectineus muscle. No suture is placed laterally, as this wall is  the femoral vein (figure 7). T e external oblique fascia is reapproximated  with either interrupted or running nonabsorbable sutures and then routine  closure of Scarpa’ fascia and the skin is performed. A small dressing is  applied to cover the incision.    Posto PeratIvecare Inthe uncomplicated case, the patient 1s quickly  discharged home with written instructions concerning activities, signs  of bleeding or infection, or any other unusual reaction. Most are able to  resume normal activities within a few days. m=    T is chapter shows the key anatomic features of importance that the skilled  surgeon must know thoroughly during any type of laparoscopic operation  for inguinal and femoral hernia repair.   T e first concept is to recognize that the parietal peritoneum covers cer-  tain structures forming five ligaments that are useful landmarks in identify-  ing the hernia spaces when approaching the groin from the intraperitoneal  route as in the TAPP repair. T ese ligaments include the median umbilical  ligament (1) running from the bladder to the umbilicus, the medial umbilical  ligaments (3), which are the remnants of the obliterated umbilical arteries,  and the lateral umbilical ligaments (4) formed by the peritoneum covering  the inferior epigastric vessels (13). T e spatial relationships of these ligaments  allow recognition of the various types of hernias. A direct inguinal hernia  (19) occurs in the medial space bounded by the inferior epigastric vessels or  lateral umbilical ligament, the iliopubic tract (21), the pubic tubercle (23) (the  medial end of the muscular conjoined tendon [internal oblique muscle]).  An indirect inguinal hernia presents through the internal ring (18) above the  iliopubic tract and is lateral to the lateral umbilical ligament containing the  epigastric vessels (13) on the posterior surface of the rectus muscle (2). A view  of the femoral hernia space (20) can be seen below the iliopubic tract (21)  and medial to the femoral vessels exiting through the femoral canal. During  the laparoscopic repair, the direct, indirect, and femoral spaces should all be  covered with mesh.   T e second important concept concerns the spaces that occur beneath  the peritoneal covering (17). T e preperitoneal space is the space bounded  by the peritoneum posteriorly and the transversalis fascia anteriorly. T e  space of Retzius is that space between the pubis and the bladder. T e lateral  extent of this space is named Bogros’ space. T e transversalis fascia forms  the floor of the inguinal canal and the iliopectineal arch, iliopubic tract,  and crura of the deep inguinal ring. T e iliopectineal arch divides the vas-  cular compartment (iliac vessels) from the neuromuscular compartment  (iliopsoas muscle, femoral nerve, and the lateral femoral cutaneous nerve).  T e iliopubic tract is an aponeurotic band that begins near the anterior  superior iliac spine and inserts on the pubic tubercle (23) medially. In its  medial extent, it contributes to the formation of Cooper’ ligament (22). It    forms the inferior margin of the deep musculoaponeurotic layer made up  of the transversus abdominis muscle and aponeurosis and the transversalis  fascia. Laterally, it extends to the iliacus and psoas fascia. It forms with  fibers of the transversalis fascia, the anterior margin of the femoral sheath  and the medial border of the femoral ring and canal. Its lower margin is  attached to the inguinal ligament. T e iliopubic tract is an important land-  mark. Dissection or tacking of preperitoneal mesh should not take place  inferior to the iliopubic tract except in the limited region of Cooper’ liga-  ment. Dissection or tack placement centrally beneath the iliopubic tract  will injure the femoral vein, artery, and nerve, whereas placement laterally  may damage the lumbar nerve branches. T e superior and inferior crura  of the deep inguinal ring are formed by the transversalis fascia. Cooper’s  ligament is formed by the periosteum of the superior pubic ramus and the  iliopubic tract.   T e inferior epigastric vessels give of two branches: the external sper-  matic vessel that travels in the spermatic cord and the iliopubic branch.  T e latter may form a corona mortis. T is vascular anomaly presents as a  branch of either the inferior epigastric or the external iliac that passes over  the pubic tubercle en route to the obturator system. Either the arterial or  the venous system may be involved in this “triangle of death?’ which may  cause significant hemorrhage during dissection and exposure of Cooper’s  ligament or mesh fixation with penetrating tacks.   Finally, there are two zones that must be avoided during preperitoneal  dissection and fixation of mesh. T e first is the lateral zone that is bounded  on the medial side by the spermatic cord, superiorly by the iliopubic tract  and by the iliac crest laterally. T is is known as the “triangle of pain.’  (the next Chapter 112, figure 2) T is area contains the femoral (10), lateral  femoral cutaneous (8), anterior femoral cutaneous, and the femoral branch  of the genitofemoral nerves. Injury to these nerves may cause chronic neu-  ralgia. T e second is the inferior zone bounded by the vas deferens (24)  medially, the gonadal vessels (15) laterally, and posteriorly by the perito-  neal edge. T is zone is known as the “triangle of doom,’ as it contains the  external iliac vein (12), the deep circumflex iliac vein, and the external iliac  artery (11). (Chapter 112, figure 2, page 433) m=   2 Rectus muscle 15 SpermaticA &V  3 Medial umbilical ligament 16 Corona mortis area  4 Lateral umbilical ligament 17 Peritoneum   9 Genitofemoral nerve 22 Cooper's ligament  10 Femoral nerve 23 Pubic tubercle    IndIcatlIons T e indications for inguinal hernia repair have been  described in the preceding chapters. T e techniques that will be described  include the transabdominal preperitoneal (TAPP) and the totally extraper-  itoneal (TEP). Laparoscopic repair may be applied to indirect, direct, or  femoral hernias. Laparoscopic inguinal herniorrhaphy is contraindicated  in the presence of intraperitoneal infection, irreversible coagulopathy, and  in patients who are poor risks for general anesthesia. Relative contraindica-  tions include large sliding hernias that contain colon, long-standing irre-  ducible scrotal hernias, ascites, and previous suprapubic surgery. For TEP  repairs, specific relative contraindications include incarceration and bowel  ischemia. A thorough knowledge of the anatomy of the inguinal region is  essential when it is approached posteriorly using a laparoscope. T e view  of this area as seen from the intraperitoneal perspective in the TAPP repair,  as well as the one from the preperitoneal perspective in TEP, is shown on  the preceding Chapter 111, entitled Laparoscopic Anatomy of the Inguinal  Region. In addition, proficiency with laparoscopic skills or mentored expe-  rience with this type of hernia repair is strongly recommended.    Preo Perat Ive PreParatlon T e patient must be a suitable candi-  date for general anesthesia. Anticoagulation, aspirin, and antiplatelet drugs  such as Clopidogrel Bisulfate (Plavix) must be discontinued in advance of  the procedure in order to avoid postoperative hematoma formation. Preop-  erative antibiotics should be administered intravenously within one hour  of the incision.    equiPment and suPPllIes All laparoscopic repairs use some form of  prosthetic material. T ese include synthetic mesh created from polypro-  pylene (Marlex or Prolene), Dacron (Mersilene), or polyester (Parietex).  Expanded polytetrafluoroethylene (e-PTFE) (Gortex) is supplied as an  extruded sheet. Mesh is generally preferred to e-PTFE because the structure  allows fibrous in growth and hence greater fixation to the surrounding tis-  sues. E-PTFE, composite mesh, or biologic materials are preferred in situa-  tions in which the prosthetic would be in touch with the intestine or other  intra-abdominal organs, as it promotes less of a fibrous response and lessens  adhesions to these structures. In this regard, e-PTFE has been modified to  have polypropylene on one side. T is so-called “dual mesh” might be useful  in cases in which the mesh cannot be completely covered by peritoneum.   Fixation of the mesh is necessary to prevent migration and the tendency  for the mesh to shrink overtime. T ere are a variety of tacking devices that  may be used including helical coils, shaped like a key ring, and anchors.  T ey may be absorbable or nonabsorbable metal. Most are delivered with  5-mm disposable instruments.    PosItlIon T e patient is placed in the supine position, and the arms  are tucked. T e operating room setup and port placements are shown in  figure 1.    o PeratIve PreParatlon Skin hair is removed with a clipper. A cath-  eter is placed in the bladder and removed at the end of the case.    IncIslon and exPosure figure | shows the typical room setup for  a left inguinal hernia repair by either TAPP or TEP. T e surgeon stands  contralateral to the hernia. T e camera operator is next to the surgeon and  the assistant directly across. One or two monitors may be positioned at the  foot of the operating table. In this chapter, a left indirect inguinal TAPP is  shown with the surgeon on the patient’ right side, whereas the TEP repair  shown in Chapter 113 demonstrates a right direct inguinal repair where the  surgeon would be positioned on the patient’ left side.   figures 3 to 7 illustrate a TAPP for a left indirect inguinal hernia.  T e Hasson technique as described in Chapter 111s used to gain access to  the peritoneal cavity. A supraumbilical incision is made for placement of  the Hasson trocar. T e patient is placed in a gentle Trendelenburg position.    A 10-mm 30-degree laparoscope is passed. Two 5-mm trocars are placed  under direct laparoscopic vision in the right and left midabdomen at the  level of the umbilicus (figure 1). A diagnostic laparoscopy is performed  and the hernia spaces inspected for additional hernias. Utilizing the two  lateral trocars, a peritoneal flap is created using laparoscopic scissors and  electrocautery. T e incision is begun lateral to the medial umbilical liga-  ment, which should not be divided, as this may cause bleeding from a ves-  tigial umbilical artery. An incision is made in the peritoneum 2 to 3 cm  above the hernia sac and carried laterally to the anterior iliac spine. T e  preperitoneal space is entered and blunt dissection is carried out with a lap-  aroscopic Kittner dissector in the avascular plane between the peritoneum  and the transversalis fascia. For a direct hernia, the dissection is begun lat-  erally to expose the cord structures and epigastric vessels. As the flap is  dissected, the critical anatomic landmarks from medial to lateral include  Cooper’s ligament, the inferior epigastric vessels, the vas deferens, and the  lateral zone or fossa (figure 2). T e sites of an indirect and direct hernia  are shown. Care should be to avoid dissection in the area labeled the Trian-  gle of Pain which contains sensory nerves (figure 2), injury to which may  cause chronic pain in the inguinal region, testicle, or thigh. Likewise care is  exercised to avoid dissection in the Triangle of Doom (figure 2), the area  which contains the major vascular structures. A corona mortis, a branch  of the inferior epigastric may be seen on the lateral edge of Cooper’ liga-  ment in 30% of patients (Chapter 111). T is must be avoided when dissect-  ing Cooper’ ligament or tacking the mesh in order to prevent troublesome  bleeding. T e left indirect sac is carefully teased and dissected away from  the cord structures as it is brought back into the preperitoneal space. A  small indirect sac may be completely reduced, but a larger sac that extends  into the scrotum may need to be divided. Downward traction on the cord  structures facilitates dissection of fatty tissue in the spermatic cord (cord  lipoma). T e iliopubic tract is identified (figure 3). T e peritoneal flap is  developed inferiorly. Care is taken to avoid injury to the genital branch of  the genitofemoral nerve and the lateral femoral cutaneous nerve (Chapter 111).  After an inferior flap is created, the following structures are identified: the  inferior epigastric vessels, the symphysis pubis, and the rectus abdominis.  Dissection is then carried medially to the contralateral pubic tubercle to  allow sufficient overlap for the mesh placement to cover all of the potential  hernia spaces. figure 3 demonstrates the final peritoneal flap and space.   For bilateral hernias, the space of Retzius is dissected through two lat-  eral incisions avoiding division of the urachus. T is creates a large common  space connecting the two sides.   T e mesh 1s introduced through the 10-mm trocar (figure 4). For a  unilateral repair, the mesh can either be a preformed one or a sheet that  is at least 15 x 10 cm in size. Although not shown in the illustrations for a  bilateral repair, two similar sheets of mesh or one large (30 x 15cm) maybe  employed. For the unilateral repair, the mesh is placed over the peritoneal  opening so that it covers all of the hernia spaces (direct, indirect, and femo-  ral). A wide overlap is necessary and extends from the contralateral pubic  tubercle medially to the ipsilateral anterior iliac spine. T e mesh is unrolled  and positioned with generous overlap in all directions. A slit may be made  for the cord structures. Tacking devices are applied medially to the superior  edge and inferior one edge. T is is facilitated by direct counter-pressure  by the surgeon’ nondominant hand. T e lateral edge aspect of the mesh  is usually not tacked into place because of potential nerve injury (lateral  femoral cutaneous and the femoral branch of the genitofemoral nerve). T e  mesh is secured medially to the tissues immediately adjacent to the con-  tralateral and the 1psilateral pubic tubercle and Cooper’ ligament (figure  6). Any redundancy in the inferior edge of the mesh should be trimmed in  order to avoid rolling up.   T e next step is to close the redundant peritoneum over the mesh. T e  mesh needs to be completely covered. Once the mesh is in place, the patient  is taken out of the reverse Trendelenburg position. Desuf ation to 10 mm  Hg is accomplished. T e peritoneal flap is then tacked to the anterior  abdominal wall or sutured closed (figure 7). m    Total extraperitoneal (TEP) approach avoids entering the peritoneal cav-  ity; hence, there is the theoretical advantage of less probability for visceral  injury or incisional hernias. In addition, it avoids the problem of closure  of the peritoneal flap. It is more difficult than TAPP because the opera-  tive space is tight. T e preoperative preparation, anesthesia considerations,  patient position, and operating room setup are the same as those for TAPP.    Eq uipmEnt and SupplikES A one- or three-component dissecting bal-  loon should be used to do the initial dissection of the preperitoneal space  (figure la,b, andc).    inciSio n and Expo Sur E A 2-cm incision is made just lateral and infe-  rior to the umbilicus on the same side as the hernia. T e muscle is retracted  laterally so as to expose the posterior rectus fascia. Blunt dissection with  the s-retractors or finger opens the preperitoneal space (figure 2b). T e  dissection of this space is facilitated by the use of a single- or three-com-  ponent dissecting balloon. T is is inserted into the space via the umbilical  incision. T e bulb insufflator device is used to expand the balloon. Dur-  ing the insufflation, the surgeon monitors the dissection process with the  laparoscope which lies within the dissecting balloon (figures la, b). T e  expansion is gradual. It is important to have all the creases 1n the dissecting  balloon flatten out. T e balloon is desufflated and removed. T e smaller  stay balloon is then inserted (figure Ic) and filled with 40 mL of air. It  is used to hold traction on the fascia by being retracted back and locked.  T is 1s attached to the CO, insufflator, which is set to a pressure of 15 mm  Hg. T e patient is placed in a slight Trendelenburg position to avoid exter-  nal compression of the preperitoneal space by the abdominal viscera. T e  hernia spaces are examined. Two 5-mm trocars are placed in the midline  inferior to the umbilicus (figure 2a) T e first is two fingerbreadths above  the pubic tubercle and the second five fingerbreadths above the pubic  tubercle just below the camera port. figure 3 shows the anatomy of the  region which is explained in detail in Chapter 111. A right direct inguinal  is identified and the area is cleared (figure 4). T e pubic tubercle is    identified and slight lateral dissection is continued until the obturator vein  is visualized. Blunt dissection with laparoscopic Kittner is used to open  the preperitoneal space. Small tears in the peritoneum should be repaired  in order to prevent competing pneumoperitoneum. If this becomes prob-  lematic, a Veress needle or 5-mm trocar can be placed in the peritoneal  cavity to release the CO, pressure. T e spermatic cord is then skeleton-  ized and the preperitoneal space dissected to the same extent as the TAPP.  Although the orientation is different, the dissection and the mesh place-  ment are similar to the TAPP. T e mesh is cut to the size and shape shown  in figure 5. It is then rolled and inserted under direct vision through  the 10-mm trocar used for the camera (figure 6). T e mesh is unrolled  and positioned in order to cover all three hernia areas—indirect, direct,  and femoral (figure 7a). It may be tacked medially in place, as described  in the TAPP section, avoiding the danger points previously discussed  (figure 7a). Alternatively, some surgeons prefer to use a fibrin-based  glue to secure fixation, while others use no fixation while relying upon the  deflated peritoneum to anchor the mesh. T e trocars are removed under  direct vision. T e CO, 1s slowly vented such that the mesh does not move.  T e mesh and collapsing peritoneum are observed as the videoscope 1s  removed. T e final position of the mesh in the preperitoneal space is shown  in the cross-sectional figure 7b.    clo SurE T e fascia is closed with absorbable interrupted suture. T e  skin is closed with subcuticular absorbable suture. T e bladder catheter is  removed prior to leaving the operating room.    po Sto pEr ativEconSid ErationS Local anesthetic may be injected  into the incision sites or instilled into the preperitoneal space to facilitate  pain management. If the patient is able to void urine, then he is discharged  the day of the surgery if there are no immediate complications. T e patient  is also advised not lif greater than 15 lb (about two gallons of milk) for the  first week. Return to work is dictated by pain tolerance. Many patients are  back to work in 5to 7 days. m    IndIcatIons A hydrocele of the tunica vaginalis occurring within the  first year of life seldom requires operation, since it will often disappear with-  out treatment. Hydroceles that persist after the first year or appear later in  life usually require treatment, since they show little tendency toward spon-  taneous regression. All symptomatic hydroceles in adults or in children  older than 2 years should be removed. Most hydroceles are painless, and  symptoms arise only from the inconvenience caused by their size or weight.  T e long-continued presence of a hydrocele infrequently causes atrophy  of the testicle. Open operation is the method of choice for removing the  hydrocele. Aspiration of the hydrocele contents and injection with scleros-  ing agents are generally regarded as unsatisfactory treatment because of the  high incidence of recurrences and the frequent necessity for repetition of  the procedure. Occasionally, severe infection can be introduced by aspira-  tion. Simple aspiration, however, often may be used as a temporary mea-  sure in those cases where surgery is contraindicated or must be postponed.   T e accuracy of the diagnosis must be ascertained. Great care must be  taken to differentiate a hydrocele from a scrotal hernia or tumor of the tes-  ticle. Ultrasound imaging can be very useful in these cases. A hernia usu-  ally can be reduced, transmits a cough impulse, and is not translucent. A  hydrocele cannot be reduced into the inguinal canal and gives no impulse  on coughing unless a hernia is also present. In young children, a hydrocele  is often associated with a complete congenital type of hernial sac.    anesthesIa Either spinal or general anesthesia is satisfactory in adults.  General anesthesia is the choice in children. Local infiltration anesthesia  is generally unsatisfactory because it fails to abolish abdominal pain pro-  duced by traction on the spermatic cord. Uncomplicated hydroceles may be  excised as an ambulatory surgical procedure.    PosItlIon T e patient is placed on his back on a level table with his legs  slightly separated. T e surgeon stands on the side of the table nearest the  operative site.    o Perat Ive PreParatlon T eskin is prepared routinely, with particu-  lar care given to scrubbing the scrotal area. Iodine should be avoided for  preparation of the scrotal skin, since it will cause severe excoriation. T e  area 1s draped as for any other operation on the scrotum.    IncIslon and exPosure T e relationship of the hydrocele of the  tunica vaginalis testis to the testicle, epididymis, spermatic cord, and cover-  ing layers of the scrotum is shown in figure |. Ifthe hydrocele is associated  with an inguinal hernia, separate incisions are made. If just a hydrocele 1s  present, then after the mass is grasped firmly in one hand so as to stretch  the scrotal skin and to fix the hydrocele, an incision 6 to 10 cm long is made  on the anterior surface of the scrotum, over the most prominent part of  the hydrocele, well away from the testicle that lies inferiorly and posteri-  orly (figure 2). T e skin, dartos muscle, and thin cremasteric fascia are  incised and ref ected back together as a single layer from the underlying  parietal layer of the tunica vaginalis, which is the outer wall of the hydrocele  (figures 3 and 4).    detalls of Procedure When the hydrocele is well separated laterally  and medially from the overlying layers, its wall is grasped with two Allis for-  ceps, and a trocar attached to a suction tube is thrust into it to evacuate the  fuid (figure 5). With a finger in the opening of the sac acting as a guide and  providing traction, the surgeon completely separates the wall of the hydro-  cele from the scrotum so that the spermatic cord and testicle with attached  hydrocele sac lie entirely free in the operative field (figur es 6, 7, and 8).  T e hydrocele sac then is opened completely (figure 9). Some sur-  geons prefer to delay emptying the hydrocele until it has been dissected  completely free from the surrounding tissues and delivered outside the  scrotum.   In younger men particularly, the testicle 1s carefully inspected and pal-  pated, since hydrocele has been known to occur in the presence of testicular  neoplasm.   T e relationship of the testicle to the tunica vaginalis is shown in  figure 10. With the walls of the hydrocele sac completely freed and com-  pletely opened, the redundant sac wall is trimmed with scissors, leaving  only a margin of about 2 cm around the testicle, epididymis, and sper-  matic cord (figure 10a and b). Great care must be taken to obtain abso-  lute hemostasis, since the smallest bleeding point left uncontrolled 1s likely  to ooze slowly into the loose scrotal tissues, producing a massive scrotal  hematoma. Large and painful hematomas that are slowly absorbed after  surgery may occur if there is not careful and complete hemostasis.   When the redundant portions of the sac have been excised, the edges are  sewed behind the testicle and spermatic cord with interrupted fine suture,  thus everting the retained portion of the old hydrocele sac (figures 11  and 12). Some surgeons prefer not to evert the sac but to place a continuous  fine absorbable hemostatic suture along its margin. In children especially,  the contents of the upper portion of the cord should be inspected for a pos-  sible hernia sac.    closure T e testicle and spermatic cord are replaced carefully in  the scrotum, care being taken that no abnormal rotation of the cord has  occurred. T e testicle may be anchored to the bottom of the wall of the  scrotum with one or two absorbable sutures to prevent torsion of the cord  (figure 13). T edartos fascia is closed with interrupted absorbable sutures  (figure 14). A small Penrose drain may be brought out through a small  stab wound at the most dependent portion of the scrotum. T is allows  escape of blood and prevents hematoma. T e skin is closed with a subcuta-  neous absorbable suture.    Posto PeratIve care T e scrotum should be supported by a sus-  pensory for 1 to 2 weeks postoperatively. Ice bags should be placed under  the scrotum for the first 24 hours. T e dressing should be changed daily.  T edrain is removed in 24 to 48 hours, depending on the amount of drain-  age. Significant pain or swelling may signal a hematoma or torsion, which  can be differentiated with duplex ultrasound scanning. Plain absorbable  skin sutures will fall out as they disintegrate. T e patient may be ambula-  tory immediately after surgery. m    IndIcatlIons T e indications for subtotal thyroidectomy are decreas-  ing because of the lower incidence of endemic goiters, both colloid and  nodular, and the increasing effectiveness of medical therapy in patients  who present with thyrotoxicosis, whether this is due to Graves’ disease or  to nodular toxic goiter.   A definite indication for subtotal thyroidectomy is the removal of a soli-  tary nodule in a young person, especially female, when the mass does not  take up radioiodide on thyroid scan and hence is suspected of being malig-  nant. A simple fine needle aspiration may yield a suspicious cytology. Total  lobectomy ensures a better margin and allows pathologic examination of  the excised thyroid lobe for multicentric foci should a malignant tumor be  found. Many surgeons combine a total lobectomy on the involved side with  a subtotal lobectomy on the alternate side.   T e controversy as to whether surgical or medical treatment for thyro-  toxicosis is desirable in patients younger than 35 to 40 years and in pregnant  patients has yet to be resolved, but it is generally agreed that the use of  radioactive iodine is contraindicated. Surgical removal should be consid-  ered if antithyroid drugs are tolerated poorly or required in large, prolonged  doses and if thyrotoxicosis recurs after an apparently successful medica-  tion regimen. In the poor-risk patient or one who has had a recurrence  of toxicity following previous thyroid surgery, medical therapy is usually  the treatment of choice. Also, some pregnant patients may be best treated  with antithyroid drugs in order to defer surgery until after the patient has  delivered. However, thyroid replacement is given daily once the patient is  euthyroid to prevent the development of a goiter in the fetus.   Subtotal thyroidectomy or total thyroidectomy is performed for an  enlarged thyroid gland that produced pressure symptoms or an undesir-  able cosmetic effect (endemic goiter), for toxic goiters, and occasionally for  inflammatory conditions such as Riedel’ struma and Hashimoto’ disease.    Preo Perat Ive PreParatlon T e¢ only indication for emergency thy-  roidectomy is in that exceedingly rare situation where pressure symptoms  develop rapidly due to intrathyroid hemorrhage. In all other situations thy-  roidectomy should be considered an elective procedure performed when the  patient is in optimal physical health. T 1s 1s true particularly in thyrotoxicosis.   Patients with thyrotoxicosis should be treated with antithyroid drugs pref-  erentially until they are euthyroid. Because the (thiourea) compounds block  the synthesis of thyroxine but do not inhibit the release of the hormone from  existing colloid stores, the time required for symptomatic improvement may  vary widely from 2 weeks to as long as 3months. T e variability is in part related  to the size of the gland, since large goiters usually contain more colloid. When  the patient has become euthyroid, 1odine—given as Lugol’ solution, potasstum  iodide solution, or tablets or syrup of hydriodic acid—can be administered for  10 days before surgery (optional). If this procedure is followed, almost any thy-  roidectomy can be performed under optimal conditions. If significant tachy-  cardia due to an increased intraoperative or postoperative release of thyroid  hormone is encountered, propranolol should be used to control it.    anestheslIa Endotracheal intubation is preferred, particularly if there  has been long-standing pressure against the trachea, substernal extension,  or severe thyrotoxicosis. For the severely toxic or apprehensive patient, a  short-acting intravenous barbiturate may be given in the patient’ room to  avoid undue excitement. General inhalation anesthetic agents are used.    PosItlIon T epatient is placed in asemierect position with a folded sheet  or shoulder roll underneath the shoulders so that the head is sharply angu-  lated backward (figure 1). T e head rest of the table can be lowered to  hyperextend the neck further. T e anesthetist should make certain that the  head is perfectly aligned with the body before the line of incision is marked.  Any deviation to the side may cause the surgeon to make an inaccurately  placed incision.    o PeratIve PreParatlon T e patient’ hair may be covered with a  mesh cap to avoid contamination of the field. T eskin is prepared routinely.  Before the incision is made, it may be accurately outlined by compressing  a heavy silk thread against the skin. T e incision should be made about  two fingers above the sternal notch and should be almost exactly trans-  verse, extending well onto the borders of the sternocleidomastoid muscles  (figure 2). In the presence of a large goiter, it should be made a little higher  so that the final scar will not lie in the suprasternal notch. A short midline  crosshatch may be made across the outlined incision to provide a guide to  accurate approximation of the skin at closure (figure 2). T e site for the  incision is then draped with sterile towels secured with towel clips at the  four corners, similar to a routine abdominal draping. Transfixing sutures or  staples may be placed through the towel into the skin in the middle of the  incision on either side. T is secures the towel at the center of the incision  and avoids contamination when the flaps are reflected upward and down-  ward. Skin towels sutured or clipped to the field may be eliminated by the  use of a sterile transparent plastic drape that is made adherent to the skin  with an adhesive spray. A large sterile sheet with an oval opening completes  the draping.    IncIslon and exPosure T esurgeon stands at the patient’ right side,  since it is customary to commence the procedure at the right upper pole. He  or she should be thoroughly familiar with the anatomy of the neck, espe-  cially with the blood supply and anatomic relationships of the thyroid gland  (figures 3 to 5). A thorough understanding of the anatomy of this region  should lessen the complications of hemorrhage or injury to the recurrent  laryngeal nerve, which may course through the bifurcation of the inferior  thyroid artery, and injury to the parathyroids. A dry field is maintained  if the various fascial planes are carefully considered during the procedure  (figure 3). T e locations of the major blood vessels, the parathyroids, and  recurrent laryngeal nerve are shown in figures 3 and 5.   T e surgeon applies firm pressure over gauze sponges to one margin of  the wound, while the first assistant applies similar pressure to the oppo-  site margin. In this manner the active bleeding from subcutaneous tissue  is controlled and the margins of the wound are evenly separated. T e skin  incision is made with a deliberate sweep of the scalpel, dividing the skin and  subcutaneous tissue simultaneously if the panniculus is not too thick. T e  belly of the scalpel should be swept across the tissues but not pressed into  them. Bleeding vessels in the subcutaneous tissues are seized with hemo-  stats; the large vessels are ligated, while small vessels are merely clamped  and released or cauterized. Hemostats with finely tapered jaws that can be  applied to the vessel alone are the best type to use, because they permit  ligation without strangulation of a tab of surrounding fat. One or two mass  ligatures may do no harm, but many strangulated bits of tissue cause indu-  ration and inflammation during healing since the avascular tabs must be  absorbed. Electrocautery is preferred to control bleeding.   T e incision is deepened to the areolar tissue plane just below the platysma  muscle where an avascular space is reached. All active bleeding points are  grasped with curved, pointed hemostats that are reflected upward or down-  ward depending upon to which side of the incision they have been applied  (figure 6). Active bleeding and danger of air embolus may occur from acci-  dental openings made into the anterior jugular vein if too deep an incision is  made. Sharp dissection may be used alternately with blunt gauze dissection to  facilitate the freeing of the upper flap (figur es 7and 8). Usually, a small blood  vessel will be encountered, high up beneath the flap on either side, which  will produce troublesome bleeding unless it is ligated (figures 8 and 9).  T e dissection goes up to the thyroid cartilage, as well as down to the supra-  sternal notch. Outward and downward traction 1s then applied to the lower  skin flap as it 1s freed from the adjacent tissue down to the suprasternal notch    detalls of Procedure T is operation is based on careful  dissection of various tissue planes between the muscles, vessels, and thyroid  gland. Some type of self-retaining retractor is inserted to hold apart the skin  flaps. In the presence of a large thyroid gland division of sternohyoid and  sternothyroid muscles may be needed. In these cases, the anterior margins  of the sternocleidomastoid muscles can be freed. (figure 10). T e handle  of the scalpel can be used as a dissecting tool to develop the correct plane  of cleavage between the sternocleidomastoid muscle and the outer bound-  aries of the sternothyroid muscle (figures lland 12).   To avoid bleeding, a vertical incision is placed exactly in the midline  of the neck between the sternohyoid muscles, extending from the thyroid  notch to the level of the sternal notch (figure 13). All bleeding points are  controlled by the application of clips or hemostats. T e tissues on either  side of the incision are lifted up so that the incision 1s not carried directly  through into the thyroid gland. Electrocautery or the blunt handle of the  knife can be inserted beneath the exposed sternohyoid muscles (figures 14  and 15). At this point the loose fascia over the thyroid gland should be picked  up with forceps and incised with the scalpel in order to develop a cleavage  plane between the thyroid gland and the sternothyroid muscle (figures 16  to 18). T isis one of the most important steps in a thyroidectomy. Many dif-  ficulties may be encountered unless the proper cleavage plane is entered at  this time. When the fascia of the sternothyroid muscle has been completely  incised and reflected, the blood vessels in the capsule of the thyroid gland  are clearly visible (figure 18). After the proper cleavage plane is devel-  oped, the sternohyoid and sternothyroid muscles are pulled outward from  the thyroid gland by means of a retractor, so that any unusual blood vessel    communication between the sternothyroid muscle and the thyroid gland  can be clamped and ligated (figure 18). Once the surgeon is working in  the proper cleavage plane, the delivery of the gland may be facilitated by  inserting the two forefingers side by side to the outer edge of the thyroid  gland and separating them, thus freeing the gland without injuring blood  vessels (figures 19 and 20). If an effort is made to free the entire lateral  surface of the gland by finger dissection, it must be remembered that in  some instances the middle thyroid vein is quite large and may be torn acci-  dentally by this maneuver, resulting in troublesome bleeding.   If the thyroid is only moderately enlarged, retraction of the prethyroid  muscles forward and laterally by narrow retractors will give adequate expo-  sure for the subsequent procedure. However, if the mass of thyroid tissue is  large, it may be wiser to divide the strap (prethyroid) muscles. T ere is no  dif culty with healing or function after transverse incision of these muscles if  this is done in the upper third to avoid injury to the motor nerve supply. T e  freed margin of the sternocleidomastoid muscle on either side is retracted  laterally to avoid its inclusion (figures 20 and 21). Ultrasonic shears may  be used to divide the muscle. Alternatively, muscle clamps may be applied  over the surgeon’ finger as a guide to avoid including any part of the con-  tents of the carotid bundle. T e muscle is divided between the clamps, and  an incision is made upward and downward from the end of either clamp to  facilitate the retraction of the divided muscles (figure 21). If large anterior  jugular veins are present, it is advisable first to ligate them with transfixing  sutures adjacent to the upper and lower clamps. T e muscle clamps can  then be lifted out of the wound and will not hinder the subsequent proce-  dure. T e muscles on the left side are similarly divided.    detalls of Procedure Occasionally, as the upper mus-  cle is retracted upward and outward, a branch of the superior thyroid artery  may be encountered, extending from the muscle to the surface of the thy-  roid gland in the region of the upper pole. T is vessel should be carefully  clamped and tied (figure 22).   It is customary to begin a subtotal thyroidectomy at the right upper pole  or on the larger side. Some surgeons prefer to divide the middle thyroid  vein first (figure 26), so as to improve mobility and exposure of the upper  pole vessels. A narrow retractor is placed in the wound at the superior pole.  Blunt dissection, which allows the thyroid capsule to be pushed away from  the larynx, is best accomplished by opening a small, curved fine Crile clamp  in the membranous tissue at this point (figur e 23). At the uppermost por-  tion of the gland there is a thin fascia that almost encircles the trachea. T 1s  area must be clamped carefully, since it contains small blood vessels that, if  allowed to retract, are very dangerous to secure because of its proximity to  the superior laryngeal nerve. Traction should be maintained on the thyroid  gland by means of two babcocks, a curved hemostat, sutures in the thyroid  gland itself, or an umbilical tape snugged around the gland in the region of  the upper pole. By sharp and blunt dissection the superior thyroid vessels  are exposed well above their point of entry into the gland (figure 23).T e  surgeon now decides whether to leave any thyroid tissue at the upper pole  region and places the next clamp either at the upper limits of the gland or in  the substance of the gland, perhaps 1 cm below the top of the pole. Hemo-  stasis 1s effected more easily if the superior thyroid arteries are ligated extra-  capsularly. Moreover, if much glandular tissue is to be retained, it should be  on the posterior surface at the level of the inferior thyroid arteries, as there  is more likely to be a recurrence at the superior pole. T ree small straight  or curved hemostats are applied to the superior thyroid vessels. T e vessels  are divided, leaving one clamp on the thyroid side and two clamps on the  vessels (figure 24). T e application of two clamps to the upper pole vessels  permits a double ligation and lessens the possibility of active troublesome  bleeding. Some surgeons prefer to make the second ligation a transfixing  suture of fine silk (figure 25). T e superior pole vessels can also be ligated  with clips and an ultrasonic shear.   If the middle thyroid vein has not already been identified and ligated,  an effort should be made to locate this vessel. Often it is stretched to a thin  strand as a result of traction applied to the gland in order to displace it  (figure 23). After the superior vessels and middle thyroid vein have been  ligated, the narrow retractor is moved to the right lower pole, where the  lower pole vessels enter the gland. T ese vessels are carefully freed from  the adjacent structures, either with a small curved clamp or by finger dis-    section (figure 27). Care must be taken not to injure the trachea at the  time these vessels are divided and doubly tied (figure 28). Occasionally,  a venous plexus (or thyroidea ima) is found over the trachea entering the  inferior surface of the gland in the region of the isthmus. T is is carefully  separated from the trachea with a blunt-nosed hemostat and ligated in the  usual fashion.   As an alternative method, the surgeon may decide to start at the lower pole  and luxate the gland before the upper pole is ligated. T e thyroid tissue over  the trachea is divided, and the right lobe is reflected outward (figure 29).  T e lower pole vessels then are clamped and ligated. T e middle thyroid  vein is brought into view by medial retraction and can be tied easily. T e  upper pole is now freed by pushing the index finger behind the superior  thyroid vessels. As the superior pole is pushed forward with the finger, a  curved clamp may be inserted between the trachea and the medial surface  of the superior pole, and the vessels can be doubly clamped (figur e 30).   After the middle and inferior veins have been ligated and the superior  pole freed by either method, the next step is to expose the inferior thy-  roid artery. Traction is maintained anteriorly and medially as the artery is  exposed on the lateral inferior surface of the gland (figure 31). A narrow  retractor is inserted laterally, and by gauze dissection the lateral aspect of  the gland in the region of the inferior thyroid artery is visualized clearly. It  should be remembered, especially in the presence of a large gland that has  been displaced outward, that the recurrent laryngeal nerve may be much  higher in the wound than ordinarily is anticipated. If a total lobectomy or  extensive removal of thyroid tissue is indicated, it is necessary, by careful  dissection, to identify this nerve, which may run between the bifurcation  of the inferior thyroid artery as it enters the gland. T e fossa posterior of  the gland should also be inspected to determine, if possible, the location of  the parathyroid glands, which are usually a pinkish chocolate color. Before  commencing this dissection, it 1s wise to place hemostats on the vessels at  the margins of the gland where the major branches of the inferior thyroid  artery lie. T e application of paired clamps to the major blood vessels at a  safe distance from the region of the recurrent laryngeal nerve (figur e 32)  defines the amount of thyroid tissue that will remain and lessens the  chance of accidental injury to the nerve. With the trachea in view and the  gland lifted into the wound, another row of small, curved hemostats is  placed well into the parenchyma so that the desired amount of thyroid tis-  sue 1s retained along with the posterior capsule (figure 33). T e amount  of thyroid tissue allowed to remain in relation to recurrent laryngeal nerve  is illustrated in figure 3 page 441 and later in this Chapter as figure 41  on page 447.    detalls of Procedure With the lateral hemostats in place,  the right lobe is pushed laterally, and the isthmus is exposed. If this has not  already been done, the isthmus is divided. T e inferior border immediately  over the trachea is grasped with mouse-toothed forceps and pulled upward  as a curved clamp is inserted between the trachea and the posterior portion  of the gland (figure 34). A similar clamp is inserted from the upper side.  After the cleavage plane between the thyroid gland and the anterior surface  of the trachea has been developed, the entire isthmus is divided between  curved clamps. If the clamps enter the tracheal fascia, there will be added  discomfort in the postoperative period. T e isthmus 1s divided close to the  right side of the clamps (figure 35). T e clamps remain on the left por-  tion of the thyroid as the right lobe margin is retracted laterally (figure  36). Curved clamps are inserted across the trachea into the parenchyma of the  gland and pointed toward the lateral row of clamps (on the preceding page  445, figure 32). If the clamps are placed horizontally across the trachea, the  points will not injure the recurrent laryngeal nerve (figur e 37).T e portion to  be removed is now lifted and dissected free (figure 38). T e bleeding points  in the center of the remnant are clamped. Only small amounts of tissue are  included. Actively bleeding points that retract, especially along the tracheal  margin of the remnant, are controlled by lateral compression with the index  finger. Blind clamping of thyroid tissue, particularly at the superior edge, may  result in mjury to the recurrent laryngeal nerve (figur e 39, pomt x). All bleed-  ing points are carefully ligated. Blind, deep placement of transfixing sutures is  avoided because of the risk of injury to the underlying structures. T e surgeon  must tie beneath these clamps with great care, preferably using a surgeon’ knot  on the first throw of the tie, so that the subsequent knots can be tied without  keeping the ligature under tension. As a rule, the tissues have been clamped  under tension, and the vessels tend to retract unless securely held by the first  throw of the tie. If transfixion 1s required, it should be done with a small curved  needle, and great care should be exercised to prevent penetration of the poste-  rior capsule and possible injury to the recurrent laryngeal nerve.   When no bleeding points remain, the cavity may be irrigated with saline.  T e pyramidal lobe, which may be variable in size, is entirely removed.  T ere is usually a bleeding point at the top of this lobe; hemostats are  applied and the vessel is ligated (figure 40). In freeing the isthmus, great  care 1s taken to avoid injury to the thin tracheal fascia. If this fascia is torn,  postoperative tracheitis and undue soreness may be encountered.   T e left side is freed similarly. T e additional space left by the removal of  a large right lobe somewhat simplifies the removal of the left lobe. T e sur-  geon moves to the left side and takes every precaution to protect the recur-  rent laryngeal nerve and effect complete hemostasis. T e field is inspected  for evidence of bleeding (figure 41).    closure _ T e folded sheet is removed from beneath the neck, and the  tension on the chin is relaxed. T e wound is repeatedly irrigated with large  amounts of saline, and the field is again inspected for any bleeding.   T e wound is carefully protected while the anesthesiologist introduces  the laryngoscope to inspect the position of the vocal cords. If the position of  the vocal cords suggests injury to either nerve, the surgeon should visualize  the nerve on the involved side throughout its course and release any sutures  that may have included or damaged the nerve. While the anesthesiologist  is inspecting the vocal cords, the surgeon should inspect the specimen very  carefully for adherent parathyroid glands. Questionable tissue must be  closely inspected; any parathyroid substance found should be transplanted,  preferably into the sternocleidomastoid muscle.   T e operator must be familiar with the appearance of the parathyroid  gland, which is a pinkish-brown flattened node about 3 to 4 mm in diam-  eter. T e superior glands are usually found on the posterior surface of the  thyroid at about the level of the lower portion of the thyroid cartilage. T e    inferior glands are seen at the lower portion of the thyroid, usually under-  neath the inferior pole or lying in the fat a little below and deeper than the  thyroid substance. Usually, the inferior parathyroids are seen and can be left  behind when the small inferior thyroid veins and thyroidea ima vessels are  first divided. Regardless of the fact that the surgeon may be certain that the  parathyroid glands remain in the wound, any suspected tissue attached to  the specimen is transplanted into the neck or forearm muscles.   T e prethyroid muscles are then approximated. If the anterior jugular  veins have not previously been ligated, they should be tied with a transfixing  suture adjacent to the muscle clamps. T e anterior margins of the sternoclei-  domastoid muscles are retracted laterally as the sutures are placed beneath  the muscle clamps (figure 42). After closure of the transverse incision, the  prethyroid muscles are approximated in the midline with interrupted sutures  (figure 43). Drainage is unnecessary in a dry field; however, if a large cavity  has resulted following the removal of a large nodular gland, a small closed-  suction Silastic drain may be brought out through the center of the incision  or through a small stab wound beneath the incision.   T e hemostats are removed from the subcutaneous tissue, and all  active bleeding points are ligated with fine 0000 silk ligatures or cauter-  ized. T eskin flaps are approximated, and the platysma and subcutaneous  tissue are repaired in separate layers in order to mound up the tissues and  obviate the necessity for tension on the skin sutures (figure 44). T eskin  may be approximated with an absorbable fine subcuticular suture or with  a nonabsorbable subcuticular running pull-out suture that is removed the  next day. Skin tapes and a loose dry sterile dressing are applied.    PostoPeratIve care T e patient is immediately placed in a semi-  sitting position. Adequate precautions should be taken to prevent hyper-  extension of the neck. Oxygen therapy is administered, 4 to 5 L per minute,  until the patient has reacted. A sterile tracheotomy set should always be  available in the event of acute collapse of the trachea. Parenteral fluids are  given until the patient can take adequate fluids by mouth. T e addition of  sodium iodide and calcium gluconate depends on the patient’ general con-  dition. Liquids by mouth are permitted as tolerated. Opiates or sedatives  are used as necessary.   Early complications include hemorrhage into the wound, hoarseness and  temporary aphonia, vocal cord paralysis, and postoperative thyroid “storm.”   T e most important postoperative complication is hemorrhage in the  wound. If wound hemorrhage is suspected, the dressing 1s removed, several  skin sutures are taken out, the blood is evacuated under aseptic conditions,  and major bleeding points are ligated.   Bilateral injury of the recurrent laryngeal nerve may result in paralysis of  both vocal cords and may require tracheotomy.   T e salient symptoms of postoperative crisis are high fever, severe  tachycardia, extreme restlessness, excessive sweating, sleeplessness, vom-  iting, diarrhea, and delirium. Ice caps or cooling blankets, sedation, and  parenteral high-calorie fluids, to which 1 g of sodium iodide and 100 mg of  corticoids have been added, are indicated. T e continued administration  of approximately 15 mg of a satisfactory corticoid preparation per hour in  an intravenous drip is recommended. Oxygen, antipyretics, and multivita-  min preparations are also administered. Propranolol may be given for the  tachycardia.   Postoperative hypoparathyroidism requires calctum gluconate 10%  intravenously. Vitamin D, is administered at a dosage suf cient to maintain  a normal serum calcium level. No added oral calcium other than a glass of  milk with each meal is required. T yroid replacement with levothyroxine is  given daily to prevent the recurrence of nontoxic nodular goiter.   Any drains are removed on the first postoperative day. T e patient is  allowed to go home as soon as he or she is self-suf cient. m    IndIcatlons Hyperparathyroidism is a common endocrine disorder  usually cured by subtotal parathyroidectomy. Parathyroid overactivity doc-  umented by appropriate laboratory studies may be associated with general  hyperplasia of the parathyroid glands or with an adenoma involving one  of the four or more parathyroid glands. Kidney stones, gastrinoma, recur-  rent pancreatitis, or other conditions are some of the clinical disorders that  imply a disorder of the parathyroid glands. Hypercalcemia is discovered  as a result of more frequent calctum determinations performed as part of  a general screening survey. Hyperparathyroidism is associated with gas-  trinoma in approximately one-third of patients with the familial multiple  endocrine syndrome I (MEN I). A mitogenic cause for the relatively high  incidence of recurrent hyperparathyroidism in the familial MEN I syn-  drome suggests the need for a radical approach, which may consist of total  parathyroidectomy with autotransplantation of parathyroid slices into the  muscle in the nondominant forearm or removal of 3’ parathyroid glands.   Evidence of hyperparathyroidism associated with hypercalcemia of  12 mg/dL after renal transplantation may be an indication to consider a radi-  cal parathyroidectomy. Hypercalcemia and extremely high parathyroid hor-  mone (PTH) values may occur after renal transplantation. T is condition  often resolves spontaneously, usually within a year of the transplantation. In  general, a conservative observational approach should be taken within the  first 2 years after renal transplantation, with operative intervention on the  parathyroids only in patients who demonstrate progressive bone disease and  who are clearly symptomatic.   Parathyroidectomy should precede surgical procedures for gastrinoma  in patients with the MEN I syndrome. T ere is an apparent increase in  supernumerary parathyroid glands in those with the familial MEN I syn-  drome, which suggests the need to remove the thymus, where an accessory  parathyroid gland may be located when the cervical exploration 1s negative.  More rarely, thyroidectomy may also be considered in a valiant search for  a parathyroid gland buried within the thyroid gland if a parathyroid is not  visible under the thyroid capsule.   T e presence of one endocrine tumor suggests the desirability of a gen-  eral search for other endocrine tumors, such as gastrinoma, pheochromo-  cytoma, prolactinoma, and others, before parathyroidectomy is performed.   Recurrence of hyperparathyroidism after a parathyroidectomy requires  a review of previous surgical procedures and a review of the patholo-  gists report on the parathyroids. Were the usual four glands found, and  where were they? Were any glands verified in the thyroid, thymus, ante-  rior or posterior mediastinum, or above the thyroid? Which glands were  removed or verified by frozen section examination? Every effort should  be made to localize the parathyroids prior to any reoperation. Computed  tomography, magnetic resonance imaging, radionuclide (sestamibi), and  ultrasound scans may be useful for identifying large tumors. However,  selective venous sampling with hormonal assays may be the last and best  diagnostic option.    Preo Perat Ive PreParatlon T esurgeon should be familiar with the  usual locations of the parathyroid glands as well as their common areas of  migration (figure 1). Attempts at localization of the glands are worthwhile,  especially if previous surgery has been unsuccessful. Rarely, an adenoma of  the parathyroid is large enough to be palpable. A variety of procedures may  be used to localize the adenoma, including ultrasound at 10 MHz. Radio-  nuclide imaging with Sestamibi is the preferred test for the localization of  parathyroid adenomas. Cross-sectional imaging with CT and MRI may be  helpful in evaluating retrotracheal and mediastinal locations but are usually  reserved for patients with recurrent hyperparathyroidism. Selective venous    samplings for determination of PTH can be useful in situations of recurrent  hyperparathyroidism as well. Because of associated risks and poor accu-  racy, angiography is rarely used. T e superior glands migrate upward or  downward into the posterior mediastinum. T e lower glands migrate into  the thymus or anterior mediastinum (figure 1). In symptomatic patients  CT imaging with a stone protocol or intravenous pyelograms are made in a  search of renal calculi. T e kidney function is carefully reviewed. T e vocal  cords are inspected. T e surgeon should review the variable location of the  parathyroid glands, as well as their blood supply and the close relationship  with the recurrent laryngeal nerves. A gastrin determination may be advis-  able if gastric symptoms are present.    anesthesIa General anesthesia with orotracheal intubation is desirable.  No specific or general anesthetic drugs are specifically indicated. However,  the potential exacerbation of renal dysfunction by some anesthetic agents  should be considered in patients who have had a renal transplant. If there  is a possibility of laryngeal nerve damage, spontaneous respiration should  be prolonged with the intratracheal tube in place. T ere should be sufficient  sedation to permit direct laryngoscopy immediately following extubation  of the trachea.    PosItlon T epatient is placed in asemierect position with a folded sheet  under the shoulders and the head sharply angulated backward.    o Perat Ive PreParatlIon T e patient’ hair is completely covered to  avoid contamination of the field. T e skin is routinely prepared. T is should  include not only the cervical region but also the upper thorax, since an  upper sternal incision may be performed in a search for a mediastinal para-  thyroid adenoma. If available, the laboratory should be notified of the need  for determination of parathyroid levels through the operation with rapid  PTH assay.    IncIslon and exPosure A low collar incision is made similar to that  used in thyroidectomy and all bleeding is carefully controlled. T e tech-  nical approach is similar to that in subtotal thyroidectomy (Chapter 115,  pages 440-447), including division of the strap muscles on both sides. Self-  retaining retractors may be inserted to maintain retraction of the skin f aps.  A sample for baseline determination of PTH is taken.    detalls of Procedure A four-gland exploration is described. Image  gulded selective neck exploration is being more frequently employed. T is  procedure is not described or illustrated. T e right lobe is freed by blunt  index finger dissection (Chapter 115, figures 19 and 20, page 443) in prep-  aration for identification of the course of the recurrent laryngeal nerve and  the tan/yellow-colored parathyroid glands at the upper and lower poles of  the thyroid gland. After the two glands on the right side have been identi-  fied, a similar search is made on the left side. T e parathyroid glands may  appear normal or only slightly enlarged when hyperplasia is involved, espe-  cially in the MEN I syndrome. A solitary adenoma, when found, may be the  size of a small marble or several centimeters in diameter.   Further mobilization of the right lobe results when the middle thyroid  vein is ligated and tied (figure 2). A small hemostat is used to grasp  the thyroid and retract it upward and medially. T e surgeon may retract  the thyroid with the left thumb over a piece of gauze on the upper pole  of the thyroid. T e relationship of the recurrent laryngeal nerve to the  middle thyroid artery and the arterial blood supply to the upper pole of  the thyroid should be clearly verified (figure 3). T e loose tissue is gently  pushed aside with forceps and gauze until the color identifiable as para-  thyroid is visualized.    detalls of Procedure Many times it is difficult to be  certain whether discolored tissue is the parathyroid or a hematoma in  fatty tissue. Using fine-tooth forceps, the adenoma, if identifiable, is very  carefully dissected from the adjacent tissue, constantly keeping in mind  the location of the recurrent laryngeal nerve (figur e 3). Time is required  to develop the rather frail vascular pedicle going to the superior parathy-  roid, which is double-clamped and ligated (figure 4).   A portion of a gland may be excised for immediate frozen-section exam-  ination to determine that it is parathyroid tissue. In some instances, a small  biopsy may be taken from several areas believed to be parathyroid glands.  A numbered diagram should be made of all biopsy sites along with the ind1-  vidual frozen-section reports of the specimens removed.   T e extent of the operation should not be limited to the excision of one  obviously enlarged gland that makes a gross diagnosis of adenoma quite  likely. If a single enlarged gland is found and removed, repeat determina-  tion of arapid PTH level should show a fall of at least 50% within 10 minutes  or 85% by 15 minutes if this was the only abnormal gland. In a four-gland  exploration, the other three glands should be identified and their locations  recorded. Some prefer a biopsy verification of each one (figure 5), while  others attach a fine, deep blue nonabsorbable suture to the gland remnant  and bring a long end out into the subcutaneous tissue. T e blue suture line  serves as a visible guide to the site of the parathyroid biopsy should reopera-  tion become necessary.   In patients with the familial MEN I syndrome, three normal-appearing  glands may be excised as well as one-half of the fourth remaining gland. It is  advisable to control any oozing with a small silver clip (figur e 6) in order  to ensure certain identification of the location of any remaining parathyroid  tissue should hyperparathyroidism recur.    In rare patients with the familial MEN I syndrome, there is a disturbing  rate of recurrent hyperparathyroidism because of the mutagenic potential  of the MEN I syndrome. As a result, a radical parathyroidectomy leaving  only one-half of one gland should be considered. Resection of the thymus  should probably be considered, especially if one of the lower parathyroid  glands is missing.   In general, in a patient with recurrent hyperparathyroidism after para-  thyroidectomy, the surgeon should assume that one or more glands in the  cervical region have been overlooked or are aberrantly located or that the  patient has the familial multiple neoplasia syndrome. Mediastinal involve-  ment varies but may be present in as little as 2.5% of patients. Upper medi-  astinal tumors are usually intrathymic, near the innominate vein.   In patients with recurrent hyperparathyroidism, preoperative imaging  is helpful if 1t presents good evidence that a tumor is present in the upper  mediastinum. At operation, an effort is made to bring the thymus up into  view above the suprasternal notch in the hope of finding a readily recogniz-  able parathyroid gland within it. A transsternal approach to the thymus is  rarely required.    Posto Perat Ive care T ere are two primary complications of great  concern. One is injury to the recurrent laryngeal nerve with persistent  paralysis of a vocal cord. A second complication is hypocalcemia, even  though one-half of one gland has been preserved with meticulous tech-  nique. Chvostek’s sign, consisting of fascial muscle twitching when the fas-  cial nerve is “thumbed” with the finger, indicates hypocalcemia. Careful  monitoring of the serum calcium 1s carried out with appropriate administra-  tion of calctum gluconate daily as well as dehydrotachysterol. Calctum and  PTH determinations every 6 months over a long term are worthwhile. m=    IndIcatlIons T e presence of cortical or medullary tumors of either a  malignant or benign adenomatous nature is a well-established indication for  unilateral adrenalectomy. In recent years, however, the number of indica-  tions for bilateral adrenalectomy has gradually increased. It is occasionally  performed to control complex endocrine states after partial or unilateral  adrenalectomy has failed to alleviate hyperaldosteronism or hypercorti-  solism, as in Cushing’ syndrome.    Preo PeratIve PreParatlIon T e most important preoperative pro-  cedure is to establish a firm diagnosis. Clinical findings often indicate the  altered pathophysiology, but extensive endocrine studies are usually neces-  sary, not only to establish the disorder within the adrenals but also to rule  out associated disorders in other endocrine glands. Accordingly, the reader  should refer to current texts on diagnostic endocrinology to confirm the  diagnosis. Computed tomography scan is usually the preferred imaging  modality, but MRI can also be very useful. When adrenalectomy is decided  upon, the surgeon should investigate and, if possible, correct many of the  secondary systemic and metabolic effects that are the direct result of the  altered functional activity of the adrenal. T e management of hyperten-  sion and its cardiovascular sequelae is a major problem with pheochromo-  cytomas. Problems associated with hypercortisolism include hypokalemia  with alkalosis, hypertension, polycythemia, musculoskeletal depletion with  osteoporosis and hypercalcemia, abnormal glucose tolerance, multiple areas  of skin furunculosis, and, finally, poor wound healing. T us, the surgeon  must be aware that many organ systems and their responses to surgery are  profoundly affected by adrenal malfunction.    anestheslIa Preoperative consultation and communication among endo-  crinologist, surgeon, and anesthesiologist are necessary. T e anesthesiologist  must be prepared for adequate blood and endocrine replacement and occasion-  ally for a prolonged procedure that may be extended into the chest. Electrolytes  should be in optimum condition. Parenteral steroids need to be available at  the time of surgery for hypercortisolism or bilateral adrenalectomy. Adequate  blood must be available, as hypertension plus increased vascularity and fragile  veins around the adrenals all tend to increase blood losses.   General anesthesia with endotracheal intubation is preferred. Patients  with pheochromocytomas should have adequate preoperative prepara-  tion with a long-acting adrenergic (alpha receptor) blocking agent, such as  phenoxybenzamine hydrochloride (Dibenzyline) or doxazosin (Cardura)  for an extended period of time, if possible. Administering IV fluids the day  and evening prior to surgery helps alleviate the dehydration associated with  pheochromocytomas. To minimize wide fluctuations of blood pressure, an  intra-arterial line should be placed and hypertension controlled with an  intravenous infusion of sodium nitroprusside (Nipride). After assuring that  adequate fluid and blood replacement has been accomplished, an infusion  of norepinephrine (Levophed) may be necessary to treat hypotension. A  beta-blocker and lidocaine hydrochloride (Xylocaine) may be needed to  control tachycardia and cardiac arrhythmias. Once the tumor is out, norepi-  nephrine may be needed for several days with gradual tapering as tolerated.    PoslItIon T e patient is placed supine with the foot of the table slightly  down, so that moderate hyperextension can be obtained if necessary. A  posterior approach to the adrenals can be used, and may be useful for nor-  mal-sized adrenal glands but 1s not described here.    oPeratIve PreParatlon T e patient’ hair should be completely  removed with minimal trauma to the skin. In the anterior approach, the  skin of the lower chest and abdomen well into the flanks should be included    in the preparation, since, in making a transverse incision, it may be neces-  sary to go far into the flanks in obese patients.    IncIslon and exPosure T esurgeon stands on the patient’ right side  and outlines an incision about two to three fingerbreadths below the costal  margin with its apex about two fingers below the tip of the xiphoid process  (figure 1). A thoracoabdominal approach through the ninth interspace  may be used for large adrenal tumors occurring on the right side. When  the posterior approach is used, the incision extends from the level between  the lth and 12th ribs 5 cm from the midline and curved downward to the  midportion of the ileum. Increased vascularity in the subcutaneous tissue  is common in these cases, particularly in Cushing’ syndrome. Meticulous  ligation of all bleeding points or control with electrocoagulation should  be carried out before the peritoneal cavity is opened. Both rectus muscles  are divided, and then the transversus muscle and peritoneum are incised  through a liberal incision. T is is necessary since many of these patients  tend to be obese. Additional exposure may be obtained by dividing the  internal oblique muscles in the direction of their fibers out into the flanks.  T e falciform ligament to the liver is divided between curved hemostats  and then ligated. In some patients it may be prudent to mobilize the right  lobe of the liver by dividing the falciform and right triangular ligaments  (Chapter 81, figures land 2).    detalls of Procedure T e surgeon must first be aware of the ana-  tomic differences of the two adrenal glands (figure 2). T e right adrenal  is close to the superior pole of the kidney, the vena cava medially, and the  right lobe of the liver superiorly. Its main arterial supply comes directly to  its medial edge from the aorta (figures 2, Label 11), and the main right  adrenal vein (5) comes directly from the inferior vena cava in a parallel  manner. In contrast, the left adrenal is in proximity to the aorta medially,  the renal vein inferiorly, and the superior pole of the left kidney. Its main  arterial supply comes directly from the aorta (12), but the main left adrenal  vein (6) usually comes from the left renal vein (8). Both adrenal glands,  however, have many arterial twigs from both the inferior phrenic arteries  (9 and 10) and both renal arteries.   T e operative exposure of the right adrenal is shown first (figure 3);  it is begun with a classic Kocher maneuver, after the transverse colon and  omentum have been carefully packed away and the right lobe of the liver  has been retracted gently. T e right lobe of the liver should be fully mobi-  lized to gain a better exposure of the right adrenal. After the peritoneum  lateral to the duodenum has been incised, it is mobilized in the usual man-  ner by blunt dissection with the surgeon’ index finger under the head of the  pancreas. T e inferior vena cava is exposed in its position directly posterior  to the second portion of the duodenum (figure 4) and then cleared to  show the right renal vein. T e superior pole of the right kidney is located  and exposed with further blunt finger dissection. T e adrenal is identi-  fied by its characteristic yellowish color, lobulated appearance, and clearly  definable blunt lateral edge. T is generally avascular area is then incised  (figure 5), and additional exposure and mobility of the adrenal gland may  be obtained by gentle blunt finger dissection directly posterior to the gland.  T e surgeon should bear in mind that the vascular attachments are usually  on or near the medial and superior edges of the gland rather than on its  anterior and posterior broad surfaces. If preoperative studies show a large  adrenal tumor, especially on the right side, a thoracoabdominal incision  should be considered in order to provide exposure for mobilizing the right  lobe of the liver. It may be necessary to remove the kidney along with the  invading adrenal neoplasm.    1. Inferior vena cava  2. Aorta 2  3. Right adrenal gland   9. Right inferior phrenic artery  10. Left inferior phrenic artery  11. Right adrenal artery  12. Left adrenal artery    detalls of Procedure Usually, the principal adrenal  vein is first identified and then doubly ligated with 00 silk (figure 6).  T e surgeon then cautiously works about the medial and inferior edges of  the gland and ligates the principal artery or accessory arteries in a similar  manner. T e many minor vessels encountered must also be either carefully  ligated or secured with clips.   T e approach to the left adrenal via the transabdominal route may  take either of two courses, as demonstrated in figures 7 to 10. T e usual  approach is shown in cross section in figures 7and 8.T e abdominal con-  tents are carefully packed toward the surgeon and then, carefully grasping  the spleen, the surgeon divides the avascular splenorenal ligament so that  the spleen is mobilized somewhat toward himself or herself. With blunt dis-  section, it is then possible to dissect above Gerota’ fascia but beneath the  pancreas and primary splenic artery and vein. T is dissection may be car-  ried medially as far as the superior mesenteric vein, which will give a degree  of mobilization as shown in figure II. T e surgeon then incises Gerota’  fascia over the left kidney (figure 8) and, with blunt dissection, clears  the superior pole of the left kidney and comes upon the adrenal, which is  shown here in a somewhat medial and inferior location. T e left lobe of the  liver is also identified, but it is usually not necessary to mobilize or retract  it. T e same general principles of exposure apply to the left adrenal gland  except that the prominent adrenal vein (figure 11) is shown being secured  first. T e surgeon then works about the periphery of the gland, ligating all  prominent vessels. T is is often slow, meticulous work, but—if in doubt—it  is safer to ligate or clip each suspicious vascular area.   Many surgeons have found it useful to approach the left adrenal through  the transverse mesocolon, after mobilizing the inferior border of the body  and tail of the pancreas (figure 9). T is is accomplished by first remov-  ing most of the greater omentum from its attachment along the transverse  mesocolon and carefully securing any bleeding points in this generally avas-  cular area. Care must be taken to preserve the middle colic vessels, since the  omentum is sometimes closely blended with the mesocolon, and these ves-  sels therefore are susceptible to damage during the procedure. An incision  is then made along the distal or inferior margin of the pancreas from the  tip of its tail, back along the body to the region of the inferior mesenteric  vein (danger point [central arrow], figure 9). T is allows the surgeon to  mobilize the distal pancreas with blunt finger dissection so that it may be  elevated in a cephalad manner and to expose Gerota’ fascia directly over  the left kidney, whose midportion is usually directly encountered by this    approach. T is fascia is then incised and the dissection carried about the  superior pole of the kidney, where the adrenal can be identified (figure 12).  Its lateral edge is then approached and its removal performed as in the pro-  cedure described above.    closure T e incision is closed in the routine manner. However, reten-  tion sutures are recommended in hypercortisolism, as poor wound healing  is a known complication.    Posto PeratlIve care Blood losses must be replaced carefully, and  patient observation and blood pressure monitoring must be unfailingly fre-  quent, preferably by an intra-arterial line. Should blood pressure continue to  fall in the recovery area or during closure despite adequate endocrine replace-  ment, retroperitoneal hemorrhage from an unsecured vessel must be strongly  suspected. In patients who have had a pheochromocytoma removed and for  whom adequate fluid and blood replacement has been accomplished, a post-  operative vasopressor in the form of norepinephrine may be necessary for 24  to 36 hours, after which time it is gradually tapered as tolerated. Proprano-  lol hydrochloride (Inderal) and lidocaine hydrochloride (Xylocaine) may be  needed to control tachycardia and cardiac arrhythmias.   Patients will experience a drop in the level of circulating corticosteroids  after removal of a hyperfunctioning tumor or after subtotal or total adre-  nalectomy. T erefore they must have cortisone support before, during, and  after surgery. Hydrocortisone (Cortef) in the dose of 100 mg 1s given intra-  venously during the surgery. T is is gradually tapered down over the next  7 to 10 days to 30 to SO mg per day, which may be given orally in divided  doses (frequently 20 mg in the morning and 10 mg in the afternoon). It  is felt that 30 to SO mg per day of hydrocortisone represents reasonable  maintenance therapy. However, it may be necessary to add an active min-  eralocorticoid, such as fludrocortisone (Florinef) at 0.1 mg per day to this  if maintaining sodium and potassium balance is dif cult. In the immediate  postoperative period, however, the major problem is to ensure adequate  cortisone replacement, as it is easy to undertreat but almost impossible to  overtreat with cortisone.   T e postoperative ileus and return to alimentation should be handled  the same as for any laparotomy. Wound healing, however, will be impaired  in patients with hypercortisolism, and infection is a possibility, as many of  these patients also have extensive furunculosis. Finally, it is important that  the patient’ long-term medical management and endocrine replacement  be clearly defined. m=    IndIcatlIons T epresence of cortical or medullary tumors of a benign nature  is a well-established indication for unilateral laparoscopic adrenalectomy. T ese  tumors may be functional and produce cortisol, aldosterone, catecholamines,  and rarely testosterone and other sex hormones. In many cases the tumors are  nonfunctional and are removed because of the concern for cancer. In these situ-  ations the adrenal mass is frequently found during abdominal imaging done for  unrelated indications. T ese so-named adrenal “incidentalomas” should gener-  ally be removed if they have a cross-sectional diameter 4 cm or greater or if they  are proven to be functional. Patients with nonfunctional adrenal masses less  than 4 cm should be followed with periodic imaging to monitor changes in the  size of the mass. A benign adenoma on CT is typically a homogeneous mass with  a low attenuation value (less than 10 HU on a noncontrast image or a greater  than 50% washout on an adrenal protocol CT). It is recommended that patients  with an incidentaloma should have a I-mg dexamethasone suppression test and  a measurement of plasma-free metanephrines. In addition, patients with hyper-  tension should have determinations of serum potassium and plasma aldosterone  concentrations to plasma renin activity for an activity ratio. Surgery is consid-  ered in all patients with functional adrenal cortical tumors. All patients with  biochemical evidence of pheochromocytoma should undergo surgery except  in rare instances. Although size is not an absolute contraindication to laparo-  scopic adrenalectomy, the procedure may be difficult on lesions greater than 10  cm. Open adrenalectomy with en bloc excision is the mainstay for primary and  recurrent adrenocortical carcinoma due to the lack of effective adjuvant therapy  and the difficulty of maintaining oncologic principles with laparoscopy.    Preo Perat Ive PreParatlIon T e most important preoperative proce-  dure is to establish a firm diagnosis. Accordingly, the reader should refer to  current texts on diagnostic endocrinology for the required procedures. When  adrenalectomy is decided upon, the surgeon should investigate and, if possible,  correct many of the secondary systemic and metabolic effects that are the direct  result of the altered functional activity of the adrenal. T e management of the  hypertension and its cardiovascular sequelae is the major problem with pheo-  chromocytomas. Preoperative treatment with an alpha-receptor antagonist  such as phenoxybenzamine hydrochloride or doxazosin (Cardura) and volume  expansion is necessary in patients with pheochromocytoma in order to control  the associated hypertension. T is may take 2 weeks or more. Beta-blockers are  reserved for patients with tachycardia or cardiac arrhythmias. Problems asso-  ciated with hypercortisolism have been reviewed in the section on bilateral  adrenalectomy.    anestheslIa Preoperative consultation and communication among endo-  crinologist, surgeon, and anesthesiologist are necessary. A type and screen is  acceptable for small tumors. Autologous donation or type and cross to ensure  the availability of blood products is recommended for tumors greater than 6 cm  and for a right-sided tumor due to its proximity to the inferior vena cava. Gen-  eral anesthesia with endotracheal intubation is preferred in all cases. A cath-  eter should be placed in the urinary bladder for monitoring urine output. T e  stomach should be decompressed with an orogastric or nasogastric tube. For  patients with nonfunctional tumors, there are no special considerations for  anesthesia. Patients with hyperaldosteronism should have the blood pressure  controlled preoperatively, but rarely have life-threatening intraoperative hyper-  tension. Patients with hypercortisolism should have correction of the metabolic  abnormalities and be given a stress dose of steroids.   Patients with pheochromocytoma should have an arterial line and central  line placed. In some patients with associated hypertensive cardiomyopathy, a  pulmonary artery catheter may be helpful. During the procedure the anesthesi-  ologist should be prepared to control hypertension with an intravenous infusion  of sodium nitroprusside (Nipride). After the pheochromocytoma is removed  and ensuring that adequate f uid and blood replacement has been accomplished,  an infusion of norepinephrine (Levophed) may be necessary to treat hypoten-  sion. Propranolol hydrochloride (Inderal) and lidocaine hydrochloride (Xylo-  caine) may be needed to control tachycardia and cardiac arrhythmias.    anatomy T e surgeon must first be aware of the anatomic differences of the  two adrenal glands (see preceding Chapter 117, figur e 2 Labels 1-12). T e left adre-  nal is in proximity to the aorta medially, the renal vein inferiorly, and the superior  pole of the left kidney. It may be located near the renal hilum. Its main arterial sup-  ply comes directly from the aorta (Label 12), but the main left adrenal vein (Label  6) usually comes from the left renal vein (Label 8). In contrast, the right adrenal is  close to the superior pole of the kidney, the vena cava medially, and the right lobe  of the liver superiorly. Its main arterial supply comes directly to its medial edge  from the aorta (Label 11), and the main right adrenal vein (Label 5) comes directly  from the inferior vena cava in a parallel manner. Both adrenal glands, however,  have many arterial twigs from both the inferior phrenic arteries (Labels 9 and 10)  and both renal arteries. Both adrenal glands are within Gerota’ fascia.    Po sIt lon An adjustable vacuum beanbag should be placed on the operating  table prior to bringing the patient into the room. T e patient is positioned with    the bag being at the level of their f ank below the ribs and above the iliac crest over  the break position of the table so as to allow a “Jack knife” extension that may be  useful in obese patients.   For a left adrenalectomy the patient is placed in a lateral position with  the left arm crossing the chest and supported on a padded arm board  (figure 1). T eright arm is placed on a separate arm board and an axillary roll  is used. Liberal padding is used between and around both arms. T e abdomen  and fank area should be exposed and the left knee fexed, with a padding of  blankets or pillows between the legs.    IncIslon and exPosure For a left adrenalectomy the surgeon stands on  the patient’ right side (figure la). T e camera operator stands to the left or  right of the surgeon and the assistant on the left side of the patient. A 10-mm  30-degree laparoscope is placed either above the umbilicus or in the left lat-  eral midsubcostal position in the mid-clavicular line just above the level of the  umbilicus using the open technique of Hasson as described in Chapter 11, page  40. T e abdominal space is inf ated to 15 cm of pressure, the laparoscope is  introduced, and all four quadrants of the abdomen are examined for abnormal-  ities, safety of other planned port sites, and evidence of any metastatic disease.  A 5-mm port is placed in the far left lateral subcostal position and a 5-mm port  is placed just to the left of the midline through the upper rectus muscle sheath  just to the left of the round ligament. T is reduces the chance of lacerating the  epigastric artery, which might require suture ligation. T ese ports are in a line  about two fingerbreadths or so below the edge of the costal margin. A third  5-mm port is placed in the anterior axillary line midway between the costal  margin and the iliac crest (figure Ib).    detalls of Procedure T e operative exposure of the left adrenal is  shown first. T e splenic fexure of the colon is mobilized using an ultrasonic  device so as to expose the kidney. T e dissection is continued cephalad and the  lesser sac is entered by separating the greater omentum from the splenic f exure  and transverse colon (figure 2). It is not necessary to mobilize the spleen.  T e lesser sac is entered and the pancreas identified (figure 2). T e retroperi-  toneum is exposed to show the kidney and posterior surface of the pancreas  (figures 2 and 3). Gerota’ fascia is incised and opened to expose the upper  pole of the kidney (figures 2 and 3). Dissection is continued under Gerota’s  fascia while the assistant lifts the tail of the pancreas anteriorly (figure 3).  T is dissection should be continued as far cephalad as possible. T e inferior  pole of the adrenal gland will be seen as a bright yellow organ and the adrenal  tumor exposed (figure 3). It may be difficult to identify in obese patients with  excessive retroperitoneal fat. If one cannot identify the left adrenal, it is usu-  ally because the operative field is too caudad and more superior dissection is  needed. In these cases, identifying the left renal vein will allow the identifica-  tion of the left adrenal vein that may be traced to the adrenal gland (figure 3).  It is usually necessary to place a retractor device under Gerota’s fascia and the  tail of the pancreas in order to expose the operative field (figure 3).   Once the gland is identified, dissection is begun with the ultrasonic  device along the inferior pole working medially. T e adrenal vein is dis-  sected with a Maryland dissector so as to visualize its entire circumference.  It is doubly clipped on the patient side using a 5-mm clip applier (figure 4).  T e vein is cut sharply leaving a longer stump on the renal vein side. T e  ultrasonic device is used to dissect around the adrenal gland beginning  medially. Clips may be used to secure prominent blood vessels (figures 5  and 6). T e ultrasonic dissector effectively seals small arterial vessels that enter  the adrenal gland like the spokes of a wheel. In some patients it is necessary to  dissect the entire lateral border of the adrenal gland in order to mobilize it and  retract the gland superiorly, thus permitting identification of the adrenal vein.  T einferior attachments are divided. Finally, the avascular lateral and superior  attachments are dissected (figure 7). T e gland is now free for extraction in a  laparoscopic retrieval bag (figure 8). T e technique for extraction is described  under laparoscopic right adrenalectomy (see Chapter 119, page 458).   T e tumor bed is then inspected for any evidence of bleeding and any addi-  tional hemostasis obtained. T e retraction on the pancreas is released and it is  returned to its normal position.    Posto PeratlIve care If the patient does not have a pheochromocy-  toma, the orogastric tube and Foley catheter are removed in the postoperative  recovery area. Intravenous fuids are administered and a clear liquid diet is  ordered. Vital signs are monitored every 4 hours. T e hemoglobin is checked  on postoperative day land the diet advanced. T e patient is discharged on post-  operative days | to 3. If the patient has a pheochromocytoma, the patient may  need to be in the ICU. Monitoring of urinary output with a urinary Foley cath-  eter is required. In addition, blood pressure is monitored with an arterial line.  T e patient is transferred from the ICU when stable and the diet advanced.  For patients with a functional tumor, discussion with the endocrinologist about  resumption of preoperative medications is helpful. =    PosItIon A vacuum-assisted beanbag should be placed on the operating  table prior to bringing the patient into the room. T e patient is positioned  with the bag being at the level of their flank below the ribs and above the  iliac crest over the break position of the table so as to allow a “jack knife”  extension that may be useful in obese patients.   For a right adrenalectomy the patient is placed in the right lateral posi-  tion with the right arm crossing the chest and supported on an arm board  (figure la). T e left arm is placed on an arm board and an axillary roll  used. In general the left and right positions are mirror images of each other.  After the patient is positioned, the air is suctioned from the beanbag in  order to secure the position. In addition, the patient is secured across the  chest and hips to the table with wide adhesive tape, as the operating room  table will be tilted. Some surgeons may prefer to improve tape adhesion  with a skin preparation.    IncIslon and exPosure For aright adrenalectomy the surgeon stands  on the patient’ left side (figure la). T e camera operator stands to the sur-  geons left or right and the assistant on the patient’ right. A 10-mm 30-degree  laparoscope is inserted using the aforementioned technique either in a supra-  umbilical position or the right lateral subcostal position in the midclavicular  line just above the level of the umbilicus. A 5-mm port is placed in the right  lateral subcostal area in the anterior axillary line and another 5-mm port is  placed just to the right of the midline and the right of the round ligament. A  third 5-mm port is placed on the right side in the anterior axillary line mid-  way between the costal margin and the iliac crest (figure lb). Additional  ports or larger ports may be placed depending on the preference of the sur-  geon, the size of the tumor, and the shape and size of the patient. T e patient  is then placed in a reverse Trendelenburg (head-up) position.    detalls of the Procedure On the right side, the hepatic flexure of  the colon is mobilized from the lateral gutter using the ultrasonic device.  Any adhesions about the lateral liver or even the gallbladder may need to  be incised with sharp dissection (figure 2). A Kocher maneuver is done  to expose the inferior vena cava in its position directly posterior to the  second portion of the duodenum and possibly the right renal vein as it is  essential to know the location of these structures before entering Gerota’  fascia (figure 3). T e right lobe of the liver should be mobilized by divid-  ing posterior and lateral attachments until the diaphragm is exposed so as  to gain a better exposure of the right adrenal (figures 2 and 3). A retrac-  tor is placed to hold the liver superomedially (figures 2 and 3). T 1s may  require an additional port—either a 5-mm or a 10-mm one depending upon  which retractor device is used. T e peritoneum lateral to the duodenum is    then incised, and it is mobilized in the usual Kocher maneuver manner by  using a blunt tip dissector or the ultrasonic device (figure 3). T is area is  then incised, and the duodenum is mobilized to show the right renal vein.  Gerota’ fascia is incised and the superior pole of the right kidney 1s located  (figure 3). T e adrenal is identif ed by its characteristic yellowish color,  lobulated appearance, and its clearly def nable blunt lateral edge.   T e surgeon should bear in mind that the vascular attachments are usu-  ally on or near the medial and superior edges of the gland rather than on  its broad surfaces (as shown in Chapter 117, page 453). After mitial lateral  and inferior mobilization, the adrenal gland may be retracted laterally.  It 1s essential to identify the inferior vena cava (figure 4) and then the  right adrenal vein. T e right adrenal vein is identif ed and doubly clipped  proximally and distally using a 5-mm clip applier and divided (figures 4  and 5). T e superior attachments of the adrenal gland are then divided and  the superior arterial supply clipped or coagulated freeing the gland. Next  the inferior portion of the gland is further dissected exposing the adrenal  artery arising from the right renal artery. T isis doubly clipped (figure 6).  T e generally avascular lateral area is then incised and additional exposure  and mobility of the adrenal gland may be obtained by gentle blunt dissec-  tion directly posterior and lateral to the gland (figure 7). T e suction tip  is an excellent tool for this blunt dissection. T e gland should be free at this  point for extraction (figure 8). T e tumor bed is inspected for bleeding  and any additional hemostasis obtained.    extractlon of the adrenal Gland T e same technique is used  to remove either the right or the left gland from the peritoneal cavity. T e  10-mm laparoscope is removed, and the video camera is mounted on a  5-mm laparoscope. T is is inserted through the most inferior 5-mm trocar.  A clear plastic specimen retrieval bag device is inserted into the peritoneal  cavity through the 10-mm Hasson port. T e bag is opened and the adrenal  gland is grasped by some periadrenal fat or connective tissue. T e gland  is delivered into the bag (figure 8). T e bag is closed and separated from  its insertion device. Using gentle traction, the bag with the adrenal gland  is pulled from the abdominal cavity through the Hasson insertion site. T e  incision may need to be enlarged for larger tumors. It is not necessary to  fragment the adrenal gland into pieces as it is soft and pliable, permitting  it to be removed through a relatively small opening. T e camera is then  placed back on the 10-mm laparoscope and the bed of the adrenal gland is  irrigated and inspected for bleeding, which may be controlled by electro-  cautery, the harmonic scalpel, or clips.    closure T e Hasson trocar site is closed with interrupted absorbable  sutures. In the patient with hypercortisolism, nonabsorbable sutures may  be necessary. For Hasson incisions in the lateral abdomen or flank, the use  of a T ompson closure device may be helpful. T e skin is closed with sub-  cuticular absorbable sutures or staples.    Posto PeratlIve care T e general principles are the same as those for  open adrenalectomy and those specif to laparoscopic adrenalectomy are  described in the section on laparoscopic left adrenalectomy (see Chapter  118). =    IndIcatlIons Tracheotomy is performed for two groups of patients. T e  first group comprises those with an obstruction of the airway at or above  the level of the larynx. Such obstruction may result acutely from laryngeal  tumors, edema, fracture, foreign bodies, burns about the oropharynx, or  severe throat and neck infections.   T esecond group consists of patients with chronic or long-term respira-  tory problems. Inability to cough out tracheobronchial secretions in para-  lyzed or weakened patients may be an indication for tracheotomy, which  allows frequent and easy endotracheal suctioning. T is group of patients  includes those with prolonged unconsciousness after drug intoxication,  head injury, or brain surgery and those with bulbar or thoracic paralysis,  as in poliomyelitis. To this group are added patients with general debility,  especially in the presence of pulmonary infection or abdominal distention,  where a temporary course of respiratory support with an endotracheal tube  and mechanical ventilator for 10 to 14 days must be converted into a longer  course of pulmonary assistance. In these patients inability to maintain an  adequate gas exchange or oxygen or carbon dioxide may dictate conver-  sion of the endotracheal tube to a tracheotomy tube. Frequently, checks  of arterial blood gases will reveal hypoxemia or hypercarbia, while simple  measurements of vital capacity and negative inspiratory force will detect  insufficient respiratory muscular effort. T ese tests are important in the  decision to continue tracheal intubation with ventilator assistance. Other  candidates for tracheotomy may include patients undergoing major opera-  tive or radical resections of the mouth, jaw, or larynx, where this procedure  often is done as a precautionary measure. Antibiotics may be indicated.    anestheslIa In cooperative patients, in both elective and emergency situ-  ations, local infiltration anesthesia is preferred. In patients who are comatose  or are choking, no anesthesia may be necessary or possible. Because it helps to  ensure a good airway during tracheotomy, endotracheal intubation is especially  useful in patients whose laryngeal airway is very poor and who may obstruct  at any moment. It is also an aid in palpating the small, soft trachea of infants.    PosItlIon A sandbag or folded sheet under the shoulders helps extend  the neck (figure 1), as does lowering the head rest of the operating table.  T echin is positioned carefully in the midline.    o Perat Ive PreParatlIon In emergency tracheotomy, sterile prepa-  ration is either greatly abbreviated or omitted entirely. In routine trache-  otomy, a sterile field is prepared in the usual manner.    IncIslon and exPosure Emergency tracheotomy is done when there  is no time to prepare for a routine tracheotomy. T ere may be no sterile  surgical instruments available and no assistants.   An emergency airway is made by a transverse cut or stab through the  cricothyroid membrane. Here the airway is immediately subcutaneous, yet  the level is still under the vocal cords (figure 2). T e wound is held open  by twisting the handle of the knife blade in the wound. Later, with the air-  way ensured, the patient is removed to the operating room and a routine  tracheotomy is done.    IncIslon and exPosure A transverse incision is most commonly  used. It is made at roughly the midpoint between the notch and the thyroid  cartilage. T e procedure is demonstrated with a vertical incision which is  made in the midline of the neck from the middle of the thyroid cartilage  to just above the suprasternal notch (figure 3). T e skin, subcutaneous  tissues, and strap muscles are retracted laterally to expose the thyroid isth-  mus (figures 4 and 5). T e isthmus may be either divided and ligated or  retracted upward after the pretracheal fascia is cut. Usually, upward retrac-  tion is the better method.   After the cricoid cartilage is identified (figur e 6), the trachea is opened  vertically through its third and fourth rings (figures 7 and 8). In order  to facilitate insertion of the tracheotomy tube, either a cruciate incision is  made or a very narrow segment of one ring may be removed (figure 9).  T e transverse incision, preferred by some surgeons for cosmetic reasons,  is more time-consuming. T e difference in the final cosmetic result is neg-  ligible, since it is the tube and not the incision that causes scarring.    detalls of Procedure A tracheal hook is used to pull up the trachea  and steady it for incision (figure 9). Great care must be taken not to cut  through the trachea too deeply, since the posterior wall of the trachea is also  the anterior wall of the esophagus.   After the trachea has been incised, a previously selected tracheotomy  tube is inserted. A No. 6 tube is ordinarily suitable for an adult male and a  No. 5 or 6 tube for an adult female. Correspondingly smaller tubes are used  in children and infants. T e trachea of a newborn will accept only a No. 00  or 0 tube. T e assistant must be careful to keep the tube in the trachea by  holding one finger on the f ange; otherwise the patient may cough it out.  Plastic endotracheal tubes with an inf atable cuff usually of the size similar  to oral intubation are used.    closure Closure should be loose to prevent subcutaneous emphysema.  Only skin sutures are used. Ties hold the tube in place (figure 10). A  dressing is made by cutting a surgical gauze and pulling the gauze under  the f ange of the tube.    Posto PeratIve care Special and frequent attention is very desirable  in the first few postoperative days. T e inner tube must be cleaned every  hour or two; otherwise it may block off with accumulated secretions. After  a tract has formed, usually in 2 or 3 days, the outer tube may be removed,  cleaned, and replaced. Even then, however, the tube should be replaced rap-  idly, since the stoma constricts sufficiently in only 15 or 20 minutes to make  replacement difficult. An obturator is provided with each tracheotomy tube  to make insertion of the outer tube easier. T ere must always be a duplicate  tracheal tube at the patient’ bedside.   Suctioning of the trachea is done as needed. In the alert patient who can  cough, suctioning may not be needed at all; but in the comatose patient  suctioning may be required every 15 minutes. It 1s essential that moisture be  added to the air, since the nasal chambers are bypassed and the usual means  by which the body moistens the air are lost. T is can be accomplished by  the use of aerosol bubblers or ultrasonic nebulizers.   Blood gases and blood pH should be monitored frequently until stable  and satisfactory levels have been attained. m    IndIcatlIons Indications for percutaneous dilational tracheotomy  (PDT) are similar to those for open tracheotomy (OT) and include provid-  ing a portal for pulmonary toilet in debilitated patients or patients with  neuromuscular disease, and providing a means for prolonged ventilatory  support. Similar to OT, PDT should be considered in patients requiring  mechanical ventilation 7 to 10 days following initial intubation. If pro-  longed intubation is expected based on patient circumstances (high spinal  cord or traumatic brain injury), earlier tracheotomy may be considered.   Advantages of PDT over a prolonged translaryngeal intubation include  a reduced risk of direct endolaryngeal injury, decreased risk of ventilator-  associated pneumonia (VAP), more effective pulmonary toilet, increased  airway security and ease in weaning from mechanical ventilation, improved  patient comfort with decreased requirements for sedation, and earlier dis-  charge from the intensive care unit (ICU). In suitable patients, the major  advantage of PDT to OT is that it is performed as a bedside procedure,  obviating the need for operating room time and patient transport, as well  as being significantly more cost effective.   When evaluating a patient for PDT, a thorough history and physical  examination will identify anatomic contraindications, including previous  difficult tracheal intubation, morbid obesity, obscure cervical anatomy, goi-  ter, short thick neck, previous neck surgery (especially tracheotomy), cervi-  cal infection, facial or cervical trauma/fractures, halo traction, or known  presence of subglottic stenosis. Physiologic contraindications to PDT  include hemodynamic instability, requirement of FiO, > 0.60, a positive  end-expiratory pressure (PEEP) > 10 cm H,O, or uncontrolled coagulopa-  thy. Cervical deformity, previous radiation therapy, edema, or tumor can  also make tracheal cannulation difficult and increase the risk of morbidity.  T e need for emergency control of the airway is an absolute contraindica-  tion to PDT.   Complications of PDT include injury to posterior tracheal wall resulting  in a tracheoesophageal fistula, injury to cupula of lung with pneumothorax,  tracheal ring rupture, recurrent laryngeal nerve injury, paratracheal inser-  tion, tube dislodgement with loss of airway, stomal hemorrhage, peristomal  cellulitis, subglottic or tracheal stenosis, or a tracheoinnominate fistula. A  guidewire placed too deep in the trachea during the procedure can poten-  tially cause bronchoconstriction or lung injury.    Preo PeratlIve PreParatlIon Several components are required for  PDT placement, and these include bronchoscope, medications, tracheot-  omy insertion kit, and tracheotomy tube. Kits are available for either the  single or the serial dilator technique, and either a standard or a percutane-  ous tracheotomy tube may be used. T e tube cuff must be checked for leaks  and then be well lubricated prior to placement. We recommend that the  operator develop a materials checklist to facilitate gathering of the critical  components prior to the procedure.    anestheslIa A three-drug regimen including sedative, analgesic, and  nondepolarizing muscle relaxant agents facilitates placement. It 1s impor-  tant to maintain immobility during insertion of the introducer needle,  guidewire, dilators, and tracheotomy tube to prevent inadvertent puncture    of the posterior tracheal wall. Direct manipulation of the trachea (particu-  larly during dilation) is cough provoking, thus the recommendation for  paralytics.    PosItIon Positioning is aided with a shoulder roll to allow maximal  extension of the neck during the procedure. Neck extension elevates the  trachea out of the mediastinum and displaces the chin to allow greater  access to the anterior neck. T e palpable anatomic landmarks are shown in  figure |. T e exposed neck can then be prepped with a standard surgical  scrub and sterile drapes applied.    o Perat Ive PreParatlon T e procedure requires two operators: one  performing the tracheotomy and the second providing tracheal visualiza-  tion with flexible fiberoptic bronchoscopy. Identification and transillumi-  nation of the area between the second to fourth tracheal rings with visual  confirmation of proper tracheotomy tube positioning improves success  in patients with poorly palpable surface anatomy. A respiratory therapist  maintains the endotracheal tube (ETT) position and ventilation with 100%  oxygen. Af er all equipment is gathered, the correct level of placement of  the ETT being used for control of ventilation is verified by passing a fiber-  optic bronchoscope into the trachea by way of a special anesthesia adapter  (figure 2). T eskin is prepped with an antiseptic, and a sterile draping is  done.    IncIslon and exPosure T e tracheotomy is performed between  the second and fourth tracheal rings. Placing the tracheotomy tube above  this level may result in injury to the first ring or cricoid cartilage, which  increases the risk of subglottic stenosis or bleeding from the thyroid isth-  mus. Placing it too low can predispose to tracheoinnominate fistula. A point  midway between the cricoid cartilage and the sternal notch is palpated and  marked. Local anesthesia 1s infiltrated in the skin and subcutaneous tissues,  as well as into the trachea (figur e 3). A vertical skin incision is made in the  midline from the level of the cricoid cartilage and extending 1.0 to 15cm  downward.   T e second or third tracheal interspace is visualized in preparation for  the tracheotomy.    detalls of Procedure T e ETT should be withdrawn to 1 cm above  the anticipated needle insertion site under bronchoscopic or transillumination  guidance. In average-sized adults, the tube can be withdrawn to about the  17-cm mark at the teeth. T e bronchoscope can show indentation of the  trachea with palpation, locating the tracheotomy site. A 17-gauge sheathed  introducer needle is then advanced in the midline, angling posterior and  caudad (figure 4). Aspiration with an attached syringe containing a small  amount of water will indicate when the tracheal wall has been punctured.  Puncture of the trachea is confirmed bronchoscopically to ensure midline  needle placement (figure 4). T e stylet or needle is removed leaving the  outer cannula in the trachea. T e “J’-tip guidewire is advanced through  the cannula into the trachea toward the carina (figure 5). Afer cannula  removal, a short 14-French mini-dilator is advanced over the guidewire  using a slight twisting motion and then removed (figure 6).    detalls of Procedure For the single dilator systems,  activate the coating by immersing the distal end of the dilator in ster-  ile water or saline. Slide the dilator up to the safety ridge on the guiding  catheter, then with concurrent bronchoscopic visualization, advance the  dilator assembly using the Seldinger technique over the guidewire into the  trachea. Af er passage to the appropriate depth (marked on the dilator), it  is withdrawn and advanced several times to dilate the tract (figure 8). For  multiple dilator systems, serial dilation is performed with incrementally  larger dilators (figures 7 and 8).   T e lubricated tracheotomy tube (loaded on a dilator/guiding catheter  unit) is then advanced over the guidewire into the trachea (figure 9).  T e guidewire and dilator are then removed, leaving the tracheotomy  tube in place. T e cuff of the tracheotomy tube 1s inflated and the inner  cannula inserted. T e ventilator tubing or an Ambu bag device is discon-  nected from the ETT and attached to the PDT tube (figure 10). Te  translaryngeal ETT is not removed until correct intratracheal placement  of the tracheotomy tube has been confirmed visually by bronchoscopy  (figure 10).    closure T eincision 1s typically just large enough to accommodate the tra-  cheotomy tube and does not require closure. Nonabsorbable suture is used to  secure the tracheotomy cuff to the skin and securing tapes are placed to hold  the PDT tube in place usually over a dry sterile gauze dressing (figure 11).    Posto PeratlIve care A chest x-ray is ordered to confirm tracheotomy  tube position and evaluate for pneumothorax or pneumomediastinum. Elevate  the head of the patient’ bed 30 to 40 degrees immediately following the pro-  cedure and suction any bloody secretions. T e tracheal tapes and cuff sutures  should not be removed until the first tracheotomy tube change. Ideally, the  first tube change should not be attempted until the tract has matured, which  requires at least 7 to 10 days. If accidental decannulation occurs within the first  7 days of PDT, an oral ETT should be placed instead of attempting reinsertion  of the tracheotomy tube through the stoma. Dislodgement of a tracheotomy  tube that has been in place 2 weeks or longer can of en be managed simply by  replacing the tube through the mature tract. Humidification and frequent tra-  cheal suctioning is recommended to prevent inspissation of secretions, which  can result in mucous plugging and tracheotomy tube obstruction. m    IndIcatlIons T ere are two major indications for radical neck dissec-  tion. T e first is for the removal of palpable metastatic cervical lymph nodes,  and the second is for the removal of presumed occult metastatic disease in  the neck. T e latter indication has been termed “prophylactic neck dissec-  tion:’ “Elective neck dissection’ better describes this operation, since it is not  intended to prevent metastasis but to remove occult metastatic lymph nodes.   Before radical neck dissection is performed, the surgeon must have  assurance that the primary lesion can be controlled either by simultaneous  en bloc removal with the radical neck dissection or by radiation therapy.  However, curative radiation for cervical metastases must be confined to a  single node or small group of nodes, because patients cannot tolerate radi-  cal surgery plus radiation therapy to the entire neck. Node fixation, inva-  sion of adjacent tissues, bilateral or contralateral, and distant metastases are  relative contraindications to this procedure. In general, radical dissection  of the cervical lymph nodes in a patient who is a reasonable surgical risk  remains the preferred treatment for metastatic disease of the neck.   T e usual patient with metastatic cancer in the neck from an unknown  primary source should be treated as if the primary tumor were controlled.  If surgical treatment of the cervical metastasis is deferred until the primary  neoplasm becomes obvious, the opportunity to control the neck disease is  sometimes lost.    Preo PeratIve PreParatlon T e patient’S general medical status  should be assessed and corrective measures instituted for any treatable  abnormalities. Intraoral ulcerations represent a potential source of patho-  genic material. T e liberal preoperative use of nonirritating solutions (e.g.,  diluted hydrogen peroxide) can significantly reduce the danger of postop-  erative infection.   Only rarely will primary cancers of the hypopharynx, cervical esopha-  gus, larynx, and so forth produce respiratory obstruction or interference  with alimentation significantly enough to require preoperative tracheos-  tomy or insertion of a feeding tube.    anesthesla T e major consideration is a free airway. T e equipment  should allow free movement of the head and easy access to the endotra-  cheal tube.   T e choice of anesthetic agents varies. Consideration must be given to  the individual needs of the patient and to the need for cautery. General  endotracheal anesthesia is preferred.   Complications at surgery are the carotid sinus syndrome, pneumothorax,  and air embolus. T e carotid sinus syndrome, consisting of hypotension,  bradycardia, and cardiac irregularity, can usually be corrected by infiltrating  the carotid sinus with a local anesthetic agent. Intravenous atropine sulfate  will usually control the syndrome if the local anesthetic fails. Pheumothorax  may result from injury of the apical pleura. It is treated with a closed-tube  thoracostomy through the second intercostal space anteriorly.    PosIt Ion T e patient is placed in a dorsal recumbent position. T e head  of the table is somewhat elevated to lessen the blood pressure, particularly  the venous pressure, in the head and neck and thus reduce blood loss. T e  bend of the neck should be placed on the hinge of the headpiece so that the  head may be either flexed or extended as needed. A small sandbag should  be placed under the shoulders so that the head and neck are extended while  the chin remains on a plane horizontal with the shoulders.    oPeratiIve PreParatlon T e patient’ hair should be completely  covered by a snug gauze cap to avoid contamination of the operative field.  Once the patient has been correctly positioned on the table, the skin is pre-  pared routinely. T e preparation should include a large portion of the face  on the side of the dissection, the neck from the midline posteriorly to the    sternocleidomastoid muscle of the opposite side of the neck, and the ante-  rior chest wall down to the nipple. T e entire field of dissection is outlined  with sterile towels secured by either skin staples or sutures. A large sheet  about the head and neck area completes the draping.    IncIslon and exPosure Radical neck dissection is described and  illustrated. Radical neck dissection refers to the removal of all ipsilateral  cervical lymph node groups extending from the inferior border of the  mandible superiorly to the clavicle inferiorly and from the lateral border of  the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the  digastric muscle anteriorly to the anterior border of the trapezius muscle  posteriorly. Today most surgeons employ a modified radical neck dissec-  tion or functional neck dissection.   Modified radical neck dissection is defined as the excision of all lymph  nodes routinely removed in a radical neck dissection with preservation of  one or more nonlymphatic structures (spinal accessory nerve, internal jug-  ular vein, and sternocleidomastoid muscle).   T e surgeon stands on the side of the proposed dissection. Many types  of incision have been used. T e incision illustrated allows maximum ana-  tomic visualization, whereas many surgeons prefer two nearly parallel,  oblique incisions with an intervening skin bridge that is broadly based at  both ends. T e most useful incision is a modification of the double trifur-  cate incision (figure 1), in which the angles of the skin flaps are obtuse and  connected by a short vertical incision. Some prefer to make only the upper  transverse incision with a single vertical extension that proceeds to the ster-  nocleidomastoid muscle edge and then takes a lazy-S posterior course to  the clavicle, as shown by the dashed line in figure |. T e upper arm of the  double Y extends from the mastoid process to just below the midline of  the mandible. T e lower arm extends from the trapezius in a gentle curve  to the midline of the neck. T is incision allows the greatest exposure of  the neck area while producing a good cosmetic result. Creation of the skin  flaps includes the platysma muscle (figur e 2). In most instances, if the skin  flaps are developed without inclusion of the platysma muscle, poor wound  healing and uncomfortable scarring with fixation of the skin to the deep  neck structures will result. T e two lateral skin flaps are turned back, the  posterior flap 1s extended as far as the anterior edge of the trapezius muscle,  and the anterolateral flap is extended to expose the strap muscles covering  the thyroid gland. In developing the superior skin flap, care must be taken  to preserve the mandibular marginal branch of the facial nerve (figure 2).  T is branch of the facial nerve innervates the lower lip. In the majority of  cases the nerve can be identified as it crosses over the external maxillary  artery and the anterior facial vein beneath the platysma muscle. Usually,  it lies parallel to the lower border of the mandible. Occasionally, the nerve  will lie much higher, and it may not be visualized during the neck dissec-  tion. As suggested by others, a useful maneuver to preserve this nerve is to  identify the external maxillary artery and the anterior facial vein at least  lcm below the lower border of the mandible (figure 2). After identifica-  tion, the nerve is retracted and covered by securing the upper end of the  vascular stump to the platysma muscle. If obvious or strongly suspected  tumor is present in this area, the branches of this nerve are sacrificed volun-  tarily. T e inferior skin flap should be reflected down to expose the superior  aspect of the clavicle.    detalls of Procedure Once the four skin flaps have been created,  the inferior limits are outlined. T e sternocleidomastoid muscle is severed  just above its insertion into the clavicle and the sternum (figure 3). T e  dissection is then shifted to the posterior cervical triangle. Using both sharp  and blunt dissection, the surgeon exposes the anterior border of the trapezius    detalls of Procedure As one approaches the most pos-  teroinferior angle of the neck dissection, the first important structure to be  seen is the external jugular vein. It is ligated and divided at the posteroinfe-  rior corner (figure 5).T en the posterior cervical triangle can be completely  cleaned of its areolar and lymphatic tissues. T e spinal accessory nerve should  be preserved as long as it is not involved with tumor or enlarged lymph nodes.  T e spinal accessory nerve must be divided (figure 6) if clean dissection  of this area 1s impossible. Dissection 1s carried forward along the superior  aspects of the clavicle. T e posterior belly of the omohyoid muscle and the  transverse cervical artery and vein are visualized (figure 6). T e posterior  belly of the omohyoid muscle is severed (figur e 7) in order to allow greater  exposure of the deep muscles and the brachial plexus. T e phrenic nerve is  found lying upon the anterior scalene muscle between the brachial plexus  and the internal jugular vein (figure 8a). To avoid paralysis of the corre-  sponding leaf of the diaphragm, this nerve should be preserved unless it has    been invaded by the cancer. T e phrenic nerve lies upon the scalenus anti-  cus muscle. Its exposure has been facilitated by the previous transection of  the lower end of the sternocleidomastoid muscle. Just medial to the phrenic  nerve, the internal jugular vein 1s seen (figure 8a). T 1s vessel, which lies  within the carotid sheath (figure 8b), is dissected free (figure 9), doubly  ligated by a stick tie on the inferior ligation, and then divided (figure 10).  By division of the internal jugular vein, avoiding the thoracic duct on the left  side, the dissection has been carried down to the prevertebral fascia overlying  the deep muscle structures of the neck. T e inferior compartment of the neck  is then outlined medially by division of the pretracheal fascia just lateral to  the strap muscles of the thyroid (figure 11). T 1s facilitates exposure of the  common carotid artery, which permits the dissection to be carried superi-  orly. With the lateral limits of the dissection defined and the common carotid  artery exposed, dissection is started inferiorly and extended superiorly,  following the floor of the neck or the prevertebral fascia.    detalls of Procedure T is dissection consists of turn-  ing up the areolar and lymphoid tissues of the neck lying along the course  of the internal jugular vein, which 1s reflected upward with these struc-  tures (figure 12). All loose areolar tissue about the carotid artery 1s com-  pletely removed. T is dissection may be carried out without danger to any  of the vital structures, since both the vagus nerve and the common carotid  artery are in full view and the other important nerve structures—namely,  the phrenic nerve and the brachial plexus—are covered by the prevertebral  fascia (figure 12). As the dissection proceeds superiorly, branches of the  cervical plexus are seen penetrating the fascia; they should be divided as  they emerge through the fascia.   In the anterior part of this phase of the dissection, tributaries of the  superior thyroid, superior laryngeal, and pharyngeal veins are seen as they  cross the operative field to enter the jugular vein. T ese may be ligated as  the dissection proceeds. T e carotid bifurcation can usually be identified by  the appearance of the superior thyroid artery (figure 12). With reasonable  care this vessel can be preserved. After exposure of the bifurcation, dis-  section proceeds superiorly with some caution to expose the hypoglossal  nerve as it crosses both the internal and external carotid arteries 1cm or so  above the carotid bifurcation (figure 12). T e surgeon should watch for  this nerve as it emerges deep to the posterior belly of the digastric muscle.    T e hypoglossal nerve continues forward into the submaxillary triangle,  where it lies inferior to the main submaxillary salivary duct.   After identification of the hypoglossal nerve, attention should be directed  to the submental area of the neck. T e fascia from the midline of the neck  is divided (figure 13). T 1s facilitates exposure of the anterior belly of the  digastric muscle and the underlying mylohyoid muscle. Complete expo-  sure of the digastric muscle in the submental compartment is necessary to  remove the paired submental nodes (figures 13 and 14). By following the  anterior digastric muscle from anterior to posterior, the submaxillary gland  is exposed. T e submaxillary gland is dissected from its bed by approach-  ing the gland anteriorly (figure 15). By mobilizing the gland from its bed  from anterior to posterior, the lingual nerve, which lies in the most superior  aspect of the submaxillary space, the submaxillary duct, which lies in the  midportion of the compartment, and the hypoglossal nerve, which lies in  the most inferior aspect of the area, are identified (figure 16). T is expo-  sure may be eased by traction on the submaxillary gland with a tenaculum.  T is allows the surgeon to visualize the posterior edge of the mylohyoid  muscle and to retract this muscle anteriorly (figure 16), thereby expos-  ing the three important structures: the lingual nerve, the salivary duct, and  the hypoglossal nerve. To facilitate removal of the submaxillary gland, the  major salivary duct is divided and ligated.    detalls of Procedure T e anterior belly of the omohy-  oid muscle is divided from the sling of the digastric muscles; the dissec-  tion can then be completed after the posterior belly of the digastric muscle  is exposed (figure 17). Retraction of the posterior belly of the digastric  superiorly exposes the internal jugular vein for clamping and division  (figure 18). Retraction of the posterior belly of the digastric muscle also  allows complete exposure of the hypoglossal nerve (figure 18). T e internal  jugular vein must be clamped high, since the upper limit of the internal jugu-  lar chain of lymphatics is one of the most common areas for metastatic cancer  in the neck. To ensure that it has been divided high, the tail of the parotid  (figure 19) is sacrificed as the complete surgical specimen 1s excised. If  extensive node involvement is present in the upper jugular chain of lym-  phatics, additional exposure can be obtained by total division of the poste-  rior belly and its subsequent total removal. T e dissection is completed with  the division of the sternocleidomastoid muscle at the mastoid process.    closure Hemostasis is secured in all areas of the neck. T e platysma is  closed using interrupted 0000 sutures. T e skin is approximated with inter-  rupted 0000 subcutaneous nonabsorbable sutures. Before closure of the pla-  tysma and the skin, closed-suction Silastic catheters are placed beneath both  the anterior and posterior skin flaps and connected to suction (figure 20).  T e placement of the catheters is important to ensure complete removal  of fluid from beneath the flaps and to eliminate dead space in the area of    dissection. A vacuum-type suction source can be attached to the patient,  thus permitting early ambulation. Such catheters have eliminated bulky  and uncomfortable pressure dressings.    Posto PeratIvecare T e patient is placed immediately in a sem1-sit-  ting position to reduce venous pressure within the neck. Oxygen therapy is  administered at 4 to 5 L/min until the patient has reacted. T e most imme-  diate danger is airway obstruction, especially when the neck dissection has  been combined with an intraoral resection. Elective tracheostomy is done  when either radical neck dissection is combined with removal of a por-  tion of the mandible or the patient has had significant intraoral excision.  If tracheostomy has not been performed, it is advisable to have a sterile  tracheostomy set at the bedside.   Another early complication is hemorrhage. T e wound should be  inspected frequently for such a dif culty. Only moderate analgesia is  necessary to control the patient’ pain, since the operative site has been  almost completely denervated by division of the cervical cutaneous nerves.  Excessive sedation is unwise owing to the danger of asphyxia by airway  obstruction.   T esuction catheters can usually be removed by the fourth or fifth post-  operative day.   Tube feedings are necessary only in those patients who have had a com-  bined neck dissection with intraoral dissection. m    IndIcatIons T e indications for repairing Zenker’ diverticulum are  partial obstruction, dysphagia, a choking sensation, pain on swallowing,  or coughing spells associated with aspirations of fluid from the diverticu-  lum. T e diagnosis is confirmed by a barium swallow. T e pouch appears  suspended by a narrow neck from the esophagus. Zenker’s diverticulum is  a hernia of mucosa through a weak point located in the midline of the pos-  terior wall of the esophagus where the inferior constrictors of the pharynx  meet the cricopharyngeal muscle (figure 1). T eneck of the diverticulum  arises just above the cricopharyngeal muscle, lies behind the esophagus,  and usually projects left of midline. Swallowed barium collects and remains  in the herniated mucosa of the esophagus. T e procedure described is an  open technique and should be applied when a peroral stapling technique 1s  not feasible. T e open approach has the advantage of complete removal of  the pouch with a low chance of recurrence. Furthermore, it provides a his-  tological specimen to exclude carcinoma within the pouch. It may be use-  ful in treating small pouches, with cricopharyngeal myotomy alone, which  cannot be treated endoscopically. Disadvantages of the open procedure  consist of a longer hospital stay and significant complications including  recurrent laryngeal nerve injury and pharyngeal leak with mediastinitis.    Preo Perat Ive PreParatlIon T e patient should be on a clear liquid  diet for several days before operation. He or she should gargle with an anti-  septic mouthwash. Antibiotic therapy may be initiated.    anesthesIa Endotracheal anesthesia is preferred through a cuffed  endotracheal tube that is inflated to prevent any aspiration of material from  the diverticulum. If general anesthesia is contraindicated, the operation can  be performed under local or regional infiltration.    PosltlIon T e patient is placed in a semi-erect position with a folded  sheet under the shoulders. T e head is angulated backward (figure 2).T e  chin may be turned toward the right side if the surgeon wishes.    o Perat Ive PreParatlon T e patient’ hair is covered with a snug  gauze or mesh cap to avoid contamination of the field. T e skin 1s prepared  routinely, and the line of incision is marked along the anterior border of the  sternocleidomastoid muscle, centered at the level of the thyroid cartilage  (figure 2). Skin towels may be eliminated by using a sterile adherent trans-  parent plastic drape. A large sterile sheet with an oval opening completes  the draping.    IncIslon and exPosure T esurgeon stands on the patient’ left side.  He or she should be thoroughly familiar with the anatomy of the neck and  aware that a sensory branch of the cervical plexus, the cervical cutaneous  nerve, crosses the incision 2 or 3 cm below the angle of the jaw (figure 3).  T esurgeon applies firm pressure over the sternocleidomastoid muscle with  a gauze sponge. T e first assistant applies similar pressure on the opposite  side. T e incision is made through the skin and platysma muscle along the  anterior border of the sternocleidomastoid muscle. Bleeding in the subcuta-  neous tissues 1s controlled by hemostats and ligation with fine 0000 sutures.    detalls of Procedure As the surgeon approaches the upper extent  of the wound, he or she must avoid dividing the cervical cutaneous nerve,  which lies in the superficial investing fascia (figure 3). T e sternocleido-  mastoid muscle is then retracted laterally and its fascial attachments along    the anterior border are divided. T e omohyoid muscle crosses the lower  portion of the incision and is divided between clamps (figure 4). Hemo-  stasis is obtained bya 00 ligature. T e inferior end of the omohyoid muscle is  retracted posteriorly, while the superior end isretracted medially(figur e 5).  As the middle cervical fascia investing the omohyoid and strap muscles  is divided in the upper portion of the wound, the superior thyroid artery  is exposed, divided between clamps, and ligated (figures 4 and 5). T e  cervical visceral fascia containing the thyroid gland, trachea, and esopha-  gus is entered medial to the carotid sheath. T e posterior surfaces of the  pharynx and esophagus are exposed by blunt dissection. T e diverticulum  is then usually easy to recognize unless inflammation is present, causes  adhesions to the surrounding structures (figures 6 and 7). If dif culty is  encountered in outlining the diverticulum, the anesthesiologist can pass a  rubber or plastic catheter down into it. Air is injected into this catheter to  distend the diverticulum. T e lower end of the diverticulum is freed from its  surrounding structures by blunt and sharp dissection, its neck is identified,  and its origin from the esophagus located (figur es 6 and 7). Special atten-  tion is given to the removal of all connective tissue surrounding the diver-  ticulum at its origin. T 1s area must be cleaned until there remains only the  mucosal herniation through the defect in the muscular wall between the  inferior constrictors of the pharynx and the cricopharyngeal muscle below.  T e cricopharyngeal muscle is divided (figure 8). T 1s 1s a critical por-  tion of the operation. Care must be taken not to divide the two recurrent  laryngeal nerves, which may lie on either side of the neck of the diverticu-  lum or in the tracheoesophageal groove, more anteriorly (figure 7). T e  NG tube is palpated in the esophagus and the diverticulum is pulled away  from the cervival esophagus (figure 8). A linear stapling device is applied  to the neck of the esophagus and closed with care taken not to narrow the  esophageal lumen (figure 9). T eneck of the diverticulum 1s divided with  the stapling device and the diverticulum removed (figure 10). A row of  horizontal sutures closes the muscular defect between the inferior constric-  tors of the pharynx and the cricopharyngeal muscle below. T ese muscles  are brought together by interrupted 0000 sutures (figure 10).    closure After thorough irrigation, careful hemostasis is obtained. A  small closed-suction Silastic drain may be placed, and the omohyoid is  rejoined with several interrupted sutures. T e platysma is reapproximated  with fine absorbable sutures, and 0000 nonabsorbable sutures are used to  close the skin in a subcutaneous manner. Adhesive skin strips and a light-  weight sterile gauze dressing are applied. T ese must not be circumferential  about the neck.    Posto PeratlIve care T e patient is kept in a semi-sitting position  and not allowed to swallow anything by mouth. Water and tube feedings  are provided through the nasogastric tube to maintain fluid and electrolyte  balance for the first 3 days. T e drain is removed on the second postopera-  tive day unless contraindicated by excessive serosanguineous drainage or  by saliva draining from the wound. T e nasogastric tube is removed on the  second or third postoperative day, and the patient is started on clear fluids.  T e diet is advanced as tolerated. T e patient is permitted out of bed on  the first postoperative day and may ambulate with the nasogastric tube in  place but clamped off. Antibiotic coverage is optional, depending upon the  amount of contamination. m    IndIcatIons Tumors are the most common indication for surgical  exploration of the parotid gland. Most are benign mixed tumors that arise  in the lateral lobe and are treated with wide excision, including a margin of  normal tissue to prevent local recurrence. Exploration of the parotid area  must include careful identification of the facial nerve and its branches, thus  avoiding the major complication of facial nerve palsy. Malignant tumors are  also seen and require a wide excision, which may include all or a portion  of the facial nerve if it is involved. Lesions of the medial lobe may neces-  sitate a total parotidectomy; a superficial parotidectomy is carried out first  to identify and preserve the facial nerve before the medial lobe is explored.    Preo Perat Ive PreParat Ion It 1s essential that all patients undergo-  ing parotid surgery be made aware of the possible loss of facial nerve func-  tion, with its resultant functional and cosmetic consequences. Men should  shave themselves early on the morning of surgery; the hair about the ear  may be cleared by the surgeon before draping.    anesthesIa Oral endotracheal anesthesia with a flexible coupling 1s uti-  lized so that the anesthesiologist may be located at the patient’ side, thus  giving the surgeon adequate room. A short-acting muscle relaxant should  be used for the endotracheal intubation. T is allows the surgeon to identify  motor nerves by direct stimulation (gentle pinch) during the dissection.    PosItlIon T e patient is positioned on his or her back, and the face is  turned to the side opposite the lesion. T e head and neck are placed in slight  extension, and the head of the table is elevated to reduce venous pressure in  the head and neck.    oPeratIve PreParatlon After appropriate skin preparation with  detergents and antiseptic solutions, sterile towel drapes are positioned to  allow visualization of the entire ipsilateral side of the face.    IncIslon and exPosure T e incision 1s carried in the crease immed1-  ately in front of the ear, around the lobule and up in the postauricular fold  (figure 1). It then curves posteriorly over the mastoid process and swings  smoothly down into the superior cervical crease. T e superior cervical crease  is located approximately 2 cm below the angle of the mandible. It should  be remembered that with the patient’ neck extended and head turned to the  side, the facial skin is pulled down onto the neck, and the incision should be  made low enough that when the patient’ head is returned to normal posi-  tion, the incision does not lie along the body of the mandible. No incisions  are made on the cheek itself. T e cervical-facial skin flap is then elevated  with sharp dissection to expose adequately the area of the tumor. T 1s eleva-  tion takes place to the anterior border of the masseter muscle. A traction  suture may be placed through the earlobe to hold this out of the operator’  visual field (figure 2). T emasseteric parotid fascia has then been exposed,  and the parotid gland can be seen within its capsule, bounded superiorly by  the cartilages of the ear, posteriorly by the sternocleidomastoid muscle, and  medially by the digastric and stylohyoid muscles.    detalls of Procedure T esurgeon must understand clearly the sur-  gical anatomy of the facial nerve. T e main trunk of the facial nerve emerges  from the stylomastoid foramen. It courses anteriorly and slightly inferiorly  between the mastoid process and the membranous portion of the external  auditory canal. T e main trunk of the nerve usually bifurcates into the tem-  porofacial and cervicofacial divisions after it enters the gland, but occasion-  ally this occurs before entrance. T e parotid gland is commonly described  as being divided into superficial and deep lobes, the nerve passing between  the two. T ese lobes are not anatomically distinct, because the separation 1s  defined by the location of the nerve, which actually passes directly through  the glandular parenchyma. T e cervicofacial division bifurcates into the  small platysmal or cervical branch and the marginal mandibular branch  at the inferior margin of the gland. T e latter courses within the platysma  muscle just inferior to the horizontal ramus of the mandible, where it inner-  vates the lower lip. Whereas most other branches of the facial nerve have  numerous cross-anastomoses, the marginal mandibular branch has none;  therefore division of this branch will always result in paralysis of half of the  lower lip. Identification of the marginal mandibular branch before the main  nerve trunk is defined is facilitated by the fact that 97% of the time it lies  superficial to the posterior facial vein.    T e buccal zygomatic division emerges from the anterior margin of the  gland with numerous filamentous branches that innervate the muscles of  facial expression, including the periorbital muscles and circumoral muscles  of the upper lip. T e temporal branch runs superiorly and innervates the  frontal muscles. T is branch has poor regenerative potential and no cross-  anastomosis; injury to it will lead to permanent paralysis of the frontalis  muscle.   T e safest way of identifying the facial nerve is to locate and expose the  main trunk. T e anterior border of the sternocleidomastoid muscle is iden-  tified, as are the posterior facial vein and the greater auricular nerve, in  the inferior portion of the incision (figures 2 and 3). T e capsule of the  parotid gland then is mobilized from the anterior border of the sternoclei-  domastoid muscle, and dissection is carried down in an area inferior and  posterior to the cartilaginous external auditory canal.   Several landmarks are utilized here in the search for the main trunk of  the facial nerve. T e sternocleidomastoid muscle is retracted posteriorly  and the parotid gland anteriorly. T e posterior belly of the digastric can  be visualized as it pushes up into its groove (figure 4), and the nerve lies  anterior to this. T e membranous portion of the canal is the superior land-  mark, and the nerve lies approximately 5 mm from the tip of this cartilage.  By using these landmarks as well as a Faradic stimulator or gentle mechani-  cal stimulation with forceps, the surgeon safely can locate the main trunk  of the nerve (figure 5). If mechanical stimulation is used, the instruments  must not be clamped firmly on the tissue as a form of testing, but rather the  tissue should be pinched gently as the muscles of the face are observed for  motion. If an electrical nerve stimulator is used, it must be tested regularly  to be certain that it is functioning in each test situation. A final landmark  is a branch of the postauricular artery just lateral to the main trunk of the  facial nerve. If the position or bulk of the tumor makes exposure of the main  trunk of the facial nerve dif cult, it may be identified distally. As indicated  previously, the marginal mandibular branch lies superficial to the posterior  facial vein in most circumstances. T e buccal branch lies immediately supe-  rior to Stensen’s duct, and identification of this duct will lead the operator  to the buccal branch of the nerve. Dissection from distal to proximal must  be carried out carefully, because the junction of other branches of the nerve  may not be seen as easily as divisions of the nerve when the dissection 1s  carried out in the opposite direction.   Numerous methods have been described for freeing the gland from the  nerve. T e safest dissection technique is the hemostat-scissors dissection.  By dissecting bluntly with a fine hemostat and then cutting only the tissue  exposed in the open jaws, the surgeon can protect the nerve (figure 6).  T e gland may be elevated by clamping the tissue or by the use of hold-  ing sutures, and the two major divisions of the facial nerve are identified.  Dissection may proceed anteriorly along any or all of the major divisions,  depending upon the tumor’ position. Since the majority of tumors occur  in the lower portion of the lateral lobe, the upper segment of the gland is  usually mobilized first (figure 7). A moderate amount of bleeding may  be expected, but this will be controllable with finger pressure, electroco-  agulation, or fine ligatures. Once the tumor has been freed from the facial  nerve, Stensen’ duct will appear in the midanterior portion of the gland  (figure 8). Only the lateral lobe tributary is ligated, because medial lobe  atrophy will occur if the main duct is tied. After removal of the lateral lobe,  the isthmus and the medial lobe remain deep to the facial nerve; they will  appear as small islands of parotid tissue and should represent only 20% of  the total parotid gland. T e lobe may be transected when the tumor and a  surrounding portion of normal tissue have been completely separated from  the facial nerve.    closure T e wound is thoroughly irrigated and meticulous hemosta-  sis obtained. A small perforated closed-suction Silastic catheter may be  brought up through a stab wound and attached to a suction apparatus. T e  subcutaneous tissue 1s approximated with fine absorbable sutures followed  by adhesive skin strips.    Posto PeratIve care Temporary paresis from traction on the facial  nerve may occur and usually clears in a few days to a week. If the greater  auricular nerve has been divided in the course of the procedure, anesthesia  in its distribution will be permanent. m    IndIcatlIons Sentinel lymph node dissection (SLND) is an important  procedure in the staging of patients with cutaneous melanoma. Skin mel-  anomas have a straightforward lymphatic flow that can be mapped. T e  metastases rarely skip to higher lymph nodes; therefore, an SLND can pro-  vide the first evidence of metastatic spread of the melanoma. T 1s operation  is indicated in patients who do not have palpable regional lymph nodes. T e  original melanoma on histologic studies following wide excision should be  of intermediate or greater thickness (>1 mm). If thinner, the melanoma  should have associated high risk factors such as ulceration or mitotic count/  mm/ > 1. Additional risk factors to be considered are age, site, Clark’ level  of invasion, and gender. An SLND that uses both radionuclide and blue  dye is highly accurate in finding positive lymph nodes. It allows a focused  pathologic examination by the pathologist with both routine hematoxy-  lin and eosin (H&E), plus immunohistochemical staining on the lymph  nodes that are most likely to contain metastases. Finally, an SLND should  be considered prior to a wide excision of the primary melanoma site. T 1s  is especially important if a rotational skin flap 1s planned for closure, as the  resultant scar will alter the dermal lymphatic flow.    Preo Perat Ive PreParatlIon In the example shown (figure 1), the  cutaneous melanoma was excised from the midportion of the patient’ back.  T is is considered a watershed area—that is to say, the lymphatic drain-  age may go to either axilla or groin. Accordingly, a preoperative scintigram  is required to demonstrate which lymphatic basin receives the lymphatic  drainage from the tumor site. T e most common areas are the axillary and  inguinal regions for extremity or truncal lesions and cervical or supracla-  vicular regions for head and neck primaries. Other sites include deep iliac,  hypogastric, and obturator regions and the popliteal or epitrochlear regions  for legs and arms, respectively. Finally, ectopic sites are also possible.   T e skin must be cleared of any active infections, as must the excision  site for the melanoma. Preparation, inspection, and monitoring of the  radionuclide solution must be coordinated with the nuclear medicine staff.   A few hours before operation, the patient is injected with a radionuclide  solution intradermally about the perimeter of the surgical site, using sterile  technique. T 1s may be done by the radiologist or the surgeon. T e commer-  cially available human serum albumin or sulfur colloid solution tagged with  technetium 99m is filtered and sterilized. Four syringes of approximately    100 uC Te 99m filtered sulfur colloid and 0.1 mL of normal saline each are  prepared, for a total dose of about 400 uC. T e area for injection is prepared  with an antiseptic solution. Disposable paper drapes are widely placed and  the physician is gloved. Extensive shielding for radioactivity is not required,  but the site and supplies are monitored with a radiation survey meter. T e  gloved physician injects the radionuclide in an intradermal pattern about  the incision (figure 2). T e area is washed and all the disposable items are  surveyed and disposed of in a radiologically safe manner.   T e lymphatic drainage area or basin is noted on a large or whole-body  scintigram; a hand-held gamma detector is used to identify the hottest area.  T is spot is marked with indelible ink as a temporary tattoo and the patient  is transported to the operating room.    anesthesIa Deep sedation plus local or a general anesthesia may be  used.    PosItIon T e patient is placed in a comfortable supine position. If an  axillary SLND is planned, that arm should be out at a 90-degree angle on  a padded arm board. Alternative positions, such as the lateral decubitus  position, can be utilized if wide excision of a lesion on the back is planned  in conjunction with the sentinel node procedure. T e arm can be sterilely  draped with a stockinet if desired to allow manipulation of the extremity to  facilitate identification of the sentinel node. If the dissection is planned in  the neck, the head of the table may be elevated and the patient’ head turned  to the opposite side.    o PeratiIve PreParatlon T e hair is shaved about the tattoo and a  routine skin preparation and draping is performed. T e surgeon performs  another intradermal injection about the perimeter of the melanoma exci-  sion site using 1 to 3 mL of isosulfan blue vital dye (figure 3). T e area is  massaged for a few minutes, and a faint blue streaking of the dye may be  seen in the dermal lymphatics heading toward the SLND site. In this illus-  tration, the sentinel node is within the left axilla. Using a hand-held gamma  probe in a sterile cover (figure 4), the surgeon verifies that the tattoo marks  the hottest spot. A small 5-cm transverse incision is made over the tattoo  and dissection is carried into the subcutaneous fat (figure 5). T e fat is  retracted laterally and the probe explores the open incision to find the area  of maximum radioactivity (figure 6).    o PeratIve PreParatlon T e blue dye may be seen in  lymphatic channels flowing into a now palpable lymph node (figure 7).  T is node should be blue and hot. T e node 1s dissected free, as are any  neighboring lymph nodes that are faintly blue, have significant radioactivity  counts, or are clinically suspicious (figure 8). Significant radioactivity 1s  identified as a level> 10% of the counts of the hottest sentinel node or a level  greater than two or three times the background activity of the axillary tissue.  A small cluster, usually two or three lymph nodes, is excised (figure 9),  as often there is more than one sentinel node. T e nodal basin is scanned  with the probe to verify that no other hot areas or potential sentinel lymph  nodes exist. T e probe demonstrates a basal background level (figure 9).  T enodal cluster removed is examined and the lymph nodes are separated.  One node, the principal sentinel lymph node, should be blue and quite  hot (figure 10a). In this illustration, lymph nodes B and C are consid-  ered sentinel lymph nodes, as they have significant radioactivity counts.  Any other regional nodes that have any blue coloration are also considered    sentinel nodes, even if they do not have elevated radioactivity counts. A  final visual and gamma probe survey is performed about the operative site  and careful hemostasis is obtained.    closure Subcutaneous tissue and Scarpa’ fascia are closed with inter-  rupted 000 absorbable sutures. T e skin is approximated with fine subcutic-  ular sutures. Adhesive skin strips and a dry sterile dressing are applied. Skin  adhesive may be used as an alternative or adjunct to subcuticular closure,  and if used, no dressing is applied.    Posto PeratIve care In most cases, this procedure can be performed  in an ambulatory surgery setting. T e patient returns home when discharge  criteria for this surgery are met. T e patient is given written instructions  concerning activities and signs of bleeding or infection. Simple oral pain  medication should suf ce. At the follow-up visit, the surgeon reviews the  pathology findings with the patient, who may require a formal lymphad-  enectomy if any sentinel lymph nodes show metastases. m    T e regional anatomy of the breast is illustrated in figures | and 2. T e prin-  cipal blood supply to the breast comes from the medial perforating branches of  the internal mammary artery and vein after they transverse the pectoralis major  muscle and its anterior investing fascia. T e medial aspect of the breast has  lymphatic drainage into the internal mammary chain of lymph nodes within  the chest; however, this is quite variable. T e majority of the lymphatics from  the breast drain to the axillary lymph node basin. T e most proximal node or  nodes may be located in atypical locations such as within the breast in the axil-  lary tail of the upper/outer quadrant or very low on the lateral chest wall. T e  identification of these nodes using radionuclide tags and blue dye localization  techniques is one of the additional benefits of a sentinel lymph node dissec-  tion. Axillary lymph nodes have been grouped into three levels defined by their  anatomic relationship to the pectoralis minor muscle (figur e 2). Level I nodes  are defined as those lateral to the edge of the pectoralis minor muscle. T is area  includes the external mammary, subscapular, and lateral axillary nodes. Level  II nodes are behind or posterior to the muscle and are commonly defined as  the central axillary lymph nodes. Level III nodes are located medial or superior  to the pectoralis minor muscle. T 1s group includes the subclavicular or apical  lymph nodes. T ey reside in the apex of the axillary space behind the clavicle  and deep to the axillary vein. In general, level I and II nodes are removed in  axillary lymph node dissections (ALNDs). T e overall boundaries of this stan-  dard ALND are the chest wall (serratus anterior muscle) medially, axillary vein  superiorly, subscapularis muscle plus thoracodorsal and long thoracic nerves  posteriorly, and latissimus dorsi laterally.   T eaxillary vein is the major structure defining the superior border of the surgi-  cal dissection. T e axillary artery (posterior and pulsatile) plus the brachial plexus  (superior and solid) are palpable but not exposed. Common regional findings are  dual axillary veins or a very large, long thoracic vein running longitudinally along  the lateral chest. After the axillary vein is exposed by the surgeon, a key landmark  aids in finding the thoracodorsal nerve, which is deep upon the subscapularis mus-  cle. A pair of subscapular veins are identified (figure 1l).T e more superficial one  is divided, revealing the deep subscapular vein and the adjacent subscapular artery,  which may be mistaken for the thoracodorsal nerve. T is nerve, however, is poste-  rior to the axillary vein and medial to the deep subscapular vein. It tends to angle  toward the deep subscapular vein, whereas the subscapular artery is more parallel.  A gentle mechanical stimulation of this nerve will result in muscle contraction.   Also running parallel to the axillary vein and rising perpendicularly from  between the ribs on the chest wall are the sensory intercostal brachial skin  nerves. One or more of these nerves may pass directly through the axillary fat  and lymph nodes that will be removed in the dissection. Division results in hyp-  esthesia in the posterior axillary web and in the upper/inner arm. Conversely,  the long thoracic nerve runs longitudinally over the serratus anterior at the  depth of an axillary dissection. If the surgeon dissects the axillary fat and speci-  men cleanly off of the serratus anterior muscle, the long thoracic nerve will be  found not on the muscle but rather out in the axillary fat about 7 or 8 cm deep  to the lateral edge of the pectoralis minor muscle. Gentle mechanical stimula-  tion will elicit contraction of the serratus anterior muscle. It is also important to  note that the long thoracic nerve tends to arch anteriorly as it proceeds caudally.    T e principal indication for biopsy is the presence of clinically suspicious  findings on physical examination or diagnostic studies. Palpable masses  may be sampled with fine needle aspiration (FNA) for cytologic evalua-  tion. A better diagnosis is obtained with a core needle biopsy and histologic  study. Asymmetric nodularity, architectural distortion, or suspicious pat-  terns of microcalcifications may require excisional biopsy guided by wire  localization when percutaneous biopsy cannot be performed or is not con-  cordant. In general, a wide excisional biopsy with a clear margin of several  millimeters of surrounding normal glandular tissue is planned. T e place-  ment of the incision is determined by the location of the lesion (figure 3).  If possible, incisions in the upper/inner quadrants should be avoided, as they  are most visible. Circumareolar or inframammary incisions tend to give the  best cosmetic result. Curvilinear incisions along Langer’ lines may be used in  most areas; however, some surgeons prefer radial incisions, especially in the  medial breast. T e incision should be kept small and placed over the lesion. T e  incision for a wire localization need not be placed about the entrance site of the  wire, because most wires are f exible enough to be drawn through the skin and  subcutaneous fat into an open biopsy site.    IndIcatIons A simple or total mastectomy is indicated in patients who  are not candidates for breast-conserving (lumpectomy) operations or who    prefer this approach. T e principal indications are for large cancers that  persist after neoadjuvant therapy, especially in a smaller breast, in multi-  centric disease, and in elderly poor-risk patients with localized lesions. T 1s  procedure may also be utilized for breast cancer risk reduction in high-risk  populations.    anesthesIa General anesthesia is given via an endotracheal tube. Short-  acting muscle depolarizing agents are used for the intubation.    PoslItIon T epatient is placed in acomfortable supine position with the arm  on the involved side abducted approximately 90 degrees, in order to give maxi-  mum exposure of the region.    o Perat Ive PreParatlon A routine skin prep is performed and the area is  draped in a sterile manner.    IncIslon and exPosure A horizontal elliptical incision is inked so as to  include the entire areolar complex (figure 4). T e two skin edges should be  of equivalent length, as measured with a free suture between hemostats at each  end. T e two incisions should come together without tension. Incisions may  vary if immediate reconstruction is planned. Skin- or nipple-sparing techniques  may be appropriate depending on the indication for surgery.    detalls of Procedure T e skin incision is made sharply with the scalpel  and carried through the dermis. Any significant vessels should be secured with  fine ligatures or controlled with electrocautery. T e skin faps are elevated with  large skin hooks that are lifted vertically so as to provide countertraction as the  surgeon elevates the skin faps using a scalpel or electrocautery. T e dissection  proceeds superiorly almost to the clavicle, medially to the sternal edge, and infe-  riorly to the costal margin near the insertion of the rectus sheath. T is should  include virtually all of the glandular tissue of the breast. T e lateral f ap dissection  is carried to the edge of the pectoralis major muscle. T is leaves the axillary fat  and lymph nodes for a separate dissection.   A subfascial dissection is performed, lifting the breast off of the pectoralis major  muscle. It is easier to begin superiorly. As the dissection continues medially, the per-  forating internal branches of the mammary vessel are controlled with electrocautery  or ligature, using fine silk. Finally, the axillary f ap is developed such that the breast is  removed from the lateral chest wall. T e specimen is oriented for the pathologist.T e  wound is irrigated and careful hemostasis is obtained. T e perimeter may be infil-  trated with a long-acting local anesthetic. T 1s allows the anesthesiologist to awaken  the patient sooner and lessens the amount of pain medication required after surgery.  One or two closed suction drains are placed via separate stab incisions and secured in  position with nylon suture. T e dermis is approximated with interrupted 000 absorb-  able sutures. T ese sutures are often placed so as to serially bisect the incision, thus  giving the best approximation if the two skin incisions are not of equal length. Finally,  a 0000 absorbable suture is placed for subcuticular approximation of the skin. Adhe-  sive skin strips and a dry sterile dressing complete the procedure. Some prefer skin  adhesive to the subcuticular suture, and if this is utilized, adhesive skin strips are not  utilized and a dressing is not required.    Posto Perat Ive care T e patient may use the arm immediately for nor-  mal activities. Vigorous use should be curtailed for about a week, when it is  determined that the skin faps are well sealed to the pectoralis major muscle  without accumulation of serum or hematoma. T e drain is generally removed  when the output is <30 mL per day.    An elliptical incision is placed more obliquely, being angled toward the axilla.  T e entire areolar complex as well as the lesion or its biopsy scar should be  included within the ellipse. If no reconstruction is planned, the wider ellipse  illustrated in figure 51s used. After the patient is prepped and draped, the  incision is marked with ink. T e incisions are created to be of equal length.  T ere should be no redundant or excess skin at either end of the incision  upon closure. In overweight patients or those with very large breasts, a more  lateral incision with a wider angle is required. Conversely, very creative or  comma-shaped incisions that encircle only the areolar area and then proceed  laterally as a single curvilinear extension to the base of the axilla may be used  in coordination with the plastic surgeon, who will be performing a concur-  rent reconstruction (see also Chapter 127, page 488, Modified Radical Mastec-  tomy). T is incision may be combined with a separate elliptical incision about  a preceding biopsy site.   T efullradical mastectomy is no longer included in this atlas, as most surgeons  do not remove the entire pectoralis major muscle. Instead, a modified radical mas-  tectomy is performed with a wedging out ofa full-thickness section of the underly-  ing pectoralis major muscle where the cancer is attached. m    IndIcatlIons Over the past 20 years, multiple international clinical  studies have shown equivalent survival between patients treated with mod-  ified radical mastectomy and appropriately selected patients treated with  breast-conserving surgery and adjuvant radiation, hormonal therapy, and/  or chemotherapy. Accordingly, breast-conserving surgery has become the  dominant mode of treatment, with modified radical mastectomy becoming  the alternate choice in certain circumstances. A residual large cancer after  neoadjuvant therapy (especially in a small breast), multicentric cancers,  and patient preference or concerns about the complications of radiation  therapy are the principal indications for the operation. Prior to surgery,  the opposite breast should be evaluated by physical examination and mam-  mography. T e role of MRI to screen the contralateral breast 1s still an area  of controversy. Appropriate blood tests and imaging scans and mammo-  graphic studies are made in a search for potential metastases to the lung,  liver, or bone. T e standard preadmission physical examination and labo-  ratory evaluations are done in an ambulatory setting, as most patients are  admitted to the hospital on the day of operation.    Preo Perat Ive PreParatlon T e skin over the involved area should  be inspected for signs of infection. T e skin is shaved and electrical hair  clippers may be used over the axillae. Some surgeons give a single periop-  erative dose of parenteral antibiotics, particularly if a regional breast biopsy  has recently been performed.    anestheslIa General anesthesia is given via an endotracheal tube. Short-  acting muscle depolarizing agents should be requested for the intubation, such  that the motor nerves will be responsive during the axillary node dissection.    PosItlIon T e patient is placed nearest the edge of the operating table  on the side of the surgeon. T e arm is abducted and held by an assistant or  placed upon a support at right angles to the patient to facilitate the prepara-  tion of the skin. Some prefer to wrap the arm, including the hand, in sterile  drapes so that the arm can be moved upward as well as medially to facilitate  the subsequent dissection of the axilla.    o PeratIve PreParatlon T eskin is widely prepared with topical anti-  septics. T is includes not only the involved breast but also the area over the  sternum; the supraclavicular region, shoulder, axilla, and collateral chest wall;  as well as the upper abdomen on the involved side. A slight Fowler position  with a tilt away from the surgeon improves the exposure. T e surgical drape  should be secured to the skin at appropriate points around the margin of the  proposed field of operation. T e arm should be free to be moved by an assis-  tant as required for exposure in the axilla.    IncIslon and exPosure T ediagnosis of malignancy 1s usually estab-  lished by core needle biopsy under ultrasound guidance or stereotactic biopsy  prior to mastectomy. Ifthe diagnosis of malignancy has not been documented  by previous biopsy, the diagnosis is first confirmed by a biopsy of excised  tumor using frozen-section examination by the pathologist. T e specimen  is also sent for hormone binding and other immunoassays. T e underlying  pectoralis muscle should not be involved in any way by the biopsy; otherwise  that section of the muscle should be excised en bloc with the specimen.  After the biopsy wound is closed and sealed, all instruments and gloves used  in the procedure are discarded. Some prefer to have a second sterile table  available, which results in a repeated complete skin preparation and sterile  draping. An oblique elliptical incision is made that may include a short    extension laterally up toward the axilla to ensure a better exposure for the  axillary dissection and a more cosmetically acceptable closure (figure 1).  T e transverse segment of the elliptical incision includes the nipple and  areola and an appropriate distance beyond the limits of the tumor when-  ever possible. If reconstructive surgery is planned, a more limited incision  (figure |, dashed line) that preserves skin can be made in consultation  with the plastic surgeon. T e entire nipple plus an adequate margin about  the biopsy site must be taken, while a lateral, comma-like extension pro-  vides the exposure for the axillary dissection.   T e initial incisions through the skin should be only through dermis,  as it is advisable to include most of the subcutaneous tissue, especially in  the region of the axilla, with the final specimen (figure 2). T e skin flaps  require careful elevation, with control of all bleeding points as the dissec-  tion progresses. With good retraction, a plane between the breast tissue and  subdermal fat can be visualized and the dissection carried out in this plane  to assure removal of all possible breast tissue while maintaining viability of  the skin. T e flaps are elevated to the level of the clavicle superiorly, to the  edge of the sternum medially, to the rectus sheath and costal margin infe-  riorly (some prefer elevation to the level of the inframammary fold when  reconstruction is planned), and then laterally to the edge of the latissimus  dorsi muscle. Particular attention is required to remove as much subcuta-  neous fat as possible in the axillary region, because the lymph nodes and  breast tissue are very close to the skin in this region.   T e fascia over the pectoralis major muscle as well as the breast is  resected as a subfascial dissection starting near the clavicle and extending  downward over the midportion of the sternum (figure 3). T e fascia is  meticulously dissected off the pectoralis muscle without including any of  the latter within the gross specimen. If the cancer has penetrated this fascia  and invaded the pectoralis major muscle, that section of the muscle can be  excised en bloc with the specimen. It is usually not necessary to perform a  full radical mastectomy with removal of the entire pectoralis major muscle.  T e perforating intercostal arteries and veins near the sternal margins must  be carefully clamped and ligated.   T e axillary flap is retracted upward, and the fascia over the edge of the  pectoralis major is incised (figur e 4), exposing the pectoralis minor mus-  cle beneath and the junction of the coracobrachialis and pectoralis minor  origins superiorly at the coracoid process. Electrodiathermy is often used  in this operation, but it should be avoided about the axillary vessels and  nerves and for control of bleeding from intercostal perforating vessels lat-  eral to the sternum. T e loose tissue over the axillary vein is incised and the  vein wall gently exposed for a short distance beyond the subscapular vessels  (figure 5).   Level I and II lymph nodes are removed in the axillary node dissection  that begins by incising the clavipectoral fascia along the lateral edge of the  pectoralis minor muscle. Precautions are taken to avoid the medial and lat-  eral nerves to the pectoralis major muscle. T e medial nerve is so named  because it arises from the medial cord of the brachial plexus and then  passes through the pectoralis minor muscles in about 60% of patients or  passes laterally around the pectoralis minor in 40% en route to innervating  the lower region of the pectoralis major muscle (figure 6). T e dominant  lateral nerve to the pectoralis major muscle arises from the lateral cord.  It passes medial to the pectoralis minor muscle near its insertion and 1s  closely associated with the acromial thoracic artery.    detalls of Procedure T e lateral edge of the pectoralis  minor is cleared of fascia to near its insertion on the corticoid process and  several veins are ligated as they drain into the axillary vein (figure 7). A  careful search 1s made for the medial nerve to the pectoralis major, which  is preserved. Ligation rather than electrocoagulation is preferred for all ves-  sels about the axilla and for those adjacent to the sternum.   T e pectoralis major and minor are retracted upward and medially,  exposing the uppermost tissues to be divided over the axillary vein. Some  prefer to divide the pectoralis minor muscle from its insertion on the cora-  coid process as to gain better exposure of the medial area of the axillary vein  and its lymph nodes.   T e fascia over the serratus anterior muscle is dissected free, and the  axillary fat and lymph nodes are mobilized off the chest wall and axillary  vein (figure 8). T e arm, wrapped in sterile drapes, is lifted up or manipu-  lated to enhance the exposure as the dissection progresses in the axilla. T e  long thoracic nerve should be identified deep to the axillary vein. As it lies  within the loose fascia over the serratus anterior muscle, it is possible to  lift this nerve away from the muscle; hence, it must be carefully sought and  dissected out from the axillary contents to be contained within the resected  specimen. T 1s nerve should be retained intact, because a “winged” scapula  will result if it is divided. A sensory nerve that is often sacrificed is the more  transverse intercostobrachial that appears beneath the second rib and pro-  vides sensory innervation to the upper inner aspect of the arm (see Chapter  129, page 497, figure 5).   As the breast is retracted laterally (figure 9), the long thoracic nerve  as well as the thoracodorsal nerve should be free of redundant tissue. T e  thoracodorsal nerve is characteristically located adjacent to the deep sub-  scapular vein and artery. Division of the thoracodorsal nerve is avoided  unless there is tumor involvement, since its sacrifice has only a partial effect  upon the latissimus dorsi muscle.   T e specimen is freed from the latissimus dorsi muscle (figure 10) and  finally from the suspensory ligaments in the axilla, where large veins and lym-  phatics should be carefully ligated. T e operative area is repeatedly inspected  for any bleeding points, which are ligated. T e two major nerves are checked  to be certain that their course is free of ligature, and their integrity is verified    by a brisk but gentle pinch that results in an appropriate muscle twitch. T e  wound is irrigated with saline, and a final inspection is made for hemostasis  prior to closure. Two closed system perforated suction catheters are inserted  for drainage. T ey are usually introduced through separate stab wounds made  in the lower flap posteriorly. One catheter is directed up to the axilla. T e other  catheter is secured anterior to the pectoralis major muscle for drainage from  under the skin flaps. T e catheters are secured to the skin with nonabsorbable  sutures and attached to a closed system of suction (figure 11).   It is very important that the surgeon spends the necessary time and  effort to compress the skin flaps into place in the axilla and elsewhere as  the skin is finally closed. If the skin flaps are so thin that there is minimal  subcutaneous tissue, interrupted sutures are used in the skin. Alternatively,  some surgeons use a few interrupted absorbable sutures in the subcuta-  neous fat in medium-thickness skin flaps. Some surgeons will run a sub-  cuticular suture with fine absorbable material. Others will close the wound  with topical skin adhesive.   T eskin is cleaned, dried, and may be prepared with tincture of benzoin,  and approximated with steri-strips. Others apply a simple gauze dressing  and a surgical bra, whereas some prefer bulky fluffed dressings followed by  gauze or elastic bandage wrappings.    Posto PeratIvecare Skin sutures, if present, are removed in 3 to 5 days,  with the incision being reinforced with “butterfly” adhesive strips. T e suction  catheters are removed when the drainage is less than 30 mL per day. T e dura-  tion the drain tubes are in place is variable, extending from as short as several  days to a week to as long as 1month. Any collections of fluid may be aspirated  in the surgeon’ of ce using strict adherence to aseptic precautions. Normal  use of the arm 1s encouraged for the first week; thereafter, active shoulder exer-  cises are performed to ensure return of full range of motion within the ensuing  2 weeks. Physical therapy may be necessary if progress is not apparent in this  interval. T e patient is cautioned to minimize cuts and possible infection in  this arm and to report immediately any injury that results in infection, since  a rapidly spreading lymphangitis is possible. Finally, a systematic regimen for  lifelong follow-up is instituted even if the final pathologist’ report does not  indicate the need for additional therapy at the time. m=    {  \ .  / Thoracodorsal nerve adjacent  to deep subscapular vein and    IndIcatlIons_ Breast cancer patients undergoing a mastectomy or breast-  conserving procedure are candidates for axillary sentinel lymph node dis-  section (SLND) if there is no palpable or clinical evidence of axillary lymph  node involvement. T e finding of breast cancer metastases in axillary lymph  nodes changes the staging of the disease, predicts the rate of recurrence and  survival, and results in adjuvant treatment with chemotherapy, hormone  therapy, or radiation therapy. T e standard axillary lymph node dissec-  tion (ALND) of level I and II nodes has significant morbidity, of which  lifelong lymphedema is the most feared by patients. Using a combination  of radionuclide and dye injections, the correlation of SLND and standard  ALND in finding positive lymph nodes is quite high (95%) in the hands of  an experienced surgeon. Although at least one sentinel lymph node can be  identified in the majority of cases, in a small percentage, identification may  not be possible, necessitating complete axillary node dissection. In addi-  tion, a false-negative finding occurs in 3% to 10% of the patients having  SLND—that is to say, the sentinel nodes are negative, but higher nodes are  found to be positive. T e advantages of SLND are the fewer complications  versus ALND and the ability to identify sentinel lymph nodes that are not  in the traditional level I or II areas. T e identification of sentinel lymph  nodes focuses the histopathologic examination, which may include immu-  nohistochemical staining as well as the traditional hematoxylin and eosin  (H&E). T e importance of micrometastases (< 2mm.) is under study; how-  ever, the total number of nodes involved with metastases may influence the  adjuvant therapy that is offered. Contraindications to SLND include suspi-  cious, palpable axillary lymphadenopathy; and regional breast operations  (e.g., breast reduction) that alter normal lymphatic flow. Sentinel lymph  node biopsy may be considered after prior axillary surgery, but lymphatic  mapping may be necessary to identify alterations in drainage patterns and  the identification rate of sentinel nodes may be lower.    Preo PeratlIve PreParatlon T e skin should be free of infection,  as should the preceding breast biopsy site. T e preparation, delivery, and  monitoring of the radionuclide solution for injection must be coordinated  with the nuclear medicine staff.    anestheslIa General anesthesia with endotracheal intubation is pre-  ferred, as some patients will also have ALND and may be having a concur-  rent operation upon the breast. Most surgeons prefer that the anesthesiologist  uses a short-acting muscle paralyzing agent for placement of the endotra-  cheal tube such that the motor nerves can still be identified with mechanical  stimulation during the ALND.    PosItlIon T e patient is placed in a comfortable supine position with the  arm out at 90 degrees on a padded arm board (figure 1). T is position    allows easy access of the breast and axilla. Some prefer to wrap the arm,  including the hand, in sterile drapes so that the arm can be moved upward  as well as medially to facilitate the subsequent dissection.    o Perat Ive PreParatlon Approximately 90 minutes before the start  of the operation, the surgeon injects the radionuclide solution into the  breast, using sterile technique. A commercially available sulfur colloid  solution using a technetium-99m tag is sterilized after passage through a  0.22-um filter. Many techniques are used for injection of the radionuclide  and blue dye. T e injections may be placed (1) deeply about the tumor or  biopsy cavity (figure 2), (2) superficially in the subdermal or intrader-  mal site over the tumor or about the biopsy site scar, and (3) superficially  about the perimeter of the nipple in a subareolar manner. T e total dose  of radionuclide is generally about 400 uC. Shielding is not required, but  the site is monitored with a radiation survey meter. T e breast is prepared  with an antiseptic solution and sterile paper drapes are applied. T e pat-  tern shown (figure 2a) allows infiltration above, below, and at either  end of the incision from a preceding biopsy. A long 1'4-in 25-gauge nee-  dle is used for this injection about the biopsy site or breast cancer. Care  must be taken not to inject into a biopsy cavity. T e breast is washed and  the disposal items are surveyed and disposed of in a radiologically safe  manner. T e patient proceeds to the operating room. After induction of  anesthesia, the breast, chest, and upper arm are prepared and draped in  the usual manner.    IncIslon and exPosure T esame three techniques are available for  injection of about 3 to 5 mL of 1% isosulfan blue vital dye (figure 3).  After injection, the area is massaged for a few minutes. T e dermal lym-  phatics may then manifest a faint blue blush streaming toward the axilla.  Using a hand-held gamma detector with a sterile cover, the surgeon  scans toward the axilla (figure 4) looking for the area with the high-  est count rate. T is may be dif cult to find if the breast tumor or biopsy  site is high in the upper/outer quadrant, as a regional “shine through” of  the injection site radioactivity may create a very high background level.  T e angled head of the gamma counter can be used to advantage, as it  allows more medial placement of the detector with an angled view that  is away from the injection site but still points into the axilla. If the hot-  test spot is near the base of the hair-bearing axilla, a transverse incision  is made directly over it (figure 5) in such a manner that the incision  can be extended later in a medial manner for a standard ALND. Sharp  dissection with a scalpel or electrocautery is made through the first 1 to  2 cm of fat. T e probe explores the open incision to find the hottest area    detalls of Procedure Deeper dissection may reveal  some blue lymphatic channels (figure 7) flowing toward the hot region  where a lymph node may be palpable. T e lymph node 1s dissected free  along with any neighboring lymph nodes that are blue or significantly hot  (figure 8). T e definition of “significant” is any lymph node that has a  radioactivity level greater than 10% of the hottest sentinel node (or a level  greater than two or three times the background level of the axillary tissue).  Following removal of the sentinel nodal tissue, the incision is explored with  the gamma probe for any other lymph nodes with significant radioactivity.  A basal background level (figure 9) should be present except when the  detector 1s pointed toward the tumor or biopsy injection site. In addition,  the axilla should be palpated and any firm or abnormal lymph nodes should  be removed.   T e nodal tissue removed is examined and the individual lymph nodes  are separated (figure 10). In the example shown, lymph node A is labeled  as the principal sentinel lymph node. Lymph node Bis labeled as a sentinel  node. Node C is not a sentinel node, as its counts are less than 10% of the  principle sentinel node and it is not blue.    closure Ifthe sentinel lymph node 1s in the typical low axillary region,  careful hemostasis is obtained. A decision must be made as to whether to  proceed with a standard ALND through a new incision or through exten-  sion of the existing incision. If a new incision is required, then closure  is performed. Scarpa’ fascia and the subcuticular fat are closed with  interrupted 00 absorbable sutures. T e skin is approximated with 0000  absorbable sutures.    Posto PeratIve care Most patients who have both SLND and ALND  are observed overnight until the effects of the general anesthesia have  cleared. Oral intake is resumed as tolerated and oral pain medications are  given. T e serous output of the closed-suction Silastic drain is monitored.  Often it is removed before the patient is discharged or whenever the output  falls to less than 30 mL per 24 hours.   Patients with only an SLND are usually operated in an ambulatory  setting. T ey can be discharged home within a few hours when they are  alert and have stable vital signs according to the discharge protocol of the  surgical unit. m    IndIcatIons Axillary lymph node dissection is indicated for the man-  agement of clinically positive nodes secondary to breast cancer or mela-  noma. It is also the current standard of care after a positive axillary sentinel  node for melanoma and selected cases of breast cancer. Axillary node dis-  section is also considered for breast cancers when the sentinel lymph node  cannot be identified.    anesthesIa General anesthesia is administered via endotracheal tube. If  muscle depolarizing agents are used for induction, they should be short act-  ing to allow recovery of the motor nerves for evaluation during the procedure.    PosItIon T e patient is placed with the operative side close to the edge  of the table. T e arm is abducted and placed upon a support at a right angle  to the body. Some surgeons wrap the arm in sterile drapes so that the arm  is freely mobile to facilitate exposure (figure 1).    IncIslon and exPosure Incisions may vary slightly depending on  the disease process being addressed. For melanoma, transverse incisions  are preferred to allow easier access to the level III axillary nodes (figure 1).  For breast cancer, curvilinear incisions in a skin fold inferior to the hair-  bearing area are generally preferred. If a previous sentinel node biopsy inci-  sion exists, this should be excised.    detalls of Procedure T e incision is extended through the subcuta-  neous tissues and clavipectoral fascia to expose the pectoralis major muscle  medially and the latissimus dorsi muscle laterally. T e medial border of  the pectoralis major muscle is cleared to allow medial retraction of the  muscle (figure 2). T e interpectoral, or RotterS nodes, are swept later-  ally and included with the specimen. T e pectoralis minor muscle is then  exposed and the lateral edge cleared to facilitate medial retraction and  exposure of the deeper nodes. T e medial pectoral bundle 1s identified and  traced back to identify the axillary vein. T e inferior border of the vein  is cleared between the chest wall and latisstmus dorsi muscle (figure 3).  T e axillary vein is the superior extent of dissection for breast cancer, but  for melanoma, some authors suggest continuing the dissection superior to  identify the coracobrachialis muscle and carefully dissecting the fibrofatty  tissue overlying the brachial plexus down to be included with the specimen,  taking care to maintain the fascial covering overlying the brachial plexus.  As the dissection of the vein proceeds, the thoracodorsal bundle 1s iden-  tified (figure 4). Usually, there is a vein superficial to the thoracodorsal  vein that will require division and ligation. T e thoracodorsal bundle,  including the vein artery and nerve, is generally preserved, but can be sac-  rificed with minimal consequence if necessary due to bulky adenopathy.  Once the thoracodorsal bundle has been identified, its course can be  gently dissected using a Kitner. Attention is then directed to the chest  wall, where at approximately the same depth, the long thoracic nerve can    be identified (figure 4). T e course of this nerve is determined and is  protected during the dissection. Damage to the nerve results in a winged  scapula.   Once the nerves have been identified, the pectoralis major and minor  muscles are retracted medially and the fibrofatty tissue containing lymph  nodes is retracted laterally. T e fascia over the serratus anterior muscle is  dissected free and the axillary fat and lymph nodes are mobilized off the  chest wall. Level I (lateral to the pectoralis minor) and II (deep to the pec-  toralis minor) nodes are routinely removed. Level III nodes (medial to the  pectoralis minor) are removed if clinically suspicious. Some melanoma  surgeons routinely remove level III nodes as well. If exposure cannot be  adequately attained with retraction, the pectoralis minor can be removed  by dividing the muscle at the coracoid process and at the chest wall. T e  arm, if prepped into the field, can be lifted or manipulated at this point to  facilitate exposure.   Care is taken to preserve the motor nerves. As the dissection proceeds,  one or more intercostobrachial nerves will be identified running through  the specimen (figure 5). Depending on surgeon preference, these nerves,  which are sensory, can either be preserved or divided. If sacrificed, numb-  ness in the axillary region and the upper inner arm will result. T is will  often be permanent, although the area of numbness may decrease in size. If  preserved, traction on the sensory nerves may result in a burning paresthe-  sia, which usually resolves over time.   T e specimen is removed from the floor of the axilla, the subscapularis  muscle. T e dissection proceeds laterally to the latissimus dorsi muscle.  Once removed, the specimen is passed off the field. T e two major motor  nerves are checked to verify their integrity. T 1s can be accomplished by a  gentle pinch, demonstrating the appropriate muscle contraction. T e cavity  is irrigated and inspected for hemostasis.   A closed system perforated suction catheter is placed into the wound via  a separate stab incision. T e drain is secured in position with nonabsorb-  able suture and attached to a closed system of suction (figure 6).   T e wound 1s then closed in layers. Some surgeons attempt to reapproxi-  mate the clavipectoral fascia with absorbable sutures. T e deep dermis is  reapproximated with 3-0 absorbable sutures. Depending on surgeon prefer-  ence, the skin may be closed using fine absorbable subcuticular sutures or  the skin can be reapproximated with skin adhesive.    Posto PeratIvecare T eclosed suction drains are generally removed  when the drainage is < 30 mL per day. Any collections of fluid that occur  after drain removal can be aspirated in the of ce. Normal use of the arm is  encouraged once the drain is out.   Physical therapy may be helpful to improve shoulder range of motion. T e  patient is instructed to minimize cuts and possible infections of the affected  extremity and to report immediately any injury to the arm, since lymphan-  gitis and lymphedema are possible consequences. A systematic regimen for  lifelong follow-up should be instituted to identify and manage potential  lymphedema at an early stage. m    IndIcatlons Full-thickness skin loss can occur from burn, trauma,  infection, or surgical excision. A skin graft should be considered when the  defect cannot be closed primarily or with local tissue flaps and the wound  base can adequately support a skin graft. Exposed bone, joint, tendon,  blood vessels, and other significant structures are not good candidates  for skin grafting and need other methods of reconstruction (pedicled or  free flaps). Active infection and poor blood supply to the recipient sites  are contraindications. Weight bearing is a relative contraindication for skin  grafting, although glabrous skin grafts can sometimes provide an adequate  reconstruction.   Skin grafts can be categorized as split thickness or full thickness  (figure 1). Full-thickness skin grafts (FTSGs) remove all layers of the skin  and create a secondary defect at the donor site, which must be closed pri-  marily or left open to heal secondarily. For this reason, FTSGs are not fre-  quently used for large defects. Split-thickness skin grafts (STSGs) can be  of variable thickness, with the amount of dermis taken with the graft the  determinant of graft thickness. In general, the thinner the skin graft, the  more likely the graft will survive or “take” and quicker the donor site will  re-epithelialize. Donor sites heal by epithelial cells in the sweat gland and  hair follicles dividing and migrating superficially and then across the donor  site until contact inhibition occurs. T icker skin grafts tend to have better  cosmesis because they display less secondary contracture and deformity. In  cosmetic areas, including the face and hands, full-thickness grafting is more  common because of its better cosmesis.   Because of the large amount of dermis present, the buttock and lateral  hip can supply large quantities of STSG when needed (figure 2). T ethin-  ner the graft taken, the higher the number of skin grafts that can be har-  vested from that donor site. T e surgeon should be reluctant to use a donor  site that will be exposed with normal dress patterns. In the face, color match  is important for cosmesis. For this reason, the supraclavicular area, neck,  and scalp are better color matches for defects on the face, if available.    Preo PeratIve PreParatlIon In the case of the burn patient, early  excision of the burned tissue and skin grafting (within 2 weeks) will limit  the amount of hypertrophic scarring and contracture. For all cases of skin  grafting, the wound bed must be clean and clear of any evidence of infec-  tion. Frequent debridements and dressing changes may be required prior to  skin grafting. Negative pressure dressings may help stimulate granulation  tissue and prepare the wound bed. Medical issues (including nutritional  status) should be optimized.    anesthesla Generally, local anesthesia can be used for small excisions  and skin grafts. Where extensive skin grafting must be carried out, general  anesthesia is usually indicated.    PosItlon T e patient’ position is determined by the field of operation.  Frequent position changes are required sometimes because of the multisite  nature of the surgery. Care must be taken to cover the patient at all times  except for the area being operating on, as hypothermia can become a ser1-  ous problem. If possible, the donor and recipient sites should be ipsilateral  to allow the patient to have one part of his body without any surgical site,  allowing for improved comfort.    detalls of Procedure A variety of instruments are available for  use in obtaining STSGs. T e choice will depend on the individual case  and the surgeon’s experience. T e most common method of harvesting  STSGs is using a powered dermatome (figure 3), although free-hand  harvesting with a scalpel or skin knife can be performed for small grafts.  For irregular donor site areas, infiltration of a tumescent solution under  the skin can provide increased tissue turgor that may make harvesting  the graft easier.    T e donor site must be a flat, firm surface, the back and thighs being com-  monly used. T e blade is checked carefully, inserted into the dermatome,  and secured. When the desired width and thickness calibrations are deter-  mined (figure 3) and settings made using a graft sizer (figure 3a), a thin  layer of mineral oil is spread over the donor site and carefully on the der-  matome. A surgical assistant helps to keep tension on the donor site. As the  eraft is lifted the assistant gently picks up the end to the graft to apply ten-  sion (figure 4). T edermatome should be started prior to making contact  with the skin and approached at approximately a 45-degree angle. Once the  dermatome has engaged the skin and a couple of centimeters of advance-  ment occurred, the dermatome should be lowered to approximately a  30-degree angle. T e dermatome is advanced until the desired length of  skin is obtained. T e amount of pressure exerted becomes important, as  too great a pressure may produce a thicker graft of skin than is desired. If  large areas need grafting, as in extensive burns, the skin graft can be placed  through a mesher (figures 5 and 6) to increase the surface area grafted  with each graft. In most applications, meshing beyond a ratio of 3:1 makes  handling the mesh difficult with mixed results. Most meshing occurs with  aratio of 15:10 (figure 6a). In general, meshing should not take place for  erafting of the face or hands. Hemostasis must be complete in the recipi-  ent area before application of the graft. T e recipient site is then sprayed  with a thin layer of fibrin glue and the graft is carefully placed into the  defect. Grafts are very sensitive to crush injury and should be handled with  extreme care. Excessive skin is trimmed from the edges so that no graft  overlies normal skin, and the graft is carefully sutured to the adjacent skin  with interrupted absorbable sutures (figure 7). Before application of the  dressing, the wound is checked for the presence of any blood clots under  the graft. T e external dressing is then applied with nonadherent gauze adja-  cent to the graft, supported by a firm compression dressing that is carefully  applied and immobilized. If a bolster dressing is required a negative pressure  dressing placed on low, continuous suction can be placed over the graft with  a nonadherent, oil immersion gauze providing a barrier layer between the  eraft and dressing sponge (figure 8). Immobilization of joints in proximity  to the newly applied graft is important to prevent movement of the graft,  thus improving graft take. At the same time, however, patients should be  encouraged to be out of bed and ambulate as their condition will allow. Strict  bedrest is not mandatory for most patients receiving skin grafts.    T ere are several options for dressing the donor area. Any of the silver-con-  taining barrier dressings can be used to cover the donor site. Conversely,  nonadherent gauze can be applied as a single layer over the donor area and  supported by a bulky nonocclusive gauze dressing. On the following day,  the outer dressing is removed from the donor site, leaving the inner gauze  adjacent to the wound and allowed to dry, preferably with assistance of a  heat lamp. T is dressing can be left in place until it falls of as the donor site  re-epithelializes.    Posto PeratIve care T e frequency with which the dressing is  changed will vary with the case. When a bolster or negative pressure dress-  ing is used, it may be left in place for 3 to 5 days. When the dressing is  changed, the presence of a fluid collection beneath the graft does not neces-  sarily indicate a loss of the graft. T e graft should be incised over the fluid  collection and evacuated, and a firm dressing reapplied for 24 to 48 hours.  After the graft has healed fully, the daily application of a moisturizing  cream will help keep it from scaling and make it pliable. T e donor area  should be healed in 8 to 14 days and be ready for harvesting of a new graft  if necessary. @    IndIcatlIons T e role of carotid endarterectomy is the prevention of  strokes in patients with systemic disease of the vascular system. T e indica-  tions for the procedure are varied, but the chief indication 1s transient isch-  emia. When the symptoms of cerebral ischemia are transient, intermittent,  and self-resolving, the results of surgical correction of the area of carotid  stenosis are excellent. T e operation may be considered in some patients  who have recovered from old strokes who develop new symptoms. Mild  intracranial disease with severe proximal disease is another indication for  carotid endarterectomy. T e two principal indications are asymptomatic  high-grade stenosis and transient ischemia.   Duplex ultrasound blood-flow imaging studies with or without mag-  netic resonance angiography (MRA) or contrast angiography are used to  visualize the arch, carotids, and vertebral vessels. T is allows accurate doc-  umentation of any areas of stenosis as well as the extent of the collateral  blood supply. Surgical improvement is minimal in patients with complete  occlusion of the internal carotid artery, and operation is not recommended  for patients with established long-standing occlusion. T e risks of increas-  ing cerebral damage or of the patient suffering hemiplegia are ever present,  and the patient and family should be thoroughly informed of the risks.   A thorough medical evaluation of the cardiovascular system with spe-  cial attention to the coronary arteries is indicated. Other medical problems,  including diabetes, must be under complete control. T e incidence of stroke  is greater in patients with contralateral carotid occlusion, and one-stage  bilateral carotid endarterectomy is inadvisable because of the increased  incidence of complications. At least a week or more should separate two  procedures. T e operation may be delayed in patients with acute strokes,  allowing them to stabilize for 4 to 6 weeks, but there is increasing evidence  that earlier intervention may be indicated in specific cases. At that time,  imaging studies and operation can be considered.    PoslItlIon T epatient is placed in a supine position with the head slightly  extended and turned toward the contralateral side.    o PeratIve PreParatlon Afer routine skin preparation, the opera-  tive field is draped to expose the mastoid process superiorly, the angle of the  mandible anteriorly, the manubrium and clavicle inferiorly, to the trapezius  posteriorly.    IncIslon and exPosure T e incision is made along the anterior  border of the sternocleidomastoid muscle from the mastoid process to a  point two-thirds of the distance to the sternoclavicular joint (figure 1).  T e incision is carried through the platysma muscle exposing the anterior  border of the sternocleidomastoid muscle, which is then retracted later-  ally to expose the carotid sheath. Care must be taken to avoid making the  upper end of the incision too far anteriorly, where the marginal mandibu-  lar branch of the facial nerve may be injured in its course just inferior to  the horizontal ramus of the mandible. Such an injury results in paralysis of  the lower lip. In the cephalad portion of the incision, the greater auricular  nerve and sensory branches of the cervical plexus of en can be identified  and preserved if exposure is not compromised. Injury to these nerves will  result in a sensory deficit involving the earlobe or the angle of the mandible.  Gentle self-retaining retractors may be positioned at this time to provide  maximal exposure. T e omohyoid muscle may be retracted inferiorly or  divided to permit exposure of the common carotid artery, depending upon  the required extent of the procedure.    detalls of Procedure T eanatomy of the neck must be understood  clearly so that inadvertent injury to nearby cranial nerves can be avoided  (figure 2). T e vagus nerve lies within the carotid sheath generally in a  posterolateral position; injury will result in vocal cord paralysis. T e hypo-  glossal nerve passes superficial to the carotid arteries 1 to 2 cm cephalad  to the carotid bifurcation; injury will result in deviation of the tongue and  dysphagia. T e ansa hypoglossi branches from the hypoglossal nerve as it  crosses the internal carotid artery and passes inferiorly to innervate the  strap muscles. T is may be sacrificed without significant consequence to  facilitate exposure of the more distal internal carotid artery, allowing the  hypoglossal nerve to be gently retracted superiorly. T e carotid body is in  the crotch of the carotid bifurcation. Dissection in this area may result in  hypotension and bradycardia, cardiovascular effects that can be blocked  effectively by injecting the carotid body with 1% lidocaine. T e facial nerve  is at the most cephalad extent of the incision and should be well out of the  field anteriorly (figure 2).   Afer the described exposure has been obtained, the facial vein is  divided, exposing the carotid bifurcation (figure 3). T e carotid sheath  is entered and opened superiorly and inferiorly. A vessel loop is passed  about the common carotid artery proximally. A vessel loop is passed  around the external carotid artery to facilitate later placement of a vascu-  lar clamp. A vessel loop or a 00 silk ligature then is passed doubly around  the superior thyroid artery as a Potts tie to provide vascular control. T e  internal carotid artery is then dissected circumferentially at a point 1cm  distal to palpable disease and encircled with a vessel loop. Great gentle-  ness is required and care is taken during this dissection to prevent plaque  embolization.   If selective shunting is to be used, appropriate monitoring equipment  (a transducer, extension tubing, and a 22-gauge needle) must be readied  and carefully flushed with saline to free it of bubbles or particulate debris.  Clamps are placed across the external carotid artery and common carotid  artery, af er which the needle is placed within the carotid artery to measure  the carotid stump pressure (figure 4). Stump pressures greater than 40 to  50 mm Hg document significant collateral blood flow and are associated  with a lower incidence of cerebrovascular accident. Care must be taken in  the presence of extensive or ulcerated plaques to avoid plaque embolization  with this maneuver. Some rely upon continuous electroencephalographic  monitoring to gauge the adequacy of collateral blood flow and the require-  ment for intraluminal shunting; others choose to shunt all patients rou-  tinely; and still others may choose not to shunt patients at all but attain  acceptable results.   Heparin is now given intravenously by the anesthesiologist at the sur-  geon’s discretion. Bulldog clamps are placed across the internal carotid  artery, external carotid artery, and common carotid artery in sequence. An  incision then is made on the anterolateral surface of the common carotid  artery just inferior to the bifurcation. Potts scissors then are used to elon-  gate the incision proximally and distally across the area selected for end-  arterectomy (figure 5). Care must be taken to extend the arteriotomy  distally to a point beyond the end of the atheromatous plaque so that the  endarterectomy can be performed entirely under direct vision. T e incision  is carried through the thickened intima into the lumen. T e line of cleavage  is within the media, leaving the adventitia and media externa for closure as    detalls of Procedure If intraluminal shunting is elected  with a Pruitt-Inahara shunt it needs to be flushed and prepped ahead of time.  Heparinized saline is flushed through the irrigating port and hemostats are  placed on the proximal and distal limbs of the shunt directly adjacent to  the irrigating port. T e distal end is inserted first and the balloon is gently  inflated to seal off back bleeding around the shunt (figure 7). T e distal  hemostat is opened and the distal limb aspirated back through the irrigating  limb to remove all air. T e hemostat is reapplied. T e proximal end of the  shunt is then inserted into the common carotid artery and the balloon gently  inflated to prevent any antegrade flow around the shunt (figures 8 and 9).  Overinflation is to be avoided to prevent tearing of the intima or prolaps-  ing of the balloon over the end of the shunt and occluding flow. T e proxi-  mal hemostat is removed and the limb aspirated through the irrigating port  to remove any air or debris. T e aspirating process should be repeated one  more time and the hemostats removed to establish flow through the shunt.  T eshunt is checked with the Doppler probe to check for flow and the end-  arterectomy is then commenced. With experience and planning, placement  of such a shunt should consume no more than 60 to 90 seconds.  Endarterectomy is begun in the distal common carotid artery, using  a Freer elevator, blunt spatula, or a mosquito hemostat. T e appropriate    endarterectomy plane usually is identified easily in the mid to outer  media, leaving a smooth, glistening reddish-brown arterial wall behind  (figure 10).   T is dissection is continued quite carefully in an attempt to elevate the  plaque circumferentially. A blunt-tipped right-angle clamp is of en valu-  able (figure 11). T e plaque then is divided proximally with the Potts  scissors to facilitate exposure. T e endarterectomy proceeds distally in a  meticulous fashion, care being taken to maintain a single endarterectomy  plane. T e most important aspect of the procedure is the delicate feath-  ering of the endarterectomy at the distal boundary of the atheromatous  plaque. No flap or shelf can be tolerated, since a technical fault will result  in dissection af er restoration of prograde flow with subsequent throm-  bosis and probable neurologic catastrophe. Plaque is removed similarly  from the external carotid orifice by eversion endarterectomy allowing  removal of the specimen (figure 12). All residual debris is removed care-  fully with forceps in a circumferential direction. A Kittner sponge also  may be helpful in clearing the field of debris. Heparinized saline is used to  irrigate the field, allowing free removal of clot. Forceful irrigation distally  may reveal elevation of a distal flap that may require attention or tacking    detalls of Procedure Ofen, tacking sutures will be  required to prevent subintimal dissection (figure 14). T ese horizontal mat-  tress sutures of 7/0 polypropylene are placed at intervals circum ferentially, using  double-ended sutures passed from inside out and tied externally (figure 14).   Occasionally a very large artery with a short length of arteriotomy can  be closed primarily, however, patch angioplasty with prosthetic material  (dacron, PTFE, or bovine pericardium) or autologous vein is the preferred  technique for closure. Mattress sutures of double-ended 6/0 polypropyl-  ene are placed at either end (figure 15). Both needles of each end suture  pass through the patch from outside to in and then pass from lumen to the  outside of the carotid artery where the knots are tied (figure 16). T 1s pro-  vides a broad-based loop that anchors the graf. T e inferior or proximal  suture B’ is run superiorly in a continuous manner on the medial side of the  eraf and tied to A’ (figure 16). Sutures A and B are then run toward the  midpoint on the lateral side of the arteriotomy (figure 17). When approxi-  mately 1 cm of arteriotomy remains to be closed in the midportion of the  incision, the balloons are deflated and the shunt is cross clamped with a  straight mosquito hemostat. A brisk inflow and backflow are allowed so  as to flush the area as the two ends of the shunt are removed, first distally,  then proximally (figure 18). T e bulldog clamps are reapplied or the vessel  loops cinched down so as to secure active bleeding. T e remainder of the  arteriotomy then is closed rapidly, with great care being taken to flush the  region of particulate debris and air (figure 18). Following completion of  closure, the clamps are removed in a specific order: external carotid artery,  common carotid artery, and finally internal carotid artery. T is sequence  minimizes the possibility of cerebral embolization, permitting potential  emboli to be flushed into the external carotid system preferentially. T e  completed endarterectomy must have thorough hemostasis and no residual  stenosis (figure 19).    Upon completion, a Doppler or duplex ultrasound study is performed to  verify an unobstructed blood flow. Any suspicion of recurrent thrombosis  is an urgent indication to reopen the arteriotomy and remove the throm-  bus. Finally, many surgeons keep the patient in the operating room until  they awaken without a neurologic deficit. If any neurologic changes are  present, the operative site 1s re-explored immediately.    closure Meticulous hemostasis must be obtained to prevent cervical  hematoma and possible respiratory embarrassment from tracheal compres-  sion. If heparinization has been used, protamine sulfate may be given to  reverse anticoagulation. T e wound is closed in layers, approximating the  sternocleidomastoid muscle and cervical fascia, the platysma, and the skin.  A small closed-suction Silastic drain may be brought out the inferior margin  of the incision at the surgeon’ discretion.    Posto PeratIvecare Bleeding into the wound may occur from exces-  sive anticoagulation, improper hemostasis, seeping from the suture line, or  postoperative hypertension. Tracheal obstruction may occur and requires  endotracheal intubation. Re-exploration of the wound may be indicated for  hematoma evacuation.   T e effects of injury to sensory as well as motor nerves can range from  minor losses in skin sensation to drooping of the corner of the mouth  resulting from injury to the marginal branch of the facial nerve.   T e patient should remain on underphysiologic monitoring and neuro-  logic assessment for the postoperative period. Postoperative hypotension  must be avoided by adequate blood and fluid replacement. Overmedication  and cardiovascular complications must be considered. Likewise, hyperten-  sion is to be avoided because of the danger of an acute stroke or disruption of  the arterial closure. T e patient must be assessed for unimpaired swallowing  prior to self-feeding and discharge. m    IndIcatlIons T e most common indication for creation of an arterio  venous (AV) fistula is renal failure requiring chronic hemodialysis. It 1s  preferable to create a native fistula, although prosthetic material may be  needed if a suitable vein is not available.    Preo Perat Ive PreParatlon T e goal is to place an AV fistula prior  to the patient starting dialysis. T e day of surgery, electrolytes should be  checked to verify the absence of hyperkalemia. Many of the patients are  diabetic and close monitoring of blood glucose levels during the proce  dure is warranted. Antibiotic prophylaxis is administered within | hour of  the incision. A single dose is usually sufficient. In patients with a poorly  defined superficial venous system, venous mapping may be done preopera  tively to define the anatomy.    anestheslIa T e patients requiring chronic hemodialysis are poor risks  for general anesthesia. An axillary block on the side that is to be used pro  vides excellent regional anesthesia. If regional anesthesia cannot be done,  local anesthesia is a valid option.    PosItlIon T epatient is placed in the supine position. T e arm to be used  for the fistula is placed on an arm board (figure 1). T e opposite arm may  be tucked with a sheet or placed on an arm board.    o PeratIve PreParatlon Hair is removed with clippers. T e arm is  prepped circumferentially from the fingers to the axilla. After draping, a  sterile knit stocking 1s placed over the arm. T is covers the fingers and arm  to the axilla (figure 2).    detalls of Procedure T e surgeon palpates the radial pulse. T e  location of the incision is planned (figure 3). A vertical incision 1s made  in the forearm close to the wrist and lateral to the radial pulse (figure 4).  Once the incision is carried to the deep subcutaneous tissue, self retaining  retractors are placed. Sharp and blunt dissection is used to identify the  cephalic vein. T e vein is skeletonized for a distance of 2 to 3 cm. It is encir  cled with vessel loops proximally and distally. Side branches of the vein are  ligated with 4 0 silk (figure 5).T eradial artery is then dissected for a dis  tance of 2to 3cm.T ere isa vein on either side of the radial artery that may  be ligated or freed from the artery. T e artery is encircled with vessel loops  proximally and distally. Side branches are ligated as necessary with 4 0 silk.  Both vessels must be freely mobilized to enable a tension free anastomosis.  T eartery and vein are then encircled with a single vessel loop both proxi  mally and distally to allow alignment of the structures (figur e 6).    A longitudinal venotomy is made in the cephalic vein with a number 11  blade and extended for 1cm with iris scissors. T e vein is dilated to size 3.5  mm and a Silastic catheter is passed cephalad to ensure patency of the vein.  T e vein is irrigated with heparinized saline (figure 7).   T e patient is administered intravenous heparin. Fine curved or straight  bulldog clamps are placed proximally and distally on the radial artery. A  longitudinal arteriotomy of 1cm is made. In some cases the arterial wall may  be much calcified and it will be necessary to probe the artery proximally to  ensure patency. Once patency is established, the proximal bulldog clamp  is reapplied. T e artery and vein are aligned. A side to side anastomosis  is then created between the cephalic vein and radial artery using running  6 0 nonabsorbable monofilament sutures. T e needle on the arterial side  must be passed from the endothelial surface outward, ensuring the endo  thelium is tacked down (figures 8 and 9). Needle B’ (figur e 8) 1s passed  back into the lumen and then run continuously on the back wall—always  beginning into the arterial intima. At the end, it is tied externally to suture  A (figure 10). Needle A’ is passed back into the lumen and then run con  tinuously on the front wall. Once the anastomosis is nearly complete, the  proximal bulldog clamp is released transiently to ensure inf ow and to fush  out any clot. T e distal bulldog is likewise released to ensure back bleeding  and clear any clot and debris (figure 11). T e suture is then tied. T e vessel  loops are released on the vein and the distal and proximal bulldog clamps  are removed from the radial artery. T e vein proximal to the anastomosis  is then palpated for a thrill to determine patency. Absence of a thrill may  indicate a technical problem and the anastomosis should be re explored.  T is is done by making a small venotomy in the cephalic vein distal to the  anastomosis and a dilator is used to explore the anastomosis as well as the  artery and vein. It is important to ligate the cephalic vein distal to the anas  tomosis, usually with double 2 0 silk (figure 12). After ligation, the vessel  is transacted, as this releases any tension on the anastomosis and reduces  the incidence of venous hypertension of the hand. T e presence of a thrill  is reverified. Hemostasis is achieved and the subcutaneous layers are closed  with interrupted 4 0 absorbable suture. T e skin is closed with a running  subcuticular 4 0 absorbable suture. A sterile dressing is then placed.    Posto PeratIveconsIderatlIons T e patient is discharged the day  of the procedure. If needed, dialysis is continued by the temporary access  achieved prior to the operation. Occasionally, a venous side branch creat  ing diversion of f ow may need ligation. It usually takes 6 weeks for the AV  fistula to mature and be ready to be used for hemodialysis. m=    IndIcatlIons T e most common indication is for the administration of  chemotherapy or long-term parenteral nutritional support. For these pur-  poses, a port is usually used. For short-term therapies, alternatives include a  tunneled central venous catheter or a peripherally inserted central catheter  (PICC).    Preo Perat Ive PreParatlon T e procedure is usually performed as  an outpatient. Electrolytes and clotting studies should be checked prior to  the procedure. If the patient has had previous central catheters, a careful  history should be obtained, as this will help with site selection. Transcuta-  neous ultrasound can assist with vein localization. A single dose of preop-  erative antibiotics provides for prophylaxis.    PoslItIon T e patient is placed in the supine position. Fluoroscopy  should be available. T e arms are tucked at each side.    Internal Jugular veln access T e internal jugular vein may be  safer than subclavian venous access. T e internal jugular vein is located pos-  terior to the sternocleidomastoid muscle (figure 1). It is usually accessed  by a percutaneous route. T 1s chapter demonstrates a right internal jugular  cannulation.   Preliminary ultrasound of the right side of the neck is done in order to  document the patency of the internal jugular vein. With real-time ultra-  sound guidance and employing a modified Seldinger technique, a small  incision is made in the skin of the neck with a 15 blade and the internal  jugular vein is cannulated with a small-diameter needle (figure 2a). After  removing the syringe, the surgeon places a f exible guidewire (figure 2b).  T eneedle is removed, and over this wire, a 5-French dilator is placed to cre-  ate a track (figure 3). A3- to 4-cm transverse incision is made on the upper  right thorax two fingerbreadths below the clavicle and a hemostat is passed  to create a tunnel between the two incisions (figur e 4). Blunt dissection 1s  done to create a subcutaneous pocket on top of the pectoralis muscle fascia  for the reservoir (figure 4). T e Silastic catheter is advanced through the    subcutaneous tissues from the upper thoracic subcutaneous pocket to the  neck incision (figure 4). T e 5-French dilator is exchanged over a wire  for an introducer with a peel-away sheath (figure 5). T e dilator and wire  are removed from the introducer. T e Silastic catheter is advanced through  the peel-away sheath (figur e 6) and is positioned under fuoroscopy with  its tip in the right atrium (figure 7). Keeping the catheter in place with a  forceps (figure 6), the sheath is “peeled away” by pulling it apart later-  ally until it is completely split and out. T e catheter is cut to length at the  pocket and the slide-on boot is placed over the catheter. T e catheter 1s  pushed onto the chamber hubs (figure 8a), and the boot is slid down  over the catheter in order to secure its attachment to the hub (figure 8b).  Immediately following placement, each of the ports is aspirated and f ushed  to verify patency. If any resistance is encountered, then obstruction of the  catheter in the vein insertion site, the tunnel, or at the junction of the cath-  eter with the reservoir should be suspected. T ese sites should be inspected.  T e position of the catheter with its tip in the right atrrum should be veri-  fied by fuoroscopy. T e reservoir is then secured with nonabsorbable  monofilament suture to the pectoralis fascia. T e subcutaneous tissues of  the reservoir pocket are closed using interrupted 3-0 absorbable suture. T e  port must be easily palpable, and in very obese patients, the subcutaneous  fat may need to thinned directly above the port. T e skin edges are approx-  imated using a continuous subcuticular 4-0 absorbable suture. T e neck  incision is closed using a single subcuticular 4-0 absorbable suture and the  port is checked for fow in both infusion and aspiration after which it is  loaded with a dilute heparin solution. T e final configuration is shown in  figure 9 and all personnel who access the port must remember to use the  special needles that do not cut or core out a segment of the Silastic access  dome as they are inserted into the port.    alternatlIvely T e central venous system may be accessed via the  subclavian vein as shown in the following Chapter 134, page 512. In this  operation the subclavian skin entrance site is opened a few millimeters and  a tunnel is created with a small hemostat to the port-site pocket. T e sub-  cutaneous fat at the entrance may require some spreading so as to allow the  Silastic catheter to round this corner without an obstructing angulation.  T eremainder of the procedure is the same except for the need to close this  skin incision with a few absorbable subcuticular sutures followed by adhe-  sive skin strips. T e port is then aspirated, checked for free f ow in both  directions, and finally loaded with a dilute heparin solution. m    IndIcatlIons T e most common indication is for the short-term (7—10  days) administration of fluids, electrolytes, antibiotics, or other concen-  trated parenteral medications that are not well tolerated in peripheral veins.  Absence of suitable peripheral veins and patient comfort are alternative  indications, as is the inability to place a peripherally inserted central cath-  eter (PICC).    Preo PeratIve PreParatlon T e procedure may be performed at  the bedside, in the operating room, or in an outpatient ambulatory setting.  Electrolytes and clotting studies should be checked prior to the procedure.  If the patient has had previous central catheters, a careful history should be  obtained, as this will help with site selection. Transcutaneous ultrasound  can assist with vein localization.    PosItlIon T e patient is placed in the supine position, and the arms are  tucked at each side. Fluoroscopy should be available.    o Perat Ive PreParatlon T e hair is removed with clippers. T e cho-  sen side of the neck and upper thorax are prepped and draped using the  maximum sterile barrier technique.    detalls of Procedure figures land 2 show the relevant anatomy of  the subclavian vein. It may be cannulated on the right or the left side. T e  chapter shows cannulation on the right side. On the right, the subclavian  vein courses behind the medial third of the clavicle and joins the internal    jugular vein to drain into the superior vena cava. It lies anterior and inferior  to the subclavian artery. T e dome of the right lung lies behind the vessels.  Ultrasound is used to confrm the patency of the vein and location. T e  same modif ed Seldinger technique is used as described in the preceding  Chapter 133. T e patient is placed in a supine position. A rolled towel or  sheet 1s placed in the interscapular area to allow the shoulder to drop to  the side away from the infraclavicular site (figures | and 3). T e patient is  placed in a 20-degree Trendelenburg position (head down) in order to min-  imize the risk of air embolism and increase the size of the vein. T e head  is turned slightly to the opposite side. After installation of local anesthetic  to include the periosteum of the clavicle, the subclavian vein is cannulated  with a small caliber needle (figure 3). Ultrasound guidance may be used  to provide assistance. A key landmark is the point one fngerbreadth lat-  eral to the junction of the middle and medial thirds of the clavicle. T e  needle is inserted at this point and passed along a straight line toward the  sternoclavicular joint on a plane parallel to the chest wall. A flexible guide-  wire is inserted into the needle (figur e 4), and if any arrhythmia is noted,  the wire is withdrawn until the electrocardiogram returns to its usual pat-  tern. T e position of the wire is fluoroscopically verif ed. T e triple-lumen  catheter is thread over the guidewire (figure 5). Topical antiseptic and a  dry sterile dressing are placed over the entrance site. T e catheter hub and  wings are secured to the chest skin with fne nonabsorbable sutures (fig-  ure 6). A chest x-ray is obtained to verify the position of the catheter and  exclude complications such as a pneumothorax. m    IndIcatIons Aneurysms of the abdominal aorta occurring distal to the  renal arteries should, in general, be replaced. T is is particularly true if they  are enlarging, 5.5 cm or greater in males and 5.3 cm or greater in females,  producing pain or if there is evidence of impending or actual rupture. In  poor-risk patients with small aneurysms less than 5cm in diameter, obser-  vation may be the better course. Many aneurysms are corrected by endo-  vascular techniques, but an open operative approach is acceptable and a  sometime necessary alternative. Although the operation is of considerable  magnitude, anticipated mortality associated with spontaneous rupture and  exsanguination from an aneurysm is such as to warrant the risk of surgery  in the great majority of patients. Emergency operations may offer the only  chance of a patient's survival if there 1s evidence of leakage or rupture of the  aneurysm. A past history of coronary artery disease is not a contraindica-  tion to surgery.    Preo Perat Ive PreParatlon CT scan best defines the size and con-  tour of these aneurysms. Transabdominal ultrasound is a good screening  tool, but CT best defines size and proximal and distal extent. Aortography  is carried out if there is a question about the extent of the aneurysm, if distal  occlusive disease is present, and when renal vascular disease or mesenteric  insufficiency is suspected. A thorough cardiac evaluation with an electro-  cardiogram, echocardiogram, and imaging stress test is performed.   In elective resection of an aneurysm, the preoperative preparation con-  sists of emptying the large intestine by administering a mild cathartic. A  fluid load of “crystalloid” is given at approximately 100 to 150 mL per hour  beginning the evening before operation if the patient is hospitalized. Intra-  venous antibiotic coverage is started 1 hour before the anticipated incision.  A nasogastric tube is inserted, and constant bladder drainage 1s initiated to  follow accurately the hourly output of urine, especially during the immedi-  ate postoperative period. Catheters are placed for central venous and arte-  rial monitoring, while a Swan—Ganz catheter may be useful in complex  cardiac cases.    anestheslIa General anesthesia with endotracheal intubation 1s routine.  T earterial line permits instantaneous evaluation of blood pressure changes,  and blood gas sampling can be done when required. Several large-bore  (16-gauge) catheters should be placed intravenously for adequate control of  fluid and blood replacement, including a central venous line.    PosItlIon T e patient is placed in a slight head-down position to aid  in natural retraction of the small intestine from the region of the lower  abdomen. Intravenous catheters are secured in place in both arms and    adequately protected from dislodgement. T e urethral catheter is connected  to aconstant bladder drainage bottle. Since the presence of pedal pulsations  must be verified before and afer the prosthesis has been inserted, some  type of low support should be provided over the feet and lower third of the  legs to assist in evaluating the presence of arterial pulsations.    IncIsIlon and exPosure A long midline incision is made from  xiphoid to pubis (figure 1). Many surgeons use a large open ring retrac-  tor for exposure. T is retractor is secured to the side rail of the operating  table and allows for the placement of multiple individual curved or angled  adjustable retractors.    detalls of Procedure Af er rapid palpation and visualization of the  aorta and confirmation of the diagnosis of aneurysm, steps are taken to  empty the abdominal cavity of small intestine. Unless the abdominal wall  is quite thick, the greater portion of the small intestine can be retracted  upward and to the right and inserted into a plastic bag, the mouth of which  can be partly constricted by a tape (figur e 2). Saline is added to the plastic  bag to keep the intestine moist. A sterile gauze pad 1s inserted into the neck  of the plastic bag to avoid undue constriction and prevent the escape of the  small intestine from the bag. It may be advisable (if the aneurysm is sizable  and involves the right common iliac) to mobilize the appendix, terminal  ileum, and cecum and to retract the right colon upward. T e small and  large bowels are retracted laterally and superiorly using multiple adjustable  retractors. Additional exposure can be gained by dividing the peritoneum  about the ligament of Treitz to permit further retraction of the small intes-  tine upward and to the right (figure 2). In thinner individuals, the small  intestine may be tucked within the right side of the abdomen to minimize  heat loss. What at first may appear to be an inoperable aneurysm eventually  may prove to be rather easily resectable, since the aneurysm tends to bulge  anteriorly and seems to extend up so high as to suggest involvement of the  renal vessels (figure 3). T e bulk of the aneurysm tends to come forward  from under the lef renal vein. T e incised peritoneum over the anterior  surface of the aneurysm is reflected by blunt and sharp dissection until the  lef renal vein is visualized. Blunt and sharp dissection frees the lef renal  vein from the underlying aorta (figure 4). T e lef renal vein is retracted  upward with a vein retractor (figure 5) to gain additional space for the  application of the occluding clamp to the aorta above the aneurysm. T e  lef renal vein can be divided, if necessary, to gain the final exposure. It does  not need to be reanastomosed if the adrenal and gonadal vessel veins are    detalls of Procedure T e inferior mesenteric artery  is clamped (figure 6). T e aortic side may be divided and ligated from  without or, more commonly, oversewn from within af er the aneurysm is  opened. Usually, this vessel is small and sclerotic, in which case its sacrifice  is of little consequence. In some instances, it is large and serves as a major  contributor to the lef colon blood supply, especially if internal iliac and  mesenteric occlusive disease is present. In such cases the vessel will be pat-  ent but will not exhibit back bleeding. Reimplantation of this vessel into the  aortic graf may be required to protect the colon.   T e common iliac arteries then are exposed on their anterior, lateral,  and medial surfaces in preparation for clamp placement. It is not necessary  to encircle these vessels completely, and dissection posteriorly can result  in troublesome hemorrhage from the underlying iliac veins. During the  iliac artery exposure the ureters are identified and protected from injury  throughout the procedure (figure 6).   In the past, certain graf s required preclotting; however, this is not nec-  essary with woven graf s, knitted grafs sealed with collagen or gelatin, or  expanded polytetrafluoroethylene graf s.    Heparin is then injected systemically to provide protective anticoagula-  tion for the extremities during aortic clamping.   Angled vascular clamps are applied to the distal common iliac arteries.  An aortic clamp is used to occlude the aorta proximal to the aneurysm  and distal to the renal arteries. A careful identification of the position of  the renal arteries is mandatory before clamp application. T e aneurysm 1s  then opened through a linear arteriotomy (figure 7). T e mural throm-  bus is extracted (figure 8). Bleeding from the paired lumbar arteries is  controlled with full-thickness mattress or figure-of-eight nonabsorbable  suture ligatures (figure 9). T e aortic cuff is next prepared by dividing  all but the posterior wall. Leaving this portion attached prevents trouble-  some bleeding from lumbar veins of en found in this area (figure 10).  T e iliac arteries are prepared in similar fashion; the posterior wall is  undisturbed to protect the iliac veins (figure 10). Alternatively, some  surgeons prefer to completely transect the proximal aorta and the dis-  tal iliac arteries so as to provide free circumferential cuffs for graf    detalls of Procedure A graf of appropriate size is then  stretched and tailored to fit the aortic defect (figure 11). Suturing of the  graf begins in the midline posteriorly with a double-arm swedged 00 or  000 nonabsorbable suture usually made of monofilament nylon or poly-  propylene. T e initial stitch begins by passing both needles from outside  inward on the graf and from inside outward on the aorta. T is suture is  then tied (figure 12). Over-and-over suturing is then carried from the  midline position, proceeding from outside inward on the graf to inside  outward on the aorta. At the midline anteriorly, this suture is again tied  (figure 13).    Vascular clamps are temporarily applied to the iliac limbs of the graf ,  and the aortic clamp is momentarily released to check the proximal suture  line for hemostasis and the preclotting of the graf. Should leaks be noted  in the anastomosis, they can be controlled by individual mattress sutures.   T e iliac anastomoses are done in the same manner as that of the aorta  (figure 14). Just before completion of the anastomosis, the aortic clamp is  opened momentarily to flush any clots that may have accumulated in the  aorta or graf (figure 15). T is flushing out greatly lessens the incidence  of subsequent thrombosis in either extremity and justifies a modest loss of    detalls of Procedure T e clamp is closed and the  suture line completed and tied. T e completed limb is occluded by finger  control, and the aortic clamp is removed slowly. Blood flow is gradually  reestablished to the limb to prevent hypotension (figure 16). Flow should  be established first to the hypogastric artery to minimize the risk of distal  embolization. Close coordination between the surgeon and anesthesiolo-  gist 1s required at this point so that the rate of opening the graf is compen-  sated by fluids and blood administration with maintenance of stable blood  pressure.   T e other iliac anastomosis 1s carried out in similar fashion (figure 17).  T e aneurysm sac, if adequate, is closed over the graf with a running  suture (figure 18). If at all possible, closure of the proximal aneurysmal sac  should cover the aortic anastomosis so as to provide tissue between it and  the duodenum. Alternatively, some surgeons tuck a segment of omentum  in this region. T e posterior peritoneum 1s reapproximated, with care taken  not to injure the ureters.   In the presence of occlusive disease of the common iliac in addition  to the aneurysm, the common iliac may be divided and oversewn with  a continuous suture (figure 19) on both sides following removal of the  aneurysm. T e graf is tailored to permit anastomosis of the aorta above  the aneurysm with end-to-side anastomosis to the external iliacs beyond  the points of stenosis (figure 20). T is bypass procedure makes exten-  sive endarterectomy unnecessary and prevents sacrifice of the hypogastric  arteries, which are important in maintaining colonic viability.    closure T esmall intestine is returned to the peritoneal cavity from the  plastic bag, and the peritoneal cavity is cleared of blood clots and sponges.  Before closure, particular attention is given to the adequacy of the blood  supply to the sigmoid. Ordinarily, the blood supply is adequate af er liga-  tion of the inferior mesenteric artery, but occasionally reimplantation into  the graf or bypass of the inferior mesenteric artery with saphenous vein    may be necessary to preserve the viability of the lef colon and rectum.  Evidence of bleeding from the prosthesis or at the site of anastomosis is  thoroughly searched for before the closure is finally completed. T e femoral  vessels should be palpated from time to time to ensure that thrombosis has  not occurred and that a good flow of blood is going through to the lower  extremities. In case of doubt it may be necessary to reexplore one or both  sides and remove any blood clots that are found. Routine abdominal clo-  sure is done.    Posto PeratIve care Postoperative care usually is provided in an  intensive care unit for the first 24 to 48 hours. In the postoperative period  it is particularly important to ensure that there is a good blood supply to  the lower extremities and a good hourly output of urine. Blood should be  given until all major blood loss has been replaced, and the blood pres-  sure is satisfactory. T e use of a cell saver system during surgery should  lessen this need for blood replacement. Intravenous fluids are administered  slowly during the first 24 hours to ensure a steady output of urine from the  indwelling catheter. T e presence or absence of pulsation in the dorsalis  pedis arteries should be recorded. Confirmation may be difficult at first,  but the pulsations usually become more apparent later in the postoperative  period. If pulsations are absent and there is a cold extremity, thrombosis  may have occurred, and reexploration and removal of the blood clot should  be considered.   Cardiac monitoring and daily laboratory studies to evaluate the blood  volume and kidney function are performed until the convalescence becomes  uneventful. A tendency to paralytic ileus should be combatted by gastric  suction until there is evidence that peristalsis has returned. Renal failure  should be suspected if there has been preoperative evidence of impaired  renal function or if there has been a prolonged period of hypotension.   If adequate hourly output of urine is not maintained despite an adequate  intake, anuria should be suspected and appropriate therapy instituted. m    IndIcatlIons Only patients with severe and debilitating occlusive dis-  ease of the aortoiliac segment should be considered for surgery. Initial  management of aortoiliac occlusive disease is often via endovascular meth-  ods. In general, these patients will have claudication that is progressing  or disabling. Patients with rest pain, ulceration, or gangrene may require  surgery to preserve limb function. T ese patients are generally elderly and  have associated generalized atherosclerosis with a high incidence of coro-  nary artery disease and hypertension. In addition, the majority are long-  time smokers, and it is not unusual for them to have impaired pulmonary  function. T e risks associated with these comorbidities must be carefully  weighed against the benefits expected from a successful surgical procedure.  T ecareful selection of patients is of the utmost importance.    IncIslon and exPosure A midline incision is made from the  xiphoid to the pubis to afford maximum exposure (figure 1). Te  abdomen is explored for the presence of other pathology, and the intra-  abdominal arterial tree is carefully assessed. figure 2 demonstrates  typical aortoiliac occlusive disease. T e aorta is exposed by entering  the retroperitoneal space. T e posterior peritoneum is divided, and the  fourth portion of the duodenum is mobilized until the renal vein is iden-  tified. Sharp and blunt dissection is used to clear the aorta on its anterior,    lateral, and medial surfaces (figure 3). It is usually not necessary to  encircle the aorta or to free it completely; this often leads to troublesome  bleeding from lumbar arteries and veins. In addition, if the left renal  vein is not visualized, 1t may lie behind the aorta and be injured by such  a dissection.    detalls of Procedure An aortic clamp is used to clamp the aorta  proximally just below the renal arteries (figure 4). A second aortic clamp  is placed tangentially to occlude the iliac vessels and the lumbar arteries, as  depicted in figures 4 and 5. It is important to have the distal aorta freed  sufficiently so that this clamp can be placed far posteriorly to avoid inter-  ference with the arteriotomy and the anastomosis. A small vascular clamp  should be applied to the inferior mesenteric artery, close to its origin, so as  not to impair collateral circulation to the left colon. A linear arteriotomy is  made in the aorta to a point just above the inferior mesentery artery takeoff  (figure 5). An attempt is made to preserve that vessel if at all possible.  T e graft is beveled (figure 6a), and an end-to-side anastomosis is then  created (figures 6b, 7 to 9) with a running 3-0 monofilament vascular  suture much as described in Chapter 135.T e running suture then is carried  around each side of the arteriotomy, and finally the anastomosis is com-  pleted in the middle of the arteriotomy.    alternatIvetechnIque Many vascular surgeons prefer a direct end-  of-aorta to end-of-graft (“end-to-end”’) proximal anastomosis. In this tech-  nique, the aorta is dissected free circumferentially at the same level below  the renal arteries and proximal to the lumbar vessels. A pair of vascular  clamps are applied, one distal to the renal arteries and one on the distal  aorta, and the aorta is transected below the proximal clamp, leaving an ade-  quate cuff for anastomosis proximally while oversewing the distal cuff with  a 3-0 monofilament vascular suture.    detalls of Procedure A linear incision 1s made in each  groin over the femoral artery (figure 10), and the common femoral, the  profunda femoris, and the superficial femoral artery are carefully isolated.  It is important to dissect at least several centimeters of the profunda femo-  ris to evaluate the presence of disease in this vessel, especially if indicated  on preoperative imaging. If it is significantly involved, profunda endar-  terectomy or a profundoplasty should be considered, because this proce-  dure appears to increase the longevity of graft function, especially if it 1s  the main runoff vessel. A retroperitoneal tunnel is then made overlying the  iliac artery and extending into the femoral incision (figure 10) by blunt  finger dissection from above as well as from below, under the inguinal liga-  ment. It is important to make this tunnel directly on top of the artery so that  the ureter does not become entrapped or injured. Care should be given to  anterior displacement of the ureter so that after the procedure it will overlie  the prosthetic graft. Finally, it is important to remember that all of the dis-  sections, aortic and femoral, and tunneling should be completed before the  patient is systemically heparinized.   T e graft is pulled into the groin incision through the previously created  tunnel, taking care not to twist the limbs (figur e 11). Vascular clamps have  been gently placed on the common femoral, the profunda femoris, and the  superficial femoral arteries (figur e 12), and the linear arteriotomy is made.  Stay sutures may be placed to retract the edges of the artery if necessary. It  is not necessary to excise a button of artery wall. T e slack is removed from  the graft and the end is beveled to match the arteriotomy (figure 13).    T e anastomosis is carried out in the same manner as the upper end-  to-side anastomosis of the graft to the aorta, typically with 5-0 or 6-0  monofilament vascular suture (figures 14 and 15). Just before completion  of the femoral anastomosis, a clamp is placed on the origin of the opposite  iliac limb of the graft. T e aortic clamp is opened momentarily to allow  any thrombus and debris to be fushed out from the graft (figure 16).  T eclamp is replaced and the femoral anastomosis is completed. T en the  aortic clamp is removed, with digital compression of the graft in order to  ensure gradual increased f ow to the limb (figure 17). T e limb is allowed  to slowly reperfuse so that hypotension does not occur, much as was out-  lined in the aortic aneurysm procedure. A similar procedure is followed  in completing the anastomosis of the graft to the contralateral common  femoral artery.    closure T e incisions are closed in the routine manner. T e retroperi-  toneum 1s closed over the entire graft with absorbable suture to protect the  eraft from the intra-abdominal organs, and especially the duodenum. If the  retroperitoneum is inadequate for closure, omentum should be mobilized  and brought through the transverse mesocolon. It 1s then tacked to the ret-  roperitoneum over the graft. A running (0 or #1) monofilament suture with  large wide bites is used for the midline incision, whereas the groin incisions  are closed in layers with absorbable sutures.    IndIcatlIons Acute mesenteric fischemia may develop on top on  chronic mesenteric ischemia due to an underlying atherosclerotic lesion,  but may also occur de novo due to an embolic event. Typically this is a  result of cardiac dysfunction, including acute MI, cardiac aneurysm, and  dysrhythmia. T e usual presentation is “pain out of proportion to physical  findings,’ where the patient complains of the worst abdominal pain they  have ever had, but physical examination elicits a soft abdomen with no  discrete tender areas. Acute mesenteric ischemia is a surgical emergency  where time is of the essence to avoid full-thickness bowel necrosis and  even death.    Preo Perat Ive PreParatlIon Diagnosis is often made on computed  tomographic angiography (CTA) where lack of contrast 1s noted in one  or more of the mesenteric vessels. T e superior mesenteric artery is the  most commonly affected, and often the thrombus lodges at the site of  the first branch. T e arteries should be surveyed for any signs of atheroscle-  rosis and the bowel examined for any thickening, implying early ischemia  or evidence of full-thickness necrosis. As soon as a diagnosis is made, intra-  venous heparin bolus should be administered and arrangements are made  for transfer to the operative suite made. Meanwhile, the patient should be  hydrated, given prophylactic antibiotics, and hemodynamically monitored.    anesthesIa General anesthesia is employed with meticulous attention  to hemodynamic monitoring.    PosltIon T e patient is positioned supine on the operating table and  the entire abdomen and anteromedial thighs should be prepared and  draped, in case saphenous vein be needed for mesenteric bypass. Some  prefer to “frog leg” the patient so that the medial thigh is more accessible.  A nasogastric tube is inserted and left in place at the completion of the  procedure.    Procedural detalls A vertical midline abdominal incision is made.  T e abdomen is explored and note made of any area of ischemia of the  bowel or other organs. T e small bowel is eviscerated to the right and the  root of the mesentery palpated for the presence of a pulse (figure la). In  figure lb the relevant anatomy is illustrated. T e superior mesenteric  artery 1s exposed by dissecting parallel to it within the base of the mesentery.  A self-retaining retractor is used for exposure purposes. Mesenteric venous  branches and lymphatics are carefully ligated and divided. Silastic vessel  loops are placed around the artery proximally, near the takeoff from the  aorta, and distally, as well as on any side branches which should all be pre-  served (figure 2). Depending on the status of anticoagulation, additional  IV heparin may be given.   If the source of acute mesenteric ischemia 1s felt to be a more proximal,  embolic source, then the artery may be opened transversely, so that clo-  sure is accomplished more rapidly and patch angioplasty closure avoided  (figure 3a). Ifthe etiology is thought to be thrombosis due to underlying  atheroscleroticplaque, then alongitudinalincision ispreferred(figur e3b),  in order to perform endarterectomy or a bypass if necessary. Once the  transverse arteriotomy is made, an appropriately sized Fogarty catheter  (usually a 3 mm, but 2 mm or 4 mm may be used as well, depending on  the size of the native vessel) is passed proximally and distally until throm-  bus removal is complete (figure 4). T ere should be pulsatile inf ow and  adequate back bleeding. T e Silastic vessel loops are brief y loosened, first  distally and then proximally to verify blood fow. T e artery is fushed  antegrade and retrograde with heparinized saline solution (figure 5).  T e transverse arteriotomy is closed using interrupted 6-0 polypropylene  sutures and the clamps/Silastic loops are removed in order to restore distal  fow (figure 6). T e bowel is reinspected throughout its entirety and any  portions that are nonviable are resected; typically plans are made for a sec-  ond look laparotomy the next day to reassess the remaining intestine. m=    IndIcatIons Only patients with severe and debilitating occlusive dis-  ease of a unilateral aortoiliac segment should be considered for femorofem-  oral bypass. Today, endovascular angioplasty and stenting have reduced the  indications for both aortofemoral bypass and femorofemoral bypasses, but  there remains the occasional patient in whom bypass 1s the preferred treat-  ment. Not all patients with a long-standing unilateral aortoiliac occlusion  can be recannulated by endovascular techniques. In those patients where  recannulation cannot be accomplished, femorofemoral bypass may be the  preferred operative option. T e contralateral, or donor aortoiliac segment  should be free of occlusive disease. In the case where there is occlusive  disease on the donor side, balloon angioplasty and stenting may need to  be performed first to assure adequate inflow. Unilateral claudication is the  leading indication for femorofemoral bypass, but occasionally rest pain,  ulceration and gangrene may be the indication especially in the presence  of significant comorbidities in the elderly. In younger patients with unilat-  eral claudication, femorofemoral bypass may be preferred over the more  durable aortofemoral bypass to eliminate the risk of retrograde ejaculation  in those patients desiring children. While the younger patients are gener-  ally healthier and the operation is less invasive than aortofemoral bypass,  the long-term patency is reduced and these factors need to be considered  in the decision making. Elderly patients may still have generalized arterio-  sclerosis, including coronary artery disease and hypertension, and careful  selection remains important.    Preo Perat Ive PreParatlIon T e anatomy is best defined by con-  trast angiography, CTA or MRA (figure 1) and the final reconstruction is  shown in figure 2. Medical clearance is obtained as indicated. Intravenous  antibiotic coverage 1s started on call to the operating room.    anestheslIa Regional epidural anesthesia is most commonly used, but  general anesthesia may be preferred by the patient or anesthesiologist.    detalls of Procedure A linear incision is made in each groin over  the femoral artery and the common femoral, the profunda femoris, and the  superficial femoral artery are carefully isolated and encircled with Silastic  vessel loops for control. It is important to dissect at least several centime-  ters of the profunda femoris to evaluate the presence of disease in this vessel,  especially if indicated on preoperative imaging. If it is significantly involved,  profunda endarterectomy or a profundoplasty should be considered, because    this procedure appears to increase the longevity of graft function, espe-  cially if it is the main runof vessel. Prior to giving heparin, a suprapubic  subcutaneous tunnel is started with gentle subcutaneous finger dissection  (figure 3) in both groins. A tunneling device then joins the 2 groin inci-  sions and a Penrose drain is pulled through to secure the passageway. From  the suprapubic position the tunnel must form a gentle curve to each groin  to avoid kinking of the graft when it is pulled into place by too acute of  an angle. Generally the graft is sutured to the common femoral artery and  extended toward the profunda femoris as needed. However, in some cases  the common femoral artery does not extend far enough below the inguinal  ligament to allowing suturing, and the arteriotomy is made on the profunda  femoris or superficial femoral artery to avoid kinking as well.   Generally an 8-mm ringed Dacron or PTFE graft is used as the conduit  and brought onto the field. Following adequate heparinization, tension is  placed on the vessel loops in the donor groin to stop flow and the arteriotomy  made with an llor 15 blade and extended with Potts scissors. T e graft 1s bev-  eled as shown in Chapter 136, figure 12 and is sutured into place with 5-0  or 6-0 polypropylene as shown in the succeeding figures 13 to 15. Separate  sutures are started in the heel and toe of the anastomosis, flushed to evacuate  air and debris and completed. A noncrushing vascular clamp is applied to  the graft just proximal to the suture line and flow is restored to the leg and  hemostasis obtained. T e end of the Penrose drain in the contralateral groin  is grasp with the graft passer and the graft passer is pulled into the opposite  eroin. T e end of the newly attached graft is grasp and pulled into the con-  tralateral groin (figur e 4). Again acute angulation is avoided. T e vessels in  this groin are then occluded by gentle traction on the vessel loops, the site for  arteriotomy chosen. Generally the common femoral artery is the preferred  site with extension to the profunda femoris artery. Gentle traction is applied  to the graft to remove redundancy and the graft is cut to appropriate length  and beveled (figure 4). T e graft is anastomosed in a similar fashion as  done in the opposite groin with 5-0 or 6-0 polypropylene (figur es Sand 6).  All vessels are back bled and the graft flushed prior to completion of the  suture line (figures 7and 8). T e suture line is completed and flow restored  to the leg. Once hemostasis is complete, the groins are closed with absorb-  able suture in layers with a subcuticular skin closure.    Posto Perat Ive care Postoperative care is generally provided on the  general vascular surgery floor and intensive care 1s not required. T e patient  is discharged on the first or the second postoperative day. m    IndIcatlIons Surgical bypass of the femoropopliteal segment 1s reser ved  for patients with severe claudication or impending limb loss manifested  by ischemic rest pain or tissue necrosis. Often the first-line treatment is via  endovascular techniques. Typically, such patients have generalized athero-  sclerosis and a high incidence of significant coronary artery or extracranial  carotid artery occlusive disease. Multiple risk factors—including cigarette  smoking, hypertension, diabetes mellitus, and hyperlipidemia—can be  identified in the majority. Careful selection of candidates for operation is of  utmost importance, weighing the expected benefit against the potential risk.    Preo Perat Ive PreParatlon Catheter-based aortography or com-  puted tomographic angiography with full evaluation of the distal runoff is  mandatory to identify and exclude more proximal occlusive disease and to  ensure adequate distal runoff. Noninvasive vascular laboratory studies—  including duplex ultrasound scanning, segmental limb pressures and seg-  mental limb plethysmography—aid accurate physiologic assessment and  serve as a baseline for estimation of the response to therapy. Preoperative  saphenous vein mapping with duplex ultrasound is the preferred method  for assessment of the vein. It demonstrates the patency and anatomy of the  saphenous vein, as it 1s prone to variation, double systems, or unexpectedly  large perforating connectors.   Careful assessment of cardiopulmonary function is most important. An  electrocardiogram and chest x-ray are obtained and further investigations  may be prompted by the history or physical examination. Cardiac evalua-  tion with an echocardiogram or a radionuclide imaging stress test may be  prudent in order to risk stratify patients, as may be pulmonary function  studies. Further investigation may be prompted by history, physical exam1-  nation, or these initial studies. Immediately preceding operation, catheters  are placed for monitoring the central venous pressure, arterial pressure, and  urinary output. Prophylactic antibiotic therapy is begun before operation  and continued for 24 hours. T e groin and lower extremity hair is clipped  in the preoperative prep area.    anestheslIa General or regional anesthesia is employed with careful  attention given to maintaining satisfactory hemodynamic parameters.    PoslItIon T e patient is placed supine on the operating table.    the extremity. T e foot is placed in a clear plastic Lahey bag (figure 1)  after which a clear occlusive drape may be applied to the skin with special  care anteromedially over the areas of planned incision. If the contralateral  greater saphenous vein is to be used as the graft, the opposite extremity  must be prepared in a similar fashion. Any question concerning the ade-  quacy of infow from the aortoiliac segment should have already been  addressed with concomitant or previous inf ow procedure.    IncIslonandexPosure T einitial incision, which follows the course  of the greater saphenous vein (figure 1), 1s made vertically across the  inguinal crease, and early identification is made of the greater saphenous  vein at the fossa ovalis. Dissection is continued distally in a progressive  fashion to expose the entire length of vein required for the bypass. Alter-  natively, multiple incisions with intervening skin bridges may be elected.  T e creation of large skin faps must be avoided to prevent skin necro-  sis and serious wound problems. After exposure of a suitable length of  saphenous vein (figure 2), the venous tributaries are ligated and divided  between 4-0 silk ties and clips (figure 3). Flow is maintained with both  ends intact as tributaries are ligated. Precautions are taken not to gather  venous adventitia by ligating these tributaries excessively close to the  vein wall, which will result in stenosis of the bypass graft (figure 4).  T e vein should be kept in situ with f ow maintained until just before the  bypass graft is to be performed. After the saphenous vein is removed, a  ball-tipped needle is inserted into the distal lumen (figure 5) to permit  fushing and distention during graft preparation (figure 6). T e proxi-  mal vein is then clamped gently with a bulldog clamp, and the vein is  distended gently with heparinized saline. T 1s maneuver may reveal leaks  resulting from division of unidentified tributaries and stenotic areas that  may require attention. Overdistention by forceful irrigation is avoided, as  this may irreversibly damage the vein graft. At the completion of vein dis-  tention, an ink line is drawn down the graft to help avoid twisting the seg-  ment as it is brought through the tunnel later in the procedure (figure 7).  T e graft is temporarily placed in dilute Papaverine solution to maintain  vasodilation and to keep the graft moist. T e femoral arterial exposure 1s  performed as for aortofemoral bypass grafting with vessel loops passed  around the common femoral artery proximally, and the profunda femoris  and the superficial femoral arteries distally (figure 8). Care is taken to  ligate the overlying lymphatic tissue to prevent formation of a lymphocele    IncIslon and exPosure T e distal popliteal artery is  exposed immediately above the medial knee or below the knee, posterior  to the tibia (depending on the distal target vessel). T 1s is done below the  knee by opening the fascial compartment and retracting the gastrocnemius  and soleus muscles posteriorly and entering the popliteal space. Insertion  of a self-retaining retractor greatly facilitates the exposure (figure 9).T e  popliteal artery is identified medial to the posterior tibial nerve and the  popliteal vein. Often, the popliteal vein, which may be duplicated, must be  mobilized in order to get to the more lateral artery. It 1s carefully dissected    free over a distance of 4 to 5cm (figure 10), controlling any small branches  with double loops of silk ties, vessels loops, or temporarily applied clips.  Vessel loops are then passed around the vessel proximally and distally to  elevate the vessel and improve exposure (figure 11). To tunnel to the below  knee incision, the proximal popliteal space then is entered above the knee  by incising the fascia anterior to the sartorius muscle. T e graft tunnel is  developed by blunt finger dissection (figure 12) or a tunneling instrument  behind the knee in the anatomic plane. A Penrose drain is placed to tempo-  rarily mark the tract.    IncIslon and exPosure A tunnel is fashioned from the  femoral incision through to the proximal popliteal space by similar blunt  dissection in the subsartorial muscle plane. T ese tunnels are temporarily  marked with Penrose drains (figure 13).   T e patient is systemically anticoagulated with heparin. T e femoral  artery at the site chosen for anastomosis is occluded proximally and dis-  tally. T e arteriotomy site is carefully chosen to avoid significant disease or  a decision is made to perform an endarterectomy with possible patch angio-  plasty. T e artery is incised with a small-bladed knife and the arteriotomy    completed with Potts scissors (figure 14). T e vein is reversed and the dis-  tal end of the saphenous vein graft is then tailored to match the femoral  arteriotomy. T e vein is incised longitudinally (figur e 15), and the edges of  the tips are removed to create a “cobra-head” tip (figure 16). T e anasto-  mosis is started with a double ended 6-0 polypropylene suture at the heel of  the graft (figure 17). T e anastomosis is then created by running one end of  the suture toward the sidepoint of the anastomosis, using a running continu-  ous technique proceeding from outside-in on the vein and inside-out on the  artery to avoid elevating an intimal fap (figures 18 and 19).    IncIsIon and exPosure T e other suture end is then When the anastomosis is completed, the graft is tested by releasing the  run around the opposite direction. (figure 20). One method isto suture — proximal femoral control and fushing the graft first. Any significant suture  down the toe of the graft with a horizontal mattress suture (figure 21). line bleeding can be repaired at this time. Blood fow can be restored to    T e anastomosis is completed by carefully running one suture all the way — the profunda femoris and superficial femoral artery as well. Next any bleed-  around to meet the other end at its midpoint position (figure 22).T etwo ing from venous side branches can be repaired at this time with 7-0 poly-  suture ends are tied together (figure 23). propylene suture (figure 24).    IncIslon and exPosure T e graft is brought through the  previously made subsartorial tunnel, with great care being taken to avoid  kinking or twisting of the graft. If the distal target vessel is below the knee,  the graft is further tunneled through the popliteal space in the previously  created tunnel. T e leg must be straightened to ensure that the length of the  graft 1s adequate and the tension appropriate when crossing the knee joint  (figure 25). T e popliteal artery is now cross-clamped, and an arteriotomy  is performed in the usual manner (figure 26. T e anastomosis is then per-  formed in a similar fashion as to the proximal (figures 27 and 28) (Prior  to completion, an appropriately sized dilator is carefully passed through  the toe of the graft into the native artery to ensure patency. If there is any  technical problem, the anastomosis is taken down and redone). Flushing  maneuvers are performed immediately before completion, including back  bleeding of the distal arterial tree (figure 29). T e completed femoropop-  liteal reconstruction should lie comfortably within its tunnel with no ten-  sion, twisting, or kinking (figure 30).   Careful palpation for pulsation of the vein graft distally and the artery  distal to the popliteal anastomosis is performed to confirm patency.  Completion arteriography should be performed via a butterfy needle  introduced into the saphenous vein graft with injection of 15 to 25 mL of  contrast over 5 seconds. Routine arteriography confirms a technically  perfect reconstruction and provides accurate assessment of the graft  runoff. Any defects must be corrected if a successful outcome is to be  expected. Pedal pulses should be documented by Doppler or palpable for  postoperative comparison.    closure Meticulous hemostasis must be attained. Anticoagulation may  be reversed with protamine sulfate if required by continued oozing. T e  incisions are then closed in layers in the usual fashion. Skin staples are typi-  cally utilized. Dry sterile dressings are employed.    Posto Perat Ive care T ecardiopulmonary status must be observed  carefully and often in an intensive care setting. Postoperative cardiac  events are the most common medical complication. Distal pulses should  be assessed hourly for the first 24 hours and subsequently at regular inter-  vals. Antiplatelet therapy is begun soon in the postop period and continued  after discharge. T e patients begin ambulation on the day after surgery and  many can be discharged home within 2 to 3 days typically. Special attention  is given to the care of the feet. All efforts should be directed to control-  ling risk factors, such as smoking, and careful postoperative follow-up is  imperative to enhance long-term benefit.   Noninvasive vascular laboratory testing in the postoperative period  is valuable to assess hemodynamic improvement and the success of the  bypass procedure. Graft occlusion can be manifested by loss of pulses, pal-  lor, pain, paresthesias, and loss of function. If noninvasive testing is found  to be unexpectedly abnormal, duplex imaging or angiography may be help-  ful to verify occlusion or technical problem in order to revise the surgery  in a timely fashion. After discharge, patients are monitored in 3, 6, 9, and  12 months intervals during the first year with duplex imaging of the graft to  assess for stenotic areas at the proximal and distal anastomoses, as well as in  the body of the graft at sclerotic valves. If identified, these areas may require  revision to prolong the patency of the graft. =    IndIcatlIons_ Infrainguinal arterial bypass procedures may be indicated  in patients with critical limb ischemia, including rest pain, tissue loss such  as gangrene of the toes or ulceration of the foot or ankle, or with progres-  sive, severe claudication. Compared to bypass procedures using either a  synthetic graft or a reversed autogenous saphenous vein, the use of the in  situ saphenous vein technique 1s preferred by some surgeons. Currently,  there are no significant differences in patency rates between the in situ  and reversed vein grafts. Hence, the choice 1s largely a matter of surgeon  preference. In addition, this technique may be preferred when the distal  anastomosis is to the tibial and peroneal arteries. T 1s is because the vein  size tapers in the anatomic direction, in contrast to reversed vein grafts.  T e taper results in a more well-matched anastomosis as the sizes are more  comparable, and potentially in improved hemodynamic flow. It is believed  that all these factors contribute to the improved results over prosthetic  material for a biologically living bypass graft whose natural lining is not  thrombogenic.    Preo Perat Ive PreParatlIon Most patients are older and have gen-  eralized arteriosclerotic cardiovascular disease. A general medical assess-  ment is necessary, with special attention being given to associated risk  factors such as diabetes and smoking. Cardiopulmonary function should  be assessed with a chest x-ray, electrocardiography, and additional studies  as indicated while the patient’ overall condition is optimized.   Segmental Doppler pressures and waveforms are useful in evaluating  the extent of the arterial disease and serve as baseline for postoperative  studies to document improvement. However, most surgeons believe that  the best evaluation is obtained with contrast angiogram, either computed  tomography or digital subtraction. Visualization from the aorta to the foot  is essential so as to evaluate any possible obstruction of inflow, the levels  of occlusion, and the suitability of target arteries in the lower leg, ankle, or  foot. Venous mapping with duplex ultrasound is the preferred method for  assessment of the saphenous vein. It demonstrates the patency and anatomy  of the saphenous vein, as it is prone to variation, duplication, and unexpect-  edly large perforating connectors.    anesthesIa General or regional anesthesia may be used while hemody-  namic parameters are monitored carefully.    PoslItlIon T e patient is placed supine on the operating table.    o PeratIve PreParatlIon T e lower abdomen and entire leg are pre-  pared with the usual antiseptic solutions. T e sterile drapes are applied so  as to allow access to the entire leg. Gangrenous toes or a foot ulcer should  be enclosed in a sterile, impervious plastic wrap or bag.    detalls of Procedure A two-team approach may be used to prepare  both groin and ankle incisions simultaneously, but a single-team procedure  will be presented. figure | shows the femoral incision site for exposure of  the proximal termination of the saphenous vein and the femoral artery and  its branches. Two ankle incisions are shown for a planned in situ bypass to  the posterior tibial artery. A slightly curved incision is made just anterior to    the medial condyle for the vein whereas a secondary posterior one is made  for the posterior tibial artery. Additional short incisions will be made later  along the vein sites for the division of major side branches of the saphenous  vein as determined by venogram and ultrasound after arterial inflation of  the in situ graft.   A proximal incision is made to expose the common femoral, superficial  femoral, and profunda femoris arteries. T e region for proximal arterial  takeoff of the graft is chosen, and Silastic loops are placed around each  artery (figure 2). T e greater saphenous vein is dissected back to the fossa  ovalis. T e medial circumflex iliac artery lies at the lower margin of the  fossa ovalis and consequently is a reliable anatomic reference to the saphe-  nofemoral junction just above it. T e proximal saphenous vein is exposed,  and 2-0 silk ligatures are tied around each branch (figure 3), including  the fairly large and constant superficial epigastric (c), superficial external  pudendal (d), medial and lateral superficial circumflex iliacs (a and b), and  the medial superficial femoral cutaneous vein (e). T e superficial or Scar-  pa’ fascia of the fossa ovalis is incised to allow complete exposure of the  saphenofemoral venous junction. T is junction is usually just at the level of  the profunda artery.   T e end of the saphenous vein is exposed in the distal incision as is the  chosen area of the posterior tibial artery (figure 4). Next the patient is  given systemic heparin. T e vein is transected distally with an adequate  length to reach the arterial site. A venogram catheter is inserted into the cut  end of the saphenous vein (figure 4) and a retrograde on-table venogram  is obtained. Side branches are marked on the leg (figure 5). T 1s process  can be assisted by the use of a disposable ruler tape on the leg.   T e proximal end of the saphenous vein is next evaluated for suf cient  length to reach the planned anastomotic site on the femoral artery. Ordi-  narily, a Satinsky curved vascular clamp is applied to the saphenous side  of the junction. A small cuff of saphenous vein is left above the clamp for  closure with a running 6-0 monofilament vascular suture such that there  will be no constriction of the common femoral vein when the vascular  clamp is removed (figure 6). If needed, additional venous length can be  obtained by excising a portion of the anterior common femoral vein in con-  tinuity with the saphenous bulb. T is technique can also be used to create a  larger inflow anastomosis. T e common femoral vein is then repaired with  a monofilament 6-0 vascular continuous suture, taking care not to impinge  on the flow lumen of the common femoral vein.   T e proximal 5 to 7 cm of the saphenous vein is mobilized as its major  tributaries are ligated and divided. Using Potts scissors, the first valve, about  lcm into the saphenous bulb, is excised in the translucent central portion of  each valve under direct vision (figure 7). T e second valve is typically 3 to  5cm farther distal. T is second valve and the remainder of the saphenous vein  valves are cut with the retrograde valvulotome method shown in figures II  and |2 on page 43.   T e proximal arterial inflow site is controlled and the common femoral  artery is opened at about the level of the profunda femoris (figure 8). T is  allows inspection of the profunda stoma and possible endarterectomy, if    detalls of Procedure T e open proximal end of the  saphenous vein is tailored to match the arteriotomy. T e edges of the tip  may be removed to create a more oval taper and the vein may be opened in  a longitudinal direction posteriorly to create a larger opening if needed. T e  anastomosis is performed with a 6-0 monofilament polypropylene suture  that is double ended with a needle at each end. As shown in figure 9a, the  course of each stitch in this running suture begins by entering the vein from  the outside to lumen and proceeds from lumen to outside on the artery. T 1s  avoids raising an intimal flap in the artery. T e suture line is begun with a  mattress-type suture at the “heel” end of the vein (figure 9). T e lateral  or far side is run first and brought around the tip or “toe” end to join the  medial or near-side suture in the mid-portion (figure 10). T e anastomosis  is flushed with heparinized saline, and the sutures are tied. T e arterial vessel  loops are released, and the proximal saphenous vein will dilate with a pul-  satile arterial inflow. Flow will stop at the first of any residual venous valves.    exPandable valvulotome method In order to avoid the long  incisions required for total saphenous vein exposure and the use of a  hand held valve cutter passed sequentially via side branches, this method  employs a disposable, expandable valve cutter. By limiting lower extrem-  ity incisions, trauma from vein dissection may be minimized, surgical site  infections may be reduced, and post-op pain control may be better.   As the new arterial blood flow enters the vein there will be little flow  beyond the first valve. T e disposable, expandable valvulotome is tested  for function and loaded with heparinized saline as per the manufacturer’  instructions for use. T e closed unit with the valvulotome in the sheath is  inserted through the distal transected vein (figure 11) and carefully passed  to just distal to the femoral artery anastomosis. T e presence of the bul-  bous blunt tip is confirmed by palpation (figure lla) and care is taken  not to cross the fresh anastomotic suture line. T e valvulotome is deployed  according to the manufacturer’ instructions for use and carefully with-  drawn. T ere will be a slight pulling sensation when valves are crossed. T e  valvulotome is self-centering to prevent injury to the vein walls as the vein  dilates over the central cage and the leaflets are cut as the vein passes down  the tapered cage into its cutting section (figure 12). T is maneuver may  need to be done several times to render all the valves incompetent as mani-  fest by full dilation of the entire saphenous vein under arterial pressure and  possibly pulsatile inflow.   Next, small incisions (1-2 cm) are made at the previously marked side  branch sites and the branches are ligated with 3-0 silk ties. Seven typical  ligation and branch division sites are illustrated (figure 11). T 1s should  improve the flow through the vein so that it 1s pulsatile. If not, another pass  with the valvulotome can be performed.   T echoice of site for the distal bypass anastomosis is determined accord-  ing to the preoperative studies. It is important that the vein have a clear path  without angulation. Also, the vein must be of suf cient length for it to reach  the anastomotic site without tension when the leg or ankle is straightened.  An anastomosis to the posterior tibial artery is shown. T e peroneal artery  may be approached in a similar manner, whereas the anterior tibial artery    is approached by tunneling through the interosseous membrane in its  upper two-thirds or by tunneling around the anterior tibia in its lower one  third. T e appropriate arterial segment has been previously dissected over a  3- to 4-cm zone and isolated with Bulldog vascular clamps (figure 13). An  advantage of the in situ vein bypass technique is now apparent as the sizes  of the two vessels (distal artery and bypass vein) are nearly the same.   Most surgeons use magnifying loupes for the end-of-vein-to-side-of-  artery anastomosis, which is performed in a manner similar to the proximal  anastomosis (figures 9a and 10). T e vein may be incised longitudinally  and tapered to create a larger stoma. All vessels are occluded with the elastic  loops or small Bulldog vascular clamps. T e artery is opened longitudinally  (figure 14). A double-ended 6-0 or 7-0 monofilament vascular suture is  placed into the heel of the vein and then out of the artery in a mattress-  suture manner at the proximal angle. A continuous, running suture 1s  placed such that it enters through the vein and exits through the artery.  T is prevents the raising of an intimal flap as the needle point is pressed  from the lumen outward on the artery.   T eposterior suture line is run first and usually carried around the distal  tip to the mid-portion of the anterior line. T is allows better visualization  in the placement of the completed anterior line suture. T e artery and vein  are flushed with heparinized solutions and the loops and clamps are tran-  siently released to flush all segments clear of thrombus, debris, and air. T e  two suture ends are tied.   Pulsations within the in situ vein and artery are palpated or verified with  a Doppler instrument. An intraoperative on-the-table completion angio-  gram should be performed, with attention to the distal anastomosis and to  verify that all the side branches are ligated and that there are no residual  saphenous valves. T e distal anastomosis should also be inspected for any  technical errors.   T e leg is flexed and straightened to be certain that the vein does not  kink. A careful search is made along the entire vein to reveal any arteriove-  nous fistulas in the venous branches that were not recognized and ligated.  T ese fistulas may be palpated as a hum or thrill, which can also be local-  ized with a Doppler instrument. Simple division between 3-0 silk ligatures  is suf cient.   After the distal anastomosis is secured, a completion on-table angio-  gram of the entire vein graft should be obtained.    closure T esuperficial fascia is approximated with interrupted or run-  ning absorbable 3-0 sutures, taking care not to constrict or kink the vein,  and the skin is closed in the routine manner.    Posto PeratIve care T e hemodynamic status of the patient is moni-  tored carefully in the recovery or intensive care setting. Cardiac parameters  should be optimized. A record of distal pulses obtained by palpation or  Doppler is made hourly for the first day and at sequentially regular intervals  thereafter. T e patient is usually not anticoagulated but is kept well hydrated.  An ankle-brachial index is typically performed on postoperative day 1 to  ensure graft patency. =    IndIcatlIons Acute lower limb ischemia may be caused by distal embo-  lization from a more proximal source or by thrombosis of an underlying  atherosclerotic lesion or previously constructed bypass graft. T e clinical  presentation is often an emergency situation with varying degrees of limb  threatening ischemia. If a patient’ ischemia is not as severe and allows more  time for treatment, catheter-based thrombolytic therapy may be preferred  as first line, since lysis may reveal an underlying lesion that also requires  treatment. If ischemia is more profound, then proceeding to emergency  surgical intervention 1s the best, most expeditious approach.    Preo PeratIve aPProach Preoperative imaging, such as catheter-  based angiography, CT angiography, and duplex ultrasound, can be helpful  to localize the extent of the thrombus/embolus, but is not always necessary  depending on the urgency of the procedure. Since these are often emergency  surgeries, rapid preparation of the patient is essential to increase the chances  of limb salvage. As patients with embolic phenomenon often have a cardiac  source, including acute myocardial infarction, dysrhythmia, and aneurysm,  attention should be given to close hemodynamic monitoring and maximiz-  ing cardiac function as much as possible in an emergency situation.  History of prior claudication or previous surgical bypass graft points more  toward a diagnosis of thrombotic disease. An understanding of the patient’  vascular disease history is critical to determining the underlying etiology.  Heparin administration is extremely important as soon as a diagnosis of  thromboembolic phenomenon is made. Prophylactic antibiotic therapy 1s  administered just before the operation and continued for 24 hours.    anesthesIa General or regional anesthesia is generally employed; how-  ever, local with monitored anesthesia care 1s sometimes preferred in this  eroup of patients who may have other significant comorbidities. T e fea-  sibility of local anesthesia depends on the location of incision and extent  of surgery. Careful attention should be given to maintaining satisfactory  hemodynamic parameters.    o PeratIve PreParatlon T e patient is positioned supine on the  operating table. It is usually best to prep and draped the lower abdomen  and contralateral groin area in case an adjuvant in flow procedure, such  as a femoral-femoral bypass, becomes necessary. T e entire af ected leg  should be circumferentially prepared and draped as well, with the foot  preferentially placed in a sterile plastic (Lahey) bag, so that the foot may be  inspected at the end of the case (figure 1). Anticoagulation with heparin  is usually not interrupted; often with an extra dose given during surgery.    Procedural detalls A vertical groin incision is made and the femo-  ral vessels are dissected free from surrounding structures. Silastic vessel  loops are placed around the arteries proximally and distally (figur e 2). If  additional heparin is warranted, then a dose is given a few minutes prior to  occluding the vessels.   If the etiology is felt to be due to an embolic source and the vessel feels  soft and free from atherosclerosis, then a transverse arteriotomy is made  (figure 3). T e advantage is closing the arteriotomy primarily, which 1s  usually fairly quick. If a thrombotic etiology is implicated or if chronic  plaque is palpable, then a longitudinal arteriotomy may be the best choice.  T is longitudinal incision is made in the common femoral artery for plaque  in the area so that the vessel may be directly inspected and an endarterec-  tomy with patch angioplasty performed if needed. For the common plaque  at the origin of the profundus artery, an oblique longitudinal incision is  made as shown in figure 4a,b for the same reason.   A Fogarty@hrombectomy catheter (usually a 3mm, but 2mm or 4mm  may be used as well, depending on the size of the native vessel) is passed  proximally and distally into all the major branches (figure 5a). Several  passes will be required until adequate pulsatile inflow is restored, as well as  appropriate back bleeding confirmed. T ecatheter is then passed proximally  (figur e 5b) to be certain that all clot has been cleared. T e artery is flushed  antegrade and retrograde with heparinized saline solution (figure 6).  A transverse arteriotomy can be closed primarily with interrupted 6-0 poly-  propylene sutures, passed inside to outside to prevent lifting any flap inside  the artery (figure 7). All air and debris are vented prior to completing the  vessel closure and restoring flow to the leg. T e foot 1s now reassessed for  perfusion (color, capillary refill, warmth, motor function, Doppler signals)  and if adequate, the wound is irrigated and closed in multiple layers with  absorbable sutures and skin staples. If the leg remains ischemic, then the  level of impairment is reassessed and further thrombectomy performed if  needed. Lower-leg fasciotomies are performed at this time if deemed neces-  sary (see Chapter 145, pages 554-555).    Posto PeratlIve care It is critical to maintain close observation of  these patients, not only for recurrent leg thrombosis OR ischemia, but  also for delayed compartment syndrome if a fasclotomy was not done.  T e patient is kept on a heparin drip and converted to oral anticoagula-  tion if deemed appropriate. In addition, depending on the patient’s clin1-  cal status, intensive care and hemodynamic monitoring will most likely  be in order. =    IndIcatlons_ Life-threatening pulmonary embolism is a frequent com-  plication of many medical illnesses and surgical procedures when anteced-  ent venous thrombosis is associated with low-flow states, venous injuries,  obesity, prolonged immobilization, hypercoagulability, and the poorly  understood effects of certain malignancies.   Anticoagulation is generally accepted as the primary therapy for  thromboembolic disease. Venous interruption, proximal to the site of  venous thrombosis, is usually reserved for patients who have recurrent  pulmonary emboli despite well-controlled, adequate anticoagulation;  those who have a large, life-threatening embolus such that an additional  one might be fatal; those who cannot be anticoagulated because of poten-  tial bleeding problems or other contraindication for anticoagulation; or  those who are developing progressive pulmonary hypertension from  repeated emboli.   Superficial femoral ligation has been largely abandoned because of  the inability to precisely localize the proximal extent of the process and  the likelihood of undetected thrombus in the opposite extremity or deep  pelvic veins. Inferior vena caval interruption avoids these uncertainties.  Caval filters placed via the femoral or jugular veins are commonly used  today for prophylaxis against pulmonary emboli and their use has replaced  the application of partially occlusive serrated clips. Temporary and perma-  nent filters are now commercially available, with the advantage of being  able to remove the temporary filter when its presence is no longer clini-  cally needed.    Preo PeratIve PreParatlIon Since intravenous contrast is usu-  ally used during the procedure, absence of contrast allergy is impera-  tive and if present, may require premedication. Kidney function should  be assessed as well as the patient’s ability to lie flat for a period of time  during and afer the procedure. T ese patients may have impaired car-  diac function and abnormal ventilation/perfusion of the lung, requiring  vigorous cardiac and pulmonary support, and perhaps monitoring by an  anesthesiologist.    anestheslIa Local anesthesia is favored. A secure intravenous catheter  for medications (especially sedation) is essential. An anesthesiologist to  manage the patient may be imperative if there 1s impaired cardiopulmo-  nary function.    PoslItlIon T e patient is supine with the groin or right jugular area  exposed and clipped of any hair. Fluoroscopy should be available. T is pro-  cedure may be done preferably in a dedicated angiography suite.    detalls of Procedure T e groin or neck access area is prepped and  draped in the usual fashion and local anesthesia is administered. T e jugular  or femoral (figur e 1) vein is accessed with an entry needle under ultrasound  guidance if needed below the level of the inguinal ligament (figure 2).  Using fluoroscopy a fine (0.018) access wire is guided up into the inferior  vena cava in preparation for passage of a pigtail catheter into the inferior vena  cava (figure 3). A venacavagram is obtained (figure 4). T e position of  the renal veins relative to a given vertebral body level is noted. If the mnfra-  renal cava is found to be < 28 mm, nonduplicated, and free from thrombus  formation, the pigtail is advanced superiorly to above the renal veins before  the stiffer insertion wire (0.025) for the deployment sheath is inserted. T 1s  maneuver lessens the chance that the new wire may enter a caval branch or  the renal veins. T e filter deployment sheath is inserted and the position of its  tip verified using the previously noted vertebral body as a marker (figur e 5).  T e filter is placed into the deployment sheath and advanced to just the end of  the sheath. While the filter 1s held in place, the sheath is withdrawn inferiorly  leaving the filter at the correct level. Do not push or advance the filter out of  the sheath, but rather withdraw the sheath from the filter (figure 6). T e  filter is expanded with the anchoring barbs being well seated into the wall of  the cava as per the manufacturer’ instructions for use. T e superior end of  the filter should be just below the level of the renal veins (figure 6). Af er  removal of the insertion device a completion venacavagram is obtained to  ensure proper placement and lack of complications. You may use the sheath  or reinsert the guidewire and pigtail catheter for this contrast dye injection.    closure Afer removal of the sheath, appropriate pressure is held for  several minutes to prevent bleeding (figure 7). T e patient should be  instructed to lay flat for 1to 2 hours af erward and the site should be moni-  tored for bleeding or hematoma formation.    Posto PeratIve care Heparin should be continued before, during, and  af er the procedure unless there is significant access site bleeding or a contra-  indication. T e patient should be monitored and the temporary filter removed  when it is no longer necessary for the purpose for which it was placed. m=    Ind Icat Ions Endovenous laser ablation of the great saphenous vein has  replaced high ligation and stripping of this vein for many centers in patients  exhibiting symptoms related to the valvular incompetence of this vein, usu-  ally with varicose veins (figure 1). In some centers radiofrequency ablation  is preferred over laser ablation, but the technics are similar. Before consider-  ing ablation, these patients must have a complete peripheral vascular exami-  nation to determine whether the varicosities are primary or secondary, to  evaluate the status both the superficial and deep venous systems, and to  ascertain the adequacy of the arterial system. Venous duplex scanning is  used to check for patency and the presence of reflux in both venous systems.    contralIndIcatlons Evidence of obstruction in the deep system may  contraindicate ablation of the superficial system because of reliance upon  it for venous return from the leg. Other contraindications include discon-  tinuity or tortuosity of the greater saphenous vein, pregnancy, and active  breastfeeding, allergy to local anesthetics, liver dysfunction, and severe  coagulation disorders. Patients are required to wear compression stock-  ing in the postoperative period, and inability to tolerate them is a relative  contraindication.    anesthesIa Some patient prefer general anesthesia, but more com-  monly, tumescent anesthesia is preferred, especially in the office setting.  Tumescent anesthesia consists of the infusion of a dilute local anesthetic  solution (usually 0.1% lidocaine) into the subcutaneous space surrounding  the veins to be treated. Epinephrine may be added to the solution for its  vasoconstrictive ef ect, and sodium bicarbonate is included for buf ering to  minimize discomfort on infusion.    PosItlIon T e patient is supine with moderate Trendelenburg position to  reduce venous hypertension and is prepped from the umbilicus through the  entire lower extremity and foot. T e toes are covered with a sterile plastic  bag or glove. If phlebectomy, which is the removal of visible varicose veins  through tiny stab incisions, is to be performed as well, the veins are marked  with indelible ink in the preoperative holding area with the patient upright  to assure adequate filling.    detalls of Procedure Using a 75 MHz ultrasound probe encased  in a sterile sleeve, the greater saphenous vein is identified at or below the  level of the knee (figure 2). If not using general anesthesia, the skin is  anesthetized with 1% lidocaine, and a 21-gauge access needle is inserted  into the vein. A 0.018-in micropuncture wire 1s inserted through the needle  into the vein to secure access and the needle removed (figure 3). A small  nick is made in the skin where the wire exits and a 4F or 5F access sheath  is inserted over the wire. T e wire and sheath dilator are removed and a  0.035-in J-tipped wire is inserted through the access sheath and passed to  the groin where its presence is confirmed by ultrasound. T e access sheath    Endovenous Laser Ablation of the Great  Saphenous Vein and Stab Phlebectomy    is removed and the long laser sheath with centimeter markings is placed  on the thigh with the distal tip at the level of the femoral pulse to get an  estimate of how much sheath will need to be inserted. T e laser sheath is  inserted over the wire (figure 4) and the dilator removed. T e laser fiber  is inserted to the lock position (figure 5) and the ultrasound is used to  locate the fiber tip in the distal greater saphenous vein bulb. Care is used to  make sure that the tip does not enter the femoral vein and 1s distal to the  superficial epigastric vein.   T e ultrasound now visualizes the catheter at the knee level and the  area adjacent to the catheter is infiltrated with the tumescence solution  for anesthesia. A 21-gauge needle attached foot—pedal-controlled pump is  used to administer the tumescence fluid. Tumescence fluid is administered  throughout the length of the laser sheath. Not only does the tumescence  fluid provide anesthesia, but it also reduces the transfer of energy from  the laser to the surrounding tissue. Laser safety goggles are now worn. T e  location of the distal laser tip is reconfirmed by ultrasound before the laser  energy 1s applied. A diode laser is used with a wavelength of 980 nm at a  power setting of 14 W. Any of a number of available lasers may be used. T e  laser is turned on and withdrawn at a rate of 50 J/cm until the signal mark-  ings at the end of the laser sheath are seen which indicate that adequate  length of vein has been treated. T e laser is turned of and the sheath and  laser fiber removed. Hemostasis is obtained by direct pressure.   If there are no stab phlebectomies, the procedure is over and a Band-  Aid placed over the puncture site. A thigh-length support stocking 1s then  applied. However, if stab phlebectomies are to be performed, they are done  now. A #11 blade or a narrow Beaver blade is used to make tiny incisions  adjacent to the previously marked varicose veins (figure 6a), and spe-  cially designed phlebectomy hooks are used to capture the vein below the  skin surface (figure 6b). T e captured vein is pulled out through the skin  incision and grasped with a hemostat. Tension is place on the vein by pull-  ing on the hemostat and as much vein as possible is bluntly dissected by  using a second hemostat to tease the surrounding tissue away from the  vein. T e vein is then removed by manual avulsion (figure 6c) and pres-  sure held on the wound for hemostasis. T 1s process is repeated until as  much varicose vein as possible is removed. When hemostasis is complete,  the limb is wiped with saline and dried. Steri-strips are used to approximate  the incision and dry sterile dressing are applied and held in place with clear  plastic adhesive. T e thigh-length support stocking 1s then applied, and the  patient taken to the recovery area.    Posto PeratlIve care T e patient is ambulatory at the time of dis-  charge and is encouraged to walk for a few minutes every hour while awake.  Mild analgesics are all that is required for perioperative pain. T e patient is  usually able to return to normal function within several days. m=    Endovenous Laser Ablation ofthe Great Saphenous Vein and Stab Phlebectomy S49    IndIcatlIons Portal decompression is indicated in patients who have  portal hypertension complicated by gastrointestinal hemorrhage from  esophageal varices that are not effectively controlled with sclerotherapy  injections. Some procedures completely interrupt portal venous flow to the  liver (end-to-side portacaval shunt), while others selectively decompress  the portal system via a collateral shunt (side-to-side portacaval, splenore-  nal, and mesocaval). T e procedure selected will depend upon the patency  of the portal and splenic veins, the results of liver function studies, the  amount of portal venous blood being shunted, whether the patient is bleed-  ing acutely, and whether the patient 1s a candidate for liver transplantation.  Selection of patients should be based on their clinical status, results  of liver function studies, and interpretation of hepatic hemodynamics as  determined by radiologic studies. Patients considered for shunting proce-  dures generally should be under 60 years of age. Ideally, there should be  no evidence of encephalopathy, jaundice, ascites, or muscle wasting. Serum  albumin should be above 3 g/dL, prothrombin time greater than 1.5 times  normal, or other evidence of intact hepatic synthetic function. Deviation  from these criteria does not absolutely contraindicate surgery, but the sur-  gical risk is directly proportional to the degree of hepatic decompensation.  Shunting procedures for portal hypertension can be divided into three  types: portacaval, splenorenal, and mesocaval. figur es a to f show diagram-  matically the basic surgical choices for diversion of the portal venous flow.    Portacaval shunt T eprimary indication for portacaval shunt is the  control of massive upper-gastrointestinal hemorrhage from varices which  cannot be controlled with endoscopic ablation or by transjugular intrahe-  patic portosystemic shunts (TIPS). Portacaval shunts are sometimes pre-  ferred when there has been prior splenectomy, splenic vein thrombosis,  reversal of flow in the portal vein, thrombosed splenorenal shunt, ascites,  or hepatic vein thrombosis. T e selection of a direct portacaval shunt, of  course, depends upon the demonstration of a patent portal vein preopera-  tively or at laparotomy.   T e side-to-side anastomosis (figure a) has been preferred by some in  the presence of portal hypertension with no evidence of a rise in pressure  on the hepatic end of the temporarily occluded portal vein. T is suggests  that the arterial blood supply is going through the liver and that lowering of  the portal pressure by the side-to-side anastomosis with the vena cava will  not result in diversion of the arterial supply to the liver. Another advan-  tage of this type of shunt is that 1t decompresses the hepatic sinusoids, and  this may be beneficial in the treatment of patients with intractable ascites  accompanied by variceal hemorrhage.   T e usefulness of the portacaval shunt in the treatment of refractory  ascites is not accepted universally, although several studies have suggested  that this is an effective mode of therapy. If shunting is indicated to control  ascites, a direct side-to-side shunt or a side-to-side H-shunt with an 8- or  10-mm ringed PTFE interposition graf 1s usually preferred. T is is particu-  larly true in unusual cases of hepatic vein thrombosis (Budd—Chiar1). No  decompressive procedure on the portal system has any beneficial effect on  liver function. T e end result of any such operation, therefore, will depend  largely upon the progress of the basic liver disease.    In an end-to-side portacaval shunt (figure b), the portal vein is ligated  in the hilus of the liver, and the distal portion of the portal vein is anasto-  mosed to the inferior vena cava. T is shunt is particularly indicated when  there is no evidence of ascites and when portal blood flow is reversed in the  hepatoportal direction, as determined by a rising pressure in the hepatic  end of the temporarily occluded portal vein. With the end-to-side anasto-  mosis, all of the portal venous blood flow is shunted from the liver, while  hepatic artery flow to the liver is preserved.    sPlenorenal shunt Inthe presence of extrahepatic block of the por-  tal vein, secondary hypersplenism, prior biliary surgery, and/or caverno-  matous changes of the portal vein, a shunt between the splenic vein and  lef renal vein may be the procedure of choice, provided the splenic vein is  patent and of adequate size (preferably 1 cm). If it is necessary or desirable  to remove the spleen, a conventional splenorenal anastomosis (figure c)  may be performed. T e distal splenorenal shunt (Warren shunt, figure d)  retains the spleen and, while selectively decompressing the esophageal vari-  ces, allows maintenance of portal pressure and perfusion of the liver, thus  providing protection against hepatic encephalopathy. T 1s shunt is particu-  larly indicated in the presence of normal liver function, high volume of  portal flow to the liver, minimal hepatocellular disease, marked splenomeg-  aly, or idiopathic portal hypertension. T e procedure consists of dividing  the splenic vein at its junction with the superior mesenteric vein, ligating  the proximal portion of the vein, and anastomosing the distal portion to the  lef renal vein. As an alternative to dividing the splenic vein, an interposi-  tion graf may be anastomosed between the splenic vein and the lef renal  vein, with ligation of the splenic vein proximal to the graf as well as ligation  of the coronary and right gastroepiploic veins.    Mesocaval shunt In most instances portal decompression may be  accomplished by portacaval or splenorenal shunt procedures. However, the  Clatworthy mesocaval shunt (figure e) is necessary in patients who have  undergone splenectomy and have either thrombosis or cavernomatous  changes of the portal vein. T e mesocaval shunt is advisable in patients with  excessive bleeding at surgery from periportal or perisplenic vessels. Finally,  it should be the procedure of choice in small children in whom the splenic  and/or portal veins may be too small for a successful procedure (minimal  size approximately 1 cm in diameter). Elective shunts in children should  be postponed, if possible, until the age of 4 years. T e procedure consists  of division of the superior vena cava and anastomosis side to end with the  superior mesenteric vein.   In cases of emergency, a lesser technical procedure without division  of the inferior vena cava can be accomplished by the interposition of a  large knitted Dacron graf between the vena cava and superior mesen-  teric vein at the level of its first branches (figure f).T 1s modification of  the mesocaval shunt (interposition mesocaval shunt or Drapanas shunt)  offers the advantages of a simplified technical approach with minimal  blood loss.   T e details of these procedures are available online in the Historical  Supplement at www.ZollingersAtlas.com. m    IndIcatlIons Compartment syndrome develops as the result of  increased pressure within the confines of a fixed space. T is may occur in  the extremities as the result of ischemia, trauma, or burn injuries. Manage  ment involves not only the treatment of the underlying pathology, but also  the physical release of the compartment to prevent further damage due to  impaired capillary perfusion and increased venous resistance.   Diagnosis of compartment syndrome can be made by obtaining formal  intracompartmental pressures (tissue perfusion becomes impaired around  20 mm Hg) (figure 1) or based on physical signs and symptoms. T ese may  include tense and tender muscle groups, pain on passive motion, and numb  ness or impaired motor function in the distribution of the nerve within the  compartment. T emost common site for compartment syndrome is the lower  leg, often due to ischemia or the restoration of f ow after a period of ischemia.  To be complete, all four compartments, anterior, lateral, superficial posterior,  and deep posterior, should undergo fasciotomy (figur es 2a and 2b).    anestheslIa In the case of fasciotomy, general anesthesia and close  hemodynamic monitoring will usually be required due to the complex  nature of these patients. As is routine before making any type of skin inci  sion, the skin should be prepared with topical cleansers.    Procedural detalls For lower leg fasciotomy the entire leg should  be prepared and draped in the usual fashion. T is may have been preceded  by a procedure to restore f ow to the leg (1.e., thrombectomy/embolectomy,  bypass, or thrombolytic therapy). T e most common approach to a four    compartment fasciotomy can be accomplished through two lower leg inci  sions (figure 3).   T e posterior compartments are approached through a skin incision  made over the medial calf, 1cm posterior to the posterior edge of the tibia,  for a similar length and the superficial posterior compartment fascia is  incised in a similar fashion (figure 4). To access the deep posterior com  partment, the gastrocnemius—soleal muscle complex is taken down from its  attachments to the tibia (figure 2b).   For the anterior and lateral compartments an incision is made several  centimeters lateral to the anterior tibia for a length of approximately 10 cm.  T e anterior compartment fascia is encountered and incised for the length  of the skin incision, taking care not to invade into the underlying muscle  to avoid bleeding, especially if the patient is anticoagulated postoperatively.  T e tip of Metzenbaum scissors are inserted into the edges of the fascial  incision proximally and distally and advanced under the skin, completing  the fasciotomy (figure 5). T e lateral compartment is incised similarly  within the same site. Care is taken not to injure the superficial branch of the  peroneal nerve which lies adjacent to the intermuscular septum between  the anterior and lateral compartments (figure 2a,b).    Posto PeratIve care T e leg wounds are dressed with saline wet  to dry dressings. Often the leg may need elevated to minimize edema and  sometimes an elastic wrap is appropriate, taking care not to impair perfu  sion further. Wounds are inspected at least daily and assessed as to the abil  ity to close them primarily or if an alternate management would be more  appropriate (1.e., vacuum assisted closure, healing by secondary intention,  or skin grafting). Infection, bleeding, and nerve injury are the most com  mon complications. =    IndIcatIons When the skin suffers a full-thickness burn (eschar) it loses  its elasticity. At the same time, there is a shifting of fuid in the underlying  subcutaneous tissues into the adjacent interstitial space. With this fuid shift  comes an increase in tissue pressure. T e inelasticity of the overlying burned  skin, when it is circumferential on an extremity, can cause these tissue pres-  sures to exceed the pulse pressure, thereby compromising blood f ow to the  extremity. On the anterior trunk, a full-thickness burn eschar can compromise  respiratory mechanics, which is seen clinically as the inability of the patient  to ventilate followed by the inability to oxygenate. To relieve these pressures  and restore perfusion and/or correct respiratory mechanics, escharotomies are  performed.    Preo PeratlIve PreParatlon Attention should be given to hemo-  dynamic stability of the patient, as well as close fuid and electrolyte man-  agement in the case of burn patients. Preoperative antibiotics are essential  to prevent infection.    anestheslIa Because all cutaneous nerves have been destroyed in the  area of full-thickness burn, no anesthetic is required prior to performing  an escharotomy.    of the circumferential eschar until subcutaneous fat is observed. T e  escharotomy incision should be placed on the medial and lateral aspect of  the circumferential full-thickness extremity burn and should extend the  entire length of the eschar (figures | and 2). On the anterior chest, the  escharotomies should be made along the lateral aspects of the trunk, with  additional incisions placed across the upper trunk and lower trunk so that  they form a rectangle (figure 3). When performing escharotomies on the  hand, the incisions should be placed on the dorsum between the metacar-  pals. If necessary, they can be extended onto the ulnar aspect of each digit  (figure 4).   When correctly made, the eschar will expand open and the subcutane-  ous fat will be seen (figure 1). If subcutaneous fat is not observed, the  escharotomy should be made deeper. Any bleeding encountered after the  escharotomy has been performed is venous and will stop with application  of thrombin-soaked pads.    Posto PeratlIve care Escharotomies are covered with the same  burn dressings being used to cover the associated full-thickness burn.  Escharotomies are not closed. Because they exist in full-thickness burn,  eventually they will be included in the debridement of the burn wound.  Management of the patient’s concomitant medical problems is of utmost  priority. =    IndIcatlIons T ecommon factors indicating amputation of a part of the  body are trauma, interference with the vascular supply, malignant neoplasm,  chronic osteomyelitis, life-threatening infections, inoperable congenital  limb deformity in children, the need to increase function, and, occasionally,  the cosmetic effect.    Preo Perat Ive PreParatlIon Inthe presence of trauma, it is first nec-  essary to evaluate carefully the overall health and status of the patient to  evaluate if limb salvage is possible. Next, the extent of tissue and vascular  damage in the extremity must be evaluated. With the recent advances in  peripheral vascular repair and grafting, reestablishment of distal blood is  often possible. With diabetes or advanced vascular disease, the usual strict  medical measures are taken to regulate these associated diseases. If there  is localized skin infection at the proposed level for amputation, the proce-  dure is delayed whenever possible. In the presence of wet gangrene, packing  the leg in ice or dry ice combined with the application of a tourniquet just  below the site of proposed amputation not only may lessen toxicity but also  may decrease the incidence of wound infection, since the lymphatics may  be cleared before amputation. T e threat of gas gangrene may be a real one  when the arterial supply to the extremity has been severely compromised,  either by intra-arterial occlusion or trauma with inadequate debridement  and a closed-space infection. A staged amputation with the first surgery  providing a “drainage amputation” may help prevent wound problems at  the final level of amputation.    anesthesla Spinal anesthesia is commonly used for major amputation  of the lower extremities, inhalation anesthesia for major amputations of  the upper extremities, and plexus block or local infiltration anesthesia for  amputation of the fingers and toes.    PosIt Ion (See Chapter 148, page 561, figure 1) In amputations of the  upper extremity, the patient is placed near the edge of the table with the  arm extended and abducted to the desired position. For amputations of the  lower extremity, the leg may be elevated with several sterile towels under  the calf.    o PeratlIve PreParatlon In the absence of infection, the extremity is  elevated to encourage venous drainage before a tourniquet is applied. T e  tourniquet is placed above the knee for amputations of the lower leg and foot,  high in the thigh for amputations of the knee and lower thigh, and above the  elbow to control the brachial artery for major amputations of the forearm.  In cases of arteriosclerosis, the tourniquet should not be used because of the  possibility of damaging the blood supply to the stump. Sterile elastic bands  may be applied to the base of the digit for minor amputations. T e skin is  prepared with the usual antiseptic solutions well above and below the pro-  posed site of amputation. In major amputations, the entire extremity may be  wrapped in and impervious stockinette to enable the assistant to hold it and  change its position as desired.    sItes for amPutatlon T eefficiency of modern prosthesis has elim1-  nated the time-honored “sites of election:’ Generally, the pathology dictates  the site of amputation, with the goal of preserving all possible length. T is  is particularly true of the upper extremity, although in the lower extrem-  ity, whenever possible, the knee should be saved, since it provides major  functional advantages. Although the blood supply to the upper extremity is  usually adequate, the reverse is often true for the lower extremity. Since an  inadequate blood supply, often after failure of a vascular bypass graft, is the  most common indication for amputating the lower extremity.   Since the profunda femoral artery tends to be the main channel after  occlusion of the superficial femoral vessels or thrombosed femoral-popliteal  bypass graft, the site of amputation must be selected well within the zone  adequately supplied by the vessel. Accordingly, the amputation is frequently  above the knee ( See figure Ic). Knee disarticulation (C) and transcondylar    amputation (B) yield an enlarged, rounded end that is cumbersome and dif-  ficult to fit with a prosthesis.   T e rule of saving all possible length does not necessarily apply to  below-knee amputation. Since the anterior margin of the tibia is usually  beveled to prevent a pressure point at the stump, there must be enough  solid tissue with good blood supply to cover it, as provided by a long pos-  terior fap which 1s transposed anteriorly over the stump. A short below-  knee stump is preferable to knee disarticulation. Ideally, for a below the  knee amputation, at least 8 cm of tibia (as measured from the tibial tuber-  osity) should be preserved to fit into a prosthetic. A below-knee amputa-  tion longer than 20 cm is probably not any more functionally effective. A  very short fibula tends to migrate laterally and may be removed in a short  below-knee stump.   Although ankle and midfoot amputations have few indications, chief y  trauma, the Syme amputation lends itself to a very serviceable end—weight-  bearing prosthesis, but it has cosmetic disadvantages in females (figure Id).  T ere is general agreement that a most satisfactory foot amputation is the  transmetatarsal (see figure 5, A-A and Long Plantar Flap). In the pres-  ence of vascular insufficiency to the lower extremity, amputations about  the ankle or foot should be rarely performed only for secure indications,  because they frequently heal poorly, necessitating higher level amputations.   Formerly, the junction of the lower and middle thirds of the forearm was  considered the optimum site for amputations; however, newer artificial limbs  that include pronation and supination movements make it desirable to save all  possible length (figur e 2). Length is again important in the hand, where a par-  tial amputation of the fingers or of all fingers, leaving an opposing surface at the  thumb for gripping, allows better function than can be provided by any pros-  thesis. A stump of any length in the forearm will give better function than an  amputation above the elbow, and it eliminates an elbow hinge in a prosthesis.    tyPes of flaPs Asa general rule it is desirable to have the scar in the  posterior of the stump in the upper extremity, since the prosthesis bears  largely on the distal surfaces of the stump. T e scar for end-bearing stumps  of the lower extremity should preferably be placed away from areas of direct  pressure. In minor amputations of the fingers and toes, long palmar and  plantar faps are made to cover the stump with a thick, protective pad of  tissue (figures 3, 4, and 6a). Racket incisions are advisable for amputa-  tions of the toes, since they may be extended upward to permit exposure of  the metatarsals (figure 5), or they may be used for amputations of digits  where all possible length must be preserved. T is is especially true for inju-  ries of the thumb (Incisions B, C, and D, figure 6). Racket incisions with  removal of the head of the metacarpal or metatarsal give a good appearance  to the extremity but considerably diminish the breadth of the foot or palm.    detalls of Procedure Sufficient soft tissue must be present to  approximate easily over the end of the bone, but excessive amounts are  avoided, since bulky soft tissue hinders the fitting of a prosthesis. Arteries  and veins should be tied individually. Nerves are divided with nonabsorb-  able sutures at as high a level as possible and buried within muscle bellies to  prevent neuroma formation. It should be remote from scar and away from  areas of pressure, since a neuroma becomes symptomatic when pressure 1s  applied. T e bone should be divided at a sufficiently high level to permit the  soft parts to approximate, producing a thick covering for its end. T e sharp  margins of bone are beveled either with a rongeur or rasp.    closure Hemostasis is achieved and a closed-suction drain may be  placed in the deep space in larger amputations. T e investing fascia is  loosely approximated with interrupted absorbable sutures. If a guillotine  “drainage” type of amputation was carried out in the presence of a progress-  ing infection, the wound is left open to be closed secondarily later, or the  extremity 1s reamputated later at a higher lever to permit primary closure.    IndIcatIons Common indications for supracondylar amputation  include trauma, poor blood supply, tumor, and progressive untreatable.  Amputation should not be performed unless all conservative measures  have failed.   T e amputation at the level of the thigh 1s described in detail here. T is  is a frequent site following failure of reconstructive or bypass arterial pro-  cedures or in the presence of unreconstructable circumstances as docu-  mented with proximal and distal arteriography.    Preo Perat Ive PreParatlon T e preoperative preparation must of  necessity vary with the indications for amputation as outlined in the pre-  ceding section. Careful evaluation must be made to determine whether  there is a localized arterial obstruction, and arteriography is essential. If  localized obstruction is present, a proximal (e.g., an iliac stent or aorto-  femoral) reconstructive procedure may restore an adequate blood inflow,  or a distal (e.g., femoropopliteal) bypass arterial graft may eliminate the  need for amputation.   When infection is present, aggressive surgical debridement is the most  critical step for success. Appropriate antibiotic regimens should be tai-  lored based on documented sensitivities. Should there be a localized skin  infection at the proposed level of amputation, the procedure is delayed if  improvement is possible. In the presence of an advancing infection a guil-  lotine or open amputation is done above the level of infection, with a sub-  sequent definitive amputation at a higher point a few days later or when  sepsis has cleared.   For elective amputations, preoperative consultation with physical ther-  apy and a prosthetist can help the patient be emotionally and physically  ready for the rehabilitation required after amputation surgery.    anestheslIa Low spinal anesthesia is used most frequently, although  inhalation anesthesia may be administered unless the patient’ condition  contraindicates it.    PosItIon T e patient is placed with the hip on the affected side out to  the margin of the table to allow full abduction of the thigh by an assistant,  and the calf or ankle may be elevated with several sterile towels. T e hair is  clipped at the operative level.    o PeratIve PreParatlon T e skin from the lower abdomen to well  below the knee is prepped. A sterile sheet is placed beneath the thigh.  T e foot and lower leg up to the knee are covered with an impervious  stockinette (figure 1). Unless there is evidence of progressive infection,  the extremity is elevated by the assistant to encourage venous drainage.  If a low amputation is planned, a sterile tourniquet can be applied high  on the thigh.    IncIslon and exPosure T e type of flap that is used varies. With  progressive infection of the lower leg, a circular incision is made for a    guillotine amputation. However, when possible, anterior and posterior  flaps are outlined with a sterile marking pen, ensuring an appropriate  stump length (figure 1). Either equal anterior and posterior flaps are used  or, more commonly, a larger anterior flap is utilized to place the final clo-  sure line away from the pressure points of the prosthesis.   T esurgeon stands on the inner side of the thigh so as to visualize better  the main arterial and nerve supply, and outlines the selected incision. Since  the skin and soft tissues retract considerably and to allow for rotation of  the skin edges, the skin incision should extend 10 to 15 cm below the point  where the bone is to be divided. T e incision is carried through the skin and  subcutaneous tissue down to the fascia over the underlying muscles.    detalls of Procedure T e surgeon must be familiar with the loca-  tion of the major nerves and vessels (figure 2). T e most superficial ves-  sels to be ligated is the great saphenous vein, located on the medial or  posteromedial aspect of the thigh, depending on the level of amputation  (figures 2 and 3). T e muscles should be divided at a slightly higher level  than the skin and fascia and allowed to retract upward so that the final flaps  for closure will consist chiefly of skin and fascia (figure 4). T e median  incision into the muscle layer is made carefully and the femoral vessels are  identified deep to the vastus medialis muscle (figur e 5). Ifa tourniquet has  not been applied, the surgeon should locate the major vessel by palpation or  by its visible pulsation. If a tourniquet has been used, the dissection 1s car-  ried out directly until the femoral vein is exposed. T is is divided between  half-length clamps. Both artery and vein are tied separately (figure 5),  and, if desired, a transfixing tie may be added distal to the original ligature  on the femoral artery.   T esciatic nerve is located posterior to the femoral vessels and is isolated  from the surrounding tissues. In the event of a high amputation with bifur-  cation of the sciatic nerve, the tibial and peroneal nerves are individually  ligated. In an effort to minimize the formation of an amputation neuroma,  the nerve is pulled down as far as possible, and a strong straight Ochsner  clamp is applied. A second similar crushing clamp is applied about 5 mm  distal to the first clamp and the nerve divided immediately below the second  clamp. T e proximal clamp is removed, and the crushed area is ligated with  a heavy 0 ligature of nonabsorbable suture (figure 6). Fine ligatures are  avoided, lest the epineural sheath be cut through, permitting the formation  of a neuroma. Absorbable ligatures are avoided since they may be absorbed  before the epineural sheath has united, causing the sheath to reopen with the  formation of aneuroma. T e distal clamp is then removed, leaving a crushed  and flattened short segment of nerve that tends to prevent the ligature from  slipping off. T e nerve is allowed to retract well upward into the muscle lay-  ers. It should never be anchored to adjacent structures. When the sciatic  nerve has retracted upward, the tissues are further freed from the posterior  surface of the femur. T e profunda femoris artery and vein must be secured  and ligated in the posterior group of muscles (figure 2).    Assistant Sartorius muscle  Biceps = y  femoris muscle | Great .  a saphenous vein  Semitendinosus muscle Gracilis muscle  Rectus ;  femoris muscle Vastus intermedius muscle Semimembranosus 
orthognathic-surgery-principles-and-practice Zollinger's Atlas of Surgical Operations (Ellison ) 10 ed (2016)_djvu.txt