Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Once all of the sutures are in place, the excess tubing is fed through the fascial opening and into the peritoneal cavity. The port is rested on the fascial surface, and the sutures are tied

(Figure 35-9).

3. CLOSURE

The wounds are inspected for hemostasis. A subcuticular closure with absorbable suture is preferred. The wounds are dressed with tissue adhesives or wound approximation tapes and small bandages.

STEP 4: POSTOPERATIVE CONSIDERATIONS

A low-potency oral narcotic combination elixir, such as acetaminophen with codeine or hydrocodone/acetaminophen, is usually sufficient for pain management.

Nausea is a common postoperative complaint that should be effectively managed to avoid retching and possible displacement of the band.

Connection

Tubing brought

out of 15-mm port site

Anterior rectus sheath

Port

Skin

A

Port secured to rectus sheath

B

FIGURE 35–9

Patients are offered sugar-free, carbonation-free clear liquids when awake. Advancing the diet to pureed foods is determined by patient progress, but no solid foods are offered for 4 postoperative weeks.

A barium swallow is used to check band position and patency before discharge. It is also helpful to have this early postoperative study for comparison and troubleshooting of problems in the future.

Most patients are observed in the hospital overnight, but outpatient band surgery is becoming more common recently, and is likely to be the most common postoperative management strategy soon.

A dedicated postoperative adjustment and follow-up schedule must be provided to achieve even reasonable results with gastric banding. Weight loss approaches that seen after gastric bypass when patients have access to band adjustments on short notice. The first adjustment is not offered until 6 weeks after the operation.

STEP 5: PEARLS AND PITFALLS

Failure to repair even the smallest hiatal hernia can result in worsening of reflux as the band is inflated, leading to frustrating symptoms and unsatisfactory outcomes.

The position of the bra line and belt line should be kept in mind when selecting the location of the 15-mm trocar to minimize discomfort over the site of the injection port.

The posterior aspect of the distal esophagus and stomach wall are at risk for injury when passing the angled dissector through the retrogastric tunnel. One must be sure no resistance is met when the instrument is inserted and flexed. In addition, there should be no esophageal or gastric tissue when passing the tip of the instrument through the peritoneum at the angle of His. Often the peritoneum overlying the left crus immediately to the left of the angle of His should be bluntly opened before passing the dissector through the pars flaccida window. If this is done, the tip of the dissector will be easily identified.

Once buckled, the band can be quite difficult or impossible to reopen. One should be sure the band is in the appropriate position and will not be too tight before closing it. If the band appears too tight, the underlying fat along the lesser curvature or at the esophagogastric junction may need to be divided with the cautery or ultrasonic shears. Rarely, the band may have to be replaced with a larger size.

Careful needle management and knot tying must be used to avoid sticking any component of the band system. Leaks of the band balloon can be fixed only by replacing the whole system. The needle should remain in view continuously.

C H A P T E R 36

MECKEL’S DIVERTICULECTOMY

Dai H. Chung

STEP 1: SURGICAL ANATOMY

Meckel’s diverticulum is an outpouching in the terminal ileum on the antimesenteric border. It exists in approximately 2% of the population but is largely asymptomatic. The frequent presence of ectopic gastric mucosa contributes to its common clinical presentation of brisk gastrointestinal (GI) hemorrhage.

STEP 2: PREOPERATIVE CONSIDERATIONS

Asymptomatic Meckel’s diverticulum is identified during abdominal cavity operation for other unrelated etiology. In general, resection of asymptomatic Meckel’s diverticulum should be considered carefully based on the patient’s overall condition and initial reasons for laparotomy.

All symptomatic Meckel’s diverticulum should be resected. Massive lower GI tract hemorrhage is its typical presentation, and the diagnosis is determined by scintigraphy with sodium technetium-99m (Tc-99m)-pertechnetate, which localizes ectopic gastric mucosa.

For Meckel’s diverticulitis, its presenting signs and symptoms are generally indistinguishable from acute appendicitis and determined only at operation.

Preoperative prophylactic antibiotic should be administered intravenously 30 minutes before skin incision.

STEP 3: OPERATIVE STEPS

1.INCISION

Patient is positioned supine and the right-sided transverse abdominal skin incision is made slightly inferior to the umbilicus (Figure 36-1).

394

2. DISSECTION

Segmental resection of ileum incorporating the Meckel’s diverticulum is the ideal resection margin, because ectopic mucosa may be present throughout the entire axis of the diverticulum (Figure 36-3). For resection, proximal and distal luminal content flow should be controlled using either gentle placement of bowel clamps or circumferential vessel loops. A stapling device may also be used to perform bowel resection.

Alternatively, wedge resection of the diverticulum is also acceptable, if no abnormal thickening at the base is confirmed. After controlling intraluminal flow, the surgeon resects the diverticulum using a knife or electrocautery (Figure 36-4).

Two-layer anastomosis is preferred using inner running chromic sutures with outer interrupted seromuscular silk stitches (Figure 36-5). For small infants (younger than 6 months), singlelayer anastomosis with full-thickness silk sutures is also acceptable. The mesenteric defect should be closed to prevent potential internal hernia.

For a laparoscopic approach, the tip of the Meckel’s diverticulum is suspended with a grasper, and an ensdoscopic gastrointestinal anastomosis (GIA) stapler is used to transect at its base. Stapling at 90 degrees to the longitudinal axis of the ileum is ideal to avoid narrowing the lumen (Figure 36-6).

3. CLOSING

Once anastomosis is complete and hemostasis is ensured, abdominal fascia closure is performed in layers using absorbable sutures (3-0 polyglycolic) in a continuous manner.

The skin is reapproximated with a subcuticular stitch of 5-0 absorbable Monocryl suture.

STEP 4: POSTOPERATIVE CARE

Nasogastric tube decompression is seldom necessary.

Patient may be started on an oral clear liquid diet on postoperative day 1 and then gradually advanced to regular diet appropriate for age.

Two doses of postoperative intravenous antibiotics are administered.

STEP 5: PEARLS AND PITFALLS

Adequate resection of Meckel’s diverticulum with complete incorporation of any ectopic mucosa is critical to this procedure.

Laparoscopic approach is gaining popularity; however, it is critical to ensure adequate resection margin at the base.

SELECTED REFERENCES

1. Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL: Meckel’s diverticulum. J Am Coll Surg 2001;192:658-662.

2. Cullen JJ, Kelly KA: Current management of Meckel’s diverticulum. Adv Surg 1996;29:207-214.

3. Brown RL, Azizkhan RG: Gastrointestinal bleeding in infants and children: Meckel’s diverticulum and intestinal duplication. Semin Pediatr Surg 1999;8:202-209.

4. Rothenberg SS: Laparoscopic segmental intestinal resection. Semin Pediatr Surg 2002;11:211-216.