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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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282 Atlas of Gastrointestinal Surgery: The Small Bowel
For a stapled anastomosis, the corners of the staple lines
are removed and a gastrointestinal stapler is inserted into both
loops of bowel (11). Once the mesentery is clear of the sta-
pler, the stapler is fired.
A second stapling device is then used to close the remaining
open lumen (12). 3-0 nonabsorbable sutures are placed at the
apex of the anastomosis to release tension on the staple line, and
11
along the final staple line to invert the mucosal edge (13). The
intestine is returned to the peritoneal cavity.
The abdominal fascia is identified, mobilized, and closed
with nonabsorbable sutures. The wound is irrigated and
hemostasis is obtained. A 3/16
th
drain is placed into the
wound. 3-0 absorbable dermal sutures are placed to
close the ostomy site obliquely. The skin is closed with
absorbable 4-0 subcuticular sutures. The drain is secured
with a 3-0 nonabsorbable suture.
12
New
lumen
connecting
proximal and
distal limbs
Reinforcing
suture at
apex of
staple line
13
Feeding Jejunostomy
Operative Indications
Feeding jejunostomies are created in a wide variety of instances. They are frequently used after extensive intra-abdominal
procedures such as a Whipple operation, major liver surgery, total gastrectomy, and major colon surgery. Many trauma sur-
geons place a feeding jejunostomy in individuals explored for major intra-abdominal trauma in which the recovery period is
anticipated to be prolonged. Many thoracic surgeons routinely place a feeding jejunostomy after esophagectomy. Feeding
jejunostomies can be placed laparoscopically, but in most instances where they are used, there is already a sizeable abdom-
inal incision. We demonstrate a feeding jejunostomy as an open procedure.
Operative Technique
If no incision has been made, a small midline incision is used.
Jejunostomy
site
284 Atlas of Gastrointestinal Surgery: The Small Bowel
imately 40 cm distal to the last anastomosis is picked.
A site 40 cm distal to the ligament of Treitz is chosen, if the
duodenum is still intact. If not, a site in the proximal jejunum approx-
Two purse strings of 2-0 silk are placed concentrically. A small
enterotomy is made, and a 16 Fr red rubber catheter, with sever-
al additional side holes, is inserted through the purse-string
sutures into the distal jejunum. The inner suture is secured first,
followed by the outer suture (1).
1
Catheter advanced
into distal jejunum
The jejunostomy catheter is imbri-
cated by placing several 3-0 silk
Lembert sutures distal to the inser-
tion site (2).
Jejunum
Catheter
2
This creates a tunnel for the jejunostomy
(3), which will subsequently allow removal
without spillage of intestinal contents.
3
Feeding Jejunostomy 285
The jejunostomy tube is brought out
through a stab wound in the left upper
quadrant. The jejunum is tacked up to
the abdominal wall at the site of the
stab wound, in all four quadrants, with
interrupted 3-0 silk sutures. One or
two additional sutures are used to tack
4
the jejunum to the under surface of the
The jejunostomy tube is
abdominal wall (4), so that the jejunum does
not volvulate on itself.
sutured in place to the skin
with 4-0 stainless steel wire,
wrapped around the jejunostomy
tube in a “Chinese finger trap” fash-
ion (5). Stainless steel wires are used
because the jejunostomy may stay in
place for weeks.
5
Operations for Acute Mesenteric Ischemia
Operative Indications
Acute embolic occlusion of the superior mesenteric artery (SMA) classically occurs when an embolus lodges in the mid
segment of the SMA, sparing the proximal jejunal and middle colic vessels (1a). The remaining small bowel and right colic
vessels are occluded, leading to ischemic bowel. The diagnosis should be strongly considered in patients with diffuse
abdominal pain and relatively benign
physical findings—the classic
description of “pain out of propor-
tion to physical findings.” A recent
myocardial infarction or atrial fibrilla-
tion may give a clue to the embolic
source. Plain abdominal X-ray films
are usually nonspecific.
In contrast, thrombotic occlusion
of the SMA most often occurs due
to severe proximal atherosclerotic
disease, thus threatening all of the
small bowel distal to the ligament of
Treitz and colon to the splenic flex-
ure (1b). Generalized atheroscle-
ACUTE CHRONIC
Thrombus
Embolus
in
midsegment
of SMA
rotic disease may be evident in
patients with chronic mesenteric vas-
cular disease and manifest as claudi-
cation, extracranial carotid disease,
or coronary artery disease.
1a
1b
Operations for Acute Mesenteric Ischemia 287
Operative Technique
The patient is positioned supine for a long midline incision to
fully examine the entire small and large bowel. A roll should
be placed transversely under the upper lumbar vertebrae to
angle the costal margin upwards, thus facilitating the dissec-
tion of the diaphragmatic hiatus and upper abdominal aorta
and its branches (2).
2
Areas of clearly nonviable small
and large bowel should be
promptly resected. The trans-
verse colon is retracted in a
cephalad direction. The pulse
of the SMA is palpated in
the root of the small bowel
SMA
Jejunum
mesentery between the thumb
and index finger at the base of
the transverse mesocolon (3).
3
288 Atlas of Gastrointestinal Surgery: The Small Bowel
The SMA is exposed by dissecting the root of
the small bowel mesentery at the base of the
transverse mesocolon in the area of the middle
colic vessel, and is controlled with vessel
loops. A transverse arteriotomy is per-
formed with a #11 blade, and the lumen
Middle
colic a.
is examined for fresh clot (4).
SMA
opened
4
SMA
The proximal clot is removed with sequential passes with a
4 or 5 Fr embolectomy catheter (5) until substantial pulsatile
inflow is achieved. Inability to pass a catheter into the aorta
may indicate severe proximal SMA arteriosclerotic disease and
vascular reconstruction may be necessary, as described in the
next section (9 and 10).
Proximal
clot
removed
5
SMA
Operations for Acute Mesenteric Ischemia 289
careful passes of a 3 Fr embolectomy catheter, as the individual
Distal
clot
removed
6
distal branches are easily damaged or incited to spasm (6).
7
Arteriotomy
closed
8
Branch
thrombus
Transillumination of the small bowel mesentery is helpful to demon-
strate the vascular arcades, which may be “milked” from the bowel
toward the arteriotomy to remove branch thrombi (7).
The transverse arteriotomy of the SMA is closed with a contin-
uous or interrupted 6-0 synthetic nonabsorbable suture (8).
290 Atlas of Gastrointestinal Surgery: The Small Bowel
Revascularization of the SMA
If severe proximal SMA arteriosclerotic disease renders arterial inflow insufficient, then an SMA bypass is indicated to
optimize reperfusion of the ischemic bowel. In cases of mesenteric infarction, the dead bowel should be resected but the
remaining bowel should not be re-anastomosed. For the vascular reconstruction, an autogenous bypass of suitable diame-
ter saphenous vein (>6 mm) is preferred. If extensive contamination is not present and hemodynamic instability noted,
then PTFE graft implantation can be more rapidly performed.
By completely releasing the ligament of Treitz,
the duodenum can be mobilized, exposing the
left side of the SMA above the mesocolon
and just below the pancreas. In this loca-
tion, the SMA is larger than the
more distal inframesocolic site
used for clot removal, and a
patulous anastomosis may be
constructed (9).
SMA
Pancreas
elevated
Ligament of
Treitz divided
9
Operations for Acute Mesenteric Ischemia 291
Importantly, the neighboring proximal infrarenal
aorta is often spared of atherosclerosis for origina-
tion of the bypass for SMA inflow. In order to
facilitate the aortic anastomosis in the proximal
infrarenal aorta, often a complete aortic cross
10
SMA
Aorta
Renal
vessels
Autogenous
bypass
(saphenous
vein)
clamp is required for hemostasis. In the rare
instance of the infrarenal aorta being large and not
significantly diseased, a partial occlusion cross
clamp can be performed with a Satinksy or
Lemole aortic clamp. An end-to-side anastomosis
to the infrarenal aorta is performed with 4-0 syn-
thetic nonabsorbable suture. The graft should be
sized for length to assume a gently curved course
to prevent kinking as the mesentery is placed back
into anatomic position (10). The end-to-side
anastomosis should be performed onto the SMA
with 5-0 synthetic nonabsorbable suture.
The patient is re-explored in 24 hours to
assess reperfusion of ischemic bowel. If necrotic
bowel had been resected, intestinal continuity can
be reestablished.
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