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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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Fundus of
1
distended
gallbladder
Omentum
5
Purse-string
suture
Scoop with stones
2
6
Catheter
Suction
7
3
Trocar
4
8
Anchoring
stitch
Peritoneum
Choledochoplasty
9
Incision in peritoneum
12
Stricture of
common
duct
Hepatoduodenal
ligament
Duodenum
13
10
Pancreas
11
Incision
Metal probe
15
Catheter
14
223
PLATE
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103
C—E--E
A
A. CHOLEDOCHOJEJUNOSTOMY (MUCOSAL
GRAFT, RODNEY SMITH)
DETAILS OF PROCEDURE e surgeon is occasionally faced with the dif-
cult problem of nding the strictured area or blind end of the hepatic
duct. e adhesions between the duodenum and hilus of the liver are
divided carefully by sharp and blunt dissection (figure 1). Great care
must be exercised to avoid unnecessary bleeding and possible injury to
the underlying structures. Usually, it is easier to start the dissection quite
far laterally and to free up the superior surface of the right lobe of the liver
from the adherent duodenum, hepatic exure of the colon, and omentum.
Sharp dissection is used along the liver margins to avoid tearing the liver
capsule, which results in a troublesome ooze. A er the edge of the adhesion has been incised, blunt dissection will be more e ective and safer in
freeing up the undersurface of the liver. e exposure should be directed
toward identifying and exposing the foramen of Winslow. e stomach
may or may not have to be dissected away from the liver. Usually, the duodenum is drawn up into the old gallbladder bed and xed by dense adhesions. e second portion of the duodenum is mobilized medially (Kocher
maneuver), following division of the peritoneum along its lateral margin
(figure 2). As the duodenum is re ected downward and the undersurface of the liver is retracted upward, the upper portion of the dilated duct
may be veri ed by aspiration of bile through a ne hypodermic needle
(figure 3), and a cholangiogram may be performed. e needle may be
le in place, and an incision is made alongside the needle until a free ow
of bile is obtained. A blunt-nosed, curved clamp is inserted upward into
the dilated duct and the opening gradually enlarged by dilatation, which
may include an additional incision to enlarge the opening. No e ort is
made to free up the entire circumference of the ductal system, since the
mucosal gra will eventually be intussuscepted well up into the duct without a direct end-to-end anastomosis (figure 6).
Following the opening of the dilated common hepatic duct, a long,
curved clamp is inserted, usually toward the le side, and extended up
through the liver substance. A rubber or Silastic tube ( or French) is
pulled down through the liver and partially out through the duct opening
(figure 4). Additional holes that will be above and below the anastomosis
are made in this tube. Following this, a Roux-en-Y arm of jejunum is prepared in the usual way using a linear staple to divide the small intestine,
If the intestine is divided between clamps then the end of the mobilized
jejunal arm is closed with two layers of interrupted silk. On the antimesenteric border of the jejunum a -cm segment of the seromuscular coat is
excised approximately cm from the closed end (figure 4). Care should
be taken to avoid making any additional openings in the mucosa except in
the very apex of the protruding mucosal pocket. e tube that was pulled
down through the liver is now directed through the small opening made in
the apex of the mucosal pocket and directed down into the arm of jejunum
for cm or more. A purse-string suture of absorbable suture is placed in
the mucosa about the tube and tied. A er the tube has been passed the
desired distance down the Roux-en-Y limb, a No. absorbable suture is
passed completely through the jejunal walls and around the tube to x it in
position when tied just distal to the mucosal outpocketing. A centimeter or
two distally a similar absorbable suture is taken to ensure further xation
(figure 6, a and b). ese are the only sutures utilized to x the tube to
the wall of the jejunum. ese sutures ensure xation of the jejunal mucosa
to the tube as it is withdrawn. Several holes are cut around the tube just
above the mucosal gra to ensure drainage of the right as well as the le
hepatic duct. Traction then is placed on the end of the tube coming out of
the dome of the liver in order to pull the mucosal gra carefully and rmly
up into place inside the common hepatic duct. is provides an intussusception of the jejunal mucosa up into the dilated common hepatic duct and
ensures direct mucosa-to-mucosa approximation (figure 6). In very high
strictures it may be necessary to use a tube into the le as well as the right
hepatic radical. Special tubes have been devised for very high strictures
that separate the right from the le hepatic ducts. e Roux-en-Y loop is
securely anchored in place beneath the liver by several absorbable sutures
placed through the seromuscular coat and the scar tissue around the opening into the duct system (figure 5).
CLOSURE e tube is brought out through a separate stab wound to one side
or the other of the incision and anchored securely in place with nonabsorbable
suture material. e wound is closed in layers a er suction drainage is instituted to the undersurface of the liver by a plastic tube with many perforations.
POSTOPERATIVE CARE e tube going to the anastomosis is placed on
low-grade constant suction to divert bile until the newly made junction
is healed. e appropriate antibiotic therapy should be adjusted following
culture and sensitivity studies of the bile. e tube may be irrigated with
saline intermittently to wash out all debris or small calculi. In addition, the
tube provides a means of taking postoperative transhepatic cholangiograms
from time to time to evaluate the security of the anastomosis and the evidence of regression in the size of the formerly obstructed ducts. Ordinarily,
the tube is le in place for a minimum of four months. A complete evaluation with liver function studies and several cultures of the bile should be
made, as well as a cholangiogram, before it is advisable to remove the tube.
B. END-TO-END ANASTOMOSIS
In rare instances the common duct may be divided accidentally and the
injury discovered at once. is is likely to occur just below the junction
of the hepatic and cystic ducts as a result of technical errors. e surgeon
should always inspect the common and hepatic ducts at the completion of
cholecystectomy to make certain that they are not angulated or otherwise
injured. If there is any question, su cient time should be spent to make
certain that the extrahepatic biliary system has not been damaged. If the
common duct has been divided completely, a direct end-to-end anastomosis
may be performed in some situations; however, it is preferable to perform a
choledochojejunostomy because of damage to the blood supply of the duct.
e peritoneum on the lateral wall of the duodenum should be divided,
and the duodenum should be mobilized to relieve any possible tension on
the suture line. Clamps are not applied to the severed ends of the ducts.
Irregular or frayed edges are excised, but clear zones are not created as the
common duct has a very tenuous blood supply. at is to say, the common
duct should not be cleaned either proximally or distally. Both ends of the
duct are held in position with guide sutures of ne or nonabsorbable mono lament (figure 7). e reconstruction is completed with
ne or absorbable mono lament. A posterior layer of interrupted sutures is placed without entering the lumen to approximate the
posterior duct walls (figure 8). Upon completion of the posterior layer
all of the sutures are divided except one at either angle to serve for purposes of traction (figure 9). e posterior layers of mucous membrane
are closed with very ne interrupted absorbable sutures. Following this the
common duct is exposed for a short distance, preferably downward, to permit the opening of the duct, as in choledochostomy, and the introduction
of a T-tube catheter (figure 10). One arm of the tube is passed up beyond
the suture line to ensure an adequate lumen for the duct when the anterior
layer of sutures is placed, and the other is directed downward. If the duct
has been divided quite low, the opening may be made above the suture line
with one arm of the tube directed downward. e mucous membrane of
the common duct is closed over the T-tube with interrupted absorbable sutures with the knots on the outside (figure 11). e second layer of
sutures is rarely necessary but may be placed close to the original layer to
reinforce the line of anastomosis (figure 12).
All the sutures taken in the duct must be accurately placed with small
needles and ne or absorbable sutures and must include only
a very small bite of tissue to avoid stenosis. A er the anastomosis has
been completed, saline is injected into the catheter to make certain that
there is no leakage about the suture line, and a cholangiogram is made. A
nal inspection veri es the absence of undue tension on the suture line. A
closed-system suction catheter made of Silastic is inserted past the foramen
of Winslow into Morison’s pouch.
CLOSURE e Silastic drain and common-duct catheter are brought out
through a stab wound lateral to the incision. e wound is closed in the
routine manner. e catheter is anchored to the skin with a silk suture and
adhesive tape. Sterile dressings are applied.
POSTOPERATIVE CARE See Plate . ■
224
1
Adhesions
Rodney Smith
Duodenum
2
Incision in
peritoneum
3
Stump of
hepatic duct
Aspiration of
contents of stump
of hepatic duct
Stump of common duct
4
6
5
Bile duct
Tube
Tube
Roux-en-Y
Mucosal graft
Graft
Jejunum
Mucosal
graft
Jejunum
End-to-end anastomosis
Gallbladder bed
7
8
Severed
common duct
11
9
10
12
225
PLATE
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104
R H D
B T (K)
INDICATIONS Cholangiocarcinomas arising at or near the bifurcation of
the common hepatic duct, commonly referred to as Klatskin tumors, are
being diagnosed earlier and treated more promptly by palliative or curative
surgical procedures. e majority of patients exhibit jaundice of increasing
intensity and many have had recent biliary exploration, where the diagnosis
was suggested by operative cholangiography. ere is a wide patient age
range and occasionally a preceding history of ulcerative colitis or sclerosing
cholangitis. Although the number who can be cured may be limited, many
patients are bene ted by palliative procedures.
PREOPERATIVE PREPARATION e seriousness of the lesion, the
di culty in determining the extent of involvement, and the necessity
for avoiding infection from the required preoperative studies in an
obstructed jaundiced patient requires meticulous preoperative evaluation. Early endoscopy of the common duct and consultation with an
expert in interventional radiology are essential. e jaundiced patient
should undergo transcutaneous transhepatic cholangiography with bile
cultures taken and appropriate antibiotics given. ese diagnostic procedures are usually performed by an interventional radiologist familiar with the technic. Following cholangiography, ring catheters may be
placed bilaterally, directed if possible through the obstructing lesion into
the duodenum with palliation of the jaundice (figure 1). If there is cho-
langiographic evidence of tumor extending into the right or le hepatic
ducts, the patient may eventually be explored to relieve the obstruction
on the side of the involved duct. Palliation, however is usually possible
with internal drainage into the duodenum through the ring catheters.
e catheters also serve as invaluable technical aids to the surgeon at the
time of laparotomy.
Hepatic arteriography or special imaging scans are also helpful in showing any occlusion of the hepatic artery as well as possible encasement of
the main portal vein, either of which contraindicates a surgical attempt at
resection of the tumor. About percent of patients will show a stage of
tumor involvement that makes attempts at surgical excision impossible.
Appropriate antibiotic therapy, intravenous alimentation, and vitamin K
are given, and blood volume de cits are corrected.
ANESTHESIA e deeply jaundiced patient should be considered a poor
surgical risk meriting special consideration by the anesthesiologist in planning the anesthesia.
POSITION The patient is placed on the table in a slightly reversed
Trendelenburg position. Intravenous catheters should be placed in both
arms. Catheter drainage of the bladder may be advisable as well as nasogastric suction.
OPERATIVE PREPARATION e skin of the lower chest and upper abdo-
men as well as the right ank should be prepared.
INCISION AND EXPOSURE Either a liberal bilateral subcostal incision
with a midline extension to the xiphoid or a midline incision from over the
xiphoid to below the umbilicus is made.
DETAILS OF PROCEDURE Bimanual palpation of the liver is carried out
in a search for possible metastases. Despite the history of deep jaundice, the
gallbladder and common duct appear normal. Metastases to regional lymph
nodes or liver are unusual, but any enlarged lymph nodes are excised for
immediate frozen section examination. e tumor tends to be well hidden
and careful palpation of the previously placed ring catheters is performed
up into the hilus of the liver until the tumor is localized. e distortion of
the ring catheters is helpful in localizing the area of tumor involvement.
Before proceeding with the tumor excision, some prefer to divide the
falciform ligament and ligate both ends with a trans xing suture. is procedure may enhance the exposure (figure 2). If a hepatic bridge or plate is
present, it is divided. e exposure of the tumor area is further improved by
dividing and ligating the cystic duct followed by enucleation of the gallbladder from the liver bed.
A Kelly hemostat is applied to the fundus of the attached gallbladder to
be used for improved traction of the common duct. e duodenum is thoroughly mobilized by the Kocher maneuver and the common duct dissected
free as far downward as possible.
e anterior wall of the lower most portion of the common duct is
opened and the ends of the ring catheters brought out (figure 3). e
common duct is divided and the lower end is oversewn.
e gallbladder and end of the common duct are re ected upward to
expose the posterior aspects of the region of the tumor (figure 4). is is
the most delicate portion of the procedure. Very gently the adhesions above
the posterior aspects of the tumor and adjacent structures, such as branches
of the hepatic artery, must be gently determined and divided. Likewise the
portal vein is very close as well as the caudate lobe of the liver. Involvement of the caudate lobe of the liver with tumor may be overlooked with
prompt recurrences of the tumor. e possibility of removing the caudate
lobe should be considered if there is suspicion of tumor involvement.
All bleeding is controlled by metal clips or ligature. e lower small
hepatic vein going to the caudate lobe may be ligated.
e tissue about the le hepatic duct is carefully divided to provide
su cient exposure of the le duct for a right-angle clamp to be carefully
inserted under the duct to permit the placement of a blood vessel loop for
possible traction (figure 5). e duct should be palpated for possible tumor
involvement.
CONTINUES
226
Percutaneous
transhepatic
catheters
1
Ligament teres
L
2
Divided
hepatic
bridge
R
Tumor at
bifurcation
Gallbladder
3
Loop about
common duct
4
5
Cytic artery
Ring catheter
Common
duct
Loop for
left hepatic
duct
227
PLATE
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105
R H D
B T (K)
DETAILS OF PROCEDURE e right duct is freed up a short
distance and a blood vessel loop passed around it for traction (figure 6).
If the tumor has involved the wall of either major duct with probable extension into the liver, the need for added lobectomy must be seriously considered. Occasionally, a third large duct, or even more, may be found on the
right side, which must be conserved for implantation. Traction sutures are
placed in the major ducts at the point of division for each duct (figure 7).
e two ducts of the specimen should be marked with di erent colored
sutures for speci c identi cation by the pathologist of possible in ltration
of tumor at the point of division. Should this be found on frozen section
study, more duct must be resected.
The Silastic transhepatic biliary stents are positioned using a Coudé
catheter as a preceding dilator that is drawn up the ducts and through
the liver by the ring catheters. First, the ring catheters with the guide
wires inside are brought out the open left and right hepatic ducts. Each
curled (ring) end is cut off and the remaining straight ring catheter is
placed into the cut leading end of a No. French Coudé catheter. Each
ring catheter is then secured with a mattress suture through itself and
the Coudé. Both catheters are pulled up into the ducts (figure 8) using
traction on the ring catheter at the surface of the liver. The Coudé catheters may need to be manipulated back and forth so as to dilate the
ductal systems.
A No. French Silastic transhepatic biliary stent is positioned in the
open end of the No. Coudé French catheter and anchored with mattress
sutures of silk which are passed through the wall of the Coudé catheter.
With traction on the Coudé catheters the Silastic stents with multiple holes
are drawn into the liver in a position with no holes beyond the exit of the
plastic tubes (figure 9). us, there are holes present within the liver and
the portion that projects into the Roux-en-Y of the jejunum. Short horizontal mattress sutures of absorbable material are placed around the stents on
the surface of the liver at their point of exit. e liver is compressed without
disruption about each catheter.
CONTINUES
228
Loop about
right hepatic
duct
6
Traction
suture
left duct
7
Right
ring catheter
9
Traction suture
right duct
Coudé catheter
sutured over
8
Coudé sutured
over Silastic stent
ring catheter
Suture
Right stent
Left stent
229
PLATE
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106
R H D
B T (K)
DETAILS OF PROCEDURE A Roux-en-Y loop of upper jeju-
num is brought into the right upper quadrant through an avascular area of
the mesocolon and anterior to the second and third portions of the duodenum. e opening in the mesocolon is closed about the jejunum and its
mesentery a er making certain the end of the Roux-en-Y extends up to and
slightly beyond the hepatic duct openings. e end of the jejunum is closed
with staples or in layers of running or interrupted sutures. e posterior
wall of the jejunum in the region of the anastomosis should be anchored to
the capsule of the liver or adjacent tissue.
It is helpful to insert interrupted sutures through the lateral angles of
each open duct for positioning and sizing an accurate anastomosis on
the jejunum (figure 10). A posterior row of sutures is placed using the
full thickness of each duct. None of these sutures is tied until all posterior
sutures are in place for each duct. e middle suture in the posterior row
may also be used to tie about the stent, so as to help prevent migration of
this tube.
e knot of the back suture line will be on the inside. e sutures are cut
at the knot, except for the suture at each angle. A small incision parallel to
the posterior suture line is made in the jejunum (figure 11).
e ends of the Silastic biliary stents are gently introduced into the lumen
of the jejunum (figure 12). Anterior, full-thickness suture lines are closed
on both ducts (figures 13 and 14). Last, the jejunum is anchored to the
adjacent liver. Regional closed-system Silastic suction catheters are placed
and the Silastic transhepatic stents are doubly sutured to the skin with
- nylon (figure 15). e abdomen is closed in a routine manner and
the stents are connected to a sterile plastic bag to allow drainage by
gravity.
POSTOPERATIVE CARE e closed system Silastic sump drains are
removed a er or days unless there is a signi cant bile output or a leak is
shown on cholangiography. If no leaks are found from the superior surface
of the liver or the anastomosis, three-way stopcocks are attached to the end
of the catheters. e patients are trained to self-administer injections of
sterile saline into the stents three times per day. Consultation with radiation
medicine and medical oncology is recommended to guide the next steps
in therapy. is should be done prior to removal of the stents as these may
be used to guide placement of radioactive seeds. External radiotherapy of
, to , rads may be given as an outpatient procedure. Following
this, patients may be readmitted for hours while iridium seeds are
drawn into the transhepatic biliary system, and , additional rads are
given by this means. Irrigations are continued by the patient three times
per day. e old stents are replaced every three or four months and new
ones are introduced under uoroscopic surveillance by placing guide wires
down through the old stent. e old stent is removed and used as a template
for the number and position of the holes. e new stent is easily placed
in proper position, and the guide wire is removed. Bile cultures are taken
from time to time, and appropriate antibiotics may be required. Duodenal obstruction rarely occurs a er radiation therapy. e long-term salvage
rate is relatively low, but a signi cant increase in average length of survival,
coupled with an increased quality of life, justi es this major procedure. ■
230
10
R’
11
L’
R
L
Corner
sutures
12
13
14
Anchor
sutures
Exit mattress
suture about
stent
15
231
PLATE
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107
C—B L
A. CHOLECYSTOGASTROSTOMY
INDICATIONS is procedure may be utilized in poor-risk patients having a
limited life expectancy because of inoperable malignant disease obstructing
the common duct that cannot be decompressed with endoscopic retrograde
cholangiopancreatography (ERCP) or transhepatic cholangiopancreatography (THCP) passage of a stent. e cystic duct must be opened and the
common-duct malignancy should be quite low, with an expectation that the
process will not reach the cystic duct region for several months. In making
this short-circuiting anastomosis, it is preferable to utilize the nearest portion
of the upper gastrointestinal tract that can be approximated easily to the gallbladder without tension. is is usually the mobilized duodenum or a direct
anastomosis to the upper jejunum may be done. If long-term survival is
anticipated, the gallbladder or common duct is anastomosed to a Roux-en-Y
arm of mobilized jejunum. A cholecystogastrostomy is done rarely. However,
the technique shown is more frequently used to anastomose the gallbladder
to the duodenum. e gallbladder should not be utilized in an attempt to
relieve obstructive jaundice if the cystic duct is obstructed or if the lower end
of the common duct is to be removed in a radical resection. Visualization
of the gallbladder and ducts by contrast media may be worthwhile to prove
beyond any doubt the site of obstruction.
PREOPERATIVE PREPARATION Although the operation is a simple one,
the patients are such poor risks that they require careful preparation to avoid
fatality. Nutritional needs may require total parenteral nutrition (TPN) support. As a rule, the patient is deeply jaundiced and there is already serious
liver damage. Blood products and large doses of vitamin K are indicated
until the prothrombin level returns to a normal range.
ANESTHESIA See Plate .
POSITION e position of the patient is adjusted as described for chole-
cystectomy (Plate ); if local anesthesia is used, this position may be modi ed for the patient’s comfort.
OPERATIVE PREPARATION e skin is prepared in the usual manner.
INCISION AND EXPOSURE Usually, a midline incision reaching from the
xiphocostal junction almost to the umbilicus is made. However, either a
transverse or a Kocher oblique incision is satisfactory for those familiar
with these approaches to the gallbladder. Bleeding and oozing points in the
wound or within the peritoneal cavity are meticulously ligated. Exploration
is carried out to determine the nature of the disease causing the obstruction, i.e., whether there is a tumor located in or about the common duct or
in the head of the pancreas, whether the tumor is primary or metastatic, or
whether there is a common duct stone. In the presence of malignant disease
obstructing the common duct without distant metastasis, the duodenum
should be mobilized and the operability of the lesion determined. Involvement about the portal vein contraindicates surgery. If extensive involvement
or dislocation of the duodenum by tumor is apparent, a gastroenterostomy
may be planned to avoid possible late obstruction. A determined attempt
should be made to prove the suspicion of tumor, even though extra e ort
may be required to obtain the biopsy. For biopsy purposes, mobilization of
the duodenum may be indicated to expose the posterior side of the head of
the pancreas, if the tumor seems more super cial there.
DETAILS OF PROCEDURE If the lesion is inoperable and the life expec-
tancy short, the surgeon must determine whether it is easier to anastomose
the distended gallbladder to the stomach, the duodenum, or the jejunum as
a palliative measure. e same type of anastomosis is used whichever viscus
is chosen. e more complicated but e cient types of anastomosis, such
as a Roux-en-Y anastomosis is not necessary unless there is a reasonable
chance of prolonged life expectancy.
As a rule, it is easy to perform the anastomosis to the stomach, preferably to cm above the pylorus and near the greater curvature. Should
such an anastomosis be likely to leave the gallbladder under tension when
the patient is erect, the anastomosis should be made to the duodenum or
upper jejunum. A portion of the bowel is held up to the gallbladder on its
medial side about to cm below the fundus (figure 1). If the gallblad-
der is greatly distended, it may be emptied through a trocar before the
anastomosis is started; if not, a posterior row of interrupted ne nonabsorbable sutures is placed to bring the two viscera in apposition without
opening either of them (figure 2). ese sutures should not enter the
lumen. e interrupted sutures (S) on the either end of the posterior
serosal layer are le long, and the others are cut to expose the eld where
the incisions into the gallbladder and stomach are to be made (figure 3).
e incision are then made with electrocautery paralleling the suture line,
with suction used to control the spread of any contents from either viscus (figure 3). e incisions are then lengthened to give a stoma of to
cm (figure 4). To avoid contamination some surgeons prefer to carry
out this procedure with enterostomy clamps applied to the gallbladder
and stomach. e bleeding from the mucosa of the stomach, which is the
only bothersome element, can be controlled easily by placing a mosquito
snap on each of the major vessels. e clamps should be loosened and
all bleeding points ligated before closure of the anterior layer. When the
eld is dry, the operator places a series of interrupted ne sutures in
the mucosal layers (figure 5). e anterior mucosal layer is closed with
interrupted sutures with the knots on the inside (figure 6). A er the
mucosal sutures are laid, an anterior row of interrupted sutures is placed
between the serosal coats to complete the anastomosis (figures 7 and 8).
e patency of the stoma is tested by palpation between the thumb and
index nger, and as a precaution several sutures may be inserted at either
angle. e eld must be free of oozing points.
CLOSURE A er the table is leveled, the omentum is brought up about the
anastomosis. A nasogastric tube is placed since gastric emptying will be
delayed. e incision is closed without drainage in a routine fashion.
POSTOPERATIVE CARE e administration of uids and food by mouth is
restricted for a few days, as in other intestinal anastomoses. e appearance
of bile in the stools and a decreasing icteric index indicate that the anastomosis is functioning. A high-vitamin, high-protein, and high-carbohydrate diet
is resumed as soon as tolerated. In elderly, poor-risk patients who refuse to
eat, a gastrostomy tube placed during surgery can be used for the refeeding
of bile mixed with milk and other liquids in order to hasten their recovery.
B. BIOPSY OF LIVER
INDICATIONS It is not uncommon during an exploratory laparotomy to
remove a small fragment of the liver for histologic study. Biopsy of the liver
is indicated in most patients who have a history of splenic or liver disease,
or in the presence of a metastatic nodule. e specimen should not be taken
from an area near the gallbladder, since the vascular and lymphatic connections between the liver and gallbladder are such that a pathologic process
involving the gallbladder may have spread to the neighboring liver, and as a
result the biopsy would not give a true picture of the liver as a whole.
DETAILS OF PROCEDURE Two deep sutures, a and b, are placed
about cm apart at the liver border (figure 1) using atraumatic type of
needle. e suture is passed through the edge of the liver and back through
again to include about one-half the original distance (figure 1a). is
prevents the suture from slipping o the biopsy margin with resultant
bleeding. ese sutures are tied with a surgeon’s knot, which will not slip
between the tying of the rst and second parts (figure 1a). e suture
should be tied as snugly as possible without cutting into the liver, for the
tension under which these knots are tied is the important factor in the
procedure. Such sutures control the blood supply to the intervening liver
substance. e two sutures are placed not more than cm apart, deep in
the liver substance; yet as they are tied, at least cm of liver are included
at the free margin to increase the size of the biopsy by making it triangular
in shape. An additional mattress suture, c, may be taken at the tip of the
triangular wound (figure 2). A er the biopsy is removed with a scalpel
(figure 3), the wound is closed by tying together the sutures, a and b, or
by placing an additional mattress suture, d, beyond the limits of the original sutures (figures 4 and 5). e area of biopsy is covered with some
type of anticoagulant matrix and omentum. ■
232
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