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

The spleen contributes to immune competence in a variety of ways, including opsonization and phagocytosis. Asplenic patients are at increased risk of overwhelming postsplenectomy infection from encapsulated bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, and H. influenzae. Following splenectomy patients should be counseled regarding the increased susceptibility to infections and vaccinated against these potential infections with Prevnar, Menactra, and ActHIB before discharge from the hospital.

SELECTED REFERENCES

1. Starnes S, Klein P, Magagna L, Pomerantz R: Computed tomographic grading is useful in the selection of patients for nonoperative management of blunt injury to the spleen. Am Surg 1998;64:743-648;748-749 [discussion].

2. Cocanour CS, Moore FA, Ware DN, et al: Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 1998;133:619-624;624-625 [discussion].

3. Ochsner MG: Factors of failure for nonoperative management of blunt liver and splenic injuries. World J Surg 2001;25:1393-1396.

6 1 4 S E C T I O N I X • C O L O N

STEP 3: OPERATIVE STEPS

1.INCISION

The site of each incision should be preemptively anesthetized with a local anesthetic injection to include the skin and peritoneum.

The incisions should be just large enough to accommodate the trocar without tension on the skin as the trocar is inserted.

2.DISSECTION

Five 10to 12-mm ports are used. One port is near the umbilicus. One port is in each of the abdominal quadrants lateral to the rectus muscles (Figure 53-3).

A 10to 12-mm port is near the umbilicus. A 5- or 10-mm port is in the left lower quadrant. A 10to 12-mm port is in right lower quadrant. A 5- or 10-mm port is in the left upper quadrant (Figure 53-4).

A 10to 12-mm port is near the umbilicus. A 10to 12-mm port is in the right lower quadrant. A 5- or 10-mm port is in the right upper quadrant. A 5- or 10-mm port is in the left lower quadrant (Figure 53-5).

Four 10to 12-mm ports are used. One port is near the umbilicus. One port is in each of the mid-clavicular lines at the level of the umbilicus. One port is in the right mid-clavicular line, 10 to 15 cm inferior to the other (Figure 53-6).

3.CLOSING

Bladeless trocar port sites up to and including 12 mm do not typically need to be closed at the fascial level.

Transabdominal laparoscopic suture passers provide a quick and relatively simple way to close small abdominal fascial incisions, especially through a deep abdominal pannus.

If no suture passer is available, larger port site fascial defects should be closed with transabdominal suture externally after appropriate retraction of the skin and subcutaneous tissue.

6 1 6 S E C T I O N I X • C O L O N

STEP 4: POSTOPERATIVE CONSIDERATIONS

Postoperative care is provided consistent with the primary disease process and extent of the operation.

STEP 5: PEARLS AND PITFALLS

The initial optical entry should be made away from sites expected to have adhesions. In a patient with extensive prior surgical history, the open insertion technique may be preferred.

Each subsequent trocar entry should be made with direct internal visualization, avoiding the epigastric vessels and the large subcutaneous vessels identified by transillumination.

One should not hesitate to use additional trocars if needed to improve exposure and the safety of the operation.

Hand-assisted laparoscopic surgery (HALS) is the approach favored by many. The hand port should be located at the proposed site of specimen extraction.

SELECTED REFERENCES

1. Ludwig KA, Lee WY: Laparoscopic partial colectomy. In Soper NJ, Swanstrom LL, Eubanks WS (eds): Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 436-448.

2. Baig MK, Wexner SD: Laparoscopic-assisted abdominoperineal resection. In Soper NJ, Swanstrom LL, Eubanks WS (eds): Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 449-458.

3.Fowler DL, Sonoda TS, McGinty J: Laparoscopic subtotal and total colectomy. In Soper NJ, Swanstrom LL and Eubanks WS (eds): Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 459-469.

CH A P T E R 54

DIVERTING END COLOSTOMY

WITH MUCOUS FISTULA OR

HARTMANN’S POUCH

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

Normal-appearing colon (usually sigmoid/descending colon) proximal to diseased bowel

STEP 2: PREOPERATIVE CONSIDERATIONS

Indications:

Relief of colonic obstruction

Complete diversion of fecal stream

Anesthesia: general

Position: supine

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