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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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Small Bowel Intussusception
Operative Indications
Small bowel obstruction secondary to intussusception occurs much less infrequently in the adult than in the pediatric age
group. In children the intussusception is virtually always ileocolic, and generally no pathologic entity can be identified as a
lead-point, except perhaps for an increase in lymphatic tissue in the terminal ileum. In the adult there is almost always lead-
point pathology, either a benign polyp or a malignant
lesion (1). Often on CT scan small bowel intussus-
ception can be identified by seeing a typical
“target sign” on cross-sectional imaging. In the
pediatric age group ileocolic intussusception
Distal
small bowel
Dilated proximal
small bowel
often can be managed successfully non-opera-
tively with barium enema reduction. In
adults, however, radiographic reduc-
tion is never attempted, and
exploratory laparotomy should
be carried out. At least 50%
of these patients will have a
malignancy as the lead-point of
the intussusception.
Polyp as lead point of
intussusception of small bowel
1
Small Bowel Intussusception 223
Operative Technique
A patient with small bowel obstruction diagnosed by CT scan with intussus-
ception should be explored through a midline incision. The area of intussuscep-
tion is always easily identified. Usually the intussusception can be reduced by
gentle firm retraction in the opposite direction of the area of intussusception.
Once it is reduced the segment of bowel involved should be resected, as in
most instances in adults pathology will be present. Sometime even with signifi-
cant force, the intussusception cannot be reduced. In that instance a little more
bowel may need to be resected. Using a linear stapler the bowel is divided both
proximal and distal to the area of intus-
susception (2). Distally the transition
between the intussusception and normal
bowel is clear, and only a 3- or 4-cm
margin is required. Proximally the bowel
may be dilated, but again a 3- or 4-cm mar-
gin is adequate. These margins may have to
be increased if the lesion proves to be
malignant. The segment of mesentery
supplying the area of intussuscep-
tion is then divided between
Kelly clamps and ligated
with 2-0 silks.
Proximal
small bowel
Mesentery
Distal
small
bowel
2
224 Atlas of Gastrointestinal Surgery: The Small Bowel
The specimen is removed from the operative field. An
end-to-end anastomosis is performed with an inner-
layer of continuous absorbable 3-0 synthetic suture
and an outer layer of interrupted 3-0 silk Lembert
sutures (3). The rent in the small bowel mesentery is
closed with either interrupted or continuous sutures.
The abdomen is copiously irrigated with an antibiotic-
containing solution, and the wound is closed in layers.
Proximal
small bowel
End-to-end
anastomosis
Distal small bowel
3
Resection of Meckel’s Diverticulum
Operative Indications
A Meckel’s diverticulum is an outpouching of the small intestine. It is a true diverticulum, containing all layers of normal
bowel. Meckel’s diverticula are the most common congenital anomolies of the small bowel, occurring in approximately 2%
of the population. The rule-of-twos states that 2% of the population have Meckel’s diverticula, they are generally 2 inch-
es in length, occur within 2 feet of the ileocecal valve, and can contain two types of heterotopic mucosa: gastric and pan-
creatic. Of individuals who develop symptoms, most do so within their first 2 years of life.
In the adult population, small bowel obstruction is the most common presentation and occurs in approximately one half
of those individuals who become symptomatic. Obstruction can occur secondary to either a volvulous or an intussuscep-
tion. Inflammation also may occur, and its differentiation from acute appendicitis may be difficult. Although radionuclide
scans may help make the diagnosis preoperatively by demonstrating gastric mucosa in the diverticulum, in most instances the
diagnosis is made at the time of surgery. It is generally agreed that if a Meckel’s diverticulum is discovered during a laparo-
tomy in a young child, it should be resected. This decision is much more controversial in adult patients. Most general sur-
geons do not resect an incidental Meckel’s diverticulum discovered during a laparotomy unless abnormal heterotopic tissue
can be palpated or an adjacent ulcer is seen or palpated.
226 Atlas of Gastrointestinal Surgery: The Small Bowel
Operative Technique
A Meckel’s diverticulum can be resected, and closed in two layers. In most
instances, however, the diverticulum should be resected with a short segment
of ileum and the bowel reanastomosed. If the patient has presented with intes-
tinal bleeding secondary to an ulcer from heterotopic gastric mucosa, the bowel
should definitely be resected, as the ulcer is generally located in adjacent nor-
mal bowel, and not in the diverticulum.
The patient is explored through a midline incision. A linear stapler is used
to divide the bowel just proximal and distal to the diverticulum (1). The
mesentery to that segment of bowel is divided between Kelly clamps and lig-
ated with 2-0 silk ties.
1
Meckelʼs
diverticulum
Resection of Meckel’s Diverticulum 227
An end-to-end anastomosis is performed
in the classic fashion with an inner continuous
layer of 3-0 synthetic absorbable suture
material and an outer interrupted layer of
3-0 silk Lembert sutures (2). The rent in the
small bowel mesentery is closed with either
interrupted or continuous sutures. The abdomen is
copiously irrigated with antibiotic-containing solu-
tion, and the wound is closed in layers.
2
CROHN’S DISEASE
Laparoscopic Ileocecal Resection for
Primary Occurrence of Crohn’s Disease
Operative Indications
Crohn’s disease is an idiopathic inflammatory disease of the gastrointestinal tract that can involve any segment along the
entire gut, but most commonly affects the distal small bowel. The peak incidence is in the third decade, the etiology is
unknown, and it affects men and women equally. The most common pattern of disease at initial presentation is involvement
of the terminal ileum and proximal colon (1, 2).
Right
colon
Cecum
Terminal ileum
Appendix
(thickened wall)
Ileum
1
Mesenteric
lymph nodes
2
Fat wrapping
Laparoscopic Ileocecal Resection for Primary Occurrence of Crohn’s Disease 229
The vast majority of patients with Crohn’s disease eventually require surgical resection, with ileocolic anastomosis.
Laparoscopic ileocecectomy has become the procedure of choice for the initial resection of Crohn’s disease of the termi-
nal ileum and cecum. Because Crohn’s disease surgery often results in minimal adhesions, resections for recurrent Crohn’s
disease may also be performed laparoscopically. Since intraoperative evaluation for other sites of Crohn’s disease is limited
during a laparoscopic approach, complete evaluation with a preoperative small bowel series and colonoscopy is beneficial.
Preoperative preparation of the patient undergoing laparoscopic resection for primary occurrence of Crohn’s disease includes
a mechanical bowel preparation, intravenous antibiotics, and prophylaxis for deep vein thrombosis.
Operative Technique
Positioning of the patient is paramount in performing a
laparoscopic resection. The patient is placed in the
lithotomy position with the left arm tucked. The
abdomen is prepped and draped widely. Video mon-
itors are placed near the head of the operating table,
and the operating surgeon stands at the patient’s left side.
To minimize the risk of injury, gastric and bladder decompres-
sion should be performed prior to port insertion.
Laparoscopic ileocectomy can be performed with four
ports: three 10-mm ports and one 5-mm port. The camera
port is inserted first. An infraumbilical incision is made, and
a Verres needle is inserted to insufflate the abdomen.
Alternatively, entrance to the abdominal cavity can be
obtained by dissecting down to the peritoneum and enter-
ing the abdomen under direct vision (Hasson technique).
The Hasson technique is favored over the blind insertion
of the trocar in patients who have had previous abdominal
surgery. Once the abdomen is insufflated, a 30-degree
camera is placed through the trocar and the abdomen is sys-
tematically explored.
230 Atlas of Gastrointestinal Surgery: The Small Bowel
The remaining three trocars are inserted under direct visualization through the laparoscope. A 5 mm port is placed in
the epigastrum and 10 mm ports are placed in the suprapubic and left lateral positions. The procedure begins with mobi-
lization of the lateral peritoneal attachments of the cecum and right
colon. To improve exposure, the patient is placed in the
Trendelenberg position with the right side tilted up.
The assisting surgeon provides initial medial
retraction of the right colon by placing a
grasper on the appendix through the epi-
gastric port. Additional retraction of the
terminal ileum and cecum is provided
by the operating surgeon through the
suprapubic port. Endoshears,
placed through the left port, are
used to divide the lateral peri-
toneal attachments (3).
Lateral
peritoneal
attachments
Right
colon
Appendix
Inflamed
terminal ileum
3
In active Crohn’s disease, an
increase in vascularity is often
seen, and electrocautery may be
needed for mobilization. When
lateral mobilization is complete and
the terminal ileum, cecum, and
ascending colon have been released
Laparoscopic Ileocecal Resection for Primary Occurrence of Crohn’s Disease 231
SMA
Ascending
colon
Ileocolic
vessels
from their retroperitoneal attachments,
the surgeon’s attention is turned
toward ligation of the vascular
pedicles. Ligation of the vascu-
lar pedicle at the root of the
mesentery is preferred since
the mesentery adjacent to
the bowel is often thick-
ened. The right meso-
colon is lifted with a
bowel grasper, and the ileo-
colic vessels are identified.
Mesenteric defects are created
and the ileocolic vessels are skeletonized
Right
mesocolon
Terminal
ileum
4
Cecum
(4). The vessels are divided with a vascular lin-
ear stapler (5) or endoclips and shears.
Ileocolic
vessels
divided
5
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