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

Ileocecal junction

Mesoappendix

Mesoappendix divided and appendiceal artery ligated

Appendix

A B

FIGURE 38–5

Ligature tied and

appendix divided

at its base Appendiceal stump invaginated and purse-string suture tied

Purse-string suture in cecum

A B

FIGURE 38–6

4 1 0 S E C T I O N I V • T H E A B D O M E N

STEP 4: POSTOPERATIVE CARE

Dietary resumption may begin immediately in the case of acute appendicitis, but if free purulence was found at operation, postoperative ileus mandates awaiting the return of bowel function.

Postoperative antibiotics are not necessary in acute appendicitis but should be continued in the presence of intra-abdominal purulence.

STEP 5: PEARLS AND PITFALLS

Placement of the skin incision slightly cephalad to the anticipated position of the appendix in its anatomic position will allow easier manipulation of the cecum, once brought out of the RLQ wound.

Despite preoperative evaluation, a missed diagnosis (normal appendix at exploration) should include a search for the underlying pathologic condition, including perforated duodenal ulcer, pancreatitis, urinary tract infections or calculi, gynecologic pathologic findings, or Meckel’s diverticulum.

SELECTED REFERENCES

1. Silen W, Cope Z: Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. New York, Oxford University Press, 2005, pp 67-83.

2. Lally KP, Cox CS Jr, Andrassy R: The appendix. In Townsend CM, Beauchamp RD, Evers BM, Mattox KL (eds): Sabiston Textbook of Surgery, 17th ed. Philadelphia, Saunders, 2004, pp 1381-1399.

C H A P T E R 39

INTUSSUSCEPTION

Dai H. Chung

STEP 1: SURGICAL ANATOMY

Intussusceptions in infants and toddlers occur as a result of invagination of proximal bowel (intussusceptum) into the lumen of the distal bowel (intussuscipiens). It typically involves the ileocolic region of the intestine with variable degree of colonic involvement. The leading point of the intussusception is typically a Peyer’s patch in the terminal ileum. Occasionally, Meckel’s diverticulum may be the leading point of the intussusception.

STEP 2: PREOPERATIVE CONSIDERATIONS

Sudden, intermittent, colicky, severe abdominal pain associated with calm, asymptomatic periods in a toddler is characteristic. It is commonly associated with a history of preceding upper respiratory tract infections. A jelly stool is another characteristic of this condition.

Abdominal radiographs may demonstrate paucity of bowel gas in the right lower quadrant along with soft tissue mass in the upper abdomen representing an intussusceptum.

When the diagnosis is suspected, hydration status along with presence of acute abdomen (peritonitis, perforation, or obstruction) should be assessed. Ultrasound examination can identify the presence of an intussusception.

Contrast (or air) enema study can confirm diagnosis and also potentially be therapeutic. Hydrostatic or pneumatic reduction of intussusception is successful in approximately 60% to 95% of cases. A history longer than 24 hours or radiologic evidence of bowel obstruction significantly reduces the likelihood of successful reduction by enema.

Contrast is instilled through a catheter from a reservoir 100 cm above the patient. Air is delivered at 80 to 150 mm Hg. The criterion for successful reduction is reflux of contrast or air into the terminal ileum.

After a successful reduction, the child is observed overnight to ensure complete resolution of symptoms and absence of recurrence.

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4 1 4 S E C T I O N I V • TH E A B D O M E N

Standard appendectomy should be performed if the adjacent cecal wall is normal (Figure 39-4). In general, inversion appendectomy is not recommended.

3. CLOSING

Once reduction is achieved or resection performed (if required) and hemostasis is ensured, abdominal fascia closure is performed in layers using 3-0 absorbable sutures in continuous manner.

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

A

Appendix cut anterior to purse string and posterior to clamp

B

Appendectomy complete

FIGURE 39–4

STEP 4: POSTOPERATIVE CARE

Nasogastric tube decompression is necessary if there were symptoms of bowel obstruction preoperatively.

The patient may be started on an oral clear liquid diet with return of bowel function and gradually advanced to regular diet.

Two postoperative doses of an intravenous antibiotic are administered.

STEP 5: PEARLS AND PITFALLS

Recognition of acute abdomen is critical to prompt surgical management and to avoid unsafe delays and risks to patients with attempts of enema reduction.

Intussusception should be reduced by pushing the involved bowel retrogradely, with only gentle pull if necessary.

SELECTED REFERENCES

1. DiFiore JW: Intussusception. Semin Pediatr Surg 1999;8:214-220.

2. Shehata S, El Kholi N, Sultan A, El Sahwi E: Hydrostatic reduction of intussusception: Barium, air or saline. Pediatr Surg Int 2000;16:380-382.

C H A P T E R 40

CORRECTION OF MALROTATION

WITH MIDGUT VOLVULUS

Carlos A. Angel

STEP 1: SURGICAL ANATOMY

In patients without malrotation, a broad mesentery and attachments at the cecum and ascending and descending colon prevent volvulation of the small bowel around the superior mesenteric vessels (Figure 40-1). Incomplete rotation of the intestine during fetal development results in lack of these attachments, a very narrow mesentery, and peritoneal bands (Ladd’s bands) that place the cecum close to the duodenum. This incomplete rotation may cause obstruction in the second or third portions of the duodenum (Figure 40-2). The absence of peritoneal attachments, in combination with a narrow mesentery and a relatively fixed point to the duodenocecal area, creates the conditions in which the midgut can volvulate (in clockwise fashion) around the superior mesenteric vessels (Figure 40-3). Although most patients present in the neonatal period or in the first year of life with bilious vomiting, this condition may remain asymptomatic until adulthood.

STEP 2: PREOPERATIVE CONSIDERATIONS

In children younger than 1 year of age, however, bilious vomiting must be considered due to malrotation until proven otherwise. The diagnosis is confirmed by upper gastrointestinal series, barium enema, or sonography. Once this condition is diagnosed, surgical correction should always be treated as an emergency.

In the presence of midgut volvulus, time is of the essence. Vigorous intravenous resuscitation and broad-spectrum antibiotics are initiated. The stomach is decompressed with an orogastric tube, and a urinary catheter is placed to measure urine output. The operation should not be delayed in an attempt to correct metabolic imbalances, because this is usually futile until the volvulus is managed.

After thorough gastric suctioning, general endotracheal anesthesia is induced with the patient supine. The abdomen is prepped with povidone-iodine (Betadine) solution.

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