Jaypee gold standard mini atlas series gastrointestinal surgery

Mini Atlas Series®

GASTROINTESTINALSURGERY

Mini Atlas Series®


S Devaji Rao MS, MNAMS, FICSTeaching Faculty, National Board of Examinations

Senior Consultant in General SurgerySurgical Gastroenterology and Surgical Oncology

St. Isabel’s Hospital and Chennai Meenakshi MultispecialityHospital, Mylapore

Harvey Multispeciality Hospital, Alwarpet,Chennai, India

®

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Mini Atlas Series® Gastrointestinal Surgery© 2009, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrievalsystem, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, orotherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is madeto ensure accuracy of material, but the publisher, printer and author will not be held responsible for anyinadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition : 2009

ISBN 978-81-8448-486-1

Typeset at JPBMP typesetting unitPrinted at Ajanta Press

Dedicatedto

My parentsMrs S Uma Bai and Dr D Siva Rao

andall my teachers

Preface

This concise book presents in-depth information of varioussurgical procedures and their complications, eachsupported by well-drawn illustrations and photographs.Many voluminous books are available which describe thesurgical procedures in detail, but rarely we see bookshighlighting the complications in a cogent and orderlymanner. Few describe them but with illustrations only andnot with supportive colour photographs. A student learnshis best, only when photographs and drawings areprovided together.

This manual should benefit not only the students ofsurgery but also all the surgeons, as every surgeon towhatever specialty he belongs to, may end up managingthe gastrointestinal tract.

If a surgeon is familiar with complications, and theirexpected days of occurrence, he or she can handle thembefore it gets complicated further. This also helps inperforming the procedures carefully averting seriouscomplications. In this book, the surgical procedures areshown in points with supportive illustrations, making themlook very simple and understandable. The student should

(viii)

understand that the procedures are not so simple as projectedin the book, but it highlights the basic principles. The studentshould also refer to operative surgery books and manualsfor details. A colour photograph manual GastrointestinalSurgery Made Easy authored by me is a good complement forthis book, which deals with the operative procedures, stepby step.

It is hoped that this carry-on-hand atlas will be of greathelp to all surgeons who deal with the gastrointestinal tract,by intention or accident.

S Devaji Rao

MINI ATLAS SERIES: GASTROINTESTINAL SURGERY

Acknowledgements

The motivating stimulus to make this manual is fromShri Jitendar P Vij, CEO, Jaypee Brothers Medical PublishersPvt. Ltd., to whom I express my very sincere thanks. Theoffer was readily accepted by me due to the exposure andteaching I have had during my career and more so, the colourphotographs which I have collected in large numbers. Wherecolour photographs cannot support, illustrative drawingsare the only solution, and at this juncture, my very sincerethanks goes to my daughter Dr Kirthana Rao, who has putall her precious time in drawing them.

My special thanks goes to my teachers who haveimparted the knowledge, which I am able to share with mycolleagues.

I express my sincere gratitude to my colleagues,Dr A Chandrasekar Rao, Dr J Vijayan, Dr Mani Veeraghavanand Dr R Surendran for allowing me to use theirphotographs.

My family members, especially my wife, Kalpana, whohas been patient enough during my preparation of thismanual, which has stolen all my free time. My special thanksto her and my daughters for their extreme tolerance.

Contents

1. Gastrointestinal Staplers ............................................. 12. Vagotomy ....................................................................... 53. Esophageal Resection ................................................. 214. Gastrectomy and Gastrostomy .................................. 395. Small Bowel Resection ............................................. 1376. Ileostomy .................................................................... 1717. Appendicectomy ....................................................... 2078. Large Bowel Resection ............................................. 2299. Colostomy .................................................................. 255

10. Abdominoperineal Resection .................................. 28111. Anterior Resection ....................................................30112. Surgery of Liver ......................................................... 31113. Surgery of Gallbladder ............................................. 33314. Surgery of Pancreas .................................................. 36715. Surgery of Spleen ...................................................... 397

Index .................................................................................... 413

Mini Atlas Series®


(2)


INTRALUMINAL STAPLERS

Intraluminal staplers (Fig. 1.1) apply titanium staples in adouble staggered circular pattern. As the instrument isfired, staples are driven through the enclosed tissue andformed against the anvil; at the same time, a circular bladeadvances to cut a uniform stoma between the intestines tobe anastomosed:

They can be applied for the following anastomosis:• End to end• End to side.

Various sizes are available to permit proper matchingof instrument diameter and organ lumen. They aredesigned to allow adjustment of closed staple height –from 1 to 2.5 mm, to compensate for various tissuethicknesses.

Fig. 1.1: Intraluminal stapler

(3)

CHAPTER 1: GASTROINTESTINAL STAPLERS

LINEAR STAPLERS

Linear staplers (Fig. 1.2) apply a double staggered row oftitanium staples to approximate internal tissues.

Various sizes are available for a variety of applicationsthroughout the alimentary tract.

Fig. 1.2: Linear stapler

(4)


Fig. 1.3: Linear cutter

LINEAR CUTTER

Linear cutter (Fig. 1.3) applies two double staggered rowsof titanium staples while simultaneously dividing the tissuebetween the rows. Staple cartridges can be reloaded in theinstrument.

(6)


HISTORY

• 1922—Truncal vagotomy for patients with ulcer diseaseby Latarjet

• 1940—Truncal vagotomy and hemigastrectomy byFarmer and Smithwick

• 1950—Various forms of vagotomy by Harkin’s group• 1960—Highly selective vagotomy by Johnston

(Fig. 2.1A), Terrence Kennedy (Fig. 2.1B), Goligher andAmdrup.

Fig. 2.1A: Johnston Fig. 2.1B: Terrence Kennedy

(7)

CHAPTER 2: VAGOTOMY

VARIETIES OF VAGOTOMIESThere are a variety of vagotomies (Fig. 2.2). They are:• Truncal vagotomy (1)• Selective vagotomy (2)• Highly selective vagotomy (3).

Fig. 2.2: Varieties of vagotomy

(8)


INDICATIONS

• Increased acid secretion and ulcer disease (Fig. 2.3).

Fig. 2.3: Endoscopy—Chronic duodenal ulcer

(9)

CHAPTER 2: VAGOTOMY

INCISION

Upper midline (Fig. 2.4).

Fig. 2.4: Upper midline incision

(10)


SURGICAL TECHNIQUESurgical technique of vagotomies (Fig. 2.5)1. Anterior vagotomy — identified by direct vision and

cut (1)2. Posterior vagotomy — identified by feel and cut by

direct vision (2).

Fig. 2.5: Surgical technique of vagotomies

(11)

CHAPTER 2: VAGOTOMY

NECROSIS OF LESSER CURVE (POST-VAGOTOMY)

Definition

Avascular necrosis of lesser curve of stomach.

Pathogenesis

• Exact cause is not known• Possibly inadvertent instrument injury to lesser curve

vessels.

Day of Occurrence

2nd to 3rd postoperative day.

Clinical Presentation

• Sudden upper abdominal pain• Marked tenderness and rigidity in the upper abdomen• Shock like picture.

Investigations

CT Scan and gastroscopy (Fig. 2.6) may be useful.

(12)


Management

Resection of necrotic area and gastroenteric anastomosis.

Fig. 2.6: Esophagoscopy necrosis of lasser curve

(13)

CHAPTER 2: VAGOTOMY

ACHALASIA (POST-VAGOTOMY)

Definition

Spasm of lower esophageal sphincter.

Pathogenesis

Exact cause is not known.

Day of Occurrence

Early postoperative period.


Difficulty in swallowing.

Investigations

• Endoscopy (Fig. 2.7) is informative• Mamometry may be useful.

(14)


Management

No treatment is required as the recovery is spontaneous.

Fig. 2.7: Esophagoscopy—Achalasia showing retained fluid

(15)

CHAPTER 2: VAGOTOMY

POST-VAGOTOMY DIARRHEA

DefinitionLoose stools after vagotomy.

PathogenesisPathogenesis is complex (Fig. 2.8).

Fig. 2.8: Pathogenesis of post-vegotomy diarrhea

(16)


Day of Occurrence

Months or years after vagotomy.


Loose stools passed many times in a day.

Investigations

No specific investigation is required.

Management

Medical

• Low carbohydrate and low milk diet• Postprandial positioning of patient• Bowel binders and antispasmodics.

Surgical

• Interpositioning of antiperistaltic jejunal segment (onlywhen stools passed > 20/day).

(17)

CHAPTER 2: VAGOTOMY

REFLUX ESOPHAGITIS AND STRICTURE

Definition

Gastroesophageal reflux of gastric contents.

Pathogenesis

Injury to right crural sling fibers during esophagealmobilization.

Day of Occurrence

Days/months/years after vagotomy.


• Upper abdominal dyspepsia• Retrosternal burning• Eructations• Chest pain.

Investigations

• Barium meal in Trendelenburg position• Endsocopy (Fig. 2.9)• Esophageal manometry• Radionuclide scan.

(18)


Management

• H2 blockers/Proton pump inhibitors• Gastrokinetics• Dilatation for strictures.

Fig. 2.9: Esophagoscopy — Severe esophagitis

(19)

CHAPTER 2: VAGOTOMY

DYSTONY OF GALLBLADDER ANDCHOLELITHIASIS

Definition

Development of stones in the gallbladder.

Pathogenesis

Division of hepatic vagi reduce the gallbladder tone, whichproduces stasis of bile leading to gallstones.

Day of Occurrence

Months after vagotomy.


• Upper abdominal dyspepsia• Right hypochondrial pain• Vomiting.

Investigations

• US is diagnostic in many cases• Radionuclide scan is useful in dystony of gallbladder.

(20)


Management

Cholecystectomy for calculous cholecystitis (Fig. 2.10).

Fig. 2.10: Multiple gallstones

(22)


HISTORY

• 1871 – Resection of cervical esophagus by Billroth(Fig. 3.1)

• 1913 – Tranhiatal esophagectomy by Denk• 1915 – Resection of thoracic esophagus for cancer by

Torek

Fig. 3.1: Christian Albert Theodor Billroth (1819 -1894)

(23)

CHAPTER 3: ESOPHAGEAL RESECTION

• 1933 – Thoracic resection with primary esophagogastricanastomosis by Ohsawa

• 1933 – Transhiatal resection with skin tube as aoesophago gastric conduit by Grey Turner

• 1938 – Transthoracic esophageal resection andreconstruction by Adams and Phemister

• 1978 – Transthoracic resection and reconstruction withdecreased morbidity and mortality by Orringer andSloan.

(24)


ESOPHAGEAL RESECTIONS (FIG. 3.2)• Transhiatal esophagectomy• Three hole esophagectomy• Right posterolateral esophagectomy• Left thoracotomy approach.

Fig. 3.2: Approaches for esophagectomy

(25)


RECONSTRUCTIONS AFTER RESECTIONS

• Cervical gastroesophagostomy (Stapled or handsewn)• Ivor Lewis approach (Esophagogastrostomy in the apex

of right chest)• Colonic interposition (Fig. 3.3).

Fig. 3.3: Reconstruction

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INDICATIONS

• Benign strictures of esophagus (Fig. 3.4A)• Malignancy of oesophagus (Fig. 3.4B)

Figs 3.4A and B: Barium swallow — (A) Corrosive stricture(B) Esophageal malignancy mid third

(27)


SURGICAL TECHNIQUE

This consists of three phases (Fig. 3.5).

Abdominal Dissection• Upper midline abdominal incision• Mobilization of stomach based on the right

gastroepiploic and right gastric arteries (1)

Fig. 3.5: Surgical technique

(28)


• Enlargement of esophageal hiatus• With downward traction on the esophagus, it is

mobilized by finger dissection• Kocher’s maneuver and pyloroplasty are necessary.

Cervical Dissection

• Left cervical incision along the anteromedial border ofsternomastoid

• Reflection of thyroid medially, sternomastoid andcarotid sheath laterally

• Blunt dissection using finger to separate the esophagusfrom the prevertebral fascia, with upward traction.The fingers from top and bottom should meet and completeness

of mobilization assessed.

Transection of Esophagus

• Transection of cervical esophagus with staples (2)• Gastroesophageal transection done with gastric tube

formation with staples (3).

Reconstruction

• Stomach is passed through esophageal bed• Esophagogastric anastomosis done in the neck (4 and

5).

(29)


ANASTOMOTIC LEAK (POSTESOPHAGECTOMY)

Definition

Leak from anastomosis of esophagus with stomach,jejunum or colon.

Pathogenesis

Disruption of anastomosis.

Day of Occurrence



• Fever• Difficulty in breathing• Chest pain.

Investigations

• X-ray chest will show pleural collection.• Gastrograffin swallow (Fig. 3.6) may demonstrate a

leak.

(30)


Management

Minor leak — chest drainage, delay oral intakeMajor leak — resection of necrotic part, esophagostomy andfeeding jejunostomy.

Fig. 3.6: Gastrograffin swallow — Leaking dye in anastomotic line

(31)


DYSPHAGIA (POSTESOPHAGOENTEROSTOMY)

Definition


Pathogenesis

Edema of anastomotic area.

Day of Occurrence

2nd to 5th postoperative day.



Investigations

• No special investigation is usually necessary• Esophagoscopy (Fig. 3.7) may be useful in later stages.

(32)


Management

As edema subsides, it will recover.

Fig. 3.7: Esophagoscopy edema and inflammation of esophago-jejunal anastomosis

(33)


HOARSENESS OF VOICE(POSTESOPHAGEAL SURGERY)

Definition

Change in voice.

Pathogenesis

Traction to the recurrent laryngeal nerves.

Day of Occurrence



Change in voice tone.

Investigations

Direct laryngoscopy (Figs 3.8A and B).

Management

Recover in due course of time.

(34)


Fig. 3.8A: Direct laryngoscopy to assess recurrentlaryngeal nerve injury

(35)


Fig. 3.8B: Vocal cord plasy

(36)


PERSISTENT DYSPHAGIA(POSTESOPHAGEAL SURGERY)

Definition

Persistence of difficulty in swallowing.

Pathogenesis

• Local recurrence of malignancy• Anastomotic stricture.

Day of Occurrence

Months after surgery.



Investigations

Endoscopy (Fig. 3.9) is diagnostic.

(37)


Management

• Benign stricture — dilatation• Malignant stricture — surgery.

Fig. 3.9: Esophagoscopy—Malignant stricture

(40)


HISTORY

• 1881 – First successful pylorectomy for benign ulcerdisease by Rydgier

• 1881 – First successful pylorectomy for malignancy byBillroth (Fig. 4.1)

• 1884 – First gastroenterostomy for benign ulcer diseaseby Rydgier

• 1885 – Reconstructive procedures after gastrectomydescribed by Billroth and his students

• 1914 – Posterior gastroenterostomy by Eugen Polya andReichel.

Fig. 4.1: Christian Theodor Billroth (1819-1894)

(41)

CHAPTER 4: GASTRECTOMY AND GASTROSTOMY

VARIETIES OF SURGERIES OF STOMACH ANDDUODENUM

• Gastrostomy (connect stomach to the exterior) (Fig. 4.2)

Fig. 4.2: Gastrostomy

(42)


• Gastrectomy (excision of stomach) (Fig. 4.3)– Upper partial (excision of upper half of stomach)– Lower partial (excision of lower half of stomach)– Subtotal (excision of lower 2/3 or ¾ of stomach)– Total (excision of whole of stomach)

Fig. 4.3: Varieties of gastrectomies

(43)


• Gastrotomy (opening and closing the stomach)• Gastrojejunostomy (joining stomach and jejunum side

to side) (Fig. 4.4)• Pyloroplasty (relaxing procedure of pyloric sphincter)

(Fig. 4.5).

Fig. 4.4: Gastrojejunostomy and pyloroplasty

(44)


INDICATIONS

• Ulcer disease and its complications• Gastric and duodenal malignancies (Figs 4.5 and 4.6)

Fig. 4.5: Partial gastrectomy for malignancy

(45)


Fig. 4.6: Total gastrectomy for malignancy

(46)


INCISIONS

Upper midline (most popular) (Fig. 4.7).

Note: It has the advantage of:• Ease• Speed• Versatility• Allows access to stomach and duodenum• Easily extendable when needed.

Fig. 4.7: Upper midline incision

(47)


SURGICAL TECHNIQUE

• Good exposure of abdomen (Fig. 4.8)• Step 1 — Division of gastrohepatic ligament and entry

into and inspection of lesser sac

Fig. 4.8: Surgical procedure

(48)


• Step 2 — Mobilization of greater curvature and markingthe line of resection on the stomach

• Step 3 — Division of left gastroepiploic vessels at themarked place

• Step 4 — Division of right gastroepiploic vessels at itsorigin from gastroduodenal artery

• Step 5 — Division of right gastric vessels• Step 6 — Division and closure of duodenum• Step 7 — Division of left gastric artery• Step 8 — Transection of stomach• Establishment of pathway by reconstruction (Fig. 4.9).

(49)


RECONSTRUCTION AFTER GASTRECTOMIESAfter removal of stomach, the continuity is established inmany ways (Fig. 4.9). They are:• After esophagogastrectomy, esophagogastrostomy or

esophago colostomy

Fig. 4.9: Mehtods of reconstructions after gastrectomy

(50)


• After partial gastrectomy, end-to-end gastro-duodenostomy (Billroth I) or end-to-side gastro-jejunostomy (Billroth II)

• After subtotal gastrectomy, end-to-side gastro-jejunostomy (Billroth II)

• After total gastrectomy, end-to-side or end-to-endesophago-jejunostomy (Roux-en-Y).Whether it is removal of part of oesophagus or stomach

or to perform a side-to-side anastomosis, hand sewntechnique or stapler technique can be adopted.

(51)


EARLY INTRAGASTRIC HEMORRHAGE(POST-GASTRECTOMY)

Definition

Bleeding in the stomach within 48 to 72 hours after surgery.

Pathogenesis

• Bleeding from the anastomotic line• Small bleeding ulcer in the proximal gastric pouch.

Day of Occurrence



Bleeding in the nasogastric tube within 48 hours aftersurgery (Fig. 4.10).

InvestigationsNothing specific is needed.

ManagementMedical

• Ice cold saline lavage• Blood transfusions.

(52)


Surgical

• Opening of gastric pouch above the gastroenterostomysite, evacuation of blood clots and saline irrigation

• ‘‘Figure of 8’’ stitch applied over the bleeding vessel.

Fig. 4.10: Early intragastric hemorrhage

(53)


DELAYED INTRAGASTRIC HEMORRHAGE(POST-GASTRECTOMY)

DefinitionBleeding in the stomach beyond 48 to 72 hours after surgery.

Pathogenesis• Bleeding from the duodenal ulcer deliberately left

behind• Bleeding from the ulcer inadequately undersewn

during the original operation.

Day of Occurrence5th to 7th postoperative day.

Clinical PresentationHematemesis and melena.

InvestigationsGastroduodenoscopy (Fig. 4.11) is informative.

ManagementMedical• Ice cold saline lavage• Blood transfusions.

(54)


Surgical

• If the original operation is gastrojejunostomy:– Bleeding ulcer if present during original surgery in

the postbulbar duodenum, anterior duodenotomyis done and ulcer oversewn (Horsley’s slit) (Fig. 4.12).

Fig. 4.11: Late intragastric hemorrhage

(55)


– If the gastric chyme is to be prevented to traversethe duodenum, Billroth II reconstruction may bedone

Fig. 4.12: Horsley's slit and oversewing of ulcer

(56)


• If the original operation is Billroth I reconstruction, itmay be revised to Billroth II or Roux-en-Yreconstruction

• If the original operation is Billroth II reconstruction,Roux-en-Y reconstruction may be done with Horsley’sslit (Fig 4.12)

• If the original operation is Billroth or Roux-en-Yreconstruction, the duodenal stump is reopened, thebleeding ulcer is transfixed and the duodenum may beclosed or a catheter duodenostomy performed

• If the original operation is pyloroplasty, antrum canbe resected with the ulcer, and reconstruction may bedone either in Billroth I, or II or Roux-en-Y fashions.

(57)


EXTRAGASTRIC HEMORRHAGE(POST-GASTRECTOMY)

Definition

Bleeding from sources outside the stomach (Fig 4.13).

Fig. 4.13: Extragastric hemorrhage

(58)


Pathogenesis

• Laceration of spleen• Injury to liver by retractors• Injury to vasa brevia• Hemorrhage from pancreatic bed• Improperly secured vessel in the greater or lesser

omentum• Hemorrhage from right gastric artery and right

gastroepiploic vessels• Bleeding from the site of vagotomy or subdiaphrag-

matic vessels.

Day of Occurrence



Symptoms

• General malaise.

Signs

• Tachycardia• Hypotension• Moist and clammy skin

(59)


• Blood in the drainage tube• Clear nasogastric aspirate.

Investigations

• Hematocrit• US or CT for collections of blood.

Management

Medical

• Blood transfusions.

Surgical

• Exploratory laparotomy if the patient does not improve• Identification of bleeding point and suturing.

(60)


DUODENAL STUMP LEAK (BILLROTH ANASTOMOSIS)

DefinitionLeakage of duodenal contents into the peritoneal cavityfollowing Billroth II anastomosis.

Pathogenesis• Severely diseased and scarred duodenal bulb• Tissue necrosis of duodenal stump by suturing• Postoperative pancreatitis• Poor nutritional state• Localized infection and sepsis.

Day of Occurrence2nd and 5th postoperative day.

Clinical Presentation• Severe abdominal pain• Fever• Shock like syndrome.

Signs• Shock like picture• Bile in the drain.

InvestigationsCT with oral contrast.

(61)


Management• Adequate drainage• Nil by mouth• Nasogastric aspiration• Feeding jejunostomy to maintain nutrition• Lateral duodenostomy (Fig 4.14).

Fig. 4.14: Lateral duodenostomy for duodenal stump leakage

(62)


GASTRODUODENOSTOMY(BILLROTH I ANASTOMOSIS) LEAK

DefinitionLeakage of duodenal contents into the peritoneal cavityafter Billroth I anastomosis.

PathogenesisSeverely diseased and scarred duodenum.

Day of Occurrence2nd and 5th postoperative day

Clinical Presentation• Subtle symptoms• Moderate degree of abdominal pain• Fever• Bile in the drain.

Investigations• Gastrograffin study• Contrast enhanced CT scan.

ManagementMedical• Nil by mouth

(63)


• Nasogastric aspiration• Supportive therapy.

Surgical• Small leaks – Omental patch application• Large leaks – Conversion to Billroth II or Roux-en-Y

reconstruction, (Fig. 4.15) supplemented by feedingjejunostomy.

• Lateral duodenostomy may be useful.

Fig. 4.15: Gastroduodenostomy leak

(64)


GASTROJEJUNOSTOMY LEAK

DefinitionLeakage of gastric contents into the peritoneal cavity after:• Side-to-side gastrojejunostomy• End-to-side gastrojejunostomy.

Pathogenesis• Increased tension on the anastomotic line• Necrosis due to jeopardized blood supply.


Clinical Presentation• Subtle symptoms• Moderate degree of abdominal pain• Fever• Bile stained fluid in the drain.

Investigations• Gastrograffin study• Contrast enhanced CT scan.

ManagementMedical• Nil by mouth

(65)


• Nasogastric aspiration• Supportive therapy.

Surgical• Small leaks — Omental patch application• Large leaks

– Conversion of Gastrojejunostomy to Billroth IIanastomosis

– Billroth II to miniresection and Billroth II or Roux-en-Y reconstruction (Fig. 4.16), supplemented byfeeding jejunostomy.

Fig. 4.16: Miniresection of stomach with Roux-en-Y reconstruction

(66)


PYLOROPLASTY LEAK

Definition

Leakage of gastric contents into the peritoneal cavity afterpyloroplasty (Fig. 4.17).

Fig. 4.17: Pyloroplasty leak

(67)


Pathogenesis• Edema and inflammatory reaction at pyloroplasty site.


Clinical Presentation• Subtle symptoms• Moderate degree of abdominal pain• Fever• Bile stained fluid in the drain.

Investigations• Gastrograffin study• Contrast enhanced CT scan

ManagementMedical• Nil by mouth• Nasogastric aspiration• Supportive therapy.

Surgical• Small leaks — Omental patch application and

gastrojejunostomy• Large leaks — Conversion to Billroth II or Roux-en-Y

reconstruction, supplemented by feeding jejunostomy.

(68)


GASTRIC REMNANT NECROSIS(POST-GASTRECTOMY)

Definition

Necrosis of remnant of stomach.

Pathogenesis

Ischemia due to ligation of left gastric artery at its base.

Day of Occurrence



• Severe abdominal pain• Fever• Shock like picture.• Dark brown fluid in the drain

Investigations

• Endoscopy• CT scan.

(69)


Management

Always Surgical

• Small viable proximal gastric remnant — Roux-en-Yside-to-side gastrojejunostomy (Fig. 4.18).

Fig. 4.18: Side-to-side Roux-en-Y gastrojejunostomy

(70)


• Questionably viable entire gastric remnant — totalgastrectomy and esophagojejunostomy (Roux-en-Y)(Fig. 4.19).

Fig. 4.19: Esophagojejunostomy (Roux-en-Y)

(71)


• Necrosis extends to lower end of esophagus — cervicalesophagostomy + feeding jejunostomy, and colonicinterpositioning at a later date (Fig. 4.20).

Fig. 4.20: Cervical esophagostomy, jejunojejunostomy withfeeding jejunostomy

(72)


STOMAL OBSTRUCTION (POST-GASTRECTOMY)

Definition

Obstruction of gastroduodenostomy or gastrojejunostomystoma (Fig. 4.21).

Fig. 4.21: Stomal obstruction

(73)


Pathogenesis

• Stomal edema• Improper surgical technique• Extensive duodenal disease• Postoperative suture line leakage• Anastomotic leakage• Acute pancreatitis• Inflammatory adhesions• Inflamed omentum.

Day of Occurrence



• Excessive nasogastric aspiration

In patients whose nasogastric tube has been removed:• Abdominal discomfort and distension• Nausea and vomiting.

Investigations

After 2 weeks:• Gastrograffin study• Endoscopy.

(74)


Management

Medical

In patients with nasogastric tube:• Maintenance of nasogastric suction• Correction of volume• Correction of electrolytesIn patients whose nasogastric tube has been removed:• Reinsertion of nasogastric tube• Correction of volume and electrolytes.

Surgical

• After Billroth I anastomosis — Dismantle gastroduode-nostomy and convert to Billroth II or Roux-en-Yreconstruction

• After Billroth II anastomosis– Kinking and adhesions — Release and feeding

jejunostomy– Herniation of loops — Reduction and preventive

measures– Non viable herniated loops — Resection and Roux-

en-Y reconstruction.

(75)


ACUTE AFFERENT LOOP OBSTRUCTION(POST-GASTRECTOMY)

Definition

Obstruction of afferent loop in Billroth II anastomosis.

Pathogenesis

• Twist of afferent loop (Fig. 4.22A)• Volvulus of afferent loop• Internal herniation• Jejunogastric intussusception• Kink at gastrojejunostomy site.

Day of Occurrence



• Severe upper abdominal pain• Tenderness upper abdomen• Upper abdominal distension• Tachycardia• Shock like picture.

(76)


Fig. 4.22A: Torsion of afferent loop

(77)


Fig. 4.22B: Gastrograffin study — Afferent loop obstruction

Investigations• Gastrograffin meal (Fig. 4.22B)• CT scan• Plain X-ray may show distended afferent loop.

(78)


Fig. 4.23: Shortening of afferent loop and end-to-end anastomosis

Management

Exploration and treatment according to pathology:• In not seriously ill patients – if loop is kinked — shortening

of loop and end-to-end anastomosis (Fig. 4.23) or Roux-en-Y reconstruction.

(79)


Fig. 4.24: Simple entero-enterostomy (Duodenojejunostomy)

• In seriously ill patients– Viable but distended afferent loop — simple entero-

enterostomy (Fig. 4.24)– If the loop is gangrenous — resection of afferent loop

and Roux-en-Y reconstruction– If there is complete necrosis of afferent loop—

pancreatoduodenectomy.

(80)


EFFERENT LOOP OBSTRUCTION(POST-GASTRECTOMY)

Definition

Obstruction of efferent loop after Billroth II anastomosis.

Pathogenesis

• Short afferent loop• Long afferent loop which may herniated behind the

efferent loop.

Day of Occurrence

4th to 7th postoperative day.


• Nausea and vomiting• Upper abdominal pain• Epigastric fullness.

Investigations

• Gastrograffin study• CT abdomen.

(81)


Management

Exploration and treatment according to pathology:• If the afferent loop is long – division of afferent loop

and Roux-en-Y reconstruction (Fig. 4.25)• If efferent loop is gangrenous — excision of gangrenous

segment, division of afferent loop with end-to-endanastomosis (Fig. 4.26A) or Roux-en-Y reconstruction(Fig. 4.26B).

Fig. 4.25: Division of afferent loop and Roux-en-Y reconstruction

(82)


Fig. 4.26A: Excision of gangrenous efferent loop and end-to-endanastomosis

Fig. 4.26B: Excision of efferent loop with Roux-en-Y reconstruction

(83)


INTRA-ABDOMINAL ABSCESS(POST-GASTRECTOMY)

Definition

Collection of pus in the abdominal cavity.

Pathogenesis• Spillage of intestinal contents during surgery• Anastomotic leaks• Incomplete resolution of generalized peritonitis.

Day of Occurrence1 week after surgery.

Clinical Presentation• General malaise• Fever of varying grades• Abdominal pain.

InvestigationsUS and CT are diagnostic.

Management• Small abscess — long-term broad spectrum antibiotics• Therapeutic aspiration under US or CT guidance

(Fig. 4.27).

(84)


• Open drainage if it is inaccessible for closed aspirationor thick pus which cannot be aspirated (Fig. 4.28).

Fig. 4.27: Aspiration of intra-abdominal abscess

Fig. 4.28: Drainage of intraperitoneal abscess by laparotomy

(85)


POSTOPERATIVE PANCREATITIS(POST-GASTRECTOMY)

DefinitionAcute inflammation of pancreatic parenchyma.

Pathogenesis• Operative trauma to head of pancreas• Extensive dissection of supracolic compartment• Injury to pancreatic ductal system.

Day of Occurrence

3rd to 7th postoperative day.

Clinical Presentation• Restlessness• Acute upper abdominal pain• Fever• Upper abdominal tenderness• Seriously ill.

Investigations• Leucocytosis• Increased serum amylase, lipase, GGT• CT or MRI will show inflamed pancreas (Fig. 4.29).

(86)


ManagementMedical• Nasogastric suction• Fluid and electrolyte management• Antibiotics• Somatostatin and its analogues.

Surgical• Necrosectomy• Drainage of pancreatic abscess• Cystogastrostomy for pseudocyst.

Fig. 4.29: CT - Enlarged and edematous pancreas —Acute pancreatitis

(87)


INADEVERTENT GASTROILEOSTOMY

Definition

Anastomosis of stomach and ileum (Fig. 4.30).

Pathogenesis

• Surgery done in extreme haste under unfavorableconditions

• Inexperienced surgeon.

Fig. 4.30: Inadvertent gastroileostomy

(88)


Day of Occurrence

3rd to 7th postoperative days.


• Foul belching• Profuse diarrhea• Electrolyte disturbances• Rapid weight loss• Malnutrition• Cachexia.

InvestigationsGastrograffin study will demonstrate the gastroileostomy.

ManagementMedical

Total parenteral nutrition.

Surgical• Simple gastroileostomy—vagotomy, antrectomy and

Billroth II anastomosis• Gastroileostomy (Billroth II fashion)—undo the

anastomosis, revision to Billroth II gastrojejunostomyor Roux-en-Y reconstruction.

(89)


ALKALINE REFLUX GASTRITIS(POST-GASTRECTOMY)

Definition

Gastritis caused by reflux of alkaline duodenal contents.

Pathogenesis

Reflux of duodenal contents (bile and pancreatic juice).

Day of Occurrence

1 week after surgery.


• Burning sensation in epigastrium• Epigastric pain• Pain worsens on food intake• Bilious vomiting• Weight loss and anemia.

Investigations

• Gastroscopy — reflux of bile into the stomach, biopsy –gastritis picture (Fig. 4.31A)

• Scintigraphy — demonstrates reflux (Fig. 4.31B).

(90)


Fig. 4.31A: Gastroscopy—Reflux of bile into stomach

(91)


Management

Medical

• H2 blockers or PPIs• Gastrokinetics.

Surgical• Billroth I or II anastomosis to be converted into Roux-

en-Y reconstruction.

Fig. 4.31B: Scintiscan — Gastroesophageal reflux

(92)


EARLY DUMPING SYNDROME(POST-GASTRECTOMY)

Definition

Gastrointestinal and vasomotor symptoms occurringwithin 10 to 40 minutes of food intake.

Pathogenesis

• Theory I: Sudden entry of large amounts of carbohydraterich fluid in the small bowel causes fluid shift fromintravascular space to bowel lumen causing vasomotorand gastrointestinal symptoms

• Theory II: Vasoactive intestinal hormones (serotonin,gastric inhibitory polypeptide and neurotensin) causevasomotor symptoms.

Day of OccurrenceFew weeks after surgery.

Clinical PresentationGastrointestinal Symptoms

• Abdominal fullness• Crampy abdominal pain• Nausea

(93)


• Vomiting• Explosive diarrhea.

Vasomotor Symptoms

• Diaphoresis• Weakness• Dizziness• Flushing and palpitations.

Investigations

No specific investigation is necessary.

Management

Medical

• Changes in dietary habits• Consumption of low carbohydrate food• Restriction of extra salt.

(94)


Surgical

• Henley’s operation: Interpositioning of jejunum betweenthe gastric remnant and duodenum (Fig. 4.32).

Fig. 4.32: Henley's operation

(95)


• Poth’s operation: Interpositioning of two separate isolatedjejunal segments (one isoperistaltic and the other anteperistaltic) between the gastric remnant and duodenum(Fig. 4.33).

Fig. 4.33: Poth's operation

(96)


• Triple limb pouch operations: Three plicated jejunalsegments converted into a single receptacle betweenthe gastric remnant and duodenum or fashioned into aRoux-en-Y limb (Figs 4.34A and B)

Fig. 4.34A: Triple limb pouch

(97)


Fig. 4.34B: Triple limb Roux-en-Y

(98)


Fig. 4.35: Reversed interposition

• Reversed interpositioning of jejunum: Interpositioning ofsingle reversed jejunal segment between the gastricremnant and duodenum (Fig. 4.35)

(99)


Fig. 4.36: Terrence Kennedy operation

• Terrence Kennedy operation: Roux-en-Y reconstructionwith interpositioning of 8 to 10 cm of reversed jejunalsegment between the gastric remnant and Roux-en-Y(Fig. 4.36).

(100)


LATE DUMPING (POST-GASTRECTOMY)

DefinitionVasomotor symptoms occurring 20 minutes after food intake.

Pathogenesis (Fig. 4.37)• Loss of proximal receptive relaxation due to vagotomy• Loss of gastric capacity due to gastric resection• Loss of control of emptying due to pyloric ablation• Loss of duodenal feedback inhibition of gastric emptying.

Day of occurrenceMonths and years after surgery.

Clinical PresentationVasomotor symptoms• Sweating• Weakness• Palpitations• Dizziness• Flushing during postprandial period.

Gastrointestinal Symptoms – absentInvestigationsNo specific investigation is useful.

(101)


ManagementMedical• Frequent small quantities of food intake• Food less in carbohydrates and rich in protein.

SurgicalProcedures described in early dumping may be chosen inselect cases, but requirement is extremely rare.

Fig. 4.37: Late dumping pathogenesis

(102)


WEIGHT LOSS (POST-GASTRECTOMY)

Definition

Loss of weight following gastric resections.

Pathogenesis (Fig. 4.38)• Stasis in long afferent loop (Billroth II)• Impaired fat absorption• Ineffective mixing of food and pancreatic juice

(pancreaticocibal asynchrony).

Day of OccurrenceMonths or years after surgery.

Clinical Presentation• Excessive weight loss• Fatigue• Pallor.

InvestigationsDecreased hematocrit.

ManagementMedical• Diet modification

(103)


• Consumption of balanced diet• Pancreatic enzymes.

SurgicalConversion of Billroth II to Billroth I or Roux-en-Y.

Fig. 4.38: Weight loss pathogenesis

(104)


ANEMIA (POST-GASTRECTOMY)

Definition

Anemia could be iron deficiency or megaloblastic anemia.

Pathogenesis (Fig. 4.39)

• Decreased food intake• Decreased small bowel transit time leading to decreased

iron uptake• B12 deficiency.

Day of Occurrence

Months or years after surgery.


• General malaise.

Investigations

• Serum iron levels are lowered in iron deficiency anemia• Serum B12 levels are lowered in megaloblastic anemia.

Management

• Iron supplements.

(105)


• Supplements of Vitamin B12 and folate (Inj. Cyanoco-balamin with folate tablets).

Fig. 4.39: Anemia pathogenesis

(106)


CHRONIC GASTRIC ATONY (POST-GASTRECTOMY)

Definition

Decreased tone of gastric remnant.


• Gastric vagal denervation leads to loss of toniccontractions of stomach

• Delayed gastric emptying leads to gastric atony.

Day of Occurrence



• Fullness and pain in epigastrium• Postprandial fullness• Nausea and vomiting.

Investigations

• Gastrograffin study• Endoscopy• Scintigraphy.

(107)


Management

Medical

Prokinetic drugs.

Surgical

• Vagotomy pyloroplasty — convert to antrectomy• Billroth I or Billroth II — convert to near total

gastrectomy and Roux-en-Y anastomosis.

Fig. 4.40: Gastric atony pathogenesis

(108)


GASTRIC STASIS AND BEZOAR FORMATION(POST-GASTRECTOMY)

Definition

Bezoars are balls of undigested material:• Hair — trichobezoars• Vegetable matter — phytobezoar• Combined — trichophytobezoar.

Pathogenesis

• Vagotomy causes antral denervation resulting ininadequate drainage and gastric stasis

• Narrowing of gastroduodenostomy stoma (Billroth I)caused gastric stasis

• Gastrojejunostomy (Billroth II) ulcers can cause gastricstasis

• Jejunogastric intussusception after Billroth II can causegastric stasis.

Gastric stasis ultimately causes stagnation of material inthe gastric remnant causing bezoars.

Day of Occurrence


(109)



• Upper abdominal pain• Abdominal distension• Vomiting.

Investigations

• Plain X-rays and contrast studies are useful• Ultrasonography is useful• Endoscopy is diagnostic (Fig. 4.41A).

Fig. 4.41A: Endoscopy — Phytobezoar

(110)


Management

Medical

• Oral administration of gastroenterase or papain todigest the fibers

• Low fiber diet prevents a bezoar• Gastrokinetics increase the gastric emptying.

Surgical

• Small bezoars are removed by endoscope• Large bezoars need open surgical removal (Fig. 4.41B).

Fig. 4.41B: Removal trichobezoar by laparotomy

(111)


SMALL GASTRIC REMNANT SYNDROME(POST-GASTRECTOMY)

Definition

Complex of symptoms caused by small gastric remnant.

Pathogenesis

Small gastric remnant leads to loss of reservoir function.

Day of Occurrence



• Upper abdominal fullness• Epigastric distress• Weight loss• Nutritional imbalances.

Investigations

Gastrograffin study shows gastric hurry.

(112)


Management

Medical

• Small feeds• Enzyme supplements• Supplements of iron, vitamins for deficiencies• Antispasmodics to reduce pain and gastric motility.

Surgical

• Hunt Lawrence pouch operation (Fig. 4.42)• Tanner’s 19 reservoir operation (Fig. 4.43).

Fig. 4.42: Hunt Lawrence pouch

(113)


Fig. 4.43: Tanner’s 19 veservoir operation

(114)


ROUX STASIS SYNDROME (POST-GASTRECTOMY)

DefinitionChronic postgastrectomy atony in patients who haveundergone Roux-en-Y gastroenterostomy as primaryreconstruction.

Pathogenesis• Exact pathology is not clear• Suggested theories are:

– Length of Roux limb seems to have direct correlationwith transit time

– Transection of jejunum prevents the pace setterpotential which delay the transit time

– Truncal vagotomy reduces the transit time.


Clinical Presentation• Epigastric fullness• Abdominal pain• Nausea• Vomiting• Malnutrition and weight loss.

(115)


Investigations

• Contrast radiography• Isotope studies• Endoscopy to rule out mechanical causes.

Management

Medical

Seldom useful.

Surgical

• Completion gastrectomy with adjustment of Roux limbto 40 cm

• Uncut Roux gastroenterostomy is useful to prevent thiscomplication (Fig. 4.44).

(116)


Fig. 4.44: Uncut Roux operation

(117)


GASTRIC REMNANT CARCINOMA(POST-GASTRECTOMY)

Definition

Malignancy in the gastric remnant.

Pathogenesis

• Pathology is not clear• Suggested cause: Reflux of duodenal contents produce

deconjugation of bile salts in the presence of gastrichypoacidity.

Day of Occurrence

Years after surgery.


• Loss of appetite and weight• Nausea• Upper abdominal pain.

Investigations

Gastroscopy is diagnostic (Fig. 4.45).

(118)


Management

• Radical excision of gastric remnant with lymph nodedissection

• Adjuvant chemotherapy.

Fig. 4.45: Gastric remnant carcinoma

(119)


RECURRENT ULCER (POST-GASTRECTOMY)DefinitionUlcer in the gastric remnant.

Pathogenesis• Incomplete vagotomy• Retained antrum after Billroth II reconstruction• G cell hyperplasia• Gastrinoma• Multiple endocrine neoplasia• Long afferent loop• Ulcerogenic drugs• Gastric stasis.

Day of OccurrenceYears after surgery.

Clinical PresentationUpper abdominal pain relieved by food intake.

InvestigationsGastroscopy is diagnostic (Fig. 4.46).

ManagementMedicalPPIs or H2 blockers.

(120)


SurgicalSurgery depends on the original operation:• Vagotomy and gastrojejunostomy — completion

vagotomy• Gastrectomy (Billroth I or II) — resection of additional

gastric tissue and Billroth II reconstruction• Vagotomy and antrectomy — resection of additional

gastric tissue and Billroth II reconstruction.Note:• Proximal gastric vagotomy is converted into truncal

vagotomy• Incomplete truncal vagotomy is converted into

complete truncal vagotomy.

Fig. 4.46: Gastroscopy — Anastomotic ulcer

(121)


GASTROJEJUNOCOLIC FISTULA(POST-GASTRECTOMY)

Definition

Communication between anastomosis (Gastrojejunostomyof Billroth II) and transverse colon.

Pathogenesis

Anastomotic leak may lead to abscess which may openinto adjacent colon to form a fistula (Fig. 4.47).

Fig. 4.47: Gastrojejunocolic fistula

(122)



Clinical Presentation• Abdominal pain• Weight loss• Malnutrition• Diarrhea• Fecal belching.

InvestigationsBarium enema (Fig. 4.48) is useful in localizing the fistula.

Management

Vagotomy, distal gastrectomy with colon resectionincluding the fistula. Reconstruction is done by Billroth IIor Roux-en-Y reconstruction.

(123)


Fig. 4.48: Barium enema — Gastrojejunocolic fistula

(124)


CHRONIC AFFERENT LOOP OBSTRUCTION(POST-GASTRECTOMY)

Definition

Longstanding mild obstruction of afferent loop.


• Long afferent loop with stasis• Volvulus or kink of long afferent loop.

Day of Occurrence

Months years after surgery.


• Post prandial upper abdominal pain• Pain relieved by vomiting.

Investigations

• Endoscopy is useful• CECT is useful.

(125)


Management

Conversion of Billroth II to Billroth I or Roux-en-Yreconstruction.

Fig. 4.49: Chronic afferent loop obstruction

(126)


CHRONIC EFFERENT LOOP OBSTRUCTION(POST-GASTRECTOMY)

Definition

Chronic obstruction of efferent loop.

Pathogenesis (Figs 4.50A and B)

• Partial or total obstruction of efferent loop• Adhesions• Internal herniation.

Day of Occurrence



• Upper abdominal pain• Distension of abdomen• Vomiting (sometimes bilious).

Investigations

• Endoscopy• CECT abdomen.

(127)


Management

• Exploratory laparotomy• Adhesion release• Conversion of Billroth II to Roux-en-Y may be needed

rarely.

Figs 4.50A and B: Efferent loop obstruction (A) Adhesions(B) Internal herniation

(128)


INTERNAL HERNIA (POST-GASTRECTOMY)

Definition

Herniation of small bowel between intestinal loops.

Pathogenesis

Herniation of loop of jejunum through (Fig 4.51):• A potential space in antecolic gastrojejunostomy• Two potential spaces in retrocolic gastrojejnunostomy.

Fig. 4.51: Internal herniation of jejunum

(129)


Day of Occurrence



Acute proximal small bowel obstruction.

Investigations

• Barium meal followthrough• Upper GI endoscopy.

Management

Reduction of herniated loop, and resection if bowel isgangrenous.

(130)


JEJUNOGASTRIC INTUSSUSCEPTION(POST-GASTRECTOMY)

Definition

Intussusception of jejunum into stomach through GJ stoma.

Pathogenesis

Reversed peristalsis of jejunum into the GJ stoma.

Day of Occurrence



• Upper abdominal pain• Nausea and vomiting• Palpable firm mass in the upper abdomen.

Investigations

• Barium meal study• Upper GI endoscopy (Fig. 4.52).

(131)


Management

• Reduction of herniated jejunum and anchoring to theparietes

• If the bowel is non-viable, resection is required.

Fig. 4.52: Gastroscopy — Jejunogastric intussusception

(132)


GASTROSTOMY

SURGICAL PROCEDURE

• Incision — upper midline• Picking up of anterior wall of stomach with Babcock

forceps (Fig. 4.53)• Stab wound in the anterior wall• Insertion of Malecot’s catheter• Fixing of catheter with absorbable suture• Fixing of stomach to parietal peritoneum.

Fig. 4.53: Gastrostomy surgery

(133)


INTRAPERITONEAL LEAK AFTER GASTROSTOMY

Definition

Leak of gastric contents into the peritoneal cavity (Fig. 4.54).

Fig. 4.54: Intraperitoneal leak

(134)


Pathogenesis

Improper fixation of gastrostomy stomach to the parietalperitoneum.

Day of Occurrence



• Fever• Abdominal pain.

Investigations

US or CT will reveal the leak and perigastric collection.

Management

Laparotomy and proper fixation of stomach to parietalperitoneum.

(135)


EXCORIATION AND INFECTION AROUNDGASTROSTOMY STOMA

Definition

Excoriation and damage of skin around the stoma.

Pathogenesis

Regurgitation of acidic gastric contents around the tubeon to the skin.

Day of Occurrence

Anytime after surgery.


Pain and seropurulent discharge around the stoma(Fig. 4.55).

Investigations

No special investigation is required.

(136)


Management

• Local skin care around the tube• Antibiotics• Replacement of gastrostomy tube.

Fig. 4.55: Discharge and excoriation around gastrostomy stoma

(138)


HISTORY

• 1920 – Discovery of non-crushing intestinal twin clampsfor resection by Lane (Fig. 5.1).

Fig. 5.1: Sir William Arbuthnot Lane (1856-1943)

(139)

CHAPTER 5: SMALL BOWEL RESECTION

INDICATIONS• Obstructive lesions (strictures, tumors, intussusception)

(Figs 5.2A and B)• Strangulations with non-viable bowel.

Fig. 5.2A: Ileo ileal intussusception

Fig. 5.2B: Lipoma the cause of ileo ileal intussusception

(140)


INCISION

• Midline (most popular) (Fig. 5.3).Note: It has the advantage of:• Ease• Speed• Versatility• Allows access to all quadrants• Easily extendable when needed.

Fig. 5.3: Midline incision

(141)


VARIETIES OF SURGERIES OF SMALL BOWEL

Varieties of small bowel surgeries (Fig. 5.4) are:• Resection and establishment of continuity (hand sewn

or stapled anastomosis)• Bypass procedures (hand sewn or stapled anastomosis)

without resections• Diversion procedures (ileostomies).

Fig. 5.4: Varieties of surgeries

(142)


TYPES OF SMALL BOWEL ANASTOMOSIS

The types of small bowel anastomosis (Fig. 5.5) are:• End-to-end• End-to-side• Side-to-side.

Fig. 5.5: Types of small bowel anastomoses

(143)


SURGICAL TECHNIQUE

Hand Sewn Technique (Fig. 5.6)

Step 1 : Marking the lines of resection and control of vesselsin the mestentery.

Fig. 5.6: Surgical technique

(144)


Step 2 : Division of bowel at marked places betweenclamps.

Step 3 : Anastomosis to establish continuity.

• Double layer anastomosis– Posterior outer row first (seromuscular) with non-

absorbable material– Posterior inner row next (running full thickness) with

absorbable material– Anterior inner row in continuity from the posterior

inner row– Anterior outer row last (seromuscular) with non-

absorbable material.Note:• Inverting anastomosis causes serosa to serosa

apposition• Inversion of mucosa reestablishes integrity of lumen

preventing leakage.

(145)


END-TO-END ANASTOMOSIS (STAPLED)

Method of stapled end-to-end anastomosis (Fig. 5.7)• Bowel is cleared about 1 cm from the cut margin• Gun is introduced into the proximal gut through

enterotomy• Proximal and distal ends each require a purse string

suture• The purse string sutures are snugged down over the

instrument ends (Fig. 5.7A)

Fig. 5.7A: End-to-end anastomosis (Staped technique)

(146)


• Anvil and head are brought together• Firing is done for application of staplers• The screw mechanism is unwound for a quarter of turn

to release the bowel• After removal of instrument, doughnuts (Fig. 5.7B) are

checked for integrity• Enterotomy is closed with sutures or a linear stapler.

Fig. 5.7B: Doughnuts

(147)


END-TO-SIDE ANASTOMOSIS (STAPLED)

Method of stapled end-to-side anastomosis (Fig. 5.8)• The gun is introduced in the bowel to have end

anastomosis (enterotomy)

Fig. 5.8: End-to-side anastomosis (Stapled technique)

(148)


• Purse string suture is made and snugged down overthe anvil

• A small incision is made in the bowel to have sideanastomosis

• The head assembly is introduced through the openingand held

• Anvil and head are brought together• Firing is done for application of staplers• The screw mechanism is unwound for a quarter of turn

to release the bowel• After removal of instrument, doughnuts are checked

for integrity• Enterotomy is closed with sutures or a linear stapler.

(149)


SIDE-TO-SIDE ANASTOMOSIS (STAPLED)

The method of stapled side-to-side anastomosis (Fig. 5.9)• Liner cutter is used for this anastomosis• The two guts which are to be anastomosed are laid

together side by side

Fig. 5.9: Side-to-side anastomosis (Stapled technique)

(150)


• Small holes are made in each tube for introduction ofstapler jaws

• The forks are introduced through these enterotomies• The forks are locked together• Stapler is activated, so that the anastomosis is made

with stapling• The forks are separated and removed• The enterotomy openings are closed with sutures or a

linear stapler.

(151)


ANASTOMOTIC LEAKAGE(INTESTINAL ANASTOMOSIS)

Definition

• Leakage of intestinal contents through the anastomoticline.

Pathogenesis

• Inadequate bowel preparation• Poor blood supply to both ends of bowel• Tension on the anastomosis

Day of Occurrence



• Abdominal pain• Fever• Leakage of intestinal contents through the drain

(Fig. 5.10).

InvestigationsNo special investigation is necessary.

(152)


Management• Nil by mouth• Intravenous fluids• Intravenous broad spectrum antibiotics• Replacement of fluids, calories and electrolytes• Minor leaks heal, larger leaks take a longer time• If fistula is formed, it may heal over a period of time• Some may require surgery, after 6 to 12 weeks.

Fig. 5.10: Anastomotic leakage

(153)


HEMORRHAGE (INTESTINAL ANASTOMOSIS)

Definition

• Bleeding from the anastomotic line (Fig. 5.11).

Fig. 5.11: Hemorrhage

(154)


Pathogenesis

• Bleeding from a marginal vessel due to improperapplication of staplers or hemostatic full thicknesssutures.


Bleeding per rectum or melena.

Reason

Improper application of staplers.

Day of Occurrence


Investigations

No specific investigation is necessary, as the bleeding isusually minor.

Management

Majority of bleeding stops without treatment.

(155)


INTRA-ABDOMINAL ABSCESS(POST INTESTINAL ANASTOMOSIS)

Definition

Collection of pus in the peritoneal cavity (Fig. 5.12).

Pathogenesis

Spillage of bowel contents into the peritoneal cavity,leading to abscess formation.

Fig. 5.12: Intra-abdominal abscesses

(156)



• General malaise• Hyperpyrexia of varying grades• Insignificant clinical examination.

Day of Occurrence

7th to 10th postoperative days.

Investigations

Ultrasonography and CT are useful in localizing abscess.

Management

Medical

• Small abscesses resolve with antibiotics.

Surgical

• Drainage of abscess under US or CT guidance (seeFig. 4.27)

• Open drainage if abscess is large and pus is thick(see Fig. 4.28).

(157)


ANASTOMOTIC STRICTURE(INTESTINAL ANASTOMOSIS)

Definition

• Narrowing of lumen of anastomotic area (Fig. 5.13).

Fig. 5.13: Stricture

(158)


Pathogenesis

• Healing of a circular anastomosis results in a stricture.

Day of Occurrence



• Constipation• Abdominal pain• Vomiting• Abdominal distension.

Investigations

Contrast studies may be useful.

Management

• Small bowel strictures are bypassed or resectionanastomosis done.

Note:• Strictures following stapler usage is rare, if the correct

size is chosen.

(159)


ADHESIONS (INTESTINAL SURGERY)

Definition

Adherence of bowels between themselves or with theparietes (Fig. 5.14).

Pathogenesis

• Postoperative fibrinous adhesions result from thehealing of local inflammatory processes in the operatedarea

Fig. 5.14: Intra-abdominal adhesions

(160)


• Resolved infections of peritoneum can causeadhesions.


• Recurrent attacks of abdominal pain• Vomiting• Constipation• Abdominal distension.

Days of Occurrence

Months–years after surgery.

Investigations

X-rays of abdomen will show distended bowel.

Management

Medical

• Nil by mouth• Intravenous fluids and electrolytes.

Surgical

• If medical management fails, adhesiolysis by open orlaparoscopic methods.

(161)


INTERNAL FISTULAE (INTESTINAL ANASTOMOSIS)

Definition

Communication between anastomotic line of small bowelwith adjacent hollow viscera (Fig. 5.15).

Fig. 5.15: Internal fistulae

(162)


Pathogenesis

• Anastomotic leak leads to collection of pus which inturn erode into the adjacent viscera

• Inflammatory bowel disease.


• Generally asymptomatic• Recurrent urinary tract infections can occur in

vesicoenteric fistulae.

Days of Occurrence


Investigations

Contrast studies are useful.

Management

• Entero-enteric fistulae do not require any treatment• Vesico-enteric fistulae require excision.

(163)


EXTERNAL FISTULAE(INTESTINAL RESECTION)

DefinitionLeakage of intestinal contents through fistulae to the exterior.

Pathogenesis• Anastomotic leak leads to collection of pus which in

turn drains through the drainage tube• Intentional external drainage of collection of pus from

the anastomotic leak• Inflammatory bowel disease.

Clinical Presentation• Has had a turbulent postoperative period• Discharging wound in the postoperative period• Fluid and electrolyte disturbances• Skin excoriation around the fistulous opening

(Fig. 5.16A)• Fever• Malnutrition, especially if large segments are lost during

surgery.

Days of OccurrenceMonths after surgery.

(164)


Investigations• Oral administration of non-absorbable marker (charcoal

or congo red)• Fistulogram (Fig. 5.16B)• US, CT with contrast or isotope scanning are useful.

ManagementMedical• Total parenteral nutritionMost lateral fistulae heal spontaneously

Fig. 5.16A: Multiple enterocutaneous fistulae

(165)


Surgical

Excision of fistulaIndicated when there is:• Evidence of obstruction• Active disease• Interruption of bowel continuity• Closure not occurred by 6 weeks.

Fig. 5.16B: Fistulogram — Ileocutaneous fistula

(166)


NUTRITIONAL DEFICIENCIES

DefinitionDeficiency of nutritional factors secondary to surgery.

Pathogenesis (Fig. 5.17)• Stagnation of intestinal contents• Stricture

Fig. 5.17: Nutritional deficiencies pathogenesis

(167)


• Stenosis• Fistulae• Blind pouch formation• Diverticulae.

Clinical Presentation• Diarrhea• Steatorrhea• Anemia• Weight loss• Abdominal pain• Multiple vitamin deficiency symptoms.

Days of OccurrenceMonths or years after surgery.

Investigations• Variety of laboratory investigations may be required.

ManagementMedical

• Supplement of deficient factors.

Surgical• Stenosis, stricture and diverticulae need surgical excision.

(168)


SHORT BOWEL SYNDROME

Definition

Symptom complex caused by short loop of bowel.


Results due to massive resections of small bowel:• Vit B12 deficiency (Resection of terminal ileum)• Water and electrolyte disturbances (resection of large

segment of ileum)• Fat malabsorption (resection of large segment of ileum).


Severe emaciation.

Days of Occurrence


Investigations

Variety of laboratory investigations.

(169)


Management

• Fat restriction• Drugs to slow intestinal motility• Oral bile salts• Intravenous hyperalimentation.

Fig. 5.18: Short bowel syndrome — Pathogenesis

(172)


HISTORY• 1879 – First recorded ileostomy by Baum• 1941 – Skin graft on the serosal surface of projecting

ileum by Dragstedt• 1951 - Projecting 5 cm of ileum and allowing to granulate

by Warren and McKittrick• 1952 – Projecting ileum covered by pedicle of skin from

abdominal wall• 1952 – Immediate suture of bowel to skin by Butler• 1952 – Turning back of ileum to the skin of abdomen by

Brooke (Fig. 6.1)• 1953 – Removal of serosa and muscular coats before

suturing by Turnbull.

Fig. 6.1: Bryan Nicholas Brooke (1915-1998)

(173)

CHAPTER 6: ILEOSTOMY

TYPES OF ILEOSTOMY

There are three types of ileostomy (Fig. 6.2A). They are:1. End ilesotomy2. Loop ileostomy3. Loop end ileostomy.

Fig. 6.2A: Types and indications

(174)


INDICATIONS FOR ILEOSTOMY

End Ileostomy

• After completion of total colectomy or proctocolectomy(Fig. 6.2B)

• As a temporary procedure in inflammatory boweldisease

• While constructing an ileal conduit for urinarydiversion.

Fig. 6.2B: Total colectomy for multiple polyposis coli

(175)


Loop Ileostomy

• Above an ileal pouch anal anastomosis fordefunctioning

• Above a continent ileal reservoir• Proximal to enterocutaneous fistula• As an alternative to colostomy when it is difficult.

Loop end Ileostomy

• As a primary procedure for the definitive stoma of ilealurinary conduits.

(176)


SURGICAL PROCEDURESurgical procedure of end ileostomy (Fig. 6.3):• A circular opening of 2 cm is made in the abdominal

wall at the site of ileostomy (1)• A loop of small intestine or terminal ileum is selected• The small intestine is brought out through the opening (2)• The bowel is fixed to the parietal peritoneum to prevent

recession.• The free end of the bowel is inverted and sutured to border

of abdominal opening with absorbable material (3).


(177)


HEMORRHAGE FROM ILEOSTOMY

Definition

Bleeding from the ileostomy (Fig. 6.4).


(178)


Pathogenesis

Bleeding from the mucosal vessels over the ileostomy.

Day of Occurrence



Blood staining of the ileostomy ouput.

Investigations

No special investigation is necessary.

Management

Application of adrenaline soaked gauze.

(179)


MUCOSAL SLOUGH OF ILEOSTOMY

Definition

Sloughing of mucosa of ileostomy (Fig. 6.5A).

Fig. 6.5A: Mucosal slough of ileostomy

(180)


Pathogenesis

Avascular necrosis due to tight appliance flange.

Day of Occurrence



Sloughed ulcer area on the ileostomy.

Investigations


Management

Medical

• If the flange of the appliance is tight, it needs to bechanged

• Minor slough needs no treatment.

(181)


Fig. 6.5B: Excision of mucosal slough

Surgical

• If the sloughing is patchy, excision (Fig. 6.5B) is done• If it is circumferential, revision surgery is required.

(182)


PARASTOMAL SKIN IRRITATION

Definition

Irritation of skin around the ileostomy stoma (Fig. 6.6).

Fig. 6.6: Parastomal skin irritation

(183)


Pathogenesis

• Allergy to pouch adhesives• Allergy to adhesive tapes• Candidiasis• Follliculitis• Trauma due to frequent pouch changes• Eczema.

Day of Occurrence



Erythematous or ulcerative skin around the stoma,sometimes bleeding.

Investigations


Management

• Treatment of dermatological lesion• Modification of appliance.

(184)


PARAILEOSTOMY ULCERATION

Definition

Ulceration around the ileostomy.

Pathogenesis• Causes of skin irritation• Neglected cases of irritation may lead to ulceration.

Day of Occurrence



Ulcerations around the ileostomy (Fig. 6.7).

Investigations

Evaluation of diabetes is required.

Management

• Local skin care• Debridement of slough over the ulcers• Non-seal, nonadhesive appliance is useful• Conventional pouch may be used till the ulcer heals.

(185)


Fig. 6.7: Paraileostomy ulceration

(186)


ILEOSTOMY OBSTRUCTION

DefinitionObstruction of ileostomy.

Pathogenesis• Edema of stoma• Adhesions• Volvulus• Entrapment of ileum in the fascial closure• Food bolus obstruction.

Day of Occurrence



• Edematpis ileostomy stoma (Fig. 6.8)• Abdominal pain• Vomiting• Abdominal distension• Diminution of ileostomy output.

InvestigationsPlain X-ray may show air fluid levels.

(187)


ManagementMedical

Irrigation of ileostomy, till returns are clear.

SurgicalIf mechanical obstruction is identified, laparotomy maybe required.

Fig. 6.8: Ileostomy obstruction

(188)


STENOSIS OF ILEOSTOMY

Definition

Narrowing of ileostomy stoma (Fig. 6.9A).

Fig. 6.9A: Stenosis of ileostomy

(189)


Pathogenesis

• Healing of circular ulceration of mucocutaneousjunction

• Tight opening in the abdominal wall while creating thestoma.

Day of Occurrence



Small ileostomy stoma.

Investigations


Management

Medical

Dilatation with fingers or metal dilators (Fig. 6.9B).

Surgical

Local repair (mobilization of terminal ileum andrefashioning) (Fig. 6.9C).

(190)


Fig. 6.9B: Dilatation of stenosis of ileostomy with (I) Finger (II) Dilator

Fig. 6.9C: Operative treatment of ileostomy stenosis

(191)


RECESSION OF ILEOSTOMY

Definition

Pulling in of the ileostomy (Fig. 6.10A).

Pathogenesis• Too large opening in the abdominal wall• Inadequate fixation of ileum at the fascial plane.

Fig. 6.10A: Recession of ileostomy

(192)


Day of OccurrenceMonths after surgery.

Clinical Presentation• Soiling of peristomal skin• Skin changes may be evident• Stoma appears pulled into the abdomen.


ManagementLocal repair (mobilization of terminal ileum andrefashioning) (Fig. 6.10B).

Fig. 6.10B: Operative treatment of ileostomy recession

(193)


PROLAPSE OF ILEOSTOMY

Definition

Prolapse of ileostomy more common with loop ileostomy(Fig. 6.11A).

Pathogenesis

Long loop of small bowel fashioned outside the skin forcreation of ileostomy.

Fig. 6.11A: Prolapse of (I) End ileostomy (II) Loop ileostomy

(194)



Clinical Presentation• Stoma appears very much above the surface of skin• Mucosa may get ulcerated recurrently, caused by the

appliance.


ManagementLocal repair (detachment of mucocutaneous junction,reduction of everted stoma, amputation of excess lengthand refashioning) (Fig. 6.11B).

Fig. 6.11B: Operative treatment of ileostomy prolapse

(195)


PARASTOMAL HERNIA

Definition

Herniation of intra-abdominal contents anywhere aroundthe stoma (Fig. 6.12A).

Pathogenesis

• Opening in the abdominal wall very large• Patulous abdominal wall.

Fig. 6.12A: Paraileostomy hernia

(196)


Day of Occurrence



Swelling in the parastomal regionAbdominal or local pain, if obstruction occurs.

Investigations


Management

• Local repair (detachment of stoma, with the help ofincision hernial sac is identified, reduced andrefashioning of stoma) (Fig. 6.12B)

• Skin may be closed by ‘Mercedes repair’ (Fig. 6.12C).

Fig. 6.12B: Operative repair of parastomal hernia

(197)


Fig. 6.12C: Mercedes repair of parastomal hernia

(198)


EXCESSIVE LENGTH OF ILEOSTOMY STOMA

Definition

Long length of ileum above the skin surface, common afterend ileostomy.

Pathogenesis

Fashioning of long length of ileum above the skin surface.

Day of Occurrence



• Long overhanging length of ileum• May ulcerate due to appliance.

Investigations


(199)


Management

Local repair (detachment of mucocutaneous junction,reduction of everted stoma, amputation of excess lengthand refashioning) (Fig. 6.13).

Fig. 6.13: Operative treatment of excessive length of ileostomy

(200)


PARASTOMAL ABSCESS

Definition

Abscesses in the area around the ileostomy (Fig. 6.14).

Fig. 6.14: Parastomal abscess

(201)


Pathogenesis

• Mucocutaneous suture line breaks• Infection of hematoma.

Day of Occurrence



Painful swellings around the stoma.

Investigations

• No special investigation is necessary• Diabetes may have to be evaluated.

Management

Drainage of abscess.

(202)


ILEOTOMY FISTULA

Definition

Fistulous opening anywhere around the ileostomy.

Pathogenesis

Suturing of bowel wall to the rectus fascia by deeper full-thickness stitch.

Day of Occurrence



Leakage of purulent material anywhere around theileostomy.

Investigations

Fistulogram may be useful.

Management

• If the fistulous opening is close to stoma, no treatmentis required

(203)


• If the fistulous opening is far from the stoma, theappliance may be made to include the fistula in theappliance.

• If the fistulous opening is very far from the stoma, andcannot be included in the appliance, bistulectomy(Fig. 6.15) is the the treatment of choice.

Fig. 6.15: Operative treatment of paraileostomy fistula

(204)


PARAILEOSTOMY GRANULOMA

Definition

Reddish swelling around the ileostomy (Fig. 6.16).

Fig. 6.16: Parastomal granuloma

(205)


Pathogenesis

• Long standing skin irritation• Neglected cases of irritation may lead to ulceration and

granuloma.

Day of Occurrence



Painful reddish swellings around the ileostomy.

Investigations

• Evaluation of diabetes is required• Dermatological causes have to be assessed.

Management

• Excision of granuloma.

(208)


HISTORY

• 1736 – First appendicectomy by Caludius Amyand• 1848 – Drainage of appendix abscess by Hancock• 1887 – Appendicectomy for gangrenous appendix by

Tait• 1889 – Muscle splitting incision for appendicectomy by

McBurney (Fig. 7.1)• 1977 – First laparoscopic appendicectomy by DeKok.

Fig. 7.1: Charles McBurney

(209)

CHAPTER 7: APPENDICECTOMY

INDICATIONS

• Acute appendicitis (Fig. 7.2 A)• Chronic appendicitis (Fig. 7.2 B)• Tumors of appendix.

Fig. 7.2A: Acute suppurative appendicitis (note the pus in the cup)

(210)


Fig. 7.2B: Appendix with fecoliths

(211)


INCISIONS

Incision for appendicectomy (Fig. 7.3)• McBurney’s incision (Most popular)• Lanz incision• Right lower paramedian incision.

Fig. 7.3: Incisions for appendicectomy

(212)


SURGICAL TECHNIQUE

Surgical technique of appendicectomy (Fig. 7.4)

Position: Supine

• Identifying the appendix• Appendix is picked-up with the fingers

Fig. 7.4: Appendicectomy surgery

(213)


• Appendix is held with Babcock’s forceps upwards• Appendicular artery identified in the mesoappendix• Appendicular artery divided between ligatures (1)• Appendix is crushed at its base• Clamp applied at the crushed site, and advanced

distally• Ligature applied at the crushed site with absorbable

material• Appendix is divided between the suture and the clamp,

and removed (2)• Purse string sutured on the cecum and appendicular

stump buried (3).

(214)


HEMORRHAGE FROM APPENDICULAR STUMP

Definition

Bleeding in the abdominal cavity (Fig. 7.5).


(215)


Pathogenesis

• Leakage of blood from the appendicular stump• Slipped ligature of the appendicular artery.

Day of Occurrence



• Severe lower abdominal pain• Guarding in right iliac fossa.

Investigations

US and CT may be contributory.

Management

Exploration of abdomen and ligation of mesoappendix.

(216)


PARALYTIC ILEUS

Definition

Delayed recovery of intestinal movements.

Pathogenesis

• Peritonitis• Electrolyte disturbances (hypokalemia).

Day of Occurrence



• Vomiting• Abdominal distension• Constipation.

Investigations

X-ray abdomen (Fig. 7.6) shows distended loops of smallbowel (Step ladder pattern).

(217)


Management

• Correction of electrolytes• Nasogastric aspiration.

Fig. 7.6: X-ray — Step ladder pattern of paralytic ileus

(218)


WOUND INFECTION AFTER APPENDICECTOMY

Definition

Infection of operative wound, may vary from mild to floridinfection.

Pathogenesis

• Spillage of infected appendicular contents• Extension of infection from appendix to abdominal

wall.

Day of Occurrence



• Fever• Discharge from wound (Fig. 7.7)• Pain in the wound.

Investigations

Pus culture to identify the incriminating organisms.

(219)


Management

• Drainage of collection of abscess• Appropriate antibiotics• Wound care.

Fig. 7.7: Wound infection (appendicectomy)

(220)


PELVIC/PARACOLIC ABSCESS

Definition

Collection of pus in the region adjacent to cecum or pelviccavity.

Pathogenesis

• Spillage of appendicular contents• Incomplete resolution of generalized peritonitis.

Day of Occurrence



• Abdominal pain• High grade fever• Constipation.

Investigations

US and CT (Fig. 7.8) are diagnostic.

(221)


Management

• Drainage under US or CT guidance or open method• Appropriate antibiotics.

Fig. 7.8: CT — Paracolic abscess

(222)


RUPTURE OF STUMP AND APPENDICOCUTANEOUS

Definition

Dehiscence of appendicular stump.

Pathogenesis• Sloughing of appendicular stump• Administration of enema in the postoperative period• Fistula may form spontaneously or after surgical

drainage.

Day of Occurrence



• Right lower quadrant pain• Vomiting• Tenderness at the operated area• Constipation• Discharging fistula (Fig. 7.9).

Investigations

• US may be useful in localizing abscess• Fistulogram is useful.

(223)


Management

Medical

• Antibiotics• Drainage of collection (appendicocutaneous fistula may

result).

Surgical

• Cecostomy will prevent further spillage• Fistula has to be excised.

Fig. 7.9: Appendicocutaneous fistula

(224)


HERNIA (POST-APPENDICECTOMY)

Definition

Prolapse of intestines at the appendicectomy scar.

Pathogenesis

Weakness of muscles due to:• Postoperative infection• Chronic cough• Chronic sneeze• Chronic constipation.

Day of Occurrence

Late postoperative period.


• Swelling of the abdomen around the operated area(Fig. 7.10)

• Pain if obstruction occurs.

Investigations


(225)


Management

Surgical repair with a mesh.

Fig. 7.10: Ventral hernia (post appendicectomy)

(226)


INTESTINAL OBSTRUCTION

Definition

Mechanical obstruction of small bowel.

Pathogenesis

Postoperative adhesions in the ileocecal area.

Day of Occurrence



• Recurrent attacks of abdominal pain• Associated vomiting and constipation.

Investigations• Plain X-ray (Fig. 7.11) may be useful• Contrast studies are useful• Laparoscopy is diagnostic.

ManagementMedicalConservative management.

(227)


Fig. 7.11: X-ray abdomen: Multiple air fluid levels ofsmall bowel obstruction

Surgical

Release of adhesions (laparoscopic or open).

(230)


HISTORY

• 1823 – First successful resection for colonic growth byReybard of Lyons

• Extraperitoneal resection of colon:– 1894 – Exteriorization and delayed excision of

sigmoid by Bloch– 1895 and 1912 – Exteriorization and simultaneous

excision of sigmoid by Paul (Fig. 8.1)– 1894 – Exteriorization and delayed excision of

sigmoid by Miculicz

Fig. 8.1: Frank Thomas Paul (1851-1941)

(231)

CHAPTER 8: LARGE BOWEL RESECTION

– 1926 – Modification of Paul’s technique (byapplication of crushing clamps) by Rankin

– 1931 – Extraperitoneal resection of right colon andsplenic flexure by Devine

• Intraperitoneal resection with ‘aseptic anastomosis’– 1898 – Halstead– 1900 – O’Hara– 1921 – Shoemaker– 1928 – Pringle– 1940 – Wangensteen– 1950 – Monro

• Intraperitoneal resection of left colon afterdefunctioning transverse colostomy– 1931, 1935, 1938 – Devine

• Intraperitoneal resection with intestinal antisepsis– 1953 – Lloyd Davies, Morgan and Goligher– 1963 to 1967 – Nonabsorbable antibiotics and

irrigants by Gabriel, Hummel, Altemeier and Hill,Mckittrick and Naunton Morgan

– 1959 to 1968 – Tyson, Wangensteen and Gilbertsen,Grant and Barbara, Black)

• 1990 - First laparoscopic colonic resection (righthemicolectomy) by Moises Jacobs.

(232)


VARIETIES OF SURGERIES OF COLON AND RECTUMVarieties of colon and rectum surgeries (Fig. 8.2)• Resection and establishment of continuity (hand sewn

or stapled anastomosis)• Bypass procedures (hand sewn or stapled anastomosis)

without resections.

Fig. 8.2: Varieties of colon and rectum surgeries

(233)


• Types of anastomosis (Fig. 8.3):– End-to-end– End-to-side– Side-to-side.

• Hand sewn anastomosis can be made in:– Single layer– Double layer.

Fig. 8.3: Types of anastomosis

(234)


INDICATIONS

• Bleeding lesions (Figs 8.4A and B)• Obstructive lesions (strictures, tumors, intussusception)

(Figs 8.4C and D)• Strangulations with nonviable bowel.

Fig. 8.4A: Benign colonic polyp

(235)


Fig. 8.4B: Colonic polyp with dysplasia

(236)


Fig. 8.4C: Malignancy of colon

(237)


Fig. 8.4D: Intussusception

(238)


INCISIONS

• Midline (most popular) (Fig. 8.5)• Left paramedian for left colon• Right paramedian for right colon.

Note: Midline incision has the advantage of:• Ease• Speed• Versatility• Allows access to all quadrants• Easily extendable when needed.

Fig. 8.5: Midline incision

(239)


SURGICAL TECHNIQUE

Hand Sewn Technique (Fig. 8.6)

• Adequate mobilization• Marking the lines of resection

Fig. 8.6: Resection of colon

(240)


• Vascular control (division of vessels betweenligatures) (1)

• Division of bowel• Anastomosis of the bowel ends (single or double

layer) (2)• Single layer anastomosis (3)

– Alignment of bowel ends– Application of full thickness sutures (outside in and

inside out)– Knotting on the outside

• Double layer anastomosis (3)– Posterior outer row first (seromuscular) with non-

absorbable material– Posterior inner row next (running full thickness) with

absorbable material– Anterior inner row in continuity from the posterior

inner row– Anterior outer row last (seromuscular) with non-

absorbable material.Note:• Inverting anastomosis causes serosa to serosa

apposition• Inversion of mucosa reestablishes integrity of lumen

preventing leakage.

(241)


WOUND INFECTION AFTER COLONIC SURGERY

Definition

Infection of laparotomy wound.

Pathogenesis

Handling of colon and soilage of the wound.

Day of Occurrence



Discharge from the laparotomy wound (Fig. 8.7).

Relevant Investigation

Culture of discharge to isolate the incriminatingorganism.

(242)


Management

• Broad spectrum antibiotics• Local wound care.

Fig. 8.7: Wound infection

(243)


ANASTOMOTIC LEAKAGE AFTER COLONICSURGERY

Definition

• Leakage of intestinal contents through the anastomoticline.

Pathogenesis

• Inadequate bowel preparation• Poor blood supply to both ends of bowel• Tension on the anastomosis.

Day of Occurrence



• Abdominal pain• Fever• Leakage of intestinal contents through the drain.

Investigations


(244)


Management• Nil by mouth• Intravenous fluids• Intravenous broad spectrum antibiotics• Replacement of fluids, calories and electrolytes• Minor leaks heal, larger leaks require surgery (Fig. 8.8)• If fistula is formed, it may heal over a period of time• Some may require surgery, after 6 to 12 weeks for fistula.

Fig. 8.8: Anastomotic leakage producing fecal peritonitis

(245)


ANASTOMOTIC STRICTURE AFTER COLONICANASTOMOSIS

Definition

• Narrowing of lumen of anastomotic area (Fig. 8.9).

Fig. 8.9: Anastomotic stricture

(246)


Pathogenesis

• Healing of a circular anastomosis results in a stricture.

Day of Occurrence



• Constipation• Abdominal pain• Vomiting• Abdominal distension.

Investigations

Contrast studies may be useful.

Management

• Small bowel strictures are bypassed or resectionanastomosis done.

Note:Strictures following stapler usage is rare, if the correct sizeis chosen.

(247)


ADHESIONS AFTER COLONIC SURGERY

Definition

Adherence of bowels between themselves or with theparietes (Fig. 8.10).

Pathogenesis• Postoperative fibrinous adhesions result from the healing

of local inflammatory processes in the operated area• Resolved infections of peritoneum can cause adhesions.

Fig. 8.10: Adhesions between intestinal loops (black arrows) and toparietes (yellow arrow)

(248)


Days of Occurrence

Months–years after surgery.


• Recurrent attacks of abdominal pain• Vomiting• Constipation• Abdominal distension.

Investigations

X-rays of abdomen will show distended bowel.

Management

Medical

• Nil by mouth• Intravenous fluids and electrolytes.

Surgical

• If medical management fails, adhesiolysis by open orlaparoscopic methods.

(249)


EXTERNAL URINARY FISTULAE AFTERCOLONIC SURGERY

Definition

Fistulous communication between the ureter and exterior.

Pathogenesis

• Inadvertent clamping, cutting or damage to the ureter.

Days of Occurrence



• Discharge of straw-colored clear fluid through drain.

Investigations

Contrast studies are useful.

(250)


Management

• Ureteric fistulae due to:– Partial injury: Ureteric catheterization and

spontaneous healing– Complete injury: Resection and anastomosis (uretero

ureterostomy, uretero neocystoscomy) (Fig. 8.11).

Fig. 8.11: Operations of repair in ureteric injuries

(251)


EXTERNAL COLONIC FISTULAE

Definition

Leakage of colonic contents through a fistulae to theexterior.

Pathogenesis

• Anastomotic leak lead to collection of pus which in turndrain through the drainage tube

• Intentional external drainage of collection of pus fromthe anastomotic leak.

Days of Occurrence



• Has had a turbulent postoperative period• Discharging wound in the postoperative period• Fluid and electrolyte disturbances• Skin excoriation around the fistulous opening (Fig. 8.12)• Fever.

(252)


Investigations

• Oral administration of non-absorbable marker (charcoalor congo red)

• Fistulogram• US, CT with contrast or isotope scanning are useful.

Fig. 8.12: External colonic fistula

(253)


Management

Most lateral fistulae heal spontaneously.

Surgical

Excision of fistulaIndicated when there is:• Evidence of obstruction• Active disease• Interruption of bowel continuity• Closure not occurred by 6 weeks.

(256)


HISTORY

• 1793 – First successful inguinal colostomy by Duret• 1797 – First transverse colostomy by Fine• 1808 – Colostomy by lumbar approach by Hendrik

Callisen• 1817 – Colostomy for imperforate anus by George Freer• 1820 – Colostomy with skin complications by Ping• 1839 – Lumbar colostomy by Amussat (Fig. 9.1)• 1931, 1935, 1938 – Defunctioning transverse colostomy

by Devine.

Fig. 9.1: Jean Zulema Amussat (1796-1856)

(257)

CHAPTER 9: COLOSTOMY

TYPES OF COLOSTOMY

There are four types of colostomy (Fig. 9.2). They are:1. Loop colostomy (C)2. Double barreled colostomy (A)

Fig. 9.2: Types of colostomy

(258)


3. Divided colostomy (B)4. Terminal colostomy (D).

Indications for Loop Colostomy• As a temporary or palliative procedure in obstructed

colonic malignancies.

Indications for Double Barreled Colostomy

• Proximal to colocutaneous fistula• As an alternative to loop colostomy.

Indication for Divided Colostomy

• As a primary procedure for the definitive stoma.

Indication for Teminal Colostomy

• As a part of abdominoperineal resection for cancer oflower rectum (Fig. 9.3).

(259)


Fig. 9.3: Carcinoma lower rectum

(260)


SURGICAL PROCEDURE

Terminal Colostomy (Fig. 9.4A)• A circular opening of 2 cm is made in the abdominal

wall at the site of colostomy (1)• The sigmoid colon is brought out through the

opening (2)• The bowel is fixed to the parietal peritoneum to prevent

recession

Fig. 9.4A: Surgical procedure of terminal colostomy

(261)


• The free end of the bowel is inverted and sutured to borderof abdominal opening with absorbable material (3).

Loop Colostomy (Fig. 9.4B)• Incision in the right upper abdomen• A loop of transverse colon is picked-up• Colon is fixed to parietes• Colon is opened with diathermy• Everting mucocutaneous suturing done with

absorbable material.

Fig. 9.4B: Surgical procedure of loop colostomy

(262)


LOSS OF VIABILITY OF COLOSTOMY

Definition

Viability of the colostomy becomes questionable.

Pathogenesis

• Inadequate blood supply• Opening in the abdominal wall smaller than the colonic

diameter.

Day of Occurrence



Blackening or darkening of colostomy (Fig. 9.5).

Investigations


(263)


Management

• Release of tight compressive dressings if necessary• If darkening does not improve, and extend downwards,

the wound should be reopened and refashioned.

Fig. 9.5: Loss of viability

(264)


PERICOLOSTOMY SKIN DAMAGE

Definition

Irritation of skin around the colostomy stoma.

Pathogenesis

• Infection of mucocutaneous junction due to fecalcontamination.

Day of Occurrence



Erythematous or ulcerative skin around the stoma,sometimes bleeding (Figs 9.6A and B).

Investigations


Management• Antibiotics• Local dressings.

(265)


Fig. 9.6B: Excoriation of skin around transverse colostomy

Fig. 9.6A: Skin damage around end colostomy

(266)


SEPARATION OF COLOSTOMY

DefinitionSeparation of mucocutaneous junction.

PathogenesisNon-healing of infected mucocutaneous junction.

Fig. 9.7A: Separation of end colostomy

(267)


Day of Occurrence3rd to 5th postoperative day.

Clinical PresentationUlcerated mucocutaneous junction (Figs 9.7A and B).


Treatment• Antibiotics• Local care dressings.

Fig. 9.7B: Ulceration and separation of colostomy

(268)


STRICTURE AND RETRACTION OF COLOSTOMY

DefinitionInward pulling of narrowed colostomy.

Pathogenesis• Healing of circular ulceration of mucocutaneous

junction• Tight opening in the abdominal wall while creating the

stoma.

Fig. 9.8A: Stricture of colostomy

(269)


Day of Occurrence



Retracted colostomy (Fig. 9.8A).

Investigations


Management

Reconstruction with a formal laparotomy (Fig. 9.8B).

Fig. 9.8B: Surgical treatment of colostomy stricture

(270)


STENOSIS OF COLOSTOMY

Definition

Narrowing of colostomy stoma.

Pathogenesis

• Healing of circular ulceration of mucocutaneousjunction

• Non-suturing of mucocutaneous junction duringsurgery

• Inadequate mucocutaneous approximation.

Day of Occurrence



Constipation and passing small diameter fecal matter(Fig. 9.9A).

Investigations


(271)


Fig. 9.9A: Stenosis of colostomy

Fig. 9.9B: Finger dilatation of stenosis of colostomy

(272)


Management

Medical

Dilatation with finger (Fig. 9.9B) or metal dilator.

Surgical

Local repair (mobilization of colostomy and refashioning)(Fig. 9.9C).

Fig. 9.9C: Operative repair of stenosis of colostomy

(273)


PROLAPSE OF COLOSTOMY

Definition

Prolapse of colostomy, which is more common with loopcolostomy (Fig. 9.10A).

Fig. 9.10A: Prolapse of loop colostomy

(274)


Pathogenesis

Construction of colostomy when the colon is dilated, andthe diameter of colon and the opening in the abdominalwall get mismatched.

Day of Occurrence



• Stoma appears very much above the surface of skin• Mucosa may get ulcerated recurrently, caused by the

appliance.

Investigations


Management

Local repair (detachment of mucocutaneous junction,reduction of everted stoma, amputation of excess lengthand refashioning) (Figs 9.10 B and C).

(275)


Fig. 9.10B: Operative repair of loop colostomy

Fig. 9.10C: Operative repair of end colostomy

(276)


PARACOLOSTOMY HERNIA

Definition

Herniation of intra-abdominal contents anywhere aroundthe stoma.

Pathogenesis• Opening in the abdominal wall very large• Patulous abdominal wall.


Clinical Presentation• Swelling in the parastomal region (Fig. 9.11A)• Abdominal or local pain, if obstruction occurs.

Investigations


Management

• Local repair (detachment of stoma, with the helpincision hernial sac is identified, reduced andrefashioned) (Fig. 9.11B).

(277)


Fig. 9.11B: Operative repair of paracolostomy hernia

Fig. 9.11A: Paracolostomy hernia

(278)


Fig. 9.12: Colostomy perforation

COLOSTOMY PERFORATION

DefinitionPerforation of colostomy (Fig. 9.12).

PathogenesisCareless intubation during irrigation or contrast studies,which may cause peritonitis due to fecal contamination.

(279)


Day of Occurrence



• Severe abdominal pain• Signs of localized peritonitis.

Investigations

• US and CT can localize collections• Endoscopy may show the perforation.

Management

Laparotomy and reconstruction of colostomy.

(282)


HISTORY

• 1884 – First combined abdominoperineal excision ofrectum by Czerny (Fig. 10.1A)

• 1908 – Popularization of combined abdominoperinealresection by Ernest Miles

• 1920 – Two stage perineoabdominal excision by GreyTurner

• 1934 – Single stage perineoabdominal excision byGabriel

• 1934 – Synchronous combined abdominoperinealoperation by Heidelberg

Fig. 10.1A: Vincenz Czerny (1842-1916)

(283)

CHAPTER 10: ABDOMINOPERINEAL RESECTION

• 1937 – Popularization of synchronous combinedabdominoperineal operation by Devine

• 1939 – Synchronous combined abdominoperinealoperation in Lithotomy – Trendelenburg (Fig. 10.1B)position by Lloyd – Davies

• 1960 – Two team, simultaneous abdominoperinealresection by Rhoads.

Fig. 10.1B: Friedrich Trendelenburg

(284)


INDICATION

• Malignancies of distal rectum or anus (Fig. 10.2).

Fig. 10.2: Specimen of carcinoma lower rectum

(285)


INCISION

• Lower midline (most convenient) (Fig. 10.3)• Lower left paramedian.Note: It has the advantage of:• Ease• Speed• Versatility• Allows access deep into pelvis• Easily extendable when needed• Site for colostomy is marked well in advance in sitting

position.

Fig. 10.3: Left lower paramedian incision with site marked for colostomy

(286)


SURGICAL TECHNIQUE

Position of patient.

Lithotomy Trendelenburg Position

• Abdominal dissection (Fig. 10.4)– Lower midline incision– Release of sigmoid colon (1)– Identification and preservation of left ureter– Release of sigmoid colon from the right side (2)– Both incisions are joined anteriorly in the rectovesical

or rectouterine pouch– Rectum dissected and separated from the urinary

bladder and prostate (3)– Rectum is separated fully in the presacral space as

far down as possible (4)– Rectum separated fully on both the lateral sides

dividing lateral ligaments containing the middlerectal vessels

– Inferior mesenteric vessels flush ligated (5).• Perineal dissection

– Elliptical incision around the anus– Rectum is separated on all sides and dissection

carried proximally to meet the abdominal surgeon(6 and 7).

(287)


• Completion of operation– The separated rectum is removed from the perineal

wound– Terminal colostomy created (8).


(288)


HEMORRHAGE AND SHOCK AFTER AP RESECTION

Definition

Bleeding from the pelvis through the drain in the perinealwound (Fig. 10.5).


(289)


Pathogenesis

Ooze from the pelvic cavity.

Day of Occurrence



• Tachycardia and hypotension• Signs of shock• Blood in the drain.

Investigations

Hematocrit to assess the blood loss.

Management

• Blood transfusions• Re-exploration if bleeding persists and requires large

transfusions.

(290)


RUPTURE OF PELVIC PERITONEUM

DefinitionPartial or complete giving way of pelvic peritoneum(Fig. 10.6).

Pathogenesis• Inadequate approximation of pelvic peritoneum• Giving way of sutures approximating the pelvic

peritoneum.

Fig. 10.6: Rupture of pelvic peritoneum

(291)


Day of Occurrence

3rd to 10th postoperative days.


• Severe abdominal pain• Bowel may be visible through the perineal wound.

Investigations

• No special investigation is necessary• Rarely ultrasound may be useful.

Management

• Surgery by abdominal route:– Bowel is released and pulled into abdomen and the

floor repaired (primarily or with a graft or mesh)– Gangrenous bowel needs to be resected.

(292)


INFECTION OF PERINEAL WOUND AFTER APRESECTION

DefinitionInfection of perineal wound.

PathogenesisInadvertent opening of anorectum and spillage of contents.

Day of Occurrence



• Pain in perineal wound• Discharge from perineal wound (Fig. 10.7).

Investigations

Culture of discharge to identify incriminating organism.

Management

• Broad spectrum antibiotics• Secondary suturing, if required.

(293)


Fig. 10.7: Infection of perineal wound

(294)


STENOSIS OF PERINEAL SCAR AFTER APRESECTION

Definition

Narrowing of perineal scar.

Pathogenesis

Results after management of perineal wound by openregime.

Day of Occurrence



• Pain in the perineal scar• Depression in the perineal sear (Fig. 10.8).

Investigations


Management

• Scar release and stretching the skin is useful• Any collection below the scar needs to be drained.

(295)


Fig. 10.8: Stenosis of perineal scar

(296)


PERINEAL HERNIA

DefinitionHernia of the perineal region.

PathogenesisWeakness of pelvic floor after extensive resections.

Day of OccurrenceMonths/years after surgery.

Fig. 10.9A: Perineal hernia through rent in pelvic peritoneum

(297)


Clinical PresentationBulge in the perineum (Fig. 10.9A and B).

InvestigationsCT may be useful.

ManagementPerineal repair with mesh is necessary.

Fig. 10.9B: Perineal hernia (Diagramatic representation)

(298)


INTERNAL HERNIATION

Definition

Herniation of small bowel in the paracolic region.

PathogenesisHerniation of small bowel lateral to the terminal colon usedto form colostomy (Fig. 10.10).

Fig. 10.10: Internal herniation of small intestine

(299)


Day of Occurrence



• Pain the left side of abdomen• Distention of abdomen• Vomiting• Fullness of the paracolostomy areas.

Investigations

• Colostogram is useful• CT abdomen is useful.

Management

Always Surgical

• Herniated small bowel requires to be reduced throughlaparotomy

• Non-viable bowel needs resection.

(301)

CHAPTER 11: ANTERIOR RESECTION

(302)


HISTORY

• 1910 – Resection of rectosigmoid by abdominalapproach by Balfour

• 1934 – Resection of rectosigmoid by abdominalapproach with restoration of continuity by telescopicand tube technique by Lockhart Mummery (Fig. 11.1)

• 1963 – Resection of rectosigmoid by abdominalapproach with restoration with special mechanicaldevices by Hallenbeck, Judd and David

• 1965 – Very low colorectal anastomosis without sutureafter anterior resection by Brummelkamp

• 1945 – Mayo clinic operation by CF Dixon, CW Mayoand others of Mayo clinic.

Fig. 11.1: JP Lockhart Mummery

(303)


INDICATIONS

• Malignancies of mid and distal rectum (Fig. 11.2).

Fig. 11.2: Colorectal specimen containing a rectal tumor

(304)


INCISIONS

• Lower midline (most convenient) [Fig. 11.3(a)]• Left lower paramedian [Fig. 11.3(b)].

Fig. 11.3: Incisions

(305)


SURGICAL TECHNIQUE

• Position of patient– Lithotomy Trendelenburg position

• Abdominal dissection– Lower midline incision– Release of sigmoid, descending colon beyond splenic

flexure– Identification and preservation of left ureter– Release of sigmoid colon from the right side– Both incisions are joined anteriorly in the rectovesical

or rectouterine pouch– Rectum dissected and separated from the urinary

bladder and prostate– Rectum is separated full in the presacral space as far

down as possible– Rectum separated fully on both the lateral sides

dividing lateral ligaments containing the middlerectal vessels

– Inferior mesenteric vessels flush ligated– Rectum stapled and transected low (using linear

stapler)– Colon transected at mid sigmoid level.

• Stapler anastomosis– Circular stapler introduced into the distal rectal

stump through the anus (Fig. 11.4A).

(306)


– Anvil is introduced into the proximal colon(Fig. 11.4B)

– Proximal and distal guts are approximated(Fig. 11.4C)

Fig. 11.4 A: Insertion of stapler in the rectal stump

(307)


Fig. 11.4 B: Anvil in the proximal colon

(308)


Fig. 11.4 C: Colon and rectum approximation

– The gun is fired to throw the staples (Fig. 11.4D)– Stapler is opened a little and gut released– Stapler is removed

(309)


Fig. 11.4 D: Firining of gun for anastomosis

(310)


• Testing the integrity of anastomosis– Checking the doughnuts (Fig. 11.5)– By filling the pelvis with saline and injecting air in

the bowel and check for the air leak– By filling the rectum with dilute povidone iodine

solution and check for the solution leak.

Fig. 11.5: Doughnuts

(312)


HISTORY

• 1716 – First surgical removal of a portion of liver by Berta• 1870 – Resection of lacerated portion of liver by Bruns• 1886 – Excision of solid tumor by Lius• 1890 – First resection of liver for tumor by Tiffany• 1910 – Near total right lobectomy by Wendel• 1952 – Anatomic hepatic lobectomy by Lortat-Jacob and

Robert• 1953 – Major hepatic resection by Quattlebaum• 1956 – Right hepatic lobectomy by finger fracture

technique (digitoclasia) by Fineberg• 1963 – Hepatic resection by digitoclasia with occlusion

of portal pedicle by Ton That Tung (Fig. 12.1).

Fig. 12.1: Ton That Tung

(313)

CHAPTER 12: SURGERY OF LIVER

VARIETIES OF HEPATIC RESECTIONSVerieties of hepatic resections (Fig. 12.2) are:• Right and left lobectomy (resection along the main portal

fissure, separating the right and left lobes of liver)• Right extended lobectomy or Trisegmentectomy (resection

of the entire right lobe, medial segment of left lobe, liver

Fig. 12.2: Varieties of hepatic resections

(314)


substance to the right of falciform ligament andligamentum teres

• Left lateral segmentectomy (removal of segments II andIII to the left of falciform ligament and the ligamentumteres

• Unisegmentectomy (removal of single segment)*• Plurisegmentectomy (removal of two or more segments

at one time)• Wedge resection (removal of small segment of liver)

*Note:• Removal of segment I is impractical, as it requires

removal of segments II and III• Removal of segments II and III individually, has no

practical value• Removal of segment IV refers to removal of quadrate

lobe• Removal of segment VI is rarely indicated• Removal of segment VIII is very difficult, as it is

connected with intrahepatic inferior vena cava andsegment I.

(315)


INDICATIONS

• Parasitic cysts (Figs 12.3A and B)• Non parasitic cysts

Figs 12.3A and B: (A) Hydatid cyst, (B) US—Simple cyst

(316)


• Granulomas• Neoplasms• Primary (Benign and Malignant) (Fig. 12.3C)• Metastatic• Trauma

Fig. 12.3C: Hepatocellular carcinoma

(317)


INCISIONS

Incisions for hepatic surgery (Fig. 12.4)• Roof Top incision (1)• Hockey stick incision (sternal or costal extensions if

necessary) (2).

Fig. 12.4: Hepatectomy incisions

(318)


SURGICAL TECHNIQUE

Principles

• Adequate mobilization of liver to be resected(transection of ligamentous attachments)

• Temporary control of blood supply to the liver (byvascular tapes or clamps) (Fig. 12.5A) or permanent(ligatures and transections)

• Compression of blood vessels within the liverparenchyma (digital compression or hemoclips)

Fig. 12.5A: Pringle maneuver

(319)


• Transection of liver parenchyma (digitoclasia,ultrasonic dissection)

• Control of bleeding from raw surface of liver (Gelfoam,oxidized cellulose, thrombin paste or powder, Argonbeam coagulation).

Steps

• Mobilization– Ligamentum teres is transected, cut end is held with

clamp for traction [(1) in Fig. 12.5B]– Anterior and posterior leaflets of coronary ligaments

are divided• Control of blood supply

– Hepatoduodenal dissection- Cystic artery and ducts are divided before

hepatoduodenal dissection [(2) in Fig 12.5B]- Identification of right hepatic artery and control

with vascular tape- Identification of right branch of portal vein and

control with vascular tape [(3) in Fig 12.5B]- Right hepatic duct is doubly ligated and divided

[(3) in Fig 12.5B]- Right hepatic artery and right branch of portal

vein are divided between ligatures [(3) in Fig12.5B].

(320)


– Control of venous drainage- Main right hepatic vein is identified, clamped,

transected, the hepatic side is ligated, the cavalside is sutured with prolene [(4) in Fig 12.5B]

• Transection of liver parenchyma– Done with digitoclysis or ultrasonic dissector [(5) in

Fig. 12.5B]– Vessels encountered during transection are clamped

with hemoclips and divided.

Fig. 12.5B: Surgical technique

(321)


• Specimen is removed• Raw surface bleeding may be controlled by

– Adequate diathermy and hemastatic agents– Approximation of anterior and posterior parts of Glisson’s

capsule (Fig. 12.5C)• Drains are required in the subphrenic space.

Fig. 12.5C: Methods to control bleeding from raw area of liver

(322)


HYPERBILIRUBINEMIA

Definition

Yellowish discoloration of sclerae and skin.

Pathogenesis

• Direct damage to liver parenchyma• Hypovolemia• Reduced hepatic blood flow• Infection.

Day of Occurrence



Yellowish discoloration of sclerae (Fig. 12.6) and skin.

Investigations

Serum bilirubin values are elevated.

(323)


Management

• Resolve spontaneously• Broad spectrum antibiotics• Biliary enteric anastomosis if there is mechanical

obstruction.

Fig. 12.6: Yellowish discoloration of sclera (hyperbilirubinemia)

(324)


PERSISTENT BILE LEAKAGE/BILIARY FISTULA

Definition

Leakage of bile from the surface of residual liver.

Pathogenesis

• Inadvertent bile duct injury• Insufficient or slipped ligature of bile duct• Peritoneal absorption of bile causes jaundice• Bile causes chemical peritonitis.

Day of Occurrence



• Drainage of bile through the drain or skin (Fig. 12.7)• Yellowish discoloration of sclerae and skin (jaundice)• Severe abdominal pain (peritonitis).

Investigations

• Serum bilirubin levels may be elevated• CT scan may show localized collections of bile• MRCP can demonstrate the site of the fistula• Isotope scan is useful in locating the site of fistula.

(325)


Management• Most bile leaks heal spontaneously if there is no distal

obstruction• Wide spectrum antibiotics• Biliary enteric anastomosis is required if there is

irremovable distal obstruction.

Fig. 12.7: External biliary fistula

(326)


SUBPHRENIC ABSCESS

Definition

Collection of pus in the subphrenic spaces (Fig. 12.8).

Pathogenesis

Infection of collected blood in the operative area.

Fig. 12.8: Subphrenic abscesses

(327)


Day of Occurrence



• General malaise• Hyperpyrexia of varying grades• Insignificant clinical examination.

Investigations

Ultrasonography and CT are useful in localizing abscess.

Management

Medical

• Small abscesses resolve with antibiotics.

Surgical

• Drainage of abscess under US or CT guidance• Open drainage if large and pus is thick.

(328)


STRICTURE OF BILE DUCTS

Definition

Narrowing of bile ducts.

Reason

Inadvertent injury to bile ducts unrecognized during firstsurgery.

Day of Occurrence



Yellowish discoloration of sclerae and skin.

Investigations

• Ultrasonography and CT are useful• ERCP (Fig. 12.9A) to delineate the obstruction and also

to stent• MRCP (Fig. 12.9B) or PTC will show the level of

obstruction.

(329)


Fig. 12.9A: ERCP — Benign stricture of CBD

(330)


Management

• ERCP sphincterotomy and stenting• Nasobiliary drainage if the stricture is passable• Percutaneous transhepatic drainage if the stricture is

not passable• Biliary enteric anastomosis if the stricture is not passable

but resectable.

Fig. 12.9B: MRCP — Benign stricture of CBD

(331)


RECURRENCE OF MALIGNANCY

Definition

Recurrence of malignancy in the residual liver (Fig. 12.10).

Pathogenesis

• Residual tumor due to insufficient clearance• Microscopic disease during primary surgery.

Fig. 12.10: CT — Recurrent hepatocellular carcinoma

(332)


Day of Occurrence



• General malaise• Loss of appetite and weight• Abdominal pain• Abdominal distension• Jaundice.

Investigations

Ultrasonography and CT abdomen are useful.

Management

• Palliative—intra-arterial embolisation, intra arterialantimitotic drugs

• Surgical—resection if the tumor is solitary.

(334)


HISTORY

• 1733 – Removal of gallstone and drainage of gallbladderby Jean-Louis Petit

• 1878 – First cholecystectomy by Marion Simms• 1878 – First successful cholecystostomy by Theodor

Kocher (Fig. 13.1A)• 1882 - First successful cholecystectomy by Carl Johann

August Langenbuch (Fig. 13.1B)• 1893 – First choledocholithotomy by Ludwig

Courvoisier (Fig. 13.1C)• 1987 – First human laparoscopic cholecystectomy by

Mouret.

Fig. 13.1B: CarlLangenbuch

Fig. 13.1C: LudwigCourvoisier (1843-1918)

Fig. 13.1A: TheodorKocher

(335)

CHAPTER 13: SURGERY OF GALLBLADDER

INDICATIONS FOR CHOLECYSTECTOMY

• Chronic calculous cholecystitis (Fig. 13.2A)• Acute calculous cholecystitis

Fig. 13.2A: Faceted gallstones in edematous gallbladder

(336)


• Acalculous cholecystitis (Fig. 13.2B)• Empyema of gallbladder• Emphysematous cholecystitis

Fig. 13.2B: Acalculous cholecystitis

(337)


• Gallbladder perforation• Gallbladder malignancy (Fig. 13.2C).

Note: Indications for laparoscopic cholecystectomy areanalogous to open cholecystectomy, and the decision toconvert to open technique should be made prior to acomplication.

Fig. 13.2C: Gallbladder malignancy with faceted gallstones

(338)


SURGICAL TECHNIQUE

Open Cholecystectomy (Figs 13.3A and B)

Incisions

• Midline (1)• Right upper paramedian (2)• Right subcostal (Kocher’s) (3).

Fig. 13.3A: Incisions for cholecystectomy

(339)


Fig. 13.3B: Kocher's incision for cholecystectomy

(340)


Surgical Procedure (Fig. 13.4)

• Retraction to visualize the structures of hepatoduodenalligament– A deep retractor to retract the costal margin– The assistant’s right hand to retract the stomach to

the left stretching the ligament– The assistant’s left hand to retract the duodenun

downwards stretching the ligament

Fig. 13.4: Open cholecystectomy

(341)


– Fundus and the Hartmann’s pouch of the gallbladderare retracted laterally to open the angle between thecystic duct and the common bile duct

– A sponge is placed in the Morrison’s pouch beneaththe free edge of the ligament which will raise thestructures towards the surgeon.

• The peritoneal reflection over the angle between thecystic duct and the common bile duct is snipped anddissected, to expose the cystic duct

• The cystic artery is identified within the triangle of Calot(space between the cystic duct and hepatic duct), doublyligated and divided (1)

• The cystic duct is divided between ligatures, leaving asmall stump (2)

• Gallbladder is dissected from its bed by blunt fingerdissection (3)

• Hemostasis established by cautery.

Laparoscopic Cholecystectomy (Figs 13.5A and B)

• Imaging instruments, diathermy devices, suctionapparatus and instrument tables are arranged in acomfortable manner

• Patient in supine position with lateral tilt• Four entry ports (Fig. 13.5A)

– Camera port at the umbilicus

(342)


– Working port at the epigastrium– Right subcostal port– Right lateral port

• Carbon dioxide pneumoperitoneum created (12-15 mmHg)

Fig. 13.5A: Ports for laparoscopic cholecystectomy

(343)


• Trocars inserted at the specified sites• Dissection started at the infundibulum (Fig. 13.5B)• Cystic artery divided between clips• Cystic duct divided between clips• Gallbladder dissected out of its bed• Gallbladder removed through epigastric port• Hemostasis established.

Fig. 13.5B: Laparoscopic cholecystectomy in progress

(344)


BILIARY PERITONITIS

Definition

Infection of peritoneal cavity by bile (Fig. 13.6).

Fig. 13.6: Biliary peritonitis

(345)


Pathogenesis

Leak of infected bile or superadded infection to the leakedbile, during surgery or perforated gallbladder.

Day of Occurrence



High grade fever, severe pain in the right upper abdomen.

Investigations

Leukocytosis and raised sedimentation rate.

Management

Higher grade broader spectrum antibiotics, to cover grampositive organisms (3rd and 4th generation cephalospor-ins), gram negative organisms (aminoglycosides) andanaerobes (metronidazole).

Prevention

Prophylactic antibiotics, proper irrigation and suction ofsubhepatic area.

(346)


HEMATOMA

Definition

Hematoma formation near the gallbladder bed (Fig. 13.7).

Fig. 13.7: Hematoma

(347)


Pathogenesis

Slipped ligature of cystic artery or ooze from gallbladderbed.

Day of Occurrence



Low grade fever, pain in the right upper abdomen.

Investigations

Ultrasonography or CT is useful.

Management

• Small collections resolve• Large collections obstructing the CBD, need aspiration

under US or CT guidance or open drainage.

Prevention

Application of double ligatures or double clips to the cysticartery proximally.

(348)


BILE COLLECTION (BILEOMA)

Definition

Collection of bile in the gallbladder bed.

Pathogenesis

• Slipped ligature of cystic duct or ooze from gallbladderbed

• Sloughing of ligature of cystic duct• Surgical error• Anomalies of ductal system• Surgery on gangrenous gallbladder.


Low grade fever, severe pain right upper abdomen.

Day of Occurrence


Investigations


(349)


Management


under US or CT guidance or open drainage (Fig. 13.8).

Prevention

Double ligature or clipping of cystic duct, proper irrigationand suction, understanding the anatomy.

Fig. 13.8: Drainage of bileoma

(350)


SUBHEPATIC ABSCESS

Definition

Collection of pus in the peritoneal cavity (Fig. 13.9).

Fig. 13.9: Abscess

(351)


Pathogenesis

• Infection of collected bile or blood or both• Collection of infected bile.

Day of Occurrence



• High grade fever• Severe pain right upper abdomen• Severe tenderness right hypochondrium.

Investigations


Management


under US or CT guidance or open drainage.

Prevention

Prophylactic antibiotics.

(352)


EXTERNAL BILIARY FISTULA

Definition

Leakage of bile through a fistulous tract between the biliarytract and exterior.

Pathogenesis

• Spontaneous leakage of bile or bileoma to the exterior• Surgical drainage of bileoma• Distal obstruction of CBD (stone or malignancy).

Day of Occurrence


Clinical presentation

• High grade fever• Discharge of bile from wound or drain site (Fig. 13.10A)• Signs of electrolyte imbalance.

Investigations

• US will demonstrate dilated biliary radicles• CT and MRI may demonstrate the pathology at the distal

CBD

(353)


• Fistulography or MR fistulography may demonstrate thepathology at the distal CBD

• MRCP (Fig. 13.10B) is useful• PTC is useful when the ductal system is dilated• Isotope studies apart from the origin of fistulous tract

gives the index of liver function and biliary secretion.

Fig. 13.10A: External biliary fistula

(354)


Management

Medical

• Correction of electrolyte and fluid imbalance• Correction of malnutrition• Control of skin excoriation• Control of intra-abdominal infection.

Surgical

• Relief of obstruction of CBD (ERCP sphincterotomy andbasketing of stone) (Fig. 13.10C)

Fig. 13.10B: MRCP—Stricture lower CBD

(355)


• Total disruption of CBD warrants fistulo-jejunostomyor choledocho-jejunostomy

• Malignancy requires pancreato-duodenectomy.

Fig. 13.10C: Sphincterotomy

(356)


CYSTIC DUCT STONE

Definition

Retained stone in the cystic duct remnant (Fig. 13.11).

Fig. 13.11: Cystic duct stone

(357)


Pathogenesis

Unidentified stone retained in the cystic duct remnant(between the ligature and the junction of cystic duct andCBD).

Day of Occurrence



• Usually asymptomatic• May present with upper abdominal pain.

Investigations

US or CT is diagnostic.

Management

• If asymptomatic, no treatment is required• If symptomatic, the stone may have to be removed.

(358)


RETAINED CBD STONES

DefinitionStones in the common bile duct after primary gallbladderor bile duct surgery.

Pathogenesis• Overlooked stones in the common bile duct• Retained stones descending from hepatic ducts.


Clinical Presentation• Upper abdominal pain• High grade fever• Obstructive jaundice.

Investigations• US shows proximal dilatation of bile ducts• CT may show the obstructing calculus• MRCP shows the obstructing calculus (Fig. 13.12A)• PTC is used when ERCP is non contributory, especially

in dilated ductal system• Per oral mother baby choledochoscopy is contributory.

(359)


Management

Removal of stone is necessary• Sphincterotomy and basketing (Fig. 13.12B) is curativeWhen the stone is impacted,• ESWL may be used to break the stone, followed by

basketing

Fig. 13.12A: ERCP — Multiple stones in CBD

(360)


• Extraction using per oral mother baby choledochoscope• Dissolution of stones may be attempted• Choledochotomy is required if endoscopic procedure

fails• Choledocho enterostomy is done for stones impacted

in the lower CBD.

Fig. 13.12B: Basketing of common bile duct stone

(361)


BENIGN CBD STRICTURE

Definition

Narrowing of common bile duct after surgery.

Pathogenesis

• Injury to the common bile duct• Primary closure of CBD after stone removal.

Day of Occurrence



• Upper abdominal pain• Obstructive jaundice• Fever.

Investigations

• US and CT show proximal dilatation of bile ducts• MRCP (Fig. 13.13A) shows the stricture• ERCP (Fig. 13.13B) shows the stricture• PTC is used when ERCP is non contributory, especially

in dilated ductal system

(362)


• Per oral mother baby choledochoscopy is contributory• Isotope studies are useful.

Fig. 13.13A: MRCP — Benign stricture of CBD

(363)


Management

• Excision of stricture and end to end anastomosis over aT tube

• Choledocho enterostomy is a good alternative• Hepaticodochoenterostomy is required for strictures of

common hepatic duct.

Fig. 13.13B: ERCP — Benign stricture of CBD

(364)


BILIARY ENTERIC FISTULA

Definition

Communication between the biliary system and intestines.

Pathogenesis

Rupture of pericholedochal abscess into the adjoiningbowel.

Day of Occurrence



Usually asymptomatic.

Investigations

• X-ray and CT (Fig. 13.14) and useful• MRCP is useful• Barium studies may show the fistula• Isotope studies are diagnostic.

(365)


Fig. 13.14: X-ray and CT—Air in the biliary system

Management

• Asymptomatic patients require no treatment• Excision of fistula is required in symptomatic patients.

(368)


HISTORY

• 1899 – Successful resection of periampullary carcinomaby Halsted (Fig. 14.1A)

• 1912 – First successful pancreaticoduodenectomy byKausch

• 1935 – Successful two-stage pancreaticoduodenectomyby Whipple (Fig. 14.1B)

• 1941 – First one-stage pancreaticoduodenectomy byTrimble.

Fig. 14.1A: William Halsted Fig. 14.1B: Whipple

(369)

CHAPTER 14: SURGERY OF PANCREAS

VARIETIES OF PANCREATIC RESECTIONS

Varieties of pancreatic resections (Fig. 14.2) are:• Resection of pancreatic tail• Distal pancreatectomy (includes splenectomy)

Fig. 14.2: Varieties of pancreatic resections

(370)


• Left pancreatectomy (removal of body and tail)• Pancreatoduodenectomy — Whipple’s operation

(removal of pancreatic head including duodenum,proximal part of jejunum and distal biliary tree)

• Subtotal pancreatectomy (removal of part of head,entire body and tail of pancreas)

• Total pancreatectomy (removal of entire pancreas).

(371)


INDICATIONS FOR PANCREATECTOMY

• Inflammation– Necrotising pancreatitis– Chronic pancreatitis with pain

• Trauma• Neoplasms (Figs 14.3A to C)

– Adenocarcinoma (85%)– Cystadenoma (mucinous/serous)

Fig. 14.3A: CT — Malignancy of body and tail of pancreas

(372)


– Cystadenocarcinoma– Islet cell tumors (neuroendocrine tumors)– Papillary cystic neoplasms

Fig. 14.3B: MRCP — Carcinoma of head of pancreas

(373)


– Lymphoma– Acinar cell tumors

• Severe hyperinsulinemic hypoglycemia.

Fig. 14.3C: CT — Pancreatic head malignancy

(374)


INCISIONS

Incisions for panereatic (Fig. 14.4)• Bilateral subcostal (1)• Long midline. (2)

Fig. 14.4: Incisions for pancreatic surgery

(375)


SURGICAL TECHNIQUE OF WHIPPLE’S OPERATIONSurgical procedure (Fig. 14.5A) :• Mobilization of duodenum and head of pancreas, with

identification of superior mesenteric vein• Mobilization of common bile duct and portal vein

(above pancreas)• Cholecystectomy (1) and division of common bile duct (2)• Elevation of neck of pancreas from superior mesenteric

and portal veins

Fig. 14.5A: Surgical technique of Whipple’s operation

(376)


• Division of stomach or duodenum (if pylorus is to bepreserved) (3)

• Division of neck of pancreas (4)• Dissection of divided pancreas from mesenteric vessels• Mobilization and division of proximal jejunum (5)• Division of mesoduodenum and attachments of

uncinate process to the superior mesenteric artery, andremoval of specimen

• Reconstruction of gastrointestinal continuity (Fig. 14.5B).

Fig. 14.5B: Recenstruction after whipple’s operation

(377)


GASTROINTESTINAL HEMORRHAGE(POST-PANCREATECTOMY)

Definition

Bleeding in the stomach (Fig. 14.6).

Fig. 14.6: Gastrointestinal hemorrhage

(378)


PathogenesisBleeding from:• Anastomotic area• Small bleeding ulcer in the gastric pouch• Erosion of ligated artery following pancreatic leak.

Day of Occurrence1st to 5th postoperative day.

Clinical PresentationBloody nasogastric aspirate.

InvestigationsHematocrit values may fall low.

ManagementMedical

• Ice cold saline• Endoscopic injection of 1:10000 adrenaline• Blood transfusions.

Surgical• Opening of gastric pouch above the anastomosis and

control of bleeding site.

(379)


EXTRAGASTRIC HEMORRHAGE(POST-PANCREATECTOMY)

Definition

Bleeding from sources outside stomach (Fig. 14.7).

Fig. 14.7: Extragastric hemorrhage

(380)


Pathogenesis• Laceration of spleen• Injury to liver by retractors• Injury to vasa brevia• Hemorrhage from pancreatic bed• Improperly secured vessel in the greater and lesser

omentum.

Day of Occurrence1st to 5th postoperative day.

Clinical Presentation• Bloody discharge from the drain in the abdominal cavity• Clear nasogastric aspirate.

Investigations• Hematocrit values may fall low• CT abdomen may be contributory.

ManagementMedical• Blood transfusion.

Surgical• Exploratory laparotomy and correction of cause.

(381)


DELAYED GASTRIC EMPTYING(POST-PANCREATECTOMY

Definition

Delay in emptying of stomach in the post-pancreativeperiod.


• Gastric atony due to disruption of gastoduodenal neuralconnection

• Ischemic injury to antropyloric muscle mechanism• Gastric dysrythmias due to intra-abdominal leaks• Gastric atony due to reduced levels of motilin.

Day of Occurrence


Clinical PresentationIncreasing nasogastric aspirate lasting for more than 2–3weeks.

InvestigationsUpper GI endoscopy after two weeks to rule out mechanicalobstruction.

(382)


ManagementMedical• Prolonged patient gastric decompression• Intravenous water and electrolyte substitution• Prokinetic drugs like bethanechol, metoclopramide,

erythromycin derivatives.

Fig. 14.8: Delayed gastric emptying — pathogenesis

(383)


BILIARY LEAK (POST-WAIPPLE’S OPERATION)

DefinitionLeakage of bile.

PathogenesisDisruption of biliary enteric anastomosis (Fig. 14.9A).

Fig. 14.9A: Biliary leak

(384)


Day of Occurrence



• Discharge of bile stained fluid through the intra-abdominal drain

• Skin excoriation around the drain (Fig. 14.9B).

Fig. 14.9B: Biliary leak and skin excoriation

(385)


Investigations

• Diagnosis is obvious, but isotope scan can demonstratethe leak

• CT is useful in locating localized collections of bile.

Management

Medical

• Most leaks heal spontaneously if there is no distalobstruction.

Surgical

• Localized collections of bile should be drained by USor CT guidance

• Open drainage of collection of bile is rarely necessary.

(386)


PANCREATIC LEAK

Definition

Leakage of pancreatic secretions (Fig. 14.10).

Fig. 14.10: Pancreatic leak

(387)


Pathogenesis

Disruption of pancreatico-enteric anastomosis.

Day of Occurrence



• Discharge of clear fluid through the intra-abdominaldrain

• Tachycardia, hyperpyrexia, tachypnea• Excoriation of skin around the drain• Abdominal tenderness.

Investigations

• Leucocytosis• Serum lactate and amylase levels may be elevated.

ManagementMedical

• Replacement of fluids and electrolytes• When the loss is less than 50ml/day, it heals

spontaneously

(388)


• Antibiotics are needed for large leaks with peritonitis• Total parenteral nutrition is useful in large leaks• May result in a pancreatic fistula.

Surgical

• Percutaneous drainage of localized collections• Laparotomy and peritoneal toileting in peritonitis• Completion pancreatectomy is rarely needed.

(389)


CHYLOUS ASCITES (POST-PANCREATECTOMY)

Definition

Leakage of lymph in the peritoneal cavity (Fig. 14.11).

Fig. 14.11: Chylous ascites

(390)


Pathogenesis

Due to extensive retroperitoneal lymph node dissectionand injury to main lymphatic channels.

Day of Occurrence



• Yellowish serous or milky discharge (chyle) throughthe intra-abdominal drain

• Amounts to several liters of fluid daily.

Investigations

CT is useful in diagnosing localized collections.

Management

• Ligation of main lymphatic channel may be required ifit does not resolve in a few weeks

• TPN may be required to maintain good nutritionalstatus.

(391)


MARGINAL ULCERATIONS

Definition

Ulceration on the anastomotic margin.

Pathogenesis

• Non-performance of vagotomy• Ulcerogenic potential of pancreatectomy.

Day of Occurrence

After 2 weeks.


• Upper abdominal discomfort• Pain abdomen• Hematemesis and melena.

Investigation

Upper GI endoscopy (Fig. 14.12) is diagnostic.

(392)


Management

Proton pump inhibitors.

Fig. 14.12: Endoscopy — Anastomotic ulcer

(393)


OBSTRUCTIVE JAUNDICE (POST AND WHIPPLE’SOPERATION)

Definition

Jaundice due to obstruction in the biliary drainage.

Pathogenesis

• Benign– Stricture of biliary enteric anastomosis

• Malignant– Local recurrence at mesenteric root– Recurrence of malignancy at hilum of liver.

Day of Occurrence

12 weeks after surgery.


Yellowish discoloration of urine, sclera (Fig. 14.13) and skin.

Investigations

• Serum bilirubin levels are high• MRCP will localize the level of obstruction• CT will localize the cause of obstruction.

(394)


Management

Surgical

• Percutaneous transhepatic drainage and stenting oftumors at hilum of liver

• Second Roux-en-Y reconstruction may relieve jaundice.

Fig. 14.13: Jaundice

(395)


ENDOCRINE AND EXOCRINE INSUFFICIENCY

DefinitionDeficiency of endocrine and exocrine components ofpancreatic secretions.


• Removal of endocrine and exocrine tissues as part ofpancreatic resection

• Fibrosis of pancreatic remnant leading to loss of isletcell tissue

• Stenosis at pancreaticojejunostomy site.

Day of Occurrence

18 months after surgery.

Clinical PresentationSevere wasting.

Investigations• Determination of blood sugar levels (endocrine

deficiency)• Determination of enzyme levels in blood and feces

(exocrine deficiency).

(396)


ManagementMedical• Replacement of insulin• Administration of enzymes rich in lipase, fat-soluble

vitamins, calcium and trace elements.

Fig. 14.14: Endocrine and exocrine deficiency — Pathogenesis

(398)


HISTORY

• 1549 – First recorded splenectomy by Adriano Zacarello• 1590 – First successful partial splenectomy by Franciscus

Rosetti• 1678 – Partial splenectomy for trauma by Nicolaus

Matthias• 1816 – First splenectomy for trauma by O’Brien• 1895 – First successful repair of lacerated spleen by

Zikoff• 1962 – First successful partial splenectomy for trauma

in modern times by Campos Christo• 1991 – Delaitre (France), Carroll (US), Cushieri (UK) (Fig.

15.1) published reports on laparoscopic splenectomy.

Fig. 15.1: Alfred Cuschieri

(399)

CHAPTER 15: SURGERY OF SPLEEN

VARIETIES OF OPERATIONS OF SPLEEN

Varieties of operations of spleen (Fig. 15.2) are:• Splenectomy• Partial splenectomy• Splenorrhaphy and autotransplantation.

Fig. 15.2: Varieties of operations of spleen

(400)


INDICATIONS

• Trauma (Fig. 15.3A)– Spontaneous rupture– Physical trauma

• Disorders of hemopoietic system– Idiopathic thrombocytic purpura

• Disorders of lymphoreticular system– Large spleen in lymphoma (Fig. 15.3B)

Fig. 15.3A: CT — Splenic injury with lower rib fracture

(401)


Fig. 15.3B: CT — Gross splenomegaly in non-Hodgkin's lymphoma

– Large spleen of hypersplenism• Adjunct procedures

– Extension of malignancy of stomach– A part of upper partial or total gastrectomy

• Splenic abscess (Fig. 15.3C).

(402)


Fig. 15.3C: CT — Splenic abscesses

(403)


INCISIONS

Incisions for splenectomy (Fig. 15.4) are:• Upper midline (1)• Left upper paramedian (2)• Left subcostal (3)• Left hockey-stick (4).

Fig. 15.4: Incisions

(404)


SURGICAL TECHNIQUESurgical technique of splenectomy (Fig. 15.5) are:• Division of ligamentous attachment (1)

– Splenophrenic ligament– Splenocolic ligament– Splenorenal ligament

• Division of vessels– Transection of short gastric vessels (2)– Ligation and division of splenic artery (3)– Ligation and division of splenic vein (4)

• Removal of spleen.

Fig. 15.5: Surgical technique of splenectomy

(405)


POST-SPLENECTOMY BLEEDING

Definition

Bleeding from the operative field (Fig. 15.6).

Fig. 15.6: Bleeding

(406)


Pathogenesis

Slippage of ligature of short gastric vessels.

Day of Occurrence

2nd to 5th postoperative days.


Bleeding from the drain in the left subphrenic space.

Investigations

Hematocrit values may fall.

Management

Medical

• Blood transfusion.

Surgical

• Exploratory laparotomy and ligation of bleedingvessels.

(407)


THROMBOCYTOSIS

Definition

Increase in platelet count.

Pathogenesis

• Elimination of splenic sequestration• Removal of regulatory humoral factor produced by

spleen• Persistent anemia• Altered platelet function.

Day of Occurrence



• Episodes of upper gastrointestinal bleeding(without encephalopathy and ascites).

Investigations

• Platelet count raised above 4,00,000/cmm (Fig. 15.7)• Liver function tests remain normal.

(408)


Management

• Good hydration• Antiplatelet drugs (acetyl salicylic acid, dipyridamole).

Fig. 15.7: Thrombocytosis

(409)


THROMBOSIS OF SPLENIC AND PORTAL VEINS

Definition

Thrombosis of splenic and portal veins (Fig. 15.8).

Fig. 15.8: Thrombosis of portal and splenic veins

(410)


Pathogenesis

• Combined effect of hypercoagulable state and stasis ofblood in splenic vein stump

• Aberrant coagulation originating in the splenic veinstump and progressing into portal vein.

Day of Occurrence



• Episodes of upper gastrointestinal bleeding(without encephalopathy and ascites).

Investigations• Ultrasonography and contrast enhanced CT of portal

vein and splenic vein• Venous phase of visceral angiography.

Management• Urgent treatment with thrombolytic agents like

heparin, intravenous antibiotics, followed byanticoagulation

• Bowel resection may be needed for bowel infarctionand ischemia.

(411)


FULMINANT SEPSIS

Definition

High grade Gram-negative infection after splenectomy.

Pathogenesis

• Lack of splenic macrophages to clear opsonisedmicroorganisms

• Lack of type-specific antibodies.

Day of Occurrence



• High grade pyrexia of abrupt onset (Fig. 15.9)• Rapid deterioratory course• Cardiovascular collapse.

Investigations

• Leucocytosis• Isolation of organism in blood by culture.

(412)


Management

Intravenous antibiotics.

Fig. 15.9: Post-splenectomy fulminant sepsis—Temperature chart

A

Abdominoperineal resection 281incision 285indication 284surgical technique 286

Achalasia 13clinical presentation 13investigations 13management 14pathogenesis 13

Acute afferent loop obstruction 75clinical presentation 75investigations 77management 78pathogenesis 75

Adhesion 159clinical presentation 160investigations 160management 160pathogenesis 159

Adhesions after colonic surgery247

clinical presentation 248investigations 248pathogenesis 247

Alkaline reflux gastritis 89clinical presentation 89investigations 89management 91pathogenesis 89

Anastomotic leak(postesophagectomy) 29

clinical presentation 29investigations 29management 30pathogenesis 29

Anastomotic leakage (intestinalanastomosis) 151


Anastomotic leakage after colonicsurgery 243


Anastomotic stricture 157clinical presentation 158investigations 158management 158pathogenesis 158

Index

(414)


Anemia 104clinical presentation 104investigations 104management 104pathogenesis 104

Anterior resection 301history 302incisions 304indications 303surgical technique 305

Appendicectomy 207incisions 211indications 209investigations 248surgical technique 212

B

Benign CBD stricture 361clinical presentation 361investigations 361management 363pathogenesis 361

Bile collection (bileoma) 348clinical presentation 348investigations 348management 349pathogenesis 348prevention 349

Biliary enteric fistula 364clinical presentation 364investigations 364

management 365pathogenesis 364

Biliary leak 383clinical presentation 384investigations 385management 385pathogenesis 383

Biliary peritonitis 344clinical presentation 345investigations 345management 345pathogenesis 345prevention 345

C

Chronic afferent loop obstruction124


Chronic efferent loop obstruction126


Chronic gastric atony 106clinical presentation 106investigations 106management 107

(415)

INDEX

medical 107surgical 107

pathogenesis 106Chylous ascites 389


Colostomy 255surgical procedure 260types 257

Colostomy perforation 278clinical presentation 279investigations 279management 279pathogenesis 278

Cystic duct stone 356clinical presentation 357investigations 357management 357pathogenesis 357

D

Delayed gastric emptying 381clinical presentation 381investigations 381management 382pathogenesis 381

Delayed intragastric hemorrhage(post-gastrectomy) 53

clinical presentation 53

investigations 53management 53pathogenesis 53

Duodenal stump leak 60clinical presentation 60investigations 60management 61pathogenesis 60signs 60

Dysphagia 31clinical presentation 31investigations 31management 32pathogenesis 31

Dystony of gallbladder andcholelithiasis 19


E

Early dumping syndrome 92clinical presentation 92investigations 93management 93pathogenesis 92

Early intragastric hemorrhage(post-gastrectomy) 51

clinical presentation 51investigations 51

(416)



Efferent loop obstruction 80clinical presentation 80investigations 80management 81pathogenesis 80

Endocrine and exocrineinsufficiency 395


Esophageal resection 21indications 26reconstructions after resections

25surgical technique 27

abdominal dissection 27cervical dissection 28reconstruction 28

Excessive length of ileostomystoma 198


Excoriation and infection aroundgastrostomy stoma 135


External biliary fistula 352clinical presentation 352investigations 352management 354pathogenesis 352

External colonic fistulae 251clinical presentation 251investigations 252management 253pathogenesis 251

External fistulae 163clinical presentation 163investigations 164management 164pathogenesis 163

External urinary fistulae aftercolonic surgery 249


Extragastric hemorrhage 379clinical presentation 380investigations 380management 380pathogenesis 380

Extragastric hemorrhage (post-gastrectomy) 57


(417)

INDEX

F

Fulminant sepsis 411clinical presentation 411investigations 411management 412pathogenesis 411

G

Gastrectomy and gastrostomy 39incisions 46indications 44reconstruction after

gastrectomies 49surgical technique 47varieties of surgeries of stomach

and duodenum 41Gastric remnant carcinoma 117


Gastric remnant necrosis 68clinical presentation 68clinical presentation 73investigations 68investigations 73management 74pathogenesis 73stomal obstruction 72

Gastric stasis and bezoar formation108


Gastroduodenostomy 62clinical presentation 62investigations 62management 62pathogenesis 62

Gastrointestinal hemorrhage 377clinical presentation 378investigations 378management 378pathogenesis 378

Gastrointestinal staplers 1intraluminal staplers 2linear cutter 4linear staplers 3

Gastrojejunocolic fistula 121clinical presentation 122investigations 122management 122pathogenesis 121

Gastrojejunostomy leak 64clinical presentation 64investigations 64management 64pathogenesis 64

(418)


H

Hematoma 346clinical presentation 347management 347pathogenesis 347prevention 347

Hemorrhage (intestinalanastomosis) 153

clinical presentation 154investigations 154management 154pathogenesis 154reason 154

Hemorrhage and shock after APresection 288


Hemorrhage from appendicularstump 214


Hemorrhage from ileostomy 177clinical presentation 178investigations 178management 178pathogenesis 178

Hernia (post-appendicectomy 224clinical presentation 224investigations 224management 225pathogenesis 224

Hoarseness of voice 33clinical presentation 33investigations 33management 33pathogenesis 33

Hyperbilirubinemia 322clinical presentation 322investigations 322management 323pathogenesis 322

I

Ileostomy 171history 172indications 174

end ileostomy 174loop end ileostomy 175loop ileostomy 175

surgical procedure 176types 173

Ileotomy fistula 202clinical presentation 202investigations 202management 202pathogenesis 202

(419)

INDEX

Ileostomy obstruction 186clinical presentation 186investigations 186management 187pathogenesis 186

Inadvertent gastroileostomy 87clinical presentation 88investigations 88management 88pathogenesis 87

Infection of perineal wound afterAP resection 292

clinical presentation 292investigation 292management 292pathogenesis 292

Internal fistulae 161clinical presentation 162investigations 162management 162pathogenesis 162

Internal hernia 128clinical presentation 129investigations 129management 129pathogenesis 128

Internal herniation 298clinical presentation 299investigations 299management 299pathogenesis 298

Intestinal obstruction 226clinical presentation 226investigations 226


Intra-abdominal abscess 155clinical presentation 156investigations 156management 156pathogenesis 155

Intra-abdominal abscess 83clinical presentation 83investigations 83management 83pathogenesis 83

Intraperitoneal leak aftergastrostomy 133


JJejunogastric intussusception 130


KKocher’s incision 339

LLarge bowel resection 229

incisions 238

(420)


indications 234surgical technique 239

Late dumping 100clinical presentation 100management 101pathogenesis 100

Loss of viability of colostomy 262clinical presentation 262investigations 262management 263pathogenesis 262

M

Marginal ulcerations 391clinical presentation 391investigation 391management 392pathogenesis 391

Mucosal slough of ileostomy 179clinical presentation 180investigations 180management 180pathogenesis 180

N

Necrosis of lesser curve 11clinical presentation 11investigation 11management 12pathogenesis 11

Nutritional deficiencies 166clinical presentation 167investigations 167management 167pathogenesis 166

O

Obstructive jaundice 393clinical presentation 393investigations 393management 394pathogenesis 393

P

Pancreatic leak 386clinical presentation 387investigations 387management 387pathogenesis 387

Paracolostomy hernia 276clinical presentation 276investigations 276management 276pathogenesis 276

Paraileostomy granuloma 204clinical presentation 205investigations 205management 205pathogenesis 205

(421)

INDEX

Paralytic ileus 216clinical presentation 216investigations 216management 217pathogenesis 216

Parastomal abscess 200clinical presentation 201investigations 201management 201pathogenesis 201

Parastomal hernia 195clinical presentation 196investigations 196management 196pathogenesis 195

Parastomal skin irritation 182clinical presentation 183investigations 183management 183pathogenesis 183

Pelvic/paracolic abscess 220investigations 220clinical presentation 220management 221pathogenesis 220

Pericolostomy skin damage 264clinical presentation 264investigations 264management 264pathogenesis 264

Persistent bile leakage/biliaryfistula 324


Persistent dysphagia 36clinical presentation 36investigations 36management 37pathogenesis 36

Postoperative pancreatiis 85clinical presentation 85investigations 85management 86pathogenesis 85

Post-splenectomy bleeding 405clinical presentation 406investigations 406management 406pathogenesis 406

Post-vagotomy diarrhea 15clinical presentation 16investigations 16management 16pathogenesis 15

Prolapse of colostomy 273clinical presentation 274investigations 274management 274pathogenesis 274

Prolapse of ileostomy 193clinical presentation 194investigations 194

(422)



Pyloroplasty leak 66pathogenesis 67clinical presentation 67investigations 67management 67

R

Recession of ileostomy 191pathogenesis 191clinical presentation 192investigations 192management 192

Recurrence of malignancy 331pathogenesis 331clinical presentation 332investigations 332management 332

Recurrent ulcer 119pathogenesis 119clinical presentation 119investigations 119management 119

Reflux esophagitis and stricture17

pathogenesis 17clinical presentation 17investigations 17management 18

Retained CBD stones 358pathogenesis 358

clinical presentation 358investigations 358management 359

Roux stasis syndrome 114pathogenesis 114clinical presentation 114investigations 115management 115

Rupture of pelvic peritoneum 290pathogenesis 290clinical presentation 291investigations 291management 291

Rupture of stump andappendicocutaneous 222


S

Separation of colostomy 266pathogenesis 266clinical presentation 267investigations 267treatment 267

Short bowel syndrome 168pathogenesis 168clinical presentation 168investigations 168management 169

(423)

INDEX

Small bowel resection 137indications 139incisions 140varieties 140types of small bowelanastomosis 142end-to-end anastomosis 145end-to-side anastomosis 147side-to-side anastomosis 149

Small gastric remnant syndrome111


Stenosis of colostomy 270pathogenesis 270clinical presentation 270investigations 270management 272

Stenosis of ileostomy 188pathogenesis 189clinical presentation 189investigations 189management 189

Stenosis of perineal scar after APresection 294


Stricture and retraction ofcolostomy 268


Stricture of bile ducts 328reason 328

clinical presentation 328investigations 328management 330

Subhepatic abscess 350pathogenesis 351clinical presentation 351investigations 351management 351prevention 351

Subphrenic abscess 326pathogenesis 326clinical presentation 327investigations 327management 327

medical 327surgical 327

Surgery of gallbladder 333history 334indications for

cholecystectomy 335surgical technique 338open cholecystectomy 338surgical procedure 340

laparoscopiccholecystectomy 341

Surgery of liver 311history 312

(424)


varieties of hepatic resections313

indications 315incisions 317surgical technique 318

principles 318steps 319

Surgery of pancreas 367history 368varieties of pancreaticresections 369

indications 371incisions 374

Surgery of spleen 397history 398varieties of operations 399

indications 400incisions 403surgical technique 404

TThrombocytosis 407

pathogenesis 407clinical presentation 407investigation 407management 408

Thrombosis of splenic and portalveins 409

pathogenesis 410clinical presentation 410investigations 410investigations 410management 410

V

Vagotomy 5varieties 7

truncal vagotomy 7selective vagotomy 7highly selective vagotomy

7indications 8incision 9surgical technique 10

W

Weight loss (post-gastrectomy)102


Whipple’s operation 375Wound infection after

appendicectomy 218pathogenesis 218clinical presentation 218investigations 218management 219

Wound infection after colonicsurgery 241

pathogenesis 241clinical presentation 241relevant investigation 241management 242

Health & Medicine

Jaypee gold standard mini atlas series gastrointestinal surgery