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Varieties of pouches
21
A
B
Temporary
loop ileostomy
D
Ileoanal
anastomosis
3
Side-to-side
C
Cecum
Ileocolic
vessels
4
Testing mobility
of ileum
Alternate level
of anastomosis
External
sphincter
muscle
Incision in mesentary
Ileum
5
Rectal cuff
Levator ani
Internal sphincter
Columns of Morgagni
Pectinate line
193
PLATE
88
DETAILS OF PROCEDURE Many surgeons advocate leav-
ing about cm of mucosa above the columns. Recurrence of in ammatory
bowel disease and malignant degeneration are possible and careful follow-up
is essential. In general, avoidance of rectal dilatation or eversion of the stump
plus a high level of anastomosis results in better fecal continence. In patients
with high-grade dysplasia in the rectum, a traditional mucosectomy may be a
better option, as it removes all the mucosa. If this technique is done, a handsewn ileoanal anastomosis would be required. e J-pouch is constructed
by rotating the terminal ileum clockwise to create a “J”-shape (as seen from
anteriorly) cm long. e anterior ends are held by semicircular silk
sutures (figure 6). e length is then checked as described above to ensure
it will reach the pelvis. e distal antimesenteric end of the pouch is opened
with electrocautery. A linear stapler is then inserted and red, creating a
pouch from the two limbs (figure 7). Multiple rings are used to complete
the full length of the pouch (to reach the upper end, the distal end is telescoped onto the stapler). A - Prolene suture is then used to create a “whipstitch” purse-string suture around the opening in the tip of the pouch. An
anvil of the circular stapler (EEA) is then inserted and the purse-string tied
around it (figure 8). e anvil must sit so that the anti-mesenteric aspect of
the ileum is draped across it. e circular stapling (EEA) instrument is then
inserted gently into the rectum by an assistant. It is advanced up to the level
of the stapled rectal stump. e sharp spike then pierces through the stump
at the staple line and it is approximated with the anvil (figure 9). e device
I A
is then closed and red, taking care not to include adjacent structures such
as the vagina. Naive or too-vigorous insertion of the circular stapler (EEA)
instrument will rip through the very short rectal stump and make the procedure much more di cult. figure 10 demonstrates the completed J-pouch
with ileorectal stump anastomosis.
If the rectal mucosa is severely diseased, then a complete mucosal proctectomy may be indicated. e mucosa is excised from the dentate line up to
include the or cm of mucosa in the rectal stump. Some prefer to outline the
dentate line with electrocoagulation followed by the submucosal injection of
:, adrenaline solution (figure 11). is tends to elevate the mucosa
and facilitate the dissection in a more bloodless eld. All mucosa must be completely removed. is dissection is o en the most time-consuming part of the
technical procedure and must be done with the greatest care (figure 12). e
underlying muscle and nerves must not be injured. A dry eld is essential.
Some prefer to grasp the stump with a Babcock forceps in the anus and
everted out the anus (figure 13). is facilitates the removal of the mucosa
under direct vision but may result in poor fecal continence (figure 14).
Others prefer to divide the mucosa at the top of the columns of Morgagni (Plate , figure 5). is avoids telescoping the rectal stump and
lessens the possibility of nerve injury where the patient may not be able to
di erentiate stool from atus postoperatively.
If a mucosal proctectomy is performed, then a hand-sewn ileoanal anastomosis must be completed. is is demonstrated in Plate .
CONTINUES
194
7
8
9
6
10
12
Anus
11
Cauterization of
pectinate line
Mobilization
of mucosa
Anus
Injection of
epinephrine
14
Internal
sphincter
muscle
Rectal mucosa
13
Everted
rectal cuff
195
PLATE
89
DETAILS OF PROCEDURE e adequacy of the blood supply
to the reservoir is again double-checked. Two interrupted sutures with needles attached (figure 15) are anchored on each side of the two- nger opening in the reservoir. ese sutures are passed by the surgeon down through
the anus, and the reservoir is placed in the proper position from above.
e two sutures on each side are then anchored to either side of the
opening at the level of the dentate line (figure 16). An additional suture
is placed in the midline anteriorly and posteriorly. Eight or ten additional
sutures may be required to ensure an accurate anastomosis. ese sutures
include the full thickness of the ileal wall, as well as a portion of the internal
sphincter (figure 17).
Any openings in the mesentery are closed with interrupted sutures to
avoid intestinal hernia. e pelvic peritoneum is closed about the pouch to
avoid twisting or displacement. A suture may be placed to anchor the pouch
to each side of the muscular rectal cu to secure the pouch in position and
lessen the possible tension on the suture in the dentate line anastomosis.
Some prefer to insert a rubber drain between the wall of the pouch and the
rectal cu . e rubber tissue drain is brought out anteriorly.
While it is tempting to avoid an ileostomy, fewer postoperative complications result if a complete diversion of the fecal stream is accomplished by ileostomy. e defunctioning ileostomy is performed through a small opening in
the le lower quadrant about cm from the pouch (figure 18). It is advisable to ensure complete diversion of the fecal stream (figure 19) by intussuscepting up the proximal limb or stoma over the rod (see also Plate ).
POSTOPERATIVE CARE Steroid therapy is gradually decreased until it
can be omitted completely. e bladder catheter is removed a er testing for
I A
sensation a er a few days. e diet is slowly increased, but may need to be
adjusted or limited depending upon the incidence of diarrhea.
Incidental obstruction, pelvic sepsis, and local problems around the
ileostomy are occasional complications a er the operation. Before closure, the integrity of the pouch and the anal anastomosis is evaluated by
radiographic procedures with water-soluble contrast. Direct evaluation of
the anastomosis for patency is also necessary. Frequently it strictures or
develops a web across it requiring examination with sedation in the GI lab.
Pouchoscopy can also be performed at this time. If no problems exist, the
ileostomy is closed within months.
e major consideration involves the degree of anal continence that has
been achieved. Patience is required during the rst year, as the capacity of
the pouch increases and sphincter control gradually improves. e control
of diarrhea during the day and soiling at night are of major concern and
may require adjustment in bulk and type of food, as well as special medication. e number of daily stools varies, with an average of six per day
and one or two per night. Patients with polyposis usually have fewer bowel
movements per day than patients with ulcerative colitis.
A troublesome complication is a poorly de ned syndrome known as
pouchitis. e stools are increased in frequency with malaise, fever, and
bloody stools, along with abdominal cramps. is complication is far more
common in patients with ulcerative colitis than in those with multiple polyposis. Speci c medication and dietary adjustments are indicated. is procedure is believed to be associated with chronic residual stasis. Intestinal
obstruction may occur in percent more of the patients.
Patients with this operation require frequent, long-term follow-up
evaluations. ■
196
15
16
Ileal mucosa
17
Mucosa anchored
to internal sphincter
Pectinate line
18
Diverting
ileostomy
Ileal mucosa
19
197
PLATE
90
INDICATIONS Cholecystectomy is indicated in symptomatic patients
with proven disease of the gallbladder, and the indications for laparoscopic
cholecystectomy are essentially those for open cholecystectomy. ere are
certain de nitive contraindications, which at present include peritonitis,
small bowel obstruction secondary to gallstone ileus, coagulopathy, and
large diaphragmatic hernia. Relative contraindications are becoming fewer
as the surgical experience of the individual surgeon increases. e factors
for increased risk include cirrhosis with portal hypertension, previous intraabdominal surgery with adhesions, and acute gangrenous cholecystitis.
PREOPERATIVE PREPARATION Following a history and physical exami-
nation, the diagnosis of biliary disease is documented with ultrasound
examination of the abdomen. e remainder of the gastrointestinal tract
may require additional studies. A chest x-ray and electrocardiogram are
usually performed and may indicate the need for further evaluation of the
cardiopulmonary systems. Routine laboratory blood tests are obtained and
should include a liver function panel as well as coagulation studies. e
risks of laparoscopy, including trocar injuries to viscera or blood vessels
and the increased risk of bile duct injuries during laparoscopic cholecystectomy, are discussed with the patient as well as the possibility of conversion to an open procedure. e management of patients with gallstones and
common duct stones remains to be de ned. An endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy are commonly tried
rst. If the common duct is successfully cleared of stones, then a staged laparoscopic cholecystectomy is performed. If the ERCP procedure is not successful, the patient should be prepared for an open cholecystectomy with
common duct exploration.
ANESTHESIA General anesthesia with endotracheal intubation is recom-
mended. Preoperative prophylactic antibiotics for anticipated bile pathogens are administered such that adequate tissue levels exist.
POSITION As laparoscopic cholecystectomy makes extensive use of sup-
porting equipment, it is important to position this equipment such that it is
easily visualized by all members of the surgical team (figure 1).
e surgeon must have a clear line of sight to both the video monitor
and the high ow CO insu ator such that he or she can monitor both the
intra-abdominal pressure and gas ow rates. In general, all members of the
team are looking across the operating table at video monitors and therefore
the positions of the video monitors may require adjustment once all members step to their nal positions at operation. e patient is placed supine
with the arms either secured at the sides or out at right angles so as to allow
the maximum access to monitoring devices by the anesthesiologist at the
head of the table. An orogastric tube is passed a er the patient is asleep. As
increased intra-abdominal pressure from the pneumoperitoneum impedes
venous return and may raise the risk of deep venous thrombosis, both
legs are either wrapped or placed in elastic stockings over which sequential pneumatic compression stockings may be placed. e electrocautery
grounding pad is placed near the hip avoiding any region where internal
C, L
metal orthopedic parts or electronic devices may have been implanted. e
position of the patient on the table relative to placement of the x-ray cassette
for a cholangiogram or the C arm for uoroscopy is rechecked. e legs,
arms, and upper chest are covered with blankets to minimize heat loss.
OPERATIVE PREPARATION e skin of the entire abdomen and lower
anterior chest is prepared in the routine manner.
INCISION AND EXPOSURE e abdomen is palpated to nd the liver
edge or unsuspected intra-abdominal masses. e patient is placed in
a mild Trendelenburg position and an appropriate site for the creation
of the pneumoperitoneum is chosen. e initial port may be placed by
an open or Hasson technique which is preferred. Alternatively, a Veress
needle technique is used as described below. In the unoperated abdomen
this is usually at the level of the umbilicus (figure 2); however, previous laparotomy incisions with presumed adhesions may suggest a more
lateral approach site which avoids the epigastric vessels (figure 2 at X).
A -cm vertical or horizontal skin incision is made and the abdominal
wall on either side of the umbilicus is grasped by the surgeon and rst
assistant either by thumb and fore nger or by towel clips so as to elevate
the abdominal wall (figure 3). A Veress needle is held like a pencil by
the surgeon who inserts it through the linea alba and peritoneum where
a characteristic popping sensation is felt (figure 4). An unobstructed
free intraperitoneal position for the Veress needle is veri ed by easy irrigation of clear saline in and out of the peritoneal space (figure 5) and
by the hanging drop method where the saline in the translucent hub of
the Veress needle is drawn into the peritoneal space when the abdominal
wall is li ed.
If one does not obtain a free ow or an unobstructed saline irrigation,
then the Veress needle may be removed and reinserted. In general it is safer
to convert the umbilical site into the Hasson open approach (Plate ) if
any di culty is experienced with the placement, irrigation, or insu ation
of the Veress needle. e appropriate tubing and cables for the CO
ation, the beroptic light source, and the laparoscopic videoscope with its
sterile sheath are positioned as are the lines for the cautery or laser, suction,
and saline irrigation. e pneumoperitoneum begins with a low ow of
about or L/min with a low-pressure limit of approximately to cmH
Once to L of CO are in, the abdomen should be hyperresonant to percussion. e ow rate may be increased; however, the pressure should be
limited to cmH
the abdomen and the Veress needle is removed. A er grasping either side
of the umbilicus, a -mm trocar port is inserted with a twisting motion,
aiming towards the pelvis (figure 6). If a disposable trocar port is used, it
is important to be certain that the safety sheath is cocked. A characteristic
popping sensation is felt as the trocar enters the peritoneal space. e trocar
is removed and the escape of free CO
Although the Veress needle technique has a long history and is preferred
by some, most general surgeons use the Hasson technique, as shown in the
following Plate . ■
O. ree to four liters of CO are required to fully in ate
gas is veri ed.
insuf-
O.
198
199
PLATE
91
INDICATIONS e rst step in most abdominal laparoscopic procedures is
insu ation of the intraperitoneal space with CO gas and the introduction
of the videoscope system. e original and most established technique uses
the Veress needle, as described in the preceding Plate . e Veress needle
can be placed in any quadrant of the abdomen, but it is most frequently
inserted just below the umbilicus, where a skin incision has been made for
the introduction of a large -mm port for the videoscope. General surgeons, however, have been cautious in adopting this technique of blind
puncture, as their training has emphasized the importance of complete
visualization of anatomy and of the planned action of their surgical instruments. Accordingly, the open or Hasson technique for entering the abdomen under direct vision has become more popular and safer. is technique can be used to enter into any quadrant of the abdomen but is most
commonly employed at the central umbilical site (figure 1). A vertical or
transverse skin incision approximately to mm in length is made just
below (figure 2) or above the umbilicus. e choice of site may be based
on the surgeon’s preference or the presence of a previous regional incision
that may have adhesions. e subcutaneous fat and tissues are bluntly dissected apart using small narrow nger retractors or a Kelly hemostat. e
white linea alba is visualized and grasped on either side with hemostats.
e linea alba is elevated with the hemostats and a vertical -mm incision
is made through the fascia (figure 2). Further dissection with a hemostat
will reveal the thickened white peritoneum, which is grasped with a pair
of laterally placed hemostats (figure 3). e peritoneum is elevated and
opened cautiously with a scalpel. A dark, empty peritoneal space is seen
and a pair of lateral stay sutures are placed. ese sutures incorporate the
peritoneum and linea alba and are later used to secure the Hasson port.
e next step is to verify that the intraperitoneal space has been entered
freely. e surgeon’s h nger is inserted (figure 4). is maneuver sizes
the hole for the port and allows the surgeon to palpate the region. Usually
this space is clear, but on occasion there are some lmy omental adhesions that can be swept away. e Hasson port with its blunt, rounded-tip
obturator is introduced into the abdomen (figure 5). e spiral collar is
screwed into the fascia so as to provide a snug gas seal, and the lateral stay
sutures are secured to the notches on the collar. e obturator is removed.
e CO
rates of CO ow and maximum pressure ( mmHg). He or she observes
the intra-abdominal pressure and the total volume of CO infused as the
abdomen enlarges and becomes tympanitic. e videoscope is white-balanced and focused. e optical end of the instrument is coated with antifog solution. e videoscope is introduced into the port and advanced into
the peritoneal space. If an angled optical instrument, typically degrees,
is used, it is important for the operator of the videoscope to establish the
correct orientation of the optics and the video head. Typically, the optical
bevel is downward-viewing ( o’clock) when the beroptic light cable is
line is attached and the stopcock opened. e surgeon sets the
H O T, L
vertical ( o’clock). e video head is correctly oriented when its cable
is positioned at o’clock posteriorly. Rotation of either instrument from
these positions will produce a rotated view on the TV monitor.
In the presence of omental adhesions or an enlarged falciform ligament,
the intraperitoneal space may not easily be entered as the videoscope comes
to the end of the Hasson port. If this area was clear to palpation with the
surgeon’s h nger, careful angulation and rotation of the videoscope usually nds the right opening. When the opening cannot be found, the port
is removed and a repeat nger palpation is performed before reinsertion of
the Hasson port. In extreme cases, when nger palpation cannot nd an
easy intraperitoneal entrance because of dense adhesions, an alternative site
for the Hasson port should be used.
e usual alternative sites (figure 1) are in the four quadrants of the
abdomen, although the Hasson port can also be placed through the midline
linea alba in the epigastric or suprapubic regions. A transverse skin incision is made and the subcutaneous fat spread with narrow nger retractors
or a Kelly hemostat. e fascia of the external oblique muscle is incised
with a scalpel. Further deep dissection is performed through the internal
oblique and transversus muscles, whose thin fascia usually does not require
incision. e white peritoneum is grasped between hemostats and elevated.
A scalpel incises the peritoneum and a clear entry into the intraperitoneal
space is veri ed by deep passage of a Kelly hemostat. A pair of lateral stay
sutures incorporating the peritoneum and fascia are placed. e remainder
of this procedure is performed as described for the umbilical site.
SUTURE OF PORT SITE Most -mm port sites do not require suture
closure of the fascia, especially if the port is passed originally in a zigzag
or oblique manner through the muscle layers of the abdominal wall. On
occasion, however, a blood vessel of the intra-abdominal wall that was not
seen with transillumination may be cut by the trocar during the placement of a port. Most small vessels will stop bleeding. However, some may
continue to drip into the intraperitoneal space and obscure visualization.
A technique for the control of these vessels or for closure of a fascial defect
is shown (figure 6). A delayed absorbable suture is placed into the tip
of a special suturing needle. e needle and suture are passed through the
inner abdominal wall about cm beyond the edge of the port entry site
(figure 6A). e suture is released from the needle tip with a long free
end showing within the abdomen. e special suturing needle is removed
and reinserted about cm beyond the opposite edge of the port entry site.
e needle tip is opened and the suture is grasped (figure 6B). e free
end of the suture and the needle are withdrawn. e suture is tied down
through the skin opening. is technique produces a mattress suture that
can secure abdominal wall blood vessels or close fascial defects created by
the placement of large ports. Both maneuvers are done under direct visualization using the videoscope.
CONTINUES
200
AB
201
PLATE
92
SUTURE OF PORT SITE e CO
port and the videoscope with its sterile light source cord inserted a er whitebalancing and focusing the system. Topical antifog solution is applied to the
optical end of the telescope, which may be either angled (30 degrees) or at
(0 degrees) (figure 7). A general examination of the intra-abdominal organs
is performed taking special note of any organ pathology or adhesions. e
nding of any trocar-related injuries to intra-abdominal viscera or blood vessels requires an immediate repair using advanced laparoscopic techniques or
more commonly open laparotomy.
ree additional trocar ports are placed, using direct visualization
of their sites of intra-abdominal penetration. e second 10-mm trocar
port is placed in the epigastrium about 5 cm below the xiphoid, with its
intra-abdominal entrance site being just to the right of the falciform ligament (figure 8). Some surgeons use a 5-mm port at this site. Two smaller
5-mm trocar ports for instruments are then placed: one in the right upper
quadrant near the midclavicular line several centimeters below the costal
margin and another quite laterally at almost the level of the umbilicus.
ese sites may be varied according to the anatomy of the patient and
the experience of the surgeon. e skin of each selected site is in ltrated
with a long-acting local anesthetic. is needle can then be advanced
into the peritoneal cavity under direct vision of the videoscope to verify
proper positioning for the planned port. e skin is opened with a scalpel,
hemostasis is obtained, and the subcutaneous fat is dilated with a small
hemostat. e patient is placed in a mild (10 to 15 degrees) reverse Trendelenburg position, although some surgeons prefer to rotate the patient
slightly to the le (right side up) for better visualization of the gallbladder
region.
Cholecystectomy, Laparoscopic
source is attached to this
2
e apex of the gallbladder fundus is grasped with a ratcheted forceps
(A) through the lateral port. e gallbladder and liver are then li ed superiorly (figure 9). is maneuver provides good exposure of the under-
surface of the liver and gallbladder. Omental or other loose adhesions to
the gallbladder are gently teased away by the surgeon (figure 9).
e infundibulum of the gallbladder is grasped with forceps (B) through the
middle port. Lateral traction with the middle forceps exposes the region of the
cystic duct and artery. Dissecting forceps (C) are used by the surgeon through
the epigastric port to open the peritoneum over the presumed junction of the
gallbladder and cystic duct (figure 10). With gentle teasing and spreading
motions, the cystic duct and artery are exposed (figure 11). Each structure
is exposed circumferentially. If possible both structures are dissected free and
identi ed prior to clipping and division. It is helpful to obtain the critical view.
To minimize bile duct injury the concept of the “critical view of safety” is helpful. In this technique, the neck of the gallbladder must be dissected o the liver
bed (i.e., unfolding Calot’s triangle) to achieve conclusive identi cation of the
two structures to be divided: the cystic duct and cystic artery. In the classic view
the liver is seen posterior to Calot’s triangle (figure 12).
e clear zone may be veri ed and elongated by sweeping back and forth
(figure 12). e importance of the second assistant manning the videoscope now becomes apparent. He or she must pull back and visualize the
entrance of each new delicate instrument through the ports and then follow
the instrument down to the area of dissection, which is maintained in the
center of the eld. Suitable magni cation is controlled by the closeness of
the videoscope to the dissection site. At this point, if the dissection is dif cult because of in ammatory swelling and scarring, the surgeon should
consider conversion to an open procedure.
CONTINUES
202
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