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

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3. CLOSING

The incision is closed in layers with running 5-0 polyglactin sutures on tapered needles. These layers include the peritoneum and posterior rectus fascia, anterior rectus fascia, Scarpa’s fascia, and subcutaneous tissue. The skin is infiltrated with 0.25% bupivacaine without epinephrine and closed with a running 6-0 subcuticular absorbable undyed monofilament suture and adhesive strips.

STEP 4: POSTOPERATIVE CARE

Continued monitoring in an intensive care setting and administering intravenous fluids, antibiotics, and analgesics are mandatory during the initial postoperative period. Prolonged ileus or short bowel syndrome may require total parenteral nutrition. The incidence of recurrent volvulus is less than 10%. Ladd’s procedure creates enough adhesions, broadens the mesentery, and eliminates the fixed point resulting from bands between the duodenum and cecum so that recurrence of midgut volvulus is unlikely and seldom reported. The risk of small bowel obstruction is not higher than that of any other open abdominal operations. Wound infections or dehiscence are rare in cases in which no intestinal resections are performed. Massive loss of bowel may lead to sepsis, septic shock, and death. In survivors, short bowel syndrome results in dependency on total parenteral nutrition and ultimately in small bowel or multiorgan transplantation.

STEP 5: PEARLS AND PITFALLS

Great attention must be paid at the time of replacing the small bowel in the intestinal cavity. It is very easy to kink or twist the intestinal blood supply, and any signs of venous congestion or intestinal ischemia should prompt the surgeon to immediately exteriorize the bowel, correct any twists or kinks of the mesentery, and resume the process of placing the intestines in order back into the intestinal cavity.

SELECTED REFERENCES

1. Spitz L: Malrotation. In Spitz L, Coran AG (eds): Rob and Smith’s Operative Surgery (Pediatric Surgery), 5th ed. London, Chapman & Hall, 1995, pp 341-347.

2. Ashcraft K: Atlas of Pediatric Surgery. Philadelphia, Saunders, 1994, pp 97-101.

A first-generation cephalosporin should be used for antibiotic prophylaxis, unless the patient is taking therapeutic antibiotics for acute cholecystitis. Clindamycin can be used if the patient has a penicillin allergy.

2. OPERATING ROOM SETUP

The patient is placed supine on the operating room table. Both arms can be out to the side, or the left arm can be tucked.

The surgeon stands on the patient’s left side, and the first assistant stands on the patient’s right side. If a second assistant is available to hold the camera, he or she stands on the patient’s left side below the surgeon.

The video monitors are arranged at the head of the bed on the right and left sides, such that the surgeons and assistants can comfortably view the monitor across from them without having to turn around.

A fluoroscopy table or table with x-ray capability is needed for possible intraoperative cholangiography.

For open cholecystectomy, the patient is supine with both arms extended.

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STEP 3: OPERATIVE STEPS

LAPAROSCOPIC CHOLECYSTECTOMY

1.INCISION/PORT PLACEMENT

The first port is placed in the supraumbilical position. An 11-mm port is used (Figure 41-1).

Access to the abdominal cavity can be performed using an open (Hasson) or closed (Veress needle) technique.

For either technique, the supraumbilical area is anesthetized with local anesthetic. A transverse supraumbilical incision is made using a scalpel.

For the open technique, electrocautery is used to dissect down to the fascia. The fascia is secured with 0 Vicryl sutures, and the peritoneal cavity is opened under direct vision. The trocar is placed directly into the peritoneal cavity and secured with the 0 Vicryl sutures on each side.

For the closed technique, the Veress needle is inserted blindly into the abdominal cavity after skin incision.

The surgeons should observe free flow of fluid into the needle to confirm intraperitoneal positioning.

The initial pressure should be low ( 3 mm Hg), confirming intraperitoneal placement. The abdomen is then insufflated to 15 mm Hg.

The 11-mm trocar can then be placed under direct vision using a zero-degree laparoscope and an optical port.

After initial port placement, a 30-degree or zero-degree laparoscope can be used. The 30-degree scope can facilitate difficult views but requires a more experienced assistant.

A 5-mm port is then placed in the right anterior axillary line along the costal margin, between the 12th rib and the iliac crest (see Figure 41-1).

A second 5-mm port is placed in the midclavicular line. Both of the 5-mm ports should be 2 fingerbreadths below the right costal margin and should be 7 to 10 cm apart (see Figure 41-1).

The final port is placed in the epigastric region (see Figure 41-1). This port should be placed last and should be positioned after the gallbladder is retracted superiorly (Figure 41-2). This allows the surgeon to place the port in a direct line to the infundibulum. This provides a good line for clip placement and avoids unnecessary torque on the instruments.

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2. DISSECTION

The patient can be placed in reverse Trendelenburg position to allow the duodenum, stomach, and other intra-abdominal contents to fall away from the dissection field.

A 5-mm locking grasper is placed through the most lateral port, and the gallbladder is retracted cephalad, toward the patient’s right shoulder (see Figure 41-2).

A second grasper is placed through the medial 5-mm port and used to retract the infundibulum of the gallbladder laterally (to the patient’s right side) and inferiorly, opening up the triangle of Calot (bounded by the cystic duct, the common hepatic duct, and the liver edge) and better exposing the cystic structures (see Figure 41-2). This can be done by the first assistant or by the operating surgeon.

Using a Maryland dissector through the epigastric port, any adhesions between the gallbladder and the omentum, hepatic flexure, stomach, and duodenum are taken down by grasping them close to the gallbladder and peeling them down along the axis of the cystic duct.

The dissection of the triangle of Calot is best performed laterally to medially, first exposing the infundibulum–cystic duct junction on the patient’s right side, then medially. The cystic duct is circumferentially dissected (see Figure 41-2).

The cystic artery, which is usually medial and superior with the infundibulum retracted laterally, is then dissected circumferentially in similar fashion using the Maryland dissector (see Figure 41-2).

No structure should be divided until the cystic duct is identified at the cystic duct– infundibulum junction and the cystic artery has been identified and dissected free.

At this point, cholangiography can be performed if indicated. Figure 41-3 demonstrates the placement of a Kumar clamp through the 5-mm port. This clamp is placed entirely across the cystic duct, occluding it and preventing flow of the contrast back into the gallbladder. A cholangiocatheter with a needle tip is then placed through the clamp and into the cystic duct distally. Contrast is injected, and a cholangiogram can be obtained to evaluate the biliary anatomy and rule out any retained stones in the common bile duct.

The cystic duct can now be ligated with clips applied with a 10-mm clip applier through the epigastric port. Two clips should be placed distally and one proximally on the duct

(Figure 41-4).

A curved or hook scissors is then used to divide between the most proximal and the two distal clips (Figure 41-5).

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The cystic artery is then clipped in similar fashion (see Figure 41-5) and divided with the scissors, leaving two clips on the distal, retained stump.

The gallbladder is then dissected out of the gallbladder fossa using electrocautery (Figure 41-6). The hook cautery is shown here, but the dissection can also be performed with a spatula, the Maryland dissector, or the scissors. This dissection is performed from the infundibulum to the fundus. The graspers in the two 5-mm ports are used to provide traction on the gallbladder, exposing the dissection plane between the gallbladder and the liver.

Before completely removing the gallbladder from the liver bed, the surgeon can use the gallbladder to retract the liver while inspecting the cystic artery and duct stumps for any signs of bleeding or bile leakage. Any bleeding from the liver bed should also be controlled at this time.

After removal of the gallbladder, the camera is placed through the epigastric port. A retrieval bag is placed through the umbilical port (Figure 41-7). Removal with a retrieval bag is recommended especially if there is spillage of bile or gallstones.

The gallbladder is placed in the retrieval bag (see Figure 41-7) and removed through the umbilical port. The camera can then be replaced and the camera returned to the umbilical port.

The patient is returned to a flat, supine position. The field is then irrigated to ensure no bleeding or bile leakage.

3. CLOSING

The ports are removed under direct vision to make sure there is no bleeding from the port sites.

The fascia at the two 11-mm ports is usually closed with interrupted 0 Vicryl suture, which can be placed using conventional methods or the laparoscopic suture passer. The fascia

at the 5-mm ports does not require closure.

The skin is then closed with absorbable subcuticular sutures.