Commonly performed procedures: (cid:142)(cid:3) Targeted biopsy (cid:142)(cid:3) Drainage (cid:142)(cid:3) FNA (Fine needl e aspiration). NB Fast patient for six hours to reduce bowel gas. If intervention is planne d perform appropriate investigations (e.g. clotting screen) and exclude coagulopathy. Endoscopic ultrasound A mainstay of pancreatic investigation. Radial imaging used to: (cid: 142)(cid:3) Assess venous invasion (cid:142)(cid:3) Locate islet cell tumors. Linear array ultrasonography provides: (cid:142)(cid:3) Excellent images of the pancreatic parenchyma (c id:142)(cid:3) The opportunity for guided intervention, e.g. FNA, trucut biopsy of tumors, ultrasound guided drainage of cystic collections and celiac plexus blockade. ERCP Endoscopic retrograde cholangio-pancreatography (ERCP) is common- place in surgical pr actice. The patient lies on an X-ray table in a semi- prone position with the head turned t o the right. Venous access is via the right hand. Under conscious sedation, an endoscope is passed into the duodenum and catheters positioned within the bile or pancreatic duct for i njection of contrast and imaging. Therapeutic procedures: (cid:142)(cid:3) Sphincterotomy (cid:142)(cid:3) Stent insertion (c id:142)(cid:3) Biopsy (cid:142)(cid:3) Stone retrieval. Major complications (commonly assoc iated with therapeutic ERCP): (cid:142)(cid:3) Pancreatitis (cid:142)(cid:3) Duodenal perfo ration (cid:142)(cid:3) Post-sphincterotomy hemorrhage. MRCP Magnetic resonance cholangio-pancreatography. In many situations this is the preferred investigation. In 72 weighted images, static fluid is repre- sented as a strong white sign al. That within the common bile duct and INVESTIGATIONAL PROCEDURES1 309 pancreatic duct can be represented as an image resembling an ERCP, which can provide excell ent diagnostic information of the biliary tree in particular (NB still inferior to direct r adiology). Contraindications and problems: (cid:142)(cid:3) Intracorporeal implants (pacemakers, intra cranial vascular clips, metallic foreign bodies) (cid:142)(cid:3) Intensive care organ support (cid:142)(cid:3) Claustrophobia (cid:142)(cid :3) Lengthy image acquisition times. Staging laparoscopy Laparoscopy is commonly used to assess upper GI malignancies. Position of patient Supine. Intraperitoneal access This is achieved using a cut-down technique with the use of a Veress needle, but is associated with the risk of visceral or vascular injury. (cid:142)(cid:3) I nsert a blunt port sub-umbilically (cid:142)(cid:3) Create a pneumo-peritoneum using carbon dioxide at a pressure of 10 \200\22313mmHg. Two further subcostal ports are then inserted under direct vision. Procedure (cid:142)(cid:3) Inspect the peritoneum by starting to the left of the falciform ligament and working clockwise, examining the lower abdomen for trans- coelomic spread before return ing to the right upper quadrant. (cid:142)(cid:3) Inspect the superior and under-surface of the liver, anterior aspect of the stomach and omentum for peritoneal metastasis. (cid:142)(cid:3) Lift the omentum allowing examination of the root of the mesentery for loc al invasion. The pancreatic head can then be assessed for mobility. (cid:142)(cid:3) Instil l 500ml of saline for cytology and also to promote an acoustic win- dow for laparoscopic ultrasound. Insert a laparoscopic ultrasound probe through the left up per quadrant port and placed along the right side of the falciform ligament, over segment f our, to identify the hepatic veins for orientation. Then examine hepatic parenchyma in segm ental fashion looking for metastasis. Then place the ultrasound probe along side the coelia c axis and superior mesenteric artery and follow the vessels proximally searching for signi ficant lymphadenopathy The pancreas is usually easily identified and the pancreatic duct fo llowed from the body towards the head of the gland. (cid:142)(cid:3) Identify the splenic veins and superior mesenteric confluents and assess them for venous involvement. (cid:142)(cid:3) Aspirate the fluid for cytology and remove the ports removed under vision to ensure there is no internal bleeding. CHAPTER 8 Hepatobiliary surgery 310 Pancreatic mobilization Elective pancreatic surgery is usually performed within specialized units. Approaching the pancreas in an unstructured manner can result in signifi- cant (par ticularly venous) hemorrhage. Most general surgeons operate on the pancreas during emergenc y trauma procedures. Nevertheless the principles of mobilization apply to all pancreatic pr ocedures and are designed to promote vascular control during procedures. Position of the patient Supine. Incision Transverse (rooftop) or midline incision. Procedure (cid:142)(cid:3) Elevate the colon and omentum and dissect the omentum from the colon to allow entry to the lesser sac. Mobilize the hepatic flexure and retract inferiorly . Open the peritoneum parallel to the duodenum to allow entry to the plane between the infe rior vena cava (IVC) and the duodenum. (cid:142)(cid:3) Extend the incision from the reflected colon up to the inferior aspect of the liver to develop the foramen of Winslow, encircling the hepato- duodenal ligament to pe rmit, if necessary, the application of a Pringle maneuver. Roll the duodenum medially expos ing the anterior aspect of the IVC, the left renal vein and the anterior aspect of the aort a. The duodenum and pancreatic head can then be held in the left hand between fingers and t humb, allowing pressure to be applied in an antero-posterior direction if significant venou s bleeding is encountered. (cid:142)(cid:3) Follow the middle colic veins downwards, often dividing a branch of the un cinate process to expose the superior mesenteric vein as it descends beneath the pancreatic neck. (cid:142)(cid:3) Expose the anterior aspect of the head of the pancreas by dividing the gas tro-epiploic vessels, which emerge from the pancreatic parenchyma close to the lower border of the pancreatic neck. (cid:142)(cid:3) Expose the portal vein as it emerges from the superior border of the pancr eatic neck by ligating the gastro-duodenal artery, divide and retract it superiorly and med ially to expose the vein. (cid:142)(cid:3) In the trauma situation, mobilize the pancreatic tail by bringing the tail and spleen forwards and medially from the posterior abdominal wall and open the lesser sac as described above and mobilize the splenic flexure and the colon and retract them inferio rly. The splenic artery can be ligated at its origin on the superior aspect of the pancreas in the midline. Divide the short gastric vessels between the stomach and spleen to expose the anterior aspect of the pancreatic tail and divide the lieno-renal ligament lateral to t he spleen, rolling the spleen and pancreas medially in the plane behind the splenic vessels . This ma- noeuvre compresses the splenic vessels and as it is performed permits vascular c ontrol to be maintained during dissection. This page intentionally left blank CHAPTER 8 Hepatobiliary surgery 312 Management of tumors Pancreatic head resection \200\224pancreatico-duodenectomy Position of the patient Supine. Incision Rooftop or midline. Procedure (cid:142)(cid:3) Mobilize the head of the pancreas as described above. Divide the omentum up to the gastro-epiploic vessels preserving the gastro- epiploic arcade down to t he level of the pylorus. Divide the lesser omentum at the level of the liver and mobilize i t down to the pylorus taking care to preserve the right gastric arcade. (cid:142)(cid:3) Transect the duodenum approximately 2cm beyond the pylorus. Per- form a retrograde cholecystectomy by exposing the anterior aspect of the common hepatic duc t and dividing it approximately 1cm below the hilar plate. Skeletalise the right side of th e hepatic artery and the portal vein down to the superior border of the pancreas. (cid:142)(cid:3) Lift the colon superiorly allowing release of the duodeno-jejunal flex- ur e divide the jejunum at the level of the first arcade and divide the mesenteric vessels dow n toward the superior mesenteric artery and vein. Having freed the vascular supply to the p roximal jejunum, pass it beneath the superior mesenteric vessels to lie in the right sub-he patic space. Hold the uncinate process and proximal jejunum in the left hand and divide the pancreatic neck to expose the superior mesenteric vein (SMV)/portal vein. The inferior mes enteric vein (IMV) often joins the SMV rather than the splenic vein. Two further veins usua lly enter the SMV/portal vein from the pancreatic head. (cid:142)(cid:3) Dissect the remaining tissue from the lateral border of the superior mesenteric artery and remove the specimen. Reconstruction There are three common reconstruction techniques. The choice is usually dete rmined by personal preference. Pylorus preserving pancreatico-duodenectomy (PPPD) (cid:142)(cid:3) Bring the distal jejuna l loop into the upper abdomen by the retro-colic route. As the initial anastomosis is usual ly end-to-side pancreatico- jejunal, an interrupted posterior layer of sutures is inserted and tied. Then perform a small enterotomy allowing a mucosa-to-mucosa pancreatico-jejunal a nastomosis to be fashioned using interrupted sutures. This anastomosis can be facilitated b y the use of a stent. Complete the anastomosis with an interrupted anterior layer. (cid:142)(cid:3) Perform an end-to-side biliary anastomosis. (cid:142)(cid:3) Place an ante rior layer of interrupted sutures from the outside to the inside of the bile duct lumen. Th en hold them in forceps for future use with the needles left in situ. (cid:142)(cid:3) Perf orm a small enterotomy. MANAGEMENT OF tumors1 313 Fig. 8.1 Kocherization of duodenum Fig. 8.2 Mobilization of head of pancreas CHAPTER 8 Hepatobiliary surgery 314 (cid:142)(cid:3) Place a posterior wall of interrupted sutures through both the jejunum and posterior bile duct. (cid:142)(cid:3) Then \200\230parachute \200\231 the duodenal loop down into position and tie the posterior row of sutures. (cid:142)(cid:3) Next place the anterior layer of sutures, already through the bile duct, t hrough the jejunum and tie them to complete the anastomosis. Finally, fashion an end-to-sid e duodenal-jejunostomy with a continuous single layer technique. The exact position and ord er of these anastomoses can vary depending on the individual anatomical orientation. Closure Mass technique. Clips or sutures to skin. Suction drain to right upper quadrant. Variations (cid:142)(cid:3) Classical \200\230Whipple \200\231 operation. Rather than pres erving the antrum, pylorus and first 2cm of the duodenum, an antrectomy is performed by div iding the stomach from the incisura to the greater curve. Reconstruction is achieved by usi ng either and end-to-side Billroth II type anastomosis in a continuous two layered techniqu e or, if a roux loop has been fashioned, by a functional end-to-end anastomosis with contin uous one or two layer sutures. (cid:142)(cid:3) Pancreatico-gastrostomy. The pancreas can be anastomosed to the posterior wall of the stomach rather than to the jejunum. This can be achieved using a \200\230dunking \200\231 technique with interrupted sutures to pancreas and stomach. Standard distal pancreatectomy with splenectomy Having mobilized the pancreatic tail, the s plenic artery is dissected at its origin from the coeliac axis and doubly ligated. The neck of the pancreas is then divided to the medial aspect of the superior mesenteric vein to ex pose the splenic vein, which is also ligated and divided. The tail of the pancreas and sple en are then resected. The cut end of the pancreas is oversewn using interrupted sutures ens uring inclusion of the main pan- creatic duct if possible and leaving a drain in situ. Splenic preserving distal pancreatectomy The anterior aspect of the pancreas is exposed and the superior and inferior aspects of the neck of the pancreas dissected to expose the supe - rior mesenteric vein. The spleen is not mobilized. The pancreas is then divided and the d issection continued towards the tail. Small pancreatic tributaries from the splenic artery and vein are ligated and divided, resect- ing the pancreatic tail whilst leaving the vessel s in situ. The cut edge of the pancreatic neck is then secured as above, and a drain left i n situ. Total pancreatectomy This is a rarely performed operation due to its potential morbidity. T he usual indications are IPMT with positive resection margins preventing a local resection or, in certain rare circumstances, chronic pancreatitis. This essentially involves a combin ation of \200\230Whipple \200\231 resection with a distal pancreatectomy. MANAGEMENT OF tumors1 315 Fig. 8.3 Pancreaticoduodenectomy (Whipple \200\231s operation) showing three anastomoses Enucleation of islet cell tumor Some pancreatic endocrine tumors may be enucleated at open or laparoscopic surgery. The main complication with this technique is the development of a postoperative pancreatic fistula due to involvement of the ductal system in the resection m argin. The extent to which the tu- mour is intraparenchymal is therefore important in the p re-operative choice of procedure as a distal pancreatectomy may be more appropriate for dee ply sited lesions. Pre-operative localization Use EUS, CT plus intra-operative ultrasound scanning to identify the lesion. Procedure This is the same whether via a rooftop incision or laparoscopy. Dissect the gastr o-colic omentum from the colon to expose the anterior aspect of the pancreas. A superficial ly sited tumor may be shelled out from underlying pancreatic tissue, excision being confirm ed by frozen section. Closure Mass, clips or sutures to skin. Leave a drain along the anterior aspect of the panc reas. CHAPTER 8 Hepatobiliary surgery 316 Management of pancreatic necrosis Surgery is usually required for the management of complic ations rather than for the necrosis itself. The commonest procedure for infected pan- creat ic necrosis, or necrosis in a patient failing to respond to conserva- tive treatment, is an open necrosectomy. This may be performed through an open anterior, a lateral retroperitone al, an anterior laparoscopic or a percutaneous approach. Open anterior approach Position of patient Supine. Incision Rooftop. Procedure (cid:142)(cid:3) Perform a laparotomy. Open the lesser sac, as previously describ ed, or by dividing the gastro-colic omentum. (cid:142)(cid:3) Mobilize both hepatic and splenic flexures to exposure the anterior aspect of the pancreatic abscess. Open the abscess through the lesser sac; use finger disse ction to tease all necrotic material out. Avoid sharp resection as this may lead to hemorrh age which is difficult to control. Cholecystectomy and operative cholangiogram are usually performed and the cavity cleared of all necrotic tissue. Closure Close the abdomen over paired drains, usually 4 \200\2236 to allow postopera- tive lavage at a rate of 250ml/hour. Complications In the event of significant oozing, pack the abscess cavity with lubricated g auze swabs with a view to a re-laparotomy 48 hours later. Lateral retroperitoneal approach Position of patient Right lateral. Incision Left flank. Procedure (cid:142)(cid:3) Mobilize the colon medially allowing retroperitoneal access to t he lesser sac. (cid:142)(cid:3) Remove the necrotic material by blunt finger dissection and manage the cavity by either drainage or packing, as described above. Anterior laparoscopic approach Position of patient Supine. MANAGEMENT OF PANCREATIC NECROSIS1 317 Access (cid:142)(cid:3) Use a cut-down technique to insert a blunt port subumbilically. Ins ert a further 10mm and 5mm ports to provide both operative access and upward retraction of the colon to expose the transverse meso-colon. (cid:142)(cid:3) Enter the lesser sac by ope ning the transverse meso-colon and remove the abscess and necrotic material through this opening. (cid:142)(cid:3) Tube drainage postoperatively to control the necrosectomy cavity. Percutaneous necrosectomy This procedure has been developed in Glasgow and involves the dil ata- tion of a drain tract to promote adequate drainage and lavage of an abscess cavity. It is most commonly used for infected necrosis. Procedure (cid:142)(cid:3) Insert a percutaneous catheter into the abscess cavity under CT guidance. (cid:142)(cid:3) Insert a guidewire into the drain and dilate the tract to 34Fr. gauge usin g either a balloon dilatation system or graduated dilator. Then insert an Amplatz \233\232 sheath to maintain tract integrity. This permits the cavity to be explored using an operati ve nephroscope and any solid material can be removed under direct vision. (cid:142)(cid:3) Suture a tube drain with a parallel lavage catheter in place at the end of the procedure to permit continuous postoperative lavage at a rate of 250ml/hour. CHAPTER 8 Hepatobiliary surgery 318 Management of pseudocyst Drainage of a pseudocyst may be either into a Roux loop or more co mmonly into the back of the stomach. It is particularly useful for post inflammatory cysts containing necrotic debris, which may prevent resolu- tion if a minimally invasive techniqu e of drainage is employed. Cysto-gastrostomy Position of patient Supine. Incision Midline. Procedure (cid:142)(cid:3) Identify the anterior aspect of the stomach and perform a longit udinal gastrostomy approximately 10 \200\22315cm in length. (cid:142)(cid:3) Confirm the site of the retroperitoneal pseudocyst by either intra- operat ive ultrasound or needle puncture. Then open the cyst with diathermy and over-sew its edge to prevent bleeding. The length of the cysto-enterostomy is usually 5 \200\22310cm. Remove any necrotic mate- rial within the cyst. (cid:142)(cid:3) Close the anterior wall of the stomach using continuous 3/0 PDS sutures. (cid:142)(cid:3) Identify the anterior aspect of the stomach and perform a longitudinal gastrostomy approximately 10 \200\22315cm in length. (cid:142)(cid:3) Confirm the site of the retroperitoneal pseudocyst by either intra- operat ive ultrasound or needle puncture. Then open the cyst with diathermy and over-sew its edge to prevent bleeding. The length of the cysto-enterostomy is usually 5 \200\22310cm. Remove any necrotic mate- rial within the cyst. (cid:142)(cid:3) Close the anterior wall of the stomach using continuous 3/0 PDS sutures. Closure Mass. Sutures or clips to skin. No drainage NB Endoscopic cysto-gastrostomy (with o r without EUS control) is becoming increasingly common and is the approach of choice where necrosis is minimal. Cyst-enterostomy Where the site of the cyst precludes drainage into the posterior aspect of the stomach, a Roux loop can be used as an alternative. The loop is brought up to lie adja cent to the pseudo-cyst and its position can, once again, be confirmed by intra-operative u ltrasound or needle puncture. The cyst is then opened and a side-to-side anastomosis establ ished using a continuous suture technique. This page intentionally left blank CHAPTER 8 Hepatobiliary surgery 320 Management of chronic pancreatitis Minimally invasive endoscopic procedures for the managem ent of chronic pancreatitis are a viable alternative to surgical decompression in selected patients. Frey procedure Position of patient Supine. (cid:142)(cid:3) Mobilize the head of the pancre as and identify the dilated pancreatic duct with either intra-operative ultrasound or needl e aspiration. (cid:142)(cid:3) Excise the anterior pancreatic parenchyma to expose the post erior aspect of the pancreatic duct leaving a tadpole-shaped defect in the anterior aspect of the pancreas. The depth of the head dissection is determined by the size of the pancreat ic head mass and the presence or absence of the significant extra-hepatic bile duct obstruc tion. (cid:142)(cid:3) Create a Roux loop after the resection is completed. Bring it through the transverse meso-colon to the retro-colic position. (cid:142)(cid:3) Anastomose this side-to-side to the pancreatic parenchyma using multiple interrupted sutures in with parachute technique to ensure correct placement. The a mount of pancreatic tissue excised in the classical procedure is 5 \200\2236g. Closure Close the wound in layers with staples to skin and a drain is left within the lesse r sac. Beger procedure A duodenum-preserving pancreatico-jejunostomy was initially described for t he management of a pancreatic head mass in the presence of an essentially normal pancreatic tail. The procedure involved formal transec- tion of the pancreas at the medial border of the superior mesen- teric/portal vein, as in a \200\230Whipple \200\231 resection. (cid:14 2)(cid:3) Core the pancreatic head out leaving a small rim of pancreatic tissue around the internal circumference of the duodenal loop and the posterior wall of the pancreas to expos e the common bile duct, which is on occasion opened. (cid:142)(cid:3) Perform an end-to-side pancreatico-jejunostomy as in the \200\230Whipple \200\231 procedure. The Roux loop is also anastomosed onto the exposed pancreatic head. (cid:142)(cid:3) This procedure has been modified extending the dissection into the pancrea tic tail for those patients with tail involvement, and may be considered as a modification of a longitudinal pancreatico-jejunostomy. Approximately 20 \200\22340g of pancreatic tissu e is removed. However, in practice, the amount removed is a function of the volume of the p ancreatic head mass, if present, and the need to decompress the biliary system. MANAGEMENT OF CHRONIC PANCREATITIS1 321 Minimally invasive thoracoscopic splanchnicectomy (MITS) This procedure is used for relief of pancreatic pain in patients with either chronic pancreatitis or pancreatic carcinoma, an d is an alternative to coeliac plexus block. Position of patient Prone. Incision Achieve intra-thoracic access using a cut-down technique similar to that described for the ATLS insertion of a chest drain, just below the inferior border of the scapula. Procedure (cid:142)(cid:3) Open the pleura, with a finger inserted to ensure there are no s ignificant adhesions. Then insert a blunt port at this site with a pneumothorax created usi ng carbon dioxide at a pressure of 6mmHg. (cid:142)(cid:3) Insert a second 5mm port two rib spaces below this. The splanchnic nerves emerge from the sympathetic chain within the chest between T5 and T12 and converge to form the greater, lesser and least splanchnic nerves, which are easily vis ible using a 30(cid:13) camera running beneath the pleura overlying the vertebral bodies. (cid:142)(cid:3) Divide the nerve branches using a nerve hook pressing against the vertebral body to avoid the intercostal vessels. Move the ports at the end of the procedure under vision and have the lung re-inflated. There is no need for long-term water-sealed dr ainage of the pleural cavity. (cid:142)(cid:3) Repeat the procedure on the opposite side, so that bilateral splanchnicectomy is performed. CHAPTER 8 Hepatobiliary surgery 322 Common pancreatic complications General considerations Pancreatic conditions are associated with considerable morbidity whether presenting with an acute illness or following elective surgery. Organ dysfunction is common and patients are usually managed in a high dependency environment. As with all surgical patients, chest infections, line sepsis and catheter rel ated sepsis occur, and low molecular weight heparin and physiotherapy is considered standar d care. Organ dysfunc- tion may require support within an intensive care unit. However, som e complications are specific to pancreatico-biliary conditions: (cid:142)(cid:3) Bleeding. Pressure bleeding from a surgical drain should be reported immediately to a senior colleagu e, particularly where sepsis has been present. An initial \200\230herald \200\231 bleed ma y be followed by an exanguinating bleed, so early recognition is essential. Although defini te definitive surgical control may be required, management may be possible by angiographic embolisation. (cid:142)(cid:3) Biliary fistula. Leakage of bile following surgery can occur following a d islodged surgical tie, a leaking anastomosis or iatrogenic ductal injury. Management is lar gely determined by the post surgical anatomy, as access to the ampulla of Vater may allow e ndoscopic decompression. The principle of management is to gain control of infection by sur gical, endoscopic or percutaneous drainage, maintaining nutritional support whilst resoluti on occurs. (cid:142)(cid:3) Pancreatic fistula. This most commonly occurs following surgery but can fo llow percutaneous drainage of a peri-pancreatic fluid collection. It many settle spontaneou sly but stenting of the pancreatic duct at ERCP can expedite resolution. Pancreatic resecti on may be required for persistent fistulas. (cid:142)(cid:3) Post ERCP pancreatitis. Abdominal pain is relatively common following ERCP due to gaseous distension. However, if this persists for more than a short period or incre ases in severity, peripancreatic or pancre- atic inflammation should be suspected. Post ERC P pancreatitis may be confirmed by a two hour post procedure serum amylase being greater th an three times normal. This is more common following interven- tional procedures, or follow ing a pancreatogram. Duodenal perforation should be suspected if there are any signs of ear ly infection or sepsis and can be confirmed by an urgent contrast CT scan. (cid:142)(cid:3) Cholangitis. This is life-threatening and usually secondary to biliary obstruction. The classical clinical syndrome with pain, fever, rigors and jaundice should b e managed by urgent biliary decompression, usually by ERCP. Delay in treatment may result i n the rapid development of multi-organ dysfunction syndrome. Chapter 9 323 Laparoscopic surgery S. Rawat, L. Horgan, and C. M. S. Royston Laparoscopic staging for abdominal malignancies 3 24 Laparoscopic splenectomy 326 Laparoscopic inguinal hernia repair 328 Laparoscopic Nissen fundoplication 332 Laparoscopic cholecystectomy 336 Laparoscopic appendicectomy 342 Obesit y surgery 346 CHAPTER 9 Laparoscopic surgery 324 Laparoscopic staging for abdominal malignancies Laparoscopy is an effective and useful tool for the diagnosis and staging of abdominal malignancies. Staging is of paramount importanc e in plan- ning treatment for localized and advanced disease. It is imperative to accuratel y identify those patients with a potentially resectable, localized tumor and those patients with advanced disease or distant metastasis. Despite improvements in preoperative staging with dynamic computed tomography (CT) and endoscopic ultrasonography, unexpected liver or p eritoneal metastases are found in 10 \200\22320% of patients with oesophageal, gastric and pancreatic cancer. The need for laparotomy can therefore be obviated in these patients. Aim of laparoscopic staging (cid:142)(cid:3) Confirm the findings of preoperative investiga tions (cid:142)(cid:3) Assess spread \200\224local and distant (cid:142)(cid:3) Biopsy of s uspicious lesions (cid:142)(cid:3) Cytology of ascitic fluid/peritoneal washing. Indications (cid:142)(cid:3) Oesophageal cancer (cid:142)(cid:3) Gastric cancer (cid:142)(c id:3) Pancreatic cancer (cid:142)(cid:3) Hepatobiliary tumors (cid:142)(cid:3) Lymphoma. Contraindications (cid:142)(cid:3) Disseminated disease (cid:142)(cid:3) Unfit for general anesthesia (cid:142)(cid:3) Open procedure is indicated for palliation (cid:142)(cid:3) Pro cedure unlikely to alter plan of care. Technique The procedure is performed under general anesthesia. Position of patient Supine. Procedure (cid:142)(cid:3) Create pneumoperitoneum. (cid:142)(cid:3) Introduce a 30(cid:13) telescope through a midline periumbilical trocar. Place one or two additional trocars in e ach upper quadrant depending on area to be visualized. (cid:142)(cid:3) Perform a systematic four-quadrant visual inspection. Carefully inspect al l peritoneal and omental surfaces for seedlings. Send ascitic fluid sample for cytology. (cid:142)(cid:3) Assess the primary tumor \200\224size, location, local extent, fixation, extension to adjacent organs. LAPAROSCOPIC STAGING FOR ABDOMINAL MALIGNANCIES1 325 (cid:142)(cid:3) Place the patient in a 20(cid:13) reverse Trendelenburg position with 10(c id:13) left lateral tilt. Visualize anterior, posterior and inferior surface of both lobes of liver. Inspect the hilum of the liver and biopsy any periportal nodes if suspected. (cid:142)(cid:3) Place the patient in a 10(cid:13) Trendelenburg position without lateral t ilt. Identify the omentum and retract it to the left upper quadrant. This allows identifica tion of ligament of Treitz and inspection of mesocolon. (cid:142)(cid:3) Incise the gastrohepatic omentum to expose the caudate lobe of the liver, vena cava and the coeliac axis. Take care to preserve any anomalous left hepatic art ery. Biopsy any suspicious enlarged lymph nodes in this region (coeliac, portal, or perigas tric). Laparoscopic ultrasonography (LUS) Laparoscopic ultrasound has enhanced the sensitivity of staging as the direct contact of the probe with the organ of interest affords superior reso lution especially in pancreatic tumors. Ultrasound probes use con- ventional B-mode and col or Doppler technology and permit identifica- tion of deep liver lesions, small peritoneal l esions, vascular invasion, and abnormal lymph nodes in the coeliac, gastric, portal, and pe ripancreatic regions. LUS may also accurately direct biopsy and assess proximity to surroun ding structures. Criteria for unresectability (cid:142)(cid:3) Metastasis: hepatic, serosal or peritoneal (c id:142)(cid:3) Involvement of the mesocolon (cid:142)(cid:3) Invasion or encasement of coel iac, hepatic, superior mesenteric artery or involvement of portal vein. Complications (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Bowel perforation (cid:142)(cid: 3) Wound infection (cid:142)(cid:3) Port site herniation and recurrence. CHAPTER 9 Laparoscopic surgery 326 Laparoscopic splenectomy Since it was first described by Delaitre and colleagues in 1992, l aparoscopic splenectomy has become the method of choice for elective splenectomy in patient s with a splenic weight estimated to be <1.5kg. Massive splenomegaly (palpable clinically) still remains a technical challenge. Increas- ing operative experience and technical refine ments have produced good results compared to open splenectomy in terms of wound infection, pulmo- nary complications, patient discomfort, outcome and length of hospital stay. Indications Essentially the same as for open splenectomy. (cid:142)(cid:3) Idiopathic throm bocytopenic purpura (cid:142)(cid:3) Hereditary spherocytosis (cid:142)(cid:3) Haemolytic a nemia (cid:142)(cid:3) Lymphoma (cid:142)(cid:3) Lymphocytic leukemia. Relative contraindications (cid:142)(cid:3) Massive splenomegaly (cid:142)(cid:3) Abscess ( cid:142)(cid:3) Tumor (cid:142)(cid:3) Splenic artery aneurysm. Preparation (cid:142)(cid:3) Preoperative immunization with pneumovax, Haemophilus influenz a and meningococcal vaccines. (cid:142)(cid:3) Cross match packed red blood cells for all patients and platelets for thrombocytopenic patients (platelets count <50 \227 109/l). (cid:142)(cid:3) Preoperative splenic artery embolization for large spleens to minimize bleeding has been suggested by some. (cid:142)(cid:3) Give steroid cover to patients with idiopathic thrombocytopenic purpura or patients on long-term corticosteroids. (cid:142)(cid:3) Take advice of hematologist regarding pre and postoperative care. (cid:142 )(cid:3) Informed consent for both laparoscopic and open splenectomy. (cid:142)(cid:3) Prop hylactic antibiotics (penicillin) at induction of general anesthesia. (cid:142)(cid:3) Two operative techniques are described \200\224the anterolateral and the posterior approach. Th e anterolateral approach is preferred as it is associated with better access, reduced opera tive time, postoperative stay and blood transfusion. Position Reverse Trendelenberg semi lateral tilt. Technique (cid:142)(cid:3) Create pneumoperitoneum (via umbilical route). Introduce 30(cid: 13) angled telescope. Place three further cannulas, 10mm in epigastrium and two 5mm in left mid-clavicular and left anterior axillary lines. (cid:142)(cid:3) Exploratory laparoscopy looking especially for accessory spleens in the hilum, gastrosplenic ligament, splenocolic ligament, splenorenal ligament and greater oment um. LAPAROSCOPIC SPLENECTOMY1 327 (cid:142)(cid:3) Divide splenocolic ligament with harmonic scalpel. (cid:142)(cid:3) Dissec t the short gastric vessels and divide them using clips, harmonic scalpel or bipolar diathermy. (cid:142)(cid:3) Retract the spleen medially, divide lienorenal ligament close to the splenic capsule using diathermy or harmonic scalpel. (cid:142)(cid:3) Clear any adhesions posteriorly to create a space for a laparoscopic stapling device to be placed across the hilum. (cid:142)(cid:3) Locate the hilar vessels. Transect it using an Endo GIA ensuring that fund us of the stomach or the tail of the pancreas is excluded. Other methods of ligation such a s clips or ties may also be used. (cid:142)(cid:3) Insert Endocatch II instrument into 12mm cannula and place spleen in bag. Withdraw the bag and remove the spleen piecemeal after section- ing into smaller pieces wit h sponge-holding forceps or digital fracture technique. (cid:142)(cid:3) If spleen is required intact for histological examination or is too large to be placed in a retrieval bag, use a small Pfannenstiel incision for organ removal. (cid:142)(cid:3) The harmonic scalpel facilitates control of the short gastric vessels and splenic attachments and reduces the operative time. Operative complications (cid:142)(cid:3) Bleeding. Correct any coagulation defect preoperat ively. Control hemorrhage with cautery, clips, endoloops, Endo GIA Staplers or open conversion. (cid:142)(cid:3) Injury to adjacent organs \200\224colon, stomach, small bowel, pancreas. Laparotomy may be required. (cid:142)(cid:3) Subphrenic abscess. Start antibiotics and drain percutaneously under CT guidance. (cid:142)(cid:3) Pancreatitis and pancreatic fistula. Percutaneous drainage for fistula. (c id:142)(cid:3) Overwhelming postsplenectomy infection (OPSI). Patients should receive preop erative vaccination at least 2 weeks before surgery. Give advice regarding immunization, fo reign travel and prophylactic antibiotics. (cid:142)(cid:3) Thrombocytosis. Can lead to DVT and pulmonary embolus. Routinely use subcutaneous heparin and TED stockings. CHAPTER 9 Laparoscopic surgery 328 Laparoscopic inguinal hernia repair Laparoscopic hernia repair has the advantages of reduce d discomfort after surgery, early return to full activity, low incidence of wound infec- ti on and chronic groin pain. Recurrence rates are comparable to Lichten- stein open mesh repa ir. In January 2001, the National Institute for Clinical Excellence (NICE) guidelines sugge sted that open mesh repair should be the preferred procedure for primary unilateral inguina l hernias, and the laparoscopic repair should be considered for recurrent or bilateral her- nias. NICE has also expressed a preference for one of the two laparo- scopic techniques av ailable, the totally extraperitoneal (TEP) rather than the transabdominal preperitoneal (TA PP) method, even though there is no proven difference in outcome between the two techniques . These guidelines have been controversial and are widely debated. Indications (cid:142)(cid:3) Recurrent inguinal hernia \200\224universally accepted indicat ion. Open sur- gery for recurrence is more difficult, with higher risk of damage to cord structures, inclu ding testicular vessels and higher risk of recurrence. (cid:142)(cid:3) Bilateral hernia \200\224laparoscopic surgery permits repair in the same session with shorter convalescence time. (cid:142)(cid:3) The role of laparoscopic repair of primary unilateral hernia is debated and is not recommended by NICE. Contraindications (cid:142)(cid:3) Patients unfit for general anesthesia (cid:142)(cid:3) A ctive infectious or inflammatory process (mesh at risk) (cid:142)(cid:3) Strangulated/incar cerated hernia (cid:142)(cid:3) Previous retropubic open prostate surgery. Preparation (cid:142)(cid:3) Obtain informed consent including conversion to open repair if necessary (cid:142)(cid:3) Consent for contralateral repair if unsuspected hernia identifi ed at laparoscopy (cid:142)(cid:3) Mark the hernia side (cid:142)(cid:3) Empty the urinary bladder immediatel y before induction of anesthesia (cid:142)(cid:3) Place the patient supine with the head en d slightly lower (Trendelenburg position) \200\224keep bowel away from operating site (cid:142)(cid:3) Place the monitor at the foot end of the table (cid:142)(cid:3) The surgeo n stands on the side opposite the hernia. Technique Repair can be performed by either TAPP approach or TEP approach. TAPP approach (cid:142)(cid:3) Create pneumoperitoneum. (cid:142)(cid:3) Position the cannu lae; one at the umbilicus (12mm) and one on each side at the lateral border of the rectus muscle (both 5mm). LAPAROSCOPIC INGUINAL HERNIA REPAIR1 329 (cid:142)(cid:3) Establish the anatomy from medial to lateral \200\224bladder, medial umbil ical ligament (obliterated umbilical artery), area of direct inguinal hernia, inferior epig astric vessels, internal ring, and anterior superior iliac spine. (cid:142)(cid:3) The internal ring is confirmed by looking for two divergent structures, wh ich emerge from it; medially the vas deferens (round ligament of the uterus in females) ben eath the peritoneum, and laterally a less distinct ridge caused by the gonadal vessels. Bet ween the two is the \200\230triangle of doom \200\231; deep to the peritoneum are the exte rnal iliac vessels. (cid:142)(cid:3) Identify whether the hernia is direct (medial to infer ior epigastric vessels) or indirect (lateral to inferior epigastric vessels), unilateral or bilateral. (cid:142)(cid:3) Create a peritoneal flap from lateral to deep ring to medial umbilical lig ament horizontally and well above and below the inguinal ring verti- cally. Inferiorly, str ip the peritoneum off the gonadal vessels and vas for a few centimeters (beware not to dama ge them). (cid:142)(cid:3) Create an identical contralateral space for bilateral hernia. (cid:142)(ci d:3) Retract the direct sac, or small indirect sac along with the peritoneal flap. (cid:142)(cid:3) Divide the large indirect sac at the level of the external ring and leave the distal part in situ. (cid:142)(cid:3) Introduce a 15 (cid:190)(cid:3)10cm mesh through the umbilical port and en sure it covers the entire posterior wall, extending behind the pubic bone to cover direct, indirect and femoral ring. (cid:142)(cid:3) Fix the mesh at Cooper \200\231s ligament and along the upper border with staples or sutures. Biologically compatible glues may be an inexpensive alternative to stap ling or suturing. (cid:142)(cid:3) Do not apply staples below and lateral to the ileopubic tract to avoid injury to the lateral femoral cutaneous nerve. Never staple close to the \200\230triangle of doom \200\231. (cid:142)(cid:3) Close the peritoneal flap by using staplers or by suturing (prevent gaping between the flaps). (cid:142)(cid:3) Ensure complete peritoneal coverage of the mesh to avoid small- bowel obstruction. (cid:142)(cid:3) Close the rectus sheath at the 10mm port site.