normal diet as tolerated. (cid:142)(cid:3) Remove the drain, if inserted, the following day provided the drainage is minimal. (cid:142)(cid:3) Encourage early ambulation. Most patients are ready for discharge within 2 4 hours. Increasing trend towards day-case laparoscopic cholecystectomy in some centers. (cid:142)(cid:3) Patient is generally able to return to normal activity within 2 weeks. Complications (cid:142)(cid:3) Bleeding \200\224during the operation from the cystic artery or the liver bed. It is usually easily controlled by electrocautery, clips, and or suture ligatures. If haemostasis is not achieved using these methods, the procedure should be conv erted to an open procedure. Major vascular damage (aorta, iliac vessels, and vena cava) can occur during introduc- tion of cannula is rare but reported. It must be remembered that th e distance between the anterior abdominal wall and the aorta and its bifurcation into the i liac vessels averages only 2.0cm in thin patients. Significant bleeding with hypotension re quires immediate laparotomy. (cid:142)(cid:3) Major bile duct injuries \200\224occur when t he common bile duct is mistaken for the cystic duct and divided (complete transection). Oth er mecha- nisms of injury include indiscriminate clipping or cautery to hastily control ble eding, clipping of the cystic duct with the tips of the clip, and occluding the common bile duct. Major bile duct injuries should be referred to and are best treated in specialized u nit for ERCP stenting, for example. (cid:142)(cid:3) Visceral injury \200\224rare but well documented. Can occur with introduct ion of a cannula, insertion of an instrument without visualization or care- less use of ele ctrocautery. (cid:142)(cid:3) Gallbladder perforation \200\224visible stones should be retrieved to prev ent complications related to lost gallstones (Intraabdominal abscess and fistula). (cid:142)(cid:3) Postoperative bile leak \200\2240.02 \200\2232.7%. Patients may present wi th symp- toms of shoulder pain, abdominal pain, and fever. Bile leak may occur from the gallbladder bed, cystic duct (dislodged clips), or as a result of injury to the common bile duct. Most bile leaks resolve spontaneously if adequately drained (ultrasound or CT scan guided), and there is no distal bile duct obstruction. MRCP/ERCP is recommended if no intra- operative c holangiogram was obtained in order to rule out a major ductal injury. ERCP should be perfor med if bile leak persists beyond 1 week after drainage. If a retained common bile duct ston e is found, it is removed. A sphincterotomy and/or stent placement decompresses the biliary system, thus helping resolution of the leak. LAPAROSCOPIC CHOLECYSTECTOMY1 341 (cid:142)(cid:3) Wound infection \200\224may occurs when bile is spilled during extraction of gallbladder or when there is direct contact between an infected gallbladder and the incisio n. Avoid seeding when removing an infected specimen through a tight trocar site. Use extrac tion bag. (cid:142)(cid:3) Incisional hernia through port sites \200\224most commonly occurs in 10mm port sites. Patient usually presents with pain and small bowel obstruction three to 5 days post-operatively. (cid:142)(cid:3) Deep vein thrombosis \200\224risk related to duration of surgery, reverse Trendelenburg position and the pressure of insufflation. Use DVT prophylaxis such as LMWH a nd TED stockings. (cid:142)(cid:3) Post-cholecystectomy syndrome \200\224this is the persistence of symptoms despite surgery. Some of these patients may have a retained stone in the bile duct \200\224 MRCP or ERCP may be needed. The gallbladder may not have been responsible for the pain in t he first place \200\224the pain may have been due to peptic ulcer, irritable bowel syndrome or to disease of the liver or pancreas. (cid:142)(cid:3) Death \200\224occurs in 0.1 \200\2230.5% of cases (1 \200\2235 per 1000 op erations). The risk increases with age. CHAPTER 9 Laparoscopic surgery 342 Laparoscopic appendicectomy It has been demonstrated to be safe and efficacious. However, i ts superi- ority to the traditional open technique continues to be debated. Decision of lap aroscopic versus open appendicectomy is based on many factors including patient \200\231s w ishes, surgeon \200\231s experience, equipment availability and time of day. Advantages (demonstrated by several prospective clinical trials): ability to explore the pe ritoneal cavity, reduced postoperative pain, decreased rate of wound infection, less postop erative adhesions, shorter hospital stay, more rapid return to normal activity, and better cosmesis. Make a definite diagnosis in females. Disadvantages: higher total cost, increased operating time, need for experienced surgeon/th eater staff and appropriate equipment. It is not yet the gold standard for the management o f appendicitis but may become the standard approach in future. Indication Acute/suspected appendicitis. Preferred in (cid:142)(cid:3) Premenopausal women with uncertain diagnosis (cid:142)(cid:3) Obese patients (large incision otherwise required) (cid:142)(cid:3) Athletes and others wh o need rapid return to full activities (cid:142)(cid:3) Patients concerned about cosmesis. Preparation (cid:142)(cid:3) Informed consent for both laparoscopic and open procedure (cid :142)(cid:3) DVT prophylaxis (cid:142)(cid:3) Prophylactic antibiotics (cid:142)(cid:3) Gen eral anesthesia with endotracheal intubation and muscle relaxation (cid:142)(cid:3) Cathete risation to reduce risk of bladder injury and aid pelvic examination. Position (cid:142)(cid:3) Patient in supine position. (cid:142)(cid:3) Surgeon and assistan t standing on patients left side, nurse on the right and monitor at the foot of the table towards the right. Technique (cid:142)(cid:3) Re-examine the abdomen when patient is anesthetized \200\224appe ndicular mass. (cid:142)(cid:3) Induce pneumoperitoneum using either Veress needle or open technique. (cid:142)(cid:3) Perform quick diagnostic laparoscopy first, through 10mm umbilical port. (cid:142)(cid:3) Place second 5mm suprapubic (lower midline, above symphysis pubis) and third 10mm trocar either in the right lower or right upper quadrant. Upper quadrant pla cement preferred because it allows better caecal retraction. LAPAROSCOPIC APPENDICECTOMY1 343 (cid:142)(cid:3) Trendelenburg with left sided tilt facilitates inspection of the right lower quadrant and appendix. (cid:142)(cid:3) Complete the diagnostic laparoscopy to exclude ovarian cyst, pelvic inflam matory disease, cholecystitis, perforated ulcer, Meckel \200\231s diver- ticulum, colonic d iverticulitis, Crohn \200\231s disease and ischaemic bowel. (cid:142)(cid:3) Identify the a ppendix. Signs of appendicitis include omental adherence, caecal inflammation, presence of turbid fluid in the region of the appendix, increased vasc ular injection of the serosa and wall thickening, perforation and gangrene. (cid:142)(cid:3) Grasp and elevate the tip of the appendix. If tip is not visible, identify the base and then follow this using two atraumatic graspers until you see the tip. (cid:142)(cid:3) Free the appendix off the surrounding adhesions to define its entire length. (cid:142)(cid:3) Divide the mesoappendix with clips, bipolar cautery or linear stapling device or tie. (cid:142)(cid:3) Identify the base of the appendix (convergence of taenia), and secure it with a pretied suture ligature/endoloop or a linear stapling device. (cid:142)(cid:3) Divide the appendix between two pre-tied endoloop ligatures. (cid:142)(cid :3) No need to bury the stump of the appendix. (cid:142)(cid:3) Place the purulent appendix into retrieval bag and remove the specimen. (cid:142)(cid:3) Irrigate the peritoneal cavity. (cid:142)(cid:3) Place suction drain into the pelvis if localized collection. (cid:142)(cid:3) Remove trocars under direct vision. (c id:142)(cid:3) Remove the Foley catheter in theater at the end of the procedure. Retrograde appendicectomy \200\224useful in severe inflammation or gangrene. Begins with dissection, ligation, and division of the appendicular base, which is then retracted to complete the di ssection. Appendicular abscess \200\224if surrounding tissue is too inflamed and friable to allow safe appendicectomy, perform laparoscopic drainage and irrigation. Place a closed su ction drain in the abscess cavity and bring it out through the right trocar site. Perform i nterval appendicectomy, either laparo- scopic or open, at a later date. Perforated appendix \200\224occlude its lumen using an endoloop proximal to the perforation to prevent spread of its content in the peritoneal cavity. Open conversion \200\224in cases with difficult di ssection, uncontrollable bleed- ing or suspected visceral damage. Normal looking appendix a nd no other pathology identified \200\224remove the appendix (early appendicitis cannot be confirmed until histological ex- amination is undertaken). Failure to remove the appendix m ay result in confusion if the patient continues to have right iliac fossa pain. Postoperative care (cid:142)(cid:3) Continue antibiotics as treatment if there is peritonit is or gross fecal spillage. (cid:142)(cid:3) Encourage early ambulation. (cid:142)(cid:3) Start oral diet usually after 8 \200\22312 hours post operative. (cid:142)(cid:3) Patients can be discharged as early as 24 hours after surgery and are advised to resume normal activities as tolerated. CHAPTER 9 Laparoscopic surgery 344 Complications (cid:142)(cid:3) Bleeding \200\224sources include the inferior epigastric art ery, appendicular artery and the staple line. Avoid injury to inferior epigastric vessels b y placing the cannula lateral to the rectus abdominis muscle. Do not hesitate to convert if bleeding is uncontrollable. (cid:142)(cid:3) Bowel perforation \200\224by inadvertent injury by diathermy or the trocar . (cid:142)(cid:3) Bladder injury \200\224avoid by catheterisation and introduction of the suprapubic cannula under direct vision. (cid:142)(cid:3) Wound infection \200\224avoid contact between the wound edges and the appendix. Use an Endobag. (cid:142)(cid:3) Intra-abdominal and pelvic abscess \200\224higher incidence in patients wi th appendicular perforation. Careful dissection and lavage are key factors in avoiding it. (cid:142)(cid:3) Recurrent appendicitis \200\224due to incomplete appendicectomy. Avoid by removing the entire appendix. (cid:142)(cid:3) Incisional hernia \200\224may develop if fascial site of 10mm port is not closed. (cid:142)(cid:3) Deep venous thrombosis and pulmonary embolism \200\224avoid by hep arin prophylaxis and TED stockings. This page intentionally left blank CHAPTER 9 Laparoscopic surgery 346 Obesity surgery Laparoscopic surgery is ideally suited to bariatric surgery. The absence of large wounds and related complications is especially advantageous in this group of patient s and obesity in itself poses less of a problem for the laparoscopic surgeon than for the o pen surgeon. All types of bariatric procedure can be performed laparoscopically and with in creasing experi- ence in similar operating times as for open surgery. Indications (cid:142)(cid:3) Morbid obesity uncorrected by dieting and non-operative interventions. (cid:142)(cid:3) BMI (body mass index) >40kg/m2. (cid:142)(cid:3) BMI >35kg/m2 with an obes ity related comorbidity (diabetes, hypertension, sleep apnoea etc.). Contraindications (cid:142)(cid:3) Previous gastrooesophageal surgery. (cid:142)(cid:3) Mul tiple previous laparotomies. (cid:142)(cid:3) Co-morbidities precluding general anesthesia. Three types of operation are commonly performed 1. Purely restrictive procedures: laparosco pically placed adjustable silicone gastric bands (LASGB) A variety of bands are now availab le and involve passing an adjustable band around the stomach just distal to the gastro-oeso phageal junction, above the lesser sac posteriorly giving a \200\230proximal \200\231 gast ric pouch of between 25 \200\22330ml. The channel/stoma between proximal and distal pouches is adjusted postoperatively in the outpatient clinic by injecting fluid into the inner bal loon via a subcutaneously placed port. Technique (cid:142)(cid:3) General anesthesia. (cid:142)(cid:3) Patient in Lloyd-Davies and reverse Trendelenberg \200\231s position on the operating table. (cid:142)(cid:3) Creation of pneumoperitoneum (Veress needle preferable). (cid:142)(cid:3) Primary 10mm laparoscope trocar in midline 4 inches beneath xiphoid. (cid:142)(cid:3) 30 laparoscope. (cid:142)(cid:3) Insertion of Nathenson retractor to retract left lobe of live r cephalad under direct vision via sub xiphoid route. (cid:142)(cid:3) 5mm left hand working cannula midclavicular line. (cid:142)(cid:3) 15mm ri ght hand working port midclavicular line. (cid:142)(cid:3) 5mm retractor cannula to right o f 15mm port anterior axillary line. (cid:142)(cid:3) Assess for presence of hiatus hernia a nd (optional) repair of crura. (cid:142)(cid:3) Dissect angle of his from left crus. (cid:1 42)(cid:3) Create retrogastric tunnel via pars lucida passing left hand instrument behind g astrooesophagel junction to emerge between left crus and angle of His. (cid:142)(cid:3) Insert band with attached tubing into abdomen through 15mm port and draw t hrough retrogastric tunnel to place band around gastro- oesophageal junction posteriorly. OBESITY SURGERY1 347 (cid:142)(cid:3) Place 25ml balloon into stomach transorally and withdraw to gastro- oesoph ageal junction (GOJ) to assess size of proximal gastric pouch. (cid:142)(cid:3) Close band locking mechanism anteriorly below level of intragastric balloon to create pouch. (cid:142)(cid:3) 3 \200\2234 anterior gastro-gastric sutures to cover the pouch anteriorly and prevent later band slippage. Complications (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Gastric perforation (cid:142)(cid: 3) Damage to band during gastro-gastric suturing. 2. Combined restrictive/malabsorptive pro cedures: Laparoscopic roux-en-Y gastric bypass Technique (cid:142)(cid:3) General anesthesi a. (cid:142)(cid:3) Patient in Reverse Trendelenberg \200\231s position on the OR table wit h modified Lloyd-Davies positioning. (cid:142)(cid:3) Creation of pneumoperitoneum (Veress needle preferable). (cid:142)(cid:3) Primary 10mm laparoscope trocar in midline 4 inches beneath xiphoid. (cid:142)(cid:3) 30(ci d:13) laparoscope. (cid:142)(cid:3) Insertion of Nathenson retractor to retract left lobe o f liver cephalad under direct vision via sub xipoid route. (cid:142)(cid:3) 12mm left hand working cannula midclavicular line. (cid:142)(cid:3) 12mm r ight hand working port midclavicular line. (cid:142)(cid:3) 5mm retractor cannula to right of 15mm port anterior axillary line. (cid:142)(cid:3) Dissection begins at lesser curve 2cm below GOJ at level of left gastric vein exposing lesser sac. (cid:142)(cid:3) First (blue cartridge) gastric staple layer placed transversely separating stomach. Repeated progressive stapling (3 \200\2234 firings in total) directed to angle of Hiss to complete transection of the stomach leaving 30ml proximal stomach. (cid:142)(cid:3) Identify duodeno-jejunal (DJ) flexure in retrocolic compartment and identify suitable site of small bowel for gastrojejunal anastomosis. This loop of jejunum m ay be divided before or after gastro-jejunal (GJ) an- astomosis and must by brought to the gastric pouch either ante-colic and ante-gastrically (in which case omental division aids p assage) or retrocolic, retrogastric (in which case passage must be made through the transve rse mesocolon). (cid:142)(cid:3) The GJ anastomosis may be sutured or stapled with either a linear stapler or circular stapler. (cid:142)(cid:3) The jejunojejunal anastomosis is then fashioned at a point 100cm distal to the GJ (sometimes 150cm in the super-obese patients). 3. Malabsorptive procedures: Biliopancreatic diversion (Scopinaro technique) This technique relies predominantly on malabsorption to maintain weight loss by ensuring a \200\230commo n alimentary channel \200\231 (ileum) of no greater than 100cm preventing nutrient absorpti on. Metabolic and mineral deficiencies are more common with this technique than with either of the above methods but sustained weight loss may be better. Two variants are CHAPTER 9 Laparoscopic surgery 348 described. The classical approach involves a distal gastrectomy (Fig. 9.2); a more recent m odification especially used by laparoscopic surgeons in- volves a \200\230sleeve \200\231 gastrectomy with duodenal switch (Fig. 9.3) either as a single or as a staged procedure. Sleeve gastrectomy with duodenal switch Stage 1: Sleeve gastrectomy. The harmonic scalpel i s used to free the greater curve of the stomach from the gastrocolic omentum. Sequential fi rings of linear staples from the antrum to the angle of His then create a gastric tube 1.5c m in diameter based on the line of the lesser curve. Bleeding from the staple line and perf oration/staple line disruption (especially at the gastro- oesophageal junction) are the maj or operative complications. Stage 2: Biliopancreatic diversion. The duodenum is freed at the junction of D1 and D2 and transected with a linear stapler. A point on the small bowel 250cm from the ileocaecal valv e is divided and the distal cut end anastomosed to the duodenum with a hand suturing techni que. The proximal end is then anastomosed into the side of this alimentary channel with eit her sutures or staples 50 \200\223100cm from the ileocaecal valve. The shorter the common c hannel the more pronounced is the malabsorptive effect and steattorrhoea is frequent with c ommon channels shorter than 75cm. Distal gastrectomy with biliopancreatic diversion (single stage operation) A distal gastrec tomy is performed with a proximal stomach remnant of approximately 150 \200\223200ml. The b iliopancreatic diversion is performed as above to restore intestinal continuity. This techn ique removes the pylo- rus and the dumping syndrome which results may aid carbohydrate mala bsorption. All the above techniques are in common use and it is currently unclear which will emerge as the \200\230best \200\231 overall technique for long-term weight loss when balanced with their complications and side effects. In general the greater the degree of obesity the more likely a malabsorptive or bypass approach will be preferred particularly when the patient has a \200\230sweet tooth \200\231 in which case purely restrictive approaches are less li kely to be effective. OBESITY SURGERY1 349 Fig. 9.2 Scopinaro biliopancreatic diversion Fig. 9.3 Sleeve gastrectomy with duodenal switch (pylorus preserving) This page intentionally left blank Chapter 10 351 Stapling in surgery V. J. Kurup, A. Gillian and David J. Leaper Introduction 352 Stapling technique in anterior resection 354 Stapling technique in oesophagojejunostomy (Roux loop) after transabdominal total gastrectomy 356 Stapling technique for transection of bleeding oesophageal varices 358 Stapling technique for transection of duodenum 360 Stapling technique for gastroenterostomy 362 Stapling technique for bowel resection and functional end-to-end anastomosis 364 Stapling technique for prolapse and hemorrhoids 366 CHAPTER 10 Stapling in surgery 352 Introduction The first linear stapler used successfully in surgery was described by Profess or Humer Hultl in Hungary in 1908. This large instrument weighed 5kg and took 2 hours to lo ad. He used the instrument to close the sto- mach during gastrectomies. In 1921 Aladar von Petz, another Hungarian, described a much lighter, easier to use instrument. These early in stru- ments inserted a double row of staples giving a B-closure to achieve haemostasis with out necrosis of the suture line. Modern instruments are disposable and some have a multiple -fire facility allowing them to be used several times without the need to re-open a basic u nit. The range of staplers consists of four categories (circular, linear, linear cutting, a nd skin staplers), along with recent variations that lend themselves to minimally invasive surgery. Within each category, several commercial models are available, many of which have their own unique features modified by the manufacturer. Some of these instruments have diff erent staple heights, which can be adapted for use in different thicknesses of tissue. Staple or sew? Staplers facilitate gastrointestinal surgery by rapidly closing or anastomos - ing bowel. Some anastomoses (e.g., choledochojejunostomy) are best done by hand but in ot hers, such as joining colon to a rectal remnant after a low anterior resection, stapling is easier and faster as it creates a more consistent anastomosis in an inaccessible location. For most pro- cedures, however, the choice is up to the surgeon. Stapling has the advantag e of speed and also facilitation of access but has the disadvantage of increased cost. Mech anical failure is now rare and malfunction is generally due to operator error. Complication s related to the stapling technique are uncommon, although anastomotic stricture may be mor e frequent than when handsewn anastomoses are performed. Stapled anastomoses cannot be expe cted to succeed under conditions that would make construction of a sutured anastomosis dang erous. There is no evidence that staples are safer than sutures, for instance, in the prese nce of advanced peritonitis or poor tissue perfusion. Modern gastrointestinal staplers are designed to preserve the viability of the tissues distal to the staple line. This is analog ous to the \200\230approximate but do not strangulate \200\231 principle used when a bowel anastomosis is hand- sewn. However, it should be stressed that these are an adjunct to, an d not a substitute for, meticulous surgical technique. Circular stapler This stapler applies a double row of staples in circular fashion while tra nsecting the tissue within the circle, and is used for creating visceral end-to-end or end- to-side anastomosis. Some of the instruments are curved with a detachable or rotatory anvil which allows much greater adaptability, particularly when transecting oesophageal varices or carrying out transabdomino-oesophagojejunal anastomosis or a low anterior resection. The re are varied diameters between 21 \200\22333mm to accommo- date the bowel lumen being anas tomosed. Circular staplers are not reloadable. INTRODUCTION1 353 Linear stapler This inserts two parallel staple lines. The lengths vary from 30 \200\22390m m, with the shorter ones being used for closing a small bowel enterotomy, the intermediate ones for closing the duodenal stump after a partial gastrec- tomy, and the longer ones for creating a new lesser curve after distal gastrectomy. Two standard staple sizes are availab le for the standard linear stapler. The 3.5mm staple is 3.5mm in leg length and 4.0mm wide across the base. The 4.8mm staple is 4.8mm in leg length but also 4.0mm wide across the bas e. The 3.5mm stapler achieves a closed size of 1.5mm, and the 4.8mm stapler closes to 2mm. Smaller (3.5mm) cartridge is blue and the larger (4.8mm) cartridge is green; mnemonic \200 \230little boy blue and the jolly green giant \200\231. The 3.5mm cartridge is appropriate for most tasks. The 4.8mm cartridge is used for thicker tissues, such as stomach. Linear cutter Here four parallel staple lines are inserted with a cutting blade between. Th e tissue is stapled before knife activation so staples are completely formed before the kni fe cuts the tissue. The lengths vary from 50 \200\22390mm permitting side-to-side anastomos is or making terminal closures. The Linear cutter may be reloaded during a single procedure . This is particu- larly useful if speed is important or in less accessible operations. The se instruments can also be used for laparoscopic work, allowing bowel anastomosis through 1 0mm ports. Accessories are available, for example the tissue-measuring (sizers) and purse-string-inser ting devices. Some operations are made easier or car- ried out more quickly with staples, a nd this justifies their cost in many cases. Skin staplers They are designed for fast skin closure with good cosmetic results. They are applied with force just sufficient to achieve approximation without producing cross-hatchin g of the skin. The wound edges must be everted during approximation. Staples are delivered one by one and are placed 5 \200\22310mm apart depending on the thickness of the skin and u nderlying structures. Metal clips Metal clips offer a secure and quick method for obtaining haemostasis provided the entire circumference of the vessel is visible. Furthermore, ligating clips can be used to mark internal structures as they can be clearly identified on X-ray. There is a wide ran ge of clip applicators with different sizes for both open and laparoscopic surgery. Multipl e clip applicators are also available. They have a ratchet mechanism, which prevents accide ntal fall of clips from the jaw, and also have an integrated mechanism that reloads the ins trument enabling comfortable, efficient and fast ligation. CHAPTER 10 Stapling in surgery 354 Stapling technique in anterior resection Advantages (cid:142)(cid:3) Permits a low anastomo sis with greater ease and safety (cid:142)(cid:3) Is time-saving and permits optimal steril ity of the operative field (cid:142)(cid:3) Has lower risk of neoplastic spillage (cid:142) (cid:3) Eliminates technical problems such as the preparation of the distal purse-string su ture and the inequality between the two intestinal stumps to be anastomosed. Preparation, anesthetic, and incision are as for hand-sewn anterior resection. The table sh ould be in Lloyd-Davies position to allow per annum access. Procedure (Also see Figs.7.44, 7.50, and 7.51) (cid:142)(cid:3) Proceed exactly as hand-sew n until the ends of the bowel have been prepared for anastomosis. (cid:142)(cid:3) Be certain that the proximal colon reaches the pelvis easily and mobi- liz e the splenic flexure if not. Additional mobility may be gained by ligating the inferior me senteric vein just below the inferior margin of the pancreas. (cid:142)(cid:3) \200\230Single stapled \200\231 anastomosis (proximal and a distal purse- string suture) or a \200\230double stapling \200\231 technique (the rectum being closed with a straight/t ransverse stapled suture and a circular anastomosis made through the stapled suture row of the closed rectum) can be used. (cid:142)(cid:3) Remember that the stapler removes an extra 8mm of rectum and this is included when distal clearance is estimated below the tumor. (cid:142)(cid:3) Place a purse-string suture in the proximal colonic resection line using a disposable purse-string device, a modified Furness clamp, or by hand. Use 2/0 Prolene on a round-bodied needle. Start extraluminally on the anterior aspect and then continuously ove r and over, in and out, to invert the bowel edge. Prolene sutures must include both muscula r and mucosal layers and must be placed close to the cut edge so as to ensure a snug approx imation of the entire bowel wall around the stapling instrument when it is tied. (cid:142)(cid:3) Place distal purse string on the rectal stump, which can be performed by h and (single staple) or staple (double stapling technique). Trans- verse or adjustable-angle linear stapler (roticulator) is used to staple the rectum below the tumor. (cid:142)(cid:3) Metal sizers used to assess which size of stapler to use can be trau- matic, and simple measurement with a ruler is safer. However, when a sizer is introduced th rough the anus it can lift a very low anterior rectal stump into the pelvis, making the ins ertion of the purse-string easier (single staple). (cid:142)(cid:3) Choose the largest stapler that can safely be introduced into the two bowe l lumens. A curved instrument usually makes this easier. If the pelvis is narrow, use an in strument with a head that can be revolved (roticulator). STAPLING TECHNIQUE IN ANTERIOR RESECTION1 355 (cid:142)(cid:3) Introduce the stapling device through the anus with its safety catch on. O pen the instrument to separate the firing end from the distal anvil. (cid:142)(cid:3) Tie t he purse-string sutures over the separated ends (single staple) or allow the spike of the g un to pass through the posterior aspect of the stapled rectal stump in the middle and just behind the staple line (double stapling). (cid:142)(cid:3) Manipulate the end of the descending colon over the top of the anvil and tie the purse-string. (cid:142)(cid:3) Connect the anvil and secured descending colon into the cartridge. (cid:14 2)(cid:3) Close the instrument and ensure that no extraneous tissues enter it. (cid:142)(ci d:3) Remove the safety catch and fire the instrument. (cid:142)(cid:3) Open the gun to sepa rate the anvil from cartridge, two to three turns and rotates the stapler through 360(cid:13), which should be easy. (cid:142)(cid:3) Remove the stapler through the anastomosis carefully as if undoing a butto n from a buttonhole, but keeping your left hand around the anastomosis. (cid:142)(cid:3) Remove the stapler, detach the anvil and remove the two colon ends. Both s hould be complete \200\230doughnuts \200\231, confirming a complete anasto- mosis, which i s secure. If these are not complete, it may be necessary to redo the anastomosis or repair the defect. (cid:142)(cid:3) Send the doughnuts for histological examination. (cid:142)(cid :3) Some surgeons test the anastomotic integrity by filling the pelvis with saline containi ng a weak antiseptic and looking for air leaks with air insufflation through the sigmoidosc ope. The presence of air bubbles confirms the presence of a leak that must be repaired by i nterrupted sutures. (cid:142)(cid:3) Consider a temporary ileostomy or colostomy when there is any doubt concerning the security of the final anastomosis. CHAPTER 10 Stapling in surgery 356 Stapling technique in oesophagojejunostomy (Roux loop) after transabdominal total gastrecto my Preparation, anesthetic, position, and incision are the same as in abdominal total gastr ectomy. Procedure (cid:142)(cid:3) After the esophagus has been transected and the specimen removed , prevent proximal retraction of the esophagus by applying stay sutures in each of the four q uadrants of the esophagus, going through all layers. (cid:142)(cid:3) Attach a hemostat to each suture. (cid:142)(cid:3) Place a 2/0 Prolene pur se-string suture as for a stapled anterior resec- tion ensuring that the ends are outside the lumen. Include full thickness no more than 3 \200\2234cm proximal to the cut edge of the esophagus. (cid:142)(cid:3) Attach a haemostat to the completed purse-string suture. (cid:142)(cid:3) Measure the oesophageal size with a calibrated sizing instrument. Some prefer to dilate the end of the esophagus by inserting a Foley catheter (size 16Fr) into the lower esophagus an d injecting approximately 7 \200\22310ml of saline, which gently dilates the end of the eso phagus for the easier introduction of the anvil of the stapler. This may permit the introdu ction of a larger stapler. (cid:142)(cid:3) Be gentle as vigorous attempts to dilate the esophagus will result in mucosal tear. (cid:142)(cid:3) Fashion a Roux loop of jejunum, either retrocolic or antecolic. This can be done quickly using a multifire side-to-side stapler. (cid:142)(cid:3) Leave the end of the proximal jejunum open, ensuring that it can reach the esophagus below the hiatus. (cid:142)(cid:3) Insert an appropriately sized circular end-to-end stapler with the anvil removed through the open end of the jejunal loop. (cid:142)(cid:3) Ensure that the safety catch is on, that the stapler is the largest you ca n safely use, and that you have checked staple heights and tissue thickness. (cid:142)(cid: 3) Push the spindle spike through the jejunum 4 \200\2235cm from the bowel end on the antim esenteric side. A curved stapler with a detachable roti- culating head makes this easier. S ome use a jejunal purse string, which is securely tied. (cid:142)(cid:3) Tie the purse string in the oesophageal resection line over the anvil and join the stapler. (cid:142)(cid:3) Close the stapler and fire it after removing the safety catch. (cid:142)(c id:3) Open the stapler two to three turns and then remove it, holding the anastomosis with your left hand and using the buttonhole technique. (cid:142)(cid:3) Confirm that there are two intact fragments (doughnuts) of oesopha- gus and jejunum on the spindle. If necessary r einforce it partially or completely with sutures. STAPLING IN OESOPHAGOJEJUNOSTOMY1 357 (cid:142)(cid:3) If the esophagus is very thick, dissect back the muscular coat as a cuff. Do not include this in the stapler. After stapling, unite the oesophageal muscle to the jej unum with a continuous ring of sutures. Feel the anastomosis through the open jejunum and e nsure that it is intact and that the efferent long loop is open. (cid:142)(cid:3) Close the open jejunum with a linear stapler or by hand using two layers of Vicryl or PDS. Stapling in oesophagojejunostomy CHAPTER 10 Stapling in surgery 358 Stapling technique for transection of bleeding oesophageal varices Indication Consider tran section when varices continue to bleed despite medical therapy, resuscitation, and insertio n of Sengstaken tube. Preparation, anesthetic, position on the table, and incision are the same as for other vari ceal procedures. Procedure (cid:142)(cid:3) Divide the phreno-oesophageal ligament and dissect free the lowe r esophagus. (cid:142)(cid:3) Place an atraumatic sling around it, taking care not to damage the vagal nerves. (cid:142)(cid:3) Pass 2/0 silk or an atraumatic sling around the cleared esophagus before the insertion of the stapling device; otherwise it is technically more difficult and there is risk of damage to the oesophageal wall when the rigid gun is in position. (cid:142)(cid:3) Make a small gastrostomy in a relatively avascular part of the high anterior surface of the stomach. (cid:142)(cid:3) Pass the sizer into the esophagus to determine the largest size of gun hea d that can be slipped into the esophagus without risk of damage. (cid:142)(cid:3) Select the correct size circular end-to-end stapler with adjustments calculated for staple height and tissue thickness. (cid:142)(cid:3) Insert the complete stapler (closed gun) into the esophagus with the safet y catch on making sure that neither the sling nor the encircling ligature around the esopha gus impedes the passage of the gun up the lumen. (cid:142)(cid:3) Advance the gun into the esophagus for 5 \200\2236cm; open the stapler thr ee or four turns so that there is a gap between the anvil and the firing end (3 \200\2234cm ). (cid:142)(cid:3) Tie encircling 2/0 silk or other easily tied braided suture into the gap, thereby inverting the whole circumference of the esophagus into the gun. It takes time to e nsure that the ligature is firmly tied. (cid:142)(cid:3) Close and then fire the gun with a protective hand around the site of anas tomosis. Open the gun two or three turns and rotate it through before removing it with the buttonhole technique. (cid:142)(cid:3) Check the doughnuts and the anastomosis which should be 2 \200\2233cm above the oesophagogastric junction. (cid:142)(cid:3) Close the gastrostomy with a linear stapler or with two layers of Vicryl or PDS. This page intentionally left blank CHAPTER 10 Stapling in surgery 360 Stapling technique for transection of duodenum Linear staple closure of the bowel is safe, haemostatic, and quick to perform. Closure of the duodenum by this method applies equally w ell to closure of other bowel segment. Preparation, anesthetic, position on the table, and incision are as for gastrectomy. Procedure (cid:142)(cid:3) Mobilize the stomach during total or Polya gastrectomy. (cid:142 )(cid:3) Prepare the duodenum for transection. (cid:142)(cid:3) Place a linear stapler (30 or 60mm long) just distal to the proposed transection line. (cid:142)(cid:3) Ensure that the catch is on and that the correct staple heights have been taken into account. (cid:142)(cid:3) Place a crushing clamp (Parker-Kerr or Payrs) adjacent and proximal to the linear stapler. (cid:142)(cid:3) Remove the safety catch and fire the staple. (cid:142)(cid:3) Divide the d uodenum between the stapler and clamp-using knife. (cid:142)(cid:3) Remove the specimen or displace it medially. (cid:142)(cid:3) Open the jaws of the stapler and remove it. (cid:142 )(cid:3) Check the staple line for bleeding. If there is a bleeding vessel, under run it with 2/0 Vicryl. (cid:142)(cid:3) Drainage to cover the risk of blowout is no more necessary than after hand-sewn closure. A new lesser curve to the stomach during distal gastrectomy can be fashioned similarly usin g the longer 90mm linear stapler. Continuity can be re-established with a gastroenterostomy using a side-to-side stapler (Polya) or an end-to-end stapler to the duodenum (Bilroth I). This page intentionally left blank CHAPTER 10 Stapling in surgery 362 Stapling technique for gastroenterostomy Stapled gastroenterostomy using a side-to-side tec hnique is easy and rapid to perform in distal gastric resection or palliative proximal bypa ss for unresectable antral cancer. Procedure (cid:142)(cid:3) After resecting the distal stomach or realizing that the antral cancer cannot be resected, bring up a loop of jejunum ante or retrocolically so that it rea ches the stomach without tension. (cid:142)(cid:3) In palliative surgery exclude the distal stomach (the 90mm linear stapler is ideal for this). (cid:142)(cid:3) Position the jejunal loop with the afferent loop to the lesser curve so th at the proposed stoma lies in the most dependent part of the stomach. (cid:142)(cid:3) Plan the position of the stomach and jejunal loop for stapling to ensure that vessels in the gastric arcade and jejunal mesentery are not embarrassed. (cid:142)(cid:3) Hold the proposed suture lines adjacent with four Babcock \200\231s forcep s. Make two enterotomies opposite each other in the duodenum and stomach with diathermy. (cid:142)(cid:3) These should admit the jaws of a side-to-side stapler and be approxi- mate ly 1cm across. Insert the open jaws of the stapler fully into each viscus and approximate t he proximal end first. (cid:142)(cid:3) Ensure that the vessels and other structures are not incorporated and fire the stapler. Open the stapler and remove it. (cid:142)(cid:3) The anastomosis can be inspected for completeness and bleeding through the now single enterotomy. (cid:142)(cid:3) Close the enterotomy with two layers of continuous 2/0 Vicryl or with a linear stapler. (cid:142)(cid:3) It is not necessary to reinforce the staple line, but a Vicryl suture placed seromuscularly at each end of the anastomosis may take the strain off it. This page intentionally left blank CHAPTER 10 Stapling in surgery 364 Stapling technique for bowel resection and functional end-to-end anastomosis After bowel re section, e.g. right hemicolectomy, an end-to-end anasto- mosis can be fashioned quickly usi ng the side-to-side stapler. Preparation, anesthetic, position on the table, and incision are the same as conventional h and-sewn anastomosis. Procedure (cid:142)(cid:3) After right hemicolectomy line up the distal ileum and transvers e colon with their open lumina adjacent using Babcock \200\231s tissue forceps. (cid:142)(cid:3) En sure that the mesentery of each viscus is as far away from the proposed anastomosis as possible. Ideally the staple line should run along the antimesenter ic border. (cid:142)(cid:3) Insert the open jaws of the stapler down each bowel limb, close and fire.