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2
1
Line of
resection
Incision
Obliquely
placed clamps
3
4
8
Posterior
serosal sutures
Testing patency
of stoma
5
6
Posterior
mucosal sutures
Alternate method
Continuous
inversion sutures
9
Anterior
mucosal suture
10
7
Anterior
serosal
sutures
11
Serosal sutures
12
14
Anterior
mucosal suture
15
Posterior
mucosal sutures
Anterior
serosal sutures
13
Enterostomy
clamp
Posterior
serosal sutures
Incision
Anchoring sutures
16
Mesentery
approximated
Stoma
113
PLATE
48
INDICATIONS Various portions of the small intestine are resected for a
variety of reasons. Emergency procedures involving interference with the
blood supply by a strangulated hernia, a volvulus due to a xed adhesion,
mesenteric thrombosis, traumatic injuries, localized tumors, and regional
enteritis are among the indications for small bowel resection. Occasionally it may be judicious to perform an enteroenterostomy in the presence
of many adhesions or extensive regional ileitis in an e ort to avoid further resection of the already shortened small bowel resulting from previous
extensive resections.
PREOPERATIVE PREPARATION e indications for operation control
the time allotted for uid, electrolyte, and blood replacement (see Plate ).
Constant gastric suction is instituted. An inlying catheter for drainage of the
bladder is useful in monitoring the adequacy of urinary output in response
to treatment. When the pulse is elevated and gangrenous intestine is suspected, plasma expanders or red cells may be administered. Intravenous
antibiotics are given, and the patient is aggressively rehydrated using central
venous pressure and urinary output as monitors.
ANESTHESIA e stomach should be on constant gastric suction, and the
suction should be adequate to avoid the danger of aspiration of gastric contents. A cu ed endotracheal tube is advisable to seal o the trachea and
avoid the possibility of aspiration pneumonia.
POSITION e patient is placed in a comfortable position with the oper-
ating table elevated at right angles to the working level of the surgeon. A
modest reverse Trendelenburg position may be helpful in improving subsequent exposure as well as in the retraction of dilated small bowel.
OPERATIVE PREPARATION e skin is prepared in the usual manner.
INCISION AND EXPOSURE e incision is made in the general area of
the suspected lesion. In the trauma patient, a long midline incision ensures
adequate exposure for an extensive exploration. When an incarcerated
hernia is likely to contain gangrenous intestine, some prefer to open the
abdomen with an oblique incision above the groin in order to divide the
viable bowel above the point of incarceration, lessening the chances of gross
contamination when the hernial sac is opened. In the presence of previous
scars, especially in the midline, a new incision may be judiciously made
beyond the end or to one side in order to lessen the chance of injuring the
underlying, probably tightly adherent small intestine.
DETAILS OF PROCEDURE A specimen of abdominal uid is taken for
culture and its color and odor evaluated as predictors of “dead intestine.”
e release of restrictions by adhesions or a hernia sac is the rst priority
in the hope that a return of adequate blood supply will follow. When the
viability of the intestine is questioned, the bowel may be placed in warm,
moist gauze for some minutes. Procaine may be injected carefully into the
mesentery to stimulate visible arterial pulsations. Obviously gangrenous
small bowel should be promptly isolated with towels in order to minimize
infection. In trauma patients, the small as well as the large intestine must
R S I, S
be thoroughly inspected for possible injury, since protruding mucosa may
temporarily block contamination. Injuries to the mesentery with hematoma formation require very careful evaluation. Multiple perforations with
extensive mesenteric injury may make resection of a segment of small bowel
a safer procedure than an attempt at multiple repairs of a segment. e possibility of another intraluminal cause of obstruction mandates evaluation of
the small intestine beyond the point of intussusception or obstruction.
OPEN-LUMEN ANASTOMOSIS OF SMALL INTESTINE Non-crushing
Scudder clamps are applied proximal to the planned point of division of the
small bowel as well as distal to the area to be resected. is prevents gross
contamination of the obstructed bowel while controlling the blood supply.
e specimen is resected (figure 1) a er a thin straight clamp is applied
obliquely to the intestinal wall with a free mesenteric serosal border of cm
or more. is leaves a clear serosal area for the application of the TL with
.-mm staples.
DETAILS OF PROCEDURE e cutting linear stapler (TLC ) can
be used to approximate the open two ends of the divided small bowel
(figure 2). A er the bowel has been divided on the modest oblique plane
with cm of freed mesenteric border, the ends are aligned. is is accomplished by placing traction sutures at the mesenteric and antimesenteric borders (figure 2). e antimesenteric border is approximated, and each of the
cutting linear stapler (TLC ) forks is inserted. e bowel must be aligned
evenly on the forks before the instrument is red (figure 3). e bowel
walls are sewn together with the stapler and the stoma is established by the
cutting knife within the cutting linear stapler (TLC ) (figure 3A). e
stapled suture line is inspected for bleeding, which, if present, is controlled
with interrupted sutures.
Traction sutures (A, A) are placed on the mesenteric border of each
segment, and another is placed centrally (B) to permit traction on the end
of the suture line on the antimesenteric border (figure 4). e common
lumen can be closed with the application of a noncutting linear stapler
(TL ). e excess bowel wall beyond the suturing instrument is excised
(figure 5). Any bleeding points a er the removal of the stapling instrument are controlled with interrupted sutures.
With time and experience, it has been found preferable to close this opening in a vertical manner from B to B, thus approximating A to A. is creates
crossed staples only at the ends (B and B), which are then carefully inspected
for possible suture reinforcement. Again, any bleeding points are controlled
with interrupted sutures. e lines of closure are carefully inspected, and
the excess intestine outside of the staple lines is excised. e security of the
suture line is evaluated, and the antimesenteric border can be approximated
if desired with interrupted sutures for distance of the anastomosis.
e mesentery is completely approximated with interrupted sutures
(figure 6). e approximation may be performed before the anastomosis is
created. e mesentery must be completely approximated to avoid any possibility of later internal herniation of a loop of intestine. e patency of the anastomosis is tested by palpation between the thumb and the index nger. ■
114
115
PLATE
49
ALTERNATIVE METHODS An alternative method of anastomosing the
small intestine that is similar to the preceding open-lumen anastomosis may
be performed a er rst resecting the specimen segment using the cutting
linear stapler (GIA) (figure 1). is prevents gross contamination by clos-
ing all lumens with a row of staples. Assuming the mesenteric mobilization,
ligation, and divisions have been performed, the specimen is removed. e
proximal and distal limbs of remaining bowel are then rotated degrees
in order to align the antimesenteric borders. Traction sutures are placed
near the planned staple line and approximately to cm distally so as to be
beyond the apex of the new anastomosis. A portion of the antimesenteric
border staple line is obliquely excised from each limb so as to create an opening large enough for insertion of the forks of the cutting linear stapler (GIA
) instrument (figure 2). Both forks are inserted fully to maximize the
size of the anastomotic opening. A er assembling the cutting linear stapler
R S I, S
(GIA ) and aligning the antimesenteric septum appropriately using the
distal traction suture, the stapling instrument is discharged (figure 3). e
anastomosis is inspected for bleeding, which, if present, is controlled with
interrupted sutures.
Traction sutures are placed at either end of the new opening, and an
additional one is placed centrally, bringing together the newly created staple lines along the antimesenteric border. e three traction sutures are
brought within the jaws of a noncutting linear stapler (TA or ), which
then closes the common opening (figure 4). e excess tissue is excised
above the stapling instrument and this suture line is inspected for hemostasis. e mesentery is reapproximated with interrupted sutures and the
patency of the anastomosis is tested by palpation (figure 5).
POSTOPERATIVE CARE See Plate . ■
116
117
PLATE
50
INDICATIONS On occasion, an enteroenterostomy may be used to bypass
an obstructed segment of small intestine involved with regional ileitis,
tumor, or extensive adhesions. A great di erence in diameter of the intestine that enters and exits a point of obstruction may make an end-to-end
anastomosis di cult. In some patients, a side-to-side anastomosis can provide relief of the obstruction with minimum risk and without sacri cing
extensive segments of small intestine. In patients who have had previous
small bowel resection or regional ileitis, it may be the procedure of choice
rather than a radical resection leading to further nutritional problems,
despite the risk of subsequent malignancy in the involved area of enteritis.
e enteroenterostomy is also used to reestablish the continuity of the small
intestine a er a variety of Roux-en-Y procedures.
DETAILS OF PROCEDURE e two loops selected for the enteroenteros-
tomy are grasped with Babcock forceps, and noncrushing Scudder clamps
may be applied to control bleeding and limit contamination from the
obstructed intestine (see figure 12, Plate ).
Traction sutures are placed in the antimesenteric border beyond the
ends of the planned anastomosis. Several additional sutures may be placed
and tied to provide stabilization of the two sides in preparation for introduction of the stapler (figure 1).
With the area well walled o with sterile towels, a small stab wound is
made with a number knife blade in the antimesenteric border of each
loop. e opening is made just large enough to admit freely the fork of
the cutting linear stapler (TLC ) instrument. A er both forks have been
introduced, the bowel walls are realigned before the instrument is red.
E, S
e knife in the instrument divides the septum ensuring an adequate stoma
between the two rows of staples (figure 2).
e cutting linear stapler (TLC) instrument is removed and the staple
line is inspected for potential bleeding. Additional sutures may be required
to control any bleeding points. Traction sutures (A,B) are placed through
the ends of both staple lines to approximate the wound edges in an everted
manner, while the stoma is held open (figure 3). e mucosal margins
may be approximated with Babcock forceps, which, along with the angle
retention sutures, ensure a complete inclusion of the bowel walls within the
TL. e stapler is red, and all excess bowel beyond the staples is excised
by cutting along the outside surface of the stapler (figure 4). e new
staple suture line is inspected for hemostasis. Several additional sutures are
placed to secure the angles of the anastomosis (figure 5), while some prefer to place additional sutures inverting the nal external staple line. e
adequacy of the stoma is determined by compressing the opposing intestinal wall between the thumb and index nger.
POSTOPERATIVE CARE Constant gastric suction is maintained. e
indications for the procedure and the amount of blood loss at the time of
operation dictate the need for blood replacement. e type and duration
of antibiotic therapy will be related to the diagnosis and the presence of
contamination at the time of operation. A careful daily check of uid and
electrolyte levels and weight is made. e input and output of the patients
are evaluated daily. While oral liquids may be tolerated, the diet is restricted
until bowel action has resumed. Early ambulation is encouraged and the
patient is alerted to report any abdominal cramps, nausea, or vomiting. ■
118
119
PLATE
51
INDICATIONS Enterostomy in the high jejunum may be utilized for feed-
ing purposes in malnourished patients, either before or a er major surgical
procedures. Enterostomy in the low ileum may be clinically indicated in the
presence of adynamic ileus when intubation and other methods of bowel
decompression have failed to relieve the obstruction or when the patient’s
condition will not permit the removal of the cause. Enterostomy may also
be done to decompress the gastrointestinal tract proximal to the point of
major resection and anastomosis or to decompress the stomach indirectly
a er gastric resection by directing a long tube in a retrograde fashion back
into the stomach. Bile, pancreatic juice, as well as gastric juice lost from
intubation or a stula can be re-fed through the tube. Intravenous hyperalimentation is usually used initially except in the presence of obstruction or
severe and persistent paralytic ileus.
PREOPERATIVE PREPARATION e preoperative preparation is deter-
mined by the underlying conditions found preoperatively. O en an enterostomy is done in conjunction with another major surgical procedure on the
gastrointestinal tract.
POSITION e patient is placed in a comfortable supine position.
OPERATIVE PREPARATION e skin is prepared routinely.
INCISION AND EXPOSURE As a rule, a midline incision is placed close
to the umbilicus. If the enterostomy is performed for adynamic ileus in
the presence of peritonitis, the incision should be so small that few sutures
are necessary in the closure. When the procedure is part of a major intestinal resection or for feeding purposes, the enterostomy tube is brought
out through a stab wound, preferably some distance away from the original
incision. If the enterostomy is primarily for feeding purposes, or for draining the stomach, the incision should be made in the region of the ligament
of Treitz in the le upper quadrant.
E
B. WITZEL ENTEROSTOMY
INDICATIONS e Witzel enterostomy may be preferred when a long-term
need for a small bowel enterostomy is clearly indicated. is procedure provides valvelike protection to the opening into the jejunum.
DETAILS OF PROCEDURE e loop of small bowel selected for t he enteros-
tomy is stripped of its contents and noncrushing clamps may be applied. A
purse-string nonabsorbable suture is placed opposite the mesenteric border at the planned site of entrance (figure 6). A modest-sized so catheter
with several openings is then brought through the abdominal wall placed
on the intestinal wall while interrupted sutures are placed about cm apart,
incorporating a small bite of the intestinal wall on either side of the catheter
(figure 7). When these sutures are tied, the catheter is buried within the
wall of the small intestine for to cm. Following this, an incision is made
into the bowel in the midportion of the purse-string suture, and the end
of the catheter is inserted into the small intestine (figure 8) and threaded
the desired distance into the lumen, a er which the purse-string suture
is tied. e remaining exposed portion of the catheter and the area of
the purse-string suture are further buried with three or four interrupted
nonabsorbable sutures (figure 9). A stab wound is made in the abdom-
inal wall and a clamp inserted as a guide to the placement of sutures between
the small intestine and the peritoneum adjacent to the suture line
(figure 10). A broad-based attachment is desirable to avoid twisting or
angulating the small intestine. A er the rst layer of sutures is tied, the catheter is withdrawn through the stab wound, permitting the anterior layer of
sutures to be placed between the peritoneum and the small intestine, which
completely seals o the area of the catheter. It is advisable to attach the
small intestine to the parietes for to cm in order to avoid volvulus of the
small intestine around a small xed point. e intestine should be anchored
to the peritoneum in the direction of peristalsis.
A. STAMM ENTEROSTOMY
INDICATIONS When used for feeding purposes, either preliminary,
complementary, or supplementary to a major resection, a Stamm enterostomy should be made close to the ligament of Treitz in the jejunum. When
intended to relieve distention in adynamic ileus, the rst presenting dilated
loop may be utilized.
DETAILS OF PROCEDURE In the enterostomy used as a means of feeding,
a loop of jejunum close to the ligament of Treitz is delivered into the wound,
and the proximal and distal ends of the bowel are identi ed. e bowel
is stripped of its contents, and enterostomy clamps are applied. Two concentric purse-string nonabsorbable sutures are taken in the submucosa
of the antimesenteric surface (figure 1). A small stab wound is made
through the intestinal wall in the center of the inner purse-string suture
(figure 2), through which the catheter is slipped into the lumen of the
distal portion of the intestine. e clamps are removed. e inner pursestring suture is tightened about the catheter. e outer purse-string suture
is pulled snug to anchor the catheter to the intestinal wall and serves to
invert a small cu of intestine about the catheter (figure 3).
CLOSURE e proximal end of the catheter is brought out through a
stab wound in the abdominal wall. e intestine adjacent to the catheter is
anchored to the overlying peritoneum with four ne nonabsorbable sutures
(figure 4). e catheter is anchored to the skin with a nonabsorbable
suture (figure 5).
CLOSURE e abdomen is closed routinely. e catheter is anchored to
the skin with a suture and an additional adhesive dressing. Alternatively, a
simpli ed feeding enterostomy may be fashioned using an or French
plastic or Silastic tube introduced through a needle passed through the
abdominal wall some distance from the incision. e needle is tunneled
intramurally through the bowel wall and the catheter directed into the
bowel lumen. It is secured by one or two purse-string sutures about the
entrance site. e bowel about the tubing is anchored to the perineum at its
entry through the abdominal wall, and the adjacent segment of intestine is
sutured to the peritoneum over approximately cm (three or four sutures)
to prevent rotation and possible volvulus.
POSTOPERATIVE CARE When the enterostomy is performed to relieve an
adynamic ileus, the catheter is attached to a drainage bottle and approximately
mL of sterile water or saline may be injected over to hours to ensure
adequate drainage through the tube. If the enterostomy is used for feeding,
the patient’s uid and calorie requirements can be partially met by homogenized milk and glucose in water or saline or with one of the many commercial
enteral feeding mixtures. ese may be started through the enterostomy tube
by continuous gravity drip at the rate of mL per hour. e calorie intake
should be increased slowly because of the common complication of diarrhea
and abdominal discomfort. Enterostomy feedings should not be continued
during the night because of the possibility that distress and/or diarrhea may
develop. e catheter usually is removed within to days unless it is
required for feeding purposes, or if the obstruction has not been relieved, as
proved by recurrent symptoms a er clamping of the catheter. ■
120
1
Stamm Enterostomy
Catheter
5
Proximal
2
3
4
Anchoring to
peritoneum
Sagittal
section
8
Witzel Enterostomy
6
7
Distal
Tunnel
sutures
Purse
string
10
9
Anchoring
sutures
Tunnel closure
over entrance site
121
PLATE
52
P—I
A. PYLOROMYOTOMY
INDICATIONS Pyloromyotomy (the Fredet-Ramstedt operation) is done
in infants with congenital hypertrophic pyloric stenosis.
PREOPERATIVE CARE e correction of dehydration and acid-base imbal-
ance by adequate parenteral uid therapy is as important as surgical skill
in lowering the mortality rate. Although prolonged gastric intubation is to
be avoided, to hours of preparation with intravenous hydration plus
suction may be necessary to restore the baby to good physiologic condition. Oral feedings are discontinued as soon as the diagnosis is made, and an
intravenous infusion is started in a scalp vein. en mL/kg of glucose
in normal saline is administered rapidly. is is followed by a solution of one
part dextrose in normal saline to one part dextrose in water (one half
normal saline with D/W) given at the rate of mL/kg per hours. e
baby should be reevaluated every hours with respect to state of hydration,
weight, and evidence of edema. Ordinarily, this solution is continued for to
hours. A er adequate urinary output is established, potassium should be
added to the intravenous solutions. In the baby who is moderately or severely
dehydrated, it is wise to determine the serum electrolyte values before initiating replacement therapy and to check the values in to hours.
B. INTUSSUSCEPTION
INDICATIONS Intussusception occurs most commonly in infants from the
age of a few months to years. Time must be taken to correct dehydration or
debility by administering parenteral uids. A stomach tube should be passed
to de ate the stomach and to reduce to a minimum the danger of aspirated
vomitus. If the intussusception has been of considerable duration and there
is evidence of bleeding, as in the characteristic mahogany stools in infants,
blood products should be administered with the operating room alerted and
hydration established satisfactory for operation. e child is taken to the x-ray
department, and here hydrostatic reduction by barium enema is attempted,
utilizing a pressure of no more than . As much as hour may be spent in
this procedure as long as manipulation of the abdomen is avoided and the
exposure to uoroscopy limited as much as possible. If the intussusception is
going to reduce, it will progressively do so. If this method fails, surgery follows immediately. If a mass lesion or cancer is suspected in an elderly patient,
then a re-section should be performed rather than a manipulation.
ANESTHESIA Meperidine or morphine should be added in appropriate
doses in older infants and children. Endotracheal intubation on the conscious
infant is the safest anesthetic technique, followed by general anesthesia.
ANESTHESIA Endotracheal intubation on the conscious infant is the saf-
est anesthetic technique, followed by general anesthesia.
POSITION A temperature-controlled blanket is placed under the infant’s
back to help compensate for the loss of body heat and to arch the abdomen
slightly to improve the operative exposure. To prevent heat loss through the
arms and legs, they are wrapped with sheet wadding, and the intravenous
site is carefully protected.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
INCISION AND EXPOSURE A gridiron incision placed below the right
costal margin, but above the inferior edge of the liver, is used. e incision
is cm long and extends laterally from the outer edge of the rectus muscle.
e omentum or the transverse colon usually presents in the wound and is
easily identi ed. By gentle traction on the omentum, the transverse colon
is delivered and, in turn, traction on the transverse colon will deliver the
greater curvature of the stomach easily into the wound. e anterior wall of
the stomach is held with a moistened gauze sponge and, upward traction on
the antral portion of the stomach, the pylorus is delivered into the wound.
DETAILS OF PROCEDURE e anterosuperior surface of the pylorus is not
very vascular and is the region selected for the pyloromyotomy (figure 2).
As the pylorus is held between the surgeon’s thumb and index nger, a longitudinal incision to cm long is made (figure 3). e incision is carried
down through the serosal and muscle coats until the mucosa is exposed,
but the mucosa is le intact (figure 4). Great care must be taken at the
duodenal end of the incision, for here the pyloric muscle ends abruptly,
in contrast with the gastric end, and the mucosa of the duodenum may be
perforated (see danger point) (figure 1). e cut muscle is now spread
apart with a straight or a half-length hemostat until the mucosa pouts up to
the level of the cut serosa (figures 4 and 5). Usually, hemorrhage can be
controlled by applying a sponge wet with saline, and only rarely is a ligature
or stitch necessary to control a bleeding vessel. e surgeon must ascertain
that no perforation of the mucous membrane exists.
CLOSURE e peritoneum and transversalis fascia are closed with a running
suture of chromic. e remaining fascial layers are closed with ne interrupted sutures. e skin margins are approximated with running nylon
sutures or subcuticular absorbable sutures reinforced with skin-adhesive strips.
POSTOPERATIVE CARE Six hours following operation, the suction is dis-
continued and the nasogastric tube removed. At this time, mL of dextrose and water is o ered to the infant. Following this, the infant is o ered
mL of an evaporated milk formula every hours until the morning a er
operation. erea er, the infant is fed progressively more formula on a
-hour schedule.
POSITION e patient is placed in a dorsal recumbent position. Feet and
hands are held at to the operating table by straps or pinned wrappings.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
INCISION AND EXPOSURE In most instances a transverse incision made
in the right lower quadrant provides adequate exposure. e lateral third
of the anterior rectus fascia and the adjacent aponeurosis of the external
oblique are incised transversely. e lateral edge of the rectus muscle may
then be retracted medially and the internal oblique and transversalis muscles divided in the direction of their bers. If more exposure is required, the
incision in the anterior rectus fascia may be extended, and a portion or all
of the right rectus muscle may be transected (figure 6).
DETAILS OF PROCEDURE e major portion of the reduction is done intra-
abdominally by milking the mass back along the descending colon, transverse colon, and ascending colon. When reduction has proceeded thus far, the
remainder can be delivered out of the abdominal cavity. e mass is pushed back
along the descending colon by squeezing the colon distal to the intussusception
(figure 7). If traction is applied, it should be extremely gentle to avoid ruptur-
ing the bowel. e discolored and edematous bowel at rst may not appear to
be viable, but the application of warm saline solution may improve its tone and
appearance. Unless the intestine is necrotic, it is better to persist in attempts at
reduction than to resort to early and unnecessary resection, required in less
than percent of the cases. An etiologic factor, such as an inverted Meckel’s
diverticulum or intestinal polyp, is found in only or percent of childhood
cases of intussusception. It is unnecessary to tack down the terminal ileum or to
anchor the mesentery. Recurrences are not common, and such preventive procedures only prolong the operation. Intussusception is uncommon in adults. It
may occur at any level of the small or large intestine. A er the intussusception
in adults has been reduced, a search should be made for the initiating cause—
i.e., tumors (especially intrinsic), adhesive bands, Meckel’s diverticulum, and so
forth. Resection is indicated if dead bowel is encountered.
CLOSURE e abdomen is closed in the routine manner. e skin margins
are approximated with nylon sutures or subcuticular absorbable sutures
reinforced with skin-adhesive strips.
POSTOPERATIVE CARE Nasogastric suction is continued until peristaltic
activity is audible or until a stool is passed. Antibiotics and colloid replacement are not necessary in an uncomplicated intussusception, but again
are most valuable adjuncts in the case requiring resection. About mL/kg
of colloid or albumin solution provides an invaluable daily supportive
measure for the seriously ill child who has had resection of a gangrenous
intussusception. Recurrence in the adult should suggest a cause overlooked
initially but probably amenable to surgical correction, such as removal of a
polyp or adhesive band. ■
122
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