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ATLAS OF
GASTROINTESTINAL
V O L U M E
T W O
SURGERY
S E C O N D
E D I T I O N
JOHN L. CAMERON, MD, FACS
The Alfred Blalock
Distinguished Service Professor
The Department of Surgery
The Johns Hopkins Medical Institutions
Baltimore, Maryland
CORINNE SANDONE, MA, CMI
Medical Illustrator
Associate Professor
Department of Art as Applied to Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
2014
PEOPLE'S MEDICAL PUBLISHING HOUSE
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introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise),
without the prior written permission of the publisher.
14 15 16 17 / LEGO / 9 8 7 6 5 4 3 2 1
ISBN-13 978-1-60795-027-1
ISBN-10 1-60795-027-8
eISBN-13 978-1-60795-235-0
Printed in Italy by Legatoria Editoriale Giovanni Olivotto.
Editor: Linda Mehta; Page Designer: Norman Reid
Library of Congress Cataloging-in-Publication Data
Cameron, John L., author.
Atlas of gastrointestinal surgery / John L. Cameron, MD, FACS, the Alfred Blalock, Distinguished Service Professor, the Department of
Surgery, the Johns Hopkins Medical Institutions, Baltimore, Maryland, Corinne Sandone, MA, CMI, Medical Illustrator, Assistant Professor,
Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. -- Second edition.
pages cm
Description based on: v. 2, published in 2013.
Includes index.
ISBN-13: 978-1-60795-027-1 (v. 2 : alk. paper)
ISBN-10: 1-60795-027a-8 (v. 2 : alk. paper)
ISBN-13: 978-1-60795-235-0 (v. 2 : ebook) 1. Digestive organs--Surgery--Atlases. I. Sandone, Corinne. II. Title.
RD540.C225 2013 617.4'3--dc23 2013047568
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The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the
accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the
product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with
new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against
the benef its anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should
not be employed as, a substitute for individual diagnosis and treatment.
CONTENTS
Contributors vi
Preface vii
Dedication viii
THE STOMACH
Vagotomy 3
Truncal Vagotomy 5
Selective Vagotomy 10
Parietal Cell Vagotomy 13
Laparoscopic Vagotomy 18
Pyloroplasty 21
Heineke–Mikulicz Pyloroplasty 23
Pyloromyotomy 25
Finney Pyloroplasty and Jabouley Modification 27
Gastric Procedures
Gastrojejunostomy 31
Vagotomy plus Antrectomy 37
Closure of a Perforated Duodenal Ulcer 49
Duodenotomy with Oversewing of a Bleeding Duodenal Ulcer 53
Wedge Resection of a Benign Gastric Ulcer 57
Control of Bleeding from a Mallory–Weiss Syndrome Tear 60
Partial Gastrectomy for Cancer 63
High Lesser Curvature (Csendes) Gastrojejunostomy 72
Total Gastrectomy for Cancer 74
Resection of a Small Gastrointestinal Stromal Tumor (GIST) 86
Resection of Large Gastrointestinal Stromal Tumor (GIST) 88
Bariatric Procedures 95
Open Roux-en-Y Gastric Bypass 97
Laparoscopic Roux-en-Y Gastric Bypass 103
Laparoscopic Adjustable Gastric Band 114
Laparoscopic Vertical Sleeve Gastrectomy 119
Laparoscopic Duodenal Switch with Biliopancreatic Diversion 123
Gastrostomy
Operative Gastrotomy 133
Percutaneous Endoscopic Gastrostomy (PEG) 138
Remedial Operations following Gastric Surgery 147
Conversion of Billroth II Gastrojejunostomy to Roux-en-Y Gastrojejunostomy 148
Reversed Jejunal Loop Interposition for Dumping following Billroth I Gastroduodenostomy 154
Reversed Jejunal Loop for Dumping following Billroth II Gastrojejunostomy 158
Reversed Midjejunal Loop for Postvagotomy Diarrhea 162
THE DUODENUM
Resection of Villous Adenoma of Ampulla of Vater 167
Closure of End Duodenal Stump Fistula 174
Closure of Lateral Wall Duodenal Fistula 179
Management of Duodenal Diverticula 185
Resection of Duodenal Wall Gastrinoma 192
Resection of the Third and Fourth Portions of the Duodenum with Duodenojejunostomy 198
Duodenojejunostomy for Superior Mesenteric Artery Syndrome 205
Surgical Management of Annular Pancreas 209
iv Atlas of Gastrointestinal Surgery
THE SMALL BOWEL
Laparotomy for Small Bowel Obstruction 217
Small Bowel Intussusception 222
Resection of Meckel's Diverticulum 225
Crohn’s Disease
Laparoscopic Ileocecal Resection for Primary Occurrence of Crohn’s Disease 228
Ileocolic Resection for Recurrent Crohn’s Disease 236
Strictureplasty for Crohn’s Disease 239
Enteric Fistulas in Crohn’s Disease 243
Crohn’s Disease of the Terminal Ileum Involving the Sigmoid Colon 244
Crohn’s Disease of the Terminal Ileum with a Sigmoid Fistula into the Sigmoid Colon,
Also Involved with Active Disease 246
Crohn’s Disease of the Distal Ileum with Enterovesical Fistula 248
Crohn’s Disease of the Distal Ileum with a Fistula into the Vaginal Cuff 251
Crohn’s Disease with Enterocutaneous Fistula 253
Other Small Bowel Procedures
Resection of Small Bowel Gastrointestinal Stromal Tumor (GIST) 255
Resection of Carcinoid Tumor of Small Bowel 258
Resection of Desmoid Tumor of Small Bowel 261
Bypass of Unresectable Small Bowel Desmoid Tumor 263
End Ileostomy 265
Loop Ileostomy 269
Laparoscopic Loop Ileostomy 273
Loop Ileostomy Reversal 277
Feeding Jejunostomy 283
Operations for Acute Mesenteric Ischemia 286
Operations for Chronic Mesenteric Ischemia 292
THE COLON
Overview of the Anatomy of the Colon 301
Appendectomy 303
Laparoscopic Appendectomy 308
Right Hemicolectomy 313
Extended Right Colectomy 323
Laparoscopic Right Hemicolectomy 326
Left Hemicolectomy 337
Extended Left Hemicolectomy 344
Laparospcopic Left Hemicolectomy 347
Sigmoid Colectomy 356
Laparoscopic Sigmoid Colectomy 363
Sigmoid Colectomy with Rectal Stump (Hartmann’s Procedure) 369
Total Abdominal Colectomy with Ileorectal Anastomosis 372
Laparoscopic Total Abdominal Colectomy 383
Total Proctocolectomy with Ileal Pouch–Anal Anastomosis 397
Laparoscopic Total Proctocolectomy with Ileal Pouch–Anal Anastomosis 417
Total Proctocolectomy with End Ileostomy 437
Laparoscopic Total Proctocolectomy with End Ileostomy 452
Subtotal Colectomy for Ulcerative Colitis 471
Surgical Management of Sigmoid Volvulus 475
Surgical Management of Cecal Volvulus and Cecal Bascule 478
End Sigmoid Colostomy 482
Loop Colostomy 485
Laparoscopic Loop Colostomy 489
Loop Colostomy Reversal 493
Atlas of Gastrointestinal Surgery v
THE RECTUM
Overview of the Anatomy of the Rectum 501
Rectal Cancer
Low Anterior Resection (Restorative Proctectomy) 502
Laparoscopic Restorative Proctectomy with Colo-anal Anastomosis 519
Abdominoperineal Resection (APR) 535
Laparoscopic Abdominoperineal Resection 548
Pelvic Exenteration 561
Transanal Resection of Rectal Tumor 577
Kraske Posterior Approach for Mid-rectal Tumors 584
Rectal Prolapse
Operative Indications 591
Sigmoid Resection with Rectopexy 593
Laparoscopic Sigmoid Resection with Rectopexy 600
Laparoscopic Rectopexy 613
Perineal Repair with Muscosal Stripping (Delorme Procedure) 621
Perineal Rectosigmoidectomy (Altemeir Procedure) 627
THE ANUS
Patient Positioning for Anorectal Procedures 635
Anal Fissure 638
Anal Abscess and Fistula
Perirectal Abscess 641
Anal Fistulotomy 643
Draining Seton for Fistula-in-Ano 646
Horseshoe Abscess and Fistula 649
Cutting Seton for Fistula-in-Ano 651
Anorectal Advancement Flap for Fistula-in-Ano 654
Anal Fistula Plug for Fistula-in-Ano 657
Complicated Fistula Repairs
Repair of Anovaginal Fistula with Anorectal Advancement Flap 661
Repair of Anovaginal Fistula with Overlapping Sphincteroplasty 664
Repair of Rectovaginal Fistula with Martius Flap 668
Repair of Rectourethral Fistula with Pedicled Gracilis Muscle Flap Interposition 673
Hemorrhoidectomy
Hemorrhoid Classification 677
Excision of Thrombosed Hemorrhoid 678
Hemorrhoid Ligation (Banding) 680
Traditional Hemorrhoidectomy 683
Stapled Hemorrhoidectomy 687
Other Anal Procedures
Flap Repair of Anal Stricture 689
Overlapping Sphincteroplasty for Fecal Incontinence 691
Sacral Neuromodulation for the Treatment of Fecal Incontinence 695
Excision and Marsupialization for Pilonidal Cyst Disease 701
Gluteal Flap Reconstruction following Excision of Pilonidal Cysts 704
Wide Local Excision for Paget’s Disease 707
Local Excision of Anal Condyloma 712
Index 715
CONTRIBUTORS
John L. Cameron, MD
James H. Black, MD
Michael A. Choti, MD
Jonathan E. Efron, MD
Susan L. Gearhart, MD
Michael A. Schweitzer, MD
Department of Surgery
The Johns Hopkins Medical Institutions
Baltimore, Maryland
Corinne Sandone, MA, CMI
Department of Art as Applied to Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
PREFACE
Many of the beginnings of gastrointestinal surgery in the United States took place at the Johns Hopkins Hospital. Dr.
William Steward Halsted, the first Chief of Surgery at Hopkins, established the first reliable intestinal suture in the 1880s.
Prior to that time, alimentary tract anastomoses by Billroth, Mikulicz, and other surgeons of Europe often ended in failure.
It was initially thought that the muscular layer of the intestine was the most important layer in which to place an intestinal
stitch. Halsted was the first to demonstrate that an intestinal suture must include the sub-mucosal layer to result in a secure
stitch. Halsted also performed some of the first biliary tract operations in the United States, and was the first surgeon in
the world to successfully resect a periampullary tumor.
Medical illustration in the United States also had its beginnings at the Johns Hopkins Hospital when, in 1894, Max
Brödel was recruited from Leipzig, Germany to join the staff and faculty of the Johns Hopkins Hospital. Brödel’s clear
and anatomically accurate illustrations of the pioneering work of Drs. Halsted, Harvey Cushing, William H. Welch,
Howard A. Kelly, and Thomas Cullen established medical illustration in this country. In 1911, the Department of Art as
Applied to Medicine was established as the twelfth department in the School of Medicine; it has been teaching medical
illustration continuously for over a century.
After Halsted, the next great surgical era at Hopkins was overseen by Dr. Alfred Blalock and his brilliant trainees who
played a dominant role in the emergence of cardiac surgery. An outstanding student of Max Brödel, Leon Schlossberg,
illustrated much of this work. In the 1970s and 1980s gastrointestinal surgery again emerged as an important focus for
the Department of Surgery. Its eminence has persisted up to the present time with a focus on advancements in treating
hepatic, biliary, and pancreatic diseases.
The alimentary tract surgeons at Hopkins have collaborated with Corinne Sandone, a key faculty member in our Department
of Art as Applied to Medicine, to produce this second edition of our atlas. This two-volume atlas includes operative procedures on the stomach, duodenum, small bowel, colon, rectum, and anus as well as the liver, biliary tract, and pancreas.
For many of the procedures, both open and laparoscopic approaches are described. We believe the artwork for this atlas
provides clarity that a camera could not capture, while maintaining the realism of the perioperative field. Also included are
illustrations depicting views that cannot be photographed: conceptual images, cut-away views, and distillations of visual
information not easily observed in the operating room. The pitfalls and technical details for success are described in the
text and are further elucidated with illustrations.
The goal of this volume is to present the alimentary tract procedures performed frequently at the Johns Hopkins Hospital in
such a fashion that other alimentary tract surgeons can learn these techniques and perform them successfully. This atlas is not
a complete compendium of all gastrointestinal procedures performed. It describes the techniques, operations, and procedures
favored and performed – and in some instances initiated – by the gastrointestinal surgeons at the Johns Hopkins Hospital.
Corinne Sandone and John L. Cameron
June 2013, Baltimore, Maryland
DEDICATION
To all who participate in the care of patients with surgical gastrointestinal diseases,
particularly those surgeons who trained or spent time here, and are now building
their own schools of gastrointestinal surgery, this atlas is dedicated.
JLC
For Dan, Carlene and Claudia - smart, funny and kind.
CS
THE STOMACH
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