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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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212 Atlas of Gastrointestinal Surgery: The Duodenum
Duodenum
The inner layer is brought forward anteriorly in a Connell
stitch fashion (5). The anastomosis is completed with an
Inner layer of
anterior row
outer layer of interrupted 3-0 silk (6). The limbs of the
jejunal loop are loosely tacked to the rent in the transverse
mesocolon with 3-0 silk.
5
Jejunum
Completed
side-to-side
duodenojejunostomy
Transverse
mesocolon
6
Surgical Management of Annular Pancreas 213
Alternatively the jejunum can be brought up in an antecolic position and anastomosed to the
first portion of the duodenum in a similar fashion (7). However, I prefer to bring the jejunum
up in a retrocolic position.
Alternative
Antecolic
duodenojejunostomy
Liver
Colon
Stomach
Duodenum
Jejunum
7
214 Atlas of Gastrointestinal Surgery: The Duodenum
An alternative to either duodenojejunostomy is to perform a gastrojejunostomy. This may be necessary when so much
chronic pancreatitis exists that it is difficult to find an area of dilated first portion of the duodenum that is thought safe for
an anastomosis. The greater curvature of the stomach is cleaned. The proximal jejunum is brought up through a rent in the
transverse mesocolon, and a posterior retrocolic gastrojejunostomy is performed. It is carried out with an outer layer of inter-
rupted 3-0 silk and an inner layer of continuous suture using 3-0 synthetic absorbable material (8). A truncal vagotomy
is performed. To be certain that the partially obstructed first portion of the duodenum is adequately decompressed, some
prefer to also perform a pyloroplasty (inset), destroying the pyloric sphincter. In my experience, however, this generally is
Alternative
Retrocolic
gastrojejunostomy
Vagus nerves
divided
Duodenum
Jejunum
Stomach
not necessary. Others have suggested performing a duoden-
oduodenostomy around the annular pancreas, anasto-
mosing the dilated redundant first portion of the
duodenum to the collapsed distal second portion.
However, because of the high risk of pancreatitis
in the annular portion of the pancreas, I do not
favor this approach.
Optional pyloroplasty
Stomach
Duodenum
Transverse
colon
Pancreas
Annular pancreas
8
THE SMALL BOWEL
Laparotomy for Small Bowel Obstruction
Operative Indications
Laparotomy for small bowel obstruction remains one of the more common operative procedures performed by general sur-
geons. Even though some surgeons advocate a laparoscopic approach, most patients with small bowel obstruction are
explored through a midline laparotomy incision. Currently, approximately three quarters of all small bowel obstructions are
caused by adhesions. This is a substantial change from the early twentieth century, when incarcerated inguinal hernias were
the primary etiology. Other causes of small bowel obstruction include small bowel tumors, metastatic tumors (usually from
colorectal cancer), intussusception, bezoars, Crohn’s disease, and gallstone ileus. Approximately 50% of patients with
small bowel obstruction secondary to adhesions require exploratory laparotomy. The remaining obstructions resolve with
the use of a nasogastric tube and intravenous fluid support. Whether or not a patient can appropriately be managed non-
operatively is a judgment that is based on experience. Factors that play an important role in this decision include the pre-
sumed etiology of the small bowel obstruction, prior surgery, incomplete obstruction versus complete obstruction, first
occurrence versus recurrent small bowel obstruction, and most importantly, the patient’s condition. If the patient is afebrile,
with a soft, non-tender abdomen and a normal white blood cell count, non-
operative management may be appropriate. However, inappropriate delay in
exploring a patient with small bowel obstruction may result in a simple obstruc-
tion developing into a strangulation obstruction.
Operative Technique
Patients with small bowel obstruction are best explored through a midline inci-
sion. A prior surgical incision is usually present, and reopening that incision, if
it is midline, should be undertaken with great care to avoid injury to bowel that
may be stuck to the undersurface of the incision. Often, as in this illustration, a
218 Atlas of Gastrointestinal Surgery: The Small Bowel
loop of small bowel is stuck to the
undersurface of the midline incision.
Other adhesions to this loop of
bowel result in a small opening,
through which a second loop of
small bowel herniates, becom-
Adhesions
Ischemic
small bowel
ing strangulated, ischemic, and
eventually necrotic (1).
Proximal
small
bowel
1
Lysis of such adhesions
should be carried out
sharply, and with care not to
create an enterotomy (2). The
adhesions are taken down, and the
ischemic bowel is released.
2
Proximal
bowel
Laparotomy for Small Bowel Obstruction 219
Ischemic
small bowel
Mesentery
Distal bowel
The ischemic bowel is resected by firing a linear sta-
pler both proximal and distal to the area of the
demarcated bowel (3). A 3- or 4-cm margin of
normal bowel is generally adequate. After the
mesentery to the necrotic bowel is divided
3
Posterior
outer row
between Kelly clamps and ligated with 2-0
silks, an end-to-end anastomosis is per-
formed. A posterior outer row of 3-0 silk
Lembert sutures is placed (4).
Proximal
bowel
Distal
bowel
4
220 Atlas of Gastrointestinal Surgery: The Small Bowel
5
Both staple lines are removed with the electrocautery
device. (5). The inner posterior row is a continuous lock-
Inner posterior
row (locking)
ing stitch of synthetic absorbable suture (6), brought
around anteriorly utilizing a Connell stitch (7).
Anterior
inner row
Proximal
bowel
Distal
bowel
7
6
Laparotomy for Small Bowel Obstruction 221
An outer interrupted layer of 3-0 silk Lembert sutures is then
placed. The rent in the small bowel mesentery is closed
Anterior
outer row
abdomen is copiously irrigated with an antibiotic-
containing solution and closed.
Whether or not to lyse all adhesions in the
abdomen, when multiple adhesions are pres-
ent, is somewhat controversial. Most surgeons
feel that if adhesions are not causing obstruc-
tion they should be left alone. Theoretically for
every adhesion lysed, two more adhesions are
with either interrupted or continuous sutures (8). The
8
formed. Therefore, lysing only those adhesions
that appear to be causing complete or partial
obstruction is the favored approach.
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