Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_595_Библиотеки_им_академика_М_И_Перельмана.pdf
132 Atlas of Complicated Abdominal Emergencies
• Injury to the distal part of the pancreas in the tail
region necessitates distal pancreatectomy with
closure of pancreatic stump and drainage of the
area. Spleen preservation can be attempted if
patient’s condition allows.
• In ductal injuries, especially combined injuries
of the head of pancreas and duodenum,
integrity of the distal CBD and ampulla of Vater
on cholangiogram will dictate the operative
procedure. Intact duct and ampulla requires
simple repair and drainage or repair and pyloric
exclusion.
• Pyloric exclusion is widely adopted in the
management of Grade III and IV combined
pancreaticoduodenal injuries. The technique
involves temporary diversion of enteric
fl ow away from the injured duodenum by
closure of the pylorus and creation of a
gastroenterostomy.
• Closure of the injured area over a T-tube in
combined injuries when D2 is involved has
also been advocated.
• Injury to the body of the pancreas with disruption
of the pancreatic duct may necessitate central
pancreatectomy (See Fig. 8).
{ Lesser sac is entered by opening the gastrocolic
ligament.
{ Careful assessment of the injured pancreatic
tissue and surrounding structures such as the
duodenum is essential to plan the next step of the
operation.
{ Disruption of the pancreatic duct at the neck and
body may necessitate central pancreatectomy but,
recently, PD disruption has been successfully
treated conservatively.
{ SMV-PV tunnel is created with careful dissection
of the neck of pancreas. Pancreatic neck is
transected using GIA stapler (with or without
buttress material).
{ Further dissection of the pancreatic body is
performed from medial-to-lateral. Vessels connected to the pancreatic tissue are progressively
ligated and divided.
{ Pancreatic neck and part of the body are transected
with cold-blade after adequate margin is achieved
with all devitalised and unhealthy tissue removed.
{ Bleeding from the cut surface of pancreas is
secured with prolene 5/0 interrupted sutures.
{ A roux loop of jejunum is brought up in retro -
colic manner without tension to facilitate PJ
anastomosis.
{ Options of anastomosis are dependent on the
surgeon’s choice. Preferably, the surgeon should
perform the type of pancreatico-enteric anastomosis that they are most familiar with at most times.
{ In single-layer PJ, both anterior and posterior
layer of anastomosis can be performed using PDS
sutures. The sutures will be placed from the pancreatic side, parenchyma-to-capsule, to bowel
side, seromuscular layer. Pancreatic stent is
usually not required.
{ In double-layer anastomosis, the outer posterior
layer can be performed using prolene 4/0 suture in
continuous manner while the inner posterior and
anterior layer can be completed using PDS 5/0
sutures in interrupted manner. Pancreatic stent can
be secured in the duct-to-seromucosa anastomosis
if necessary. The outer anterior layer of the PJ can
be completed with prolene 4/0 sutures.
Figure 8.
Central pancreatectomy and reconstruction.
• In fewer than 10% of cases, severe injury
with unreconstructable injury to the duct
or ampulla of Vater or duodenum would
require pancreaticoduodenectomy (Whipple
procedure).
Chapter 14 Surgical Management of Bile Duct & Pancreatic Emergencies 133
• Some centres would advocate the use of
somatostatin or its analogue (octreotides) in
order to reduce pancreatic secretion. However,
the evidence for administration of this
pharmacological agent is controversial at the
moment.
E) ERCP Perforation
{ Incidence of ERCP-related perforation is rare
(about 1%).
{ Types of ERCP injury can be classified as
follows:
Type I — Lateral duodenal wall injury (Or
medial injury)
Type II — Injury to the sphincter of Oddi
Type III — Ductal injury
Type IV — Retroperitoneal air only
{ Type I injuries tend to be large and remote from
the ampulla of Vater. Persistent contrast leak in the
retroperitoneal and/or intraperitoneal spaces may
be evident on scans. Exploratory laparotomy and
repair of the damaged structures is necessary.
{ Type II usually represents perivaterian injuries
with varied severity, but usually the injury is
discrete and less likely to require surgery.
{ Type III is usually due to distal bile duct injury
related to wire of basket instrumentation near the
obstructing entity (e.g. stones). The site of injury
is usually small. Conservative management is
often possible.
{ Type IV injuries are probably related to the use of
compressed air to maintain patency of a lumen
and are not true perforations. Surgical intervention is not required.
{ In short, the surgical indications after ERCP-
related duodenal perforation are as follows:
• Large amount of contrast extravasation at
the time of ERCP (defi ned as incomplete
dissipation of contrast after one minute on
follow-up plain fi lm). If the contrast dissipated
after one minute, it may represent small
contrast extravasation and a repeat Gastrografi n
study should be performed four to six hours
later. If contrast extravasation is noted, surgical
exploration should be done.
• Any follow-up scans showing fl uid collection
in the retroperitoneal or peritoneum consistent
with perforation, not pancreatitis.
• Documented ERCP perforation with chole-
lithiasis, choledocholithiasis or retained
hardware.
• Massive subcutaneous emphysema after ERCP
with what appears at endoscopy to be a large
duodenal diverticulum.
• Failure of nonsurgical management.
This page intentionally left blankThis page intentionally left blank
Chapter 15
Laparoscopic Drainage of Liver Abscess
Stephen Chang Kin Yong* and Liza Tan Bee Kun
I. Introduction
In the majority of cases, the aetiology of liver abscess
remains unknown (cryptogenic). In patients with a known
aetiology, ascending infection from choledocholithiasis
is the most common source of liver abscess. In the West,
malignancy of the head of pancreas or of bile ducts leading to biliary sepsis is a common cause of liver abscesses.
In the authors’ institutional experience, Klebsiella
pneumoniae and Escherichia coli were the most
common organisms isolated; 9.2% were amoebic in
origin. Diabetes mellitus was associated with 45.5%
of these patients.
The majority of the abscesses are found in the
right lobe of the liver. The segmental distribution
based on the authors’ institutional experience is shown
in Fig. 15.1. 97.7% of abscesses are solitary.
II. Management Strategy for Liver
Most liver abscesses can be treated by intravenous
antibiotics and percutaneous drainage without general
anaesthesia. Nevertheless, a proportion of patients
with complicated abscess require surgical drainage.
†
Abscesses
Figure 15.1.
Location of abscesses.
*K.Y. Chang, MBBS, MRCSED, MMed (Surg), FRCS (Gen Surg), FAMS, Associate Professor, YLL School of Medicine, National
University of Singapore, Senior Consultant, Research Director, Division of Hepatobiliary and Pancreatic Surgery, Liver Transplant
Program, National University Health System, Singapore.
†
B. K. Tan, MBBCh, BAo (Nul), MRCS (lve), Department of Surgery, University Surgical Cluster, National University Hospital, Singapore.
135
136 Atlas of Complicated Abdominal Emergencies
In the authors’ experience, surgical drainage can usually be achieved by a laparoscopic technique described
as follows:
Preoperative Preparation
1. Ensure adequate infusion of fluids and blood
components to restore and maintain blood volume
and coagulation ability.
2. Broad-spectrum antibiotics with a view to streamlining it to targeted therapy based on culture
results from blood or from the drained pus.
3. Ensure patient’s condition is safe for general
anaesthesia.
4. Informed consent with attention to the possible
need of more than one intervention.
III. Operative Procedure Via
Laparoscopic Approach
a. Position
The patient is prepared in the “French position”
(Fig. 15.2), which is a supine position with both
thighs abducted, knees straightened and soles
supported. In such a position, the patient can be
placed in a reverse Trendelenburg position to allow
bowels to be displaced towards the pelvis and the
patient prevented from sliding off the operating
table.
The lower limbs must be abducted enough to
permit the surgeon to position himself between
them.
Port Siting
A 10-mm transumbilical incision is made for the
camera port. Two 5-mm ports are placed along
the midclavicular line cephalad to the camera port
(Fig. 15.3).
b. Diagnostic laparoscopy
After a thorough inspection of the abdominal
organs in a systemic fashion, the camera is
focused onto the liver.
Note: The common primary diseases to look for
include appendicitis, diverticulitis, cholecystitis
and pelvic inflammatory diseases.
Figure 15.2.
Positioning of the patient.
Figure 15.3.
Port sites.
Chapter 15 Laparoscopic Drainage of Liver Abscess 137
c. Intra-operative ultrasound
The 10-mm telescope is exchanged for a 5-mm
telescope and inserted through one of the 5-mm
ports. A 10-mm laparoscopic ultrasound is introduced through the 10-mm port and a systematic
examination of the liver is performed (Fig. 15.4).
The aims of performing the ultrasound are:
i. To confirm the position of the abscess.
ii. To identify the site on the liver closest to the
abscess, i.e. the site where the abscess is “pointing”, which usually serves as the site of initial
parenchyma entry. The depth at this point is noted.
Figure 15.4.
Performing laparoscopic ultrasound.
iii. To determine if the abscess is septated.
iv. To locate any other smaller abscesses that may not
have been visible on preoperative scans.
v. To verify that no major vasculature crosses the
path of drainage, i.e. from the site of parenchyma
entry to the abscess cavity.
vi. To exclude Hydatid cyst, which is characterised
by the presence of daughter cysts within the cavity. This is a relative contraindication to laparoscopic surgical drainage.
d. Drainage procedure
Having completed the ultrasound examination
and determined the most suitable site of parenchyma entry, the surface of the liver at this site is
scored with diathermy to serve as a marker. The
laparoscopic u ltrasound probe is then withdrawn
and the 5-mm telescope is replaced by the 10-mm
telescope. An aspirator is introduced through one
of the 5-mm working ports and a hook with diathermy is introduced through the other. The site
of parenchyma entry is further diathermised to
coagulate a 1 cm diameter area of liver and induce
sufficient “dimpling” of the liver. The power of
the diathermy is then increased to 50, and the
hook is advanced through the site of entry towards
the abscess cavity keeping the power of the
138 Atlas of Complicated Abdominal Emergencies
Figure 15.5.
Breaking down the septa using the aspiration catheter.
diathermy activated all the time. When the abscess
cavity is reached, purulent material will be
released. The pus is aspirated and sent for culture
and sensitivity. The aspiration catheter is also
used to gently break down the septa within the
abscess if these were found during the ultrasound
examination (Fig. 15.5). The cavity is then washed
with saline.
Precautionary note
i. It is important to coagulate a 1 cm diameter
around the site of entry before attempting to enter
the abscess cavity. This will reduce the likelihood
of tearing the liver and induce bleeding at this site
when the aspiration catheter is introduced later to
break down the septa. The coagulated “capsule”
at the surface will resist tearing of the liver at the
point of entry and serves as point of pivoting for
the instrument movements.
ii. Advancement of the hook with diathermy into the
abscess cavity must be performed slowly in a controlled manner to allow the liver parenchyma with
its microvasculature to coagulate sufficiently to
reduce the amount of blood loss.
iii. The aspirator must be position close to the site of
entry in anticipation of the exit of the pus to
reduce contamination to the rest of the abdominal
cavity. The prior knowledge obtained during the
ultrasound step with regards to the depth of
the abscess helps the surgeon to judge when the
abscess wall is about to be breached.
Special tricks!
Occasionally there may be bleeding encountered
while trying to break down the septa within the
abscess cavity. The important point then is to stop
aspirating! This will allow the pneumo-peritoneal
pressure to build up again, which will then serve as
tamponade to further bleeding!
e. Placement of drains
A large-bore drain (14 fr) is introduced through
the 5-mm port into the cavity. A second similar
drain is placed into the sub-hepatic space near the
abscess cavity. The ports are then removed.
Special tricks!
The placement of the first drain into the cavity may
be guided by another grasper introduced via the
other 5-mm port. But given that there are only two
working ports, the placement of the second drain may
be difficult. The trick is to use the port itself to direct
the position of the drain towards the subhepatic
space!
IV. Postoperative Management
i. Post-operatively, the patient is monitored for
signs of intra-peritoneal bleeding such as tachycardia, hypotension, generalised abdominal
pain and significant bloody drainage from the
drains.
ii. The abscess catheter may be flushed daily with
10 mL of sterile saline to prevent it from being
blocked.
iii. Appropriate antibiotics are started after obtaining
the culture results.
iv. A CT scan may be repeated two weeks later to
check that no other abscesses have developed
and that the drains are still in appropriate position. It is possible to observe a reduction in size
of the abscess cavity, but it is unlikely to contract
fully.
Chapter 15 Laparoscopic Drainage of Liver Abscess 139
v. The timing of drain removal varies. The authors’
preference is that there must be absence of clinical signs of active infection, radiological evidence of contraction of the abscess cavity and
absence of any partially necrotic liver tissue in
the cavity.
Special situations
i. Abscesses in segments 7, 8
When the abscess is mainly in the superior seg-
ments of the right lobe, i.e. segments 7 and 8, it is
often pointing towards the bare area of the liver. It
is important to adequately mobilise the right lobe
of the liver to allow access to this area (Fig. 15.6).
The use of a snake retractor is useful in helping to
mobilise the liver towards the left. Often both the
falciform ligament and the right triangular ligament have to be divided to achieve this. This is a
better way than to attempt to drain the abscess
through a longer path via an entry point in the
lower segment.
ii. Ruptured abscess
This is not a contraindication to laparoscopic
approach. Certainly, percutaneous drainage will
not be adequate. The key issue is adequate lavage
of the peritoneal cavity, including the inter-loop
areas of the small bowel. An additional drain may
be placed in the pelvis to reduce the chance of
pelvic abscess.
iii. Concurrent pathology
Occasionally the causative pathology for the liver
abscess can be determined pre-operatively or during diagnostic laparoscopy. This may be addressed
at the same time of the liver abscess drainage
although additional ports may be placed to help in
the dissection of the organs involved. Usually for
an appendicectomy, an additional suprapubic port
is placed while an additional right lateral port is
placed for a cholecystectomy.
iv. Caudate lobe abscess
The drainage of a caudate lobe abscess is better
done laparoscopically than percutaneously as the
Figure 15.6.
Dividing the right triangular ligament to mobilise right lobe.
140 Atlas of Complicated Abdominal Emergencies
caudate lobe is “sandwiched” between the portal
structures and the inferior vena cava, which may
be at risk during percutaneous drainage. The laparoscopic approach will require opening the lesser
omentum and lifting the left lobe towards the
right. Occasionally the left triangular ligament
may have to be divided before the left lobe can be
lifted enough to expose the caudate lobe. More
often with the caudate abscess, the lesser omentum lying on it becomes inflamed and adherent to
the caudate lobe, but it can still be dissected from
the caudate lobe. More often, an additional port
may be necessary for the purpose of retraction.
v. Deep-seated abscess
In deep-seated abscesses in the right lobe of the
liver where there is more than 2 cm of parenchyma tissue all around the abscess, it may be
prudent to attempt drainage of the abscess percutaneously rather than surgically. If this fails, the
patient can then be brought into the operating
room for surgical drainage using the percutaneous
drainage catheter as a guide to reach the abscess.
In the occasional situation where there is an obvious concurrent pathology that needs to be
addressed in the first instance, the “percutaneous
aspect” can be done intra-operatively under laparoscopic ultrasound guidance, and the surgical
drainage can then be performed again using intraoperatively placed catheter (or guide wire) as a
guide to reach the abscess cavity.
Final Note
As in all laparoscopic procedure, it is important
that the surgeon is comfortable with the open approach
in the event that the procedure has to be converted.
This situation may arise when the patient cannot tolerate peritoneal insufflation and develops haemodynamic instability. The surgical principle remains the
same as described above except for a larger incision
placed usually at the right subcostal. In such
situations, it is therefore unlikely that a posterior
transpleural approach can be undertaken.
Chapter 16
Interventional Radiology in the Management
of Intra- Abdominal Abscess
Anil Gopinathan,* Quek Swee Tian† and Lenny Tan
Introduction
Intra- abdominal abscess, when leading to septic
shock, has a mortality of over 50%.
1970s, surgical incision and drainage was the only
practical way for achieving source control. Following
the first report of percutaneous aspiration for abdominal abscess by McFadzean in 1953,
drainage of abdominal abscesses has had to wait
another two decades for the advent of cross-sectional
imaging techniques to enable universal acceptance as a
less invasive alternative or complement to surgery.
1
Until the late
2
percutaneous
Advantages of Radiological
Drainage
1) It can avoid a major surgical undertaking without
precluding future surgery if indicated.
2) It permits multiple and repeated drain placements
with relatively little patient morbidity. This is a
major advantage as repeat laparotomies are often
a nightmare for both the patient and the surgeon.
3) It allows precise drain placement into deep intraabdominal locations that would otherwise warrant
extensive organ mobilisation and tissue dissection
to reach surgically, e.g. peripancreatic abscess.
4) It is almost always performed under local anaesthesia which is rarely feasible for most surgical
drainages.
5) Bedside drain insertion may be possible when
amenable to ultrasound guided drainage.
6) Direct procedural complications are uncommon
with radiological drainage.
7) It may be the best and only rational approach in
certain select situations, e.g. percutaneous
transhepatic biliary drainage (PTBD) in the
treatment of post-biliary enterostomy strictures.
8) Radiological drainage may be possible in certain
situations when surgical intervention is relatively
contraindicated, e.g. high surgical risk patients,
postoperative abscess following recent major
surgery.
‡
* Anil Gopinathan, MBBS, MD, DNB, FRCR (Lond), FAMS, Consultant Radiologist, Department of Diagnostic Imaging, National
University Hospital, Singapore.
†
Quek Swee Tian, MBBS, FRCR, FAMS, Chief & Senior Consultant, Department of Diagnostic Imaging, National University Hospital,
Singapore.
‡
Lenny Tan, MD, FSIR, Emeritus Consultant, Department of Diagnostic Imaging, National University Hospital, and Professor, National
University of Singapore, Singapore.
141