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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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302 Atlas of Gastrointestinal Surgery: The Colon
SMA
Transverse colon
Middle colic a.
IMV
Arc of Riolan
Descending
(left) colon
Ascending
(right)
colon
Cecum
Appendix
R. colic a.
Ileocolic a.
1
Rectum
IMA
L. colic a.
Sigmoidal a.
Marginal a.
of Drummond
Sigmoid colon
mobilized to the origin of its vascular blood supply. This mobilization is accomplished by separating the relatively avascu-
lar peritoneal attachments of the mesentery of the colon to the retroperitoneum and the omentum to the anterior surface of
the transverse colon and its mesentery. Any vessels within these attachments that need ligation are present at the splenic
and hepatic flexures. In patients with portal hypertension, the small vessels within these avascular planes may become
engorged, making mobilization more tedious.
Appendectomy
Operative Indications
The diagnosis of appendicitis is often straightforward but occasionally it may be ambiguous. The typical patient is a child
or young adult with a history of epigastric pain that has shifted to the right lower quadrant and is associated with anorex-
ia, nausea, vomiting, and a low-grade fever. A patient with a perforated appendix may have generalized peritonitis.
Appendectomy is indicated whenever there is a concern for the presence of acute or chronic inflammation, with or with-
out perforation of the appendix (1). Occasionally, at the time of exploration of the right lower quadrant, the appendix
may be normal in appearance. However, it is still recommended that the appendix be removed even if there is no other
discernable cause for the patient’s symptoms.
Occasionally, an incidental appendectomy may
be performed at the time of another
planned procedure. Preoperative prepara-
tion for an appendectomy includes broad-
spectrum antibiotics and prophylaxis
against deep vein thrombosis.
Ileocolic a.
Terminal ileum
Mesoappendix
Cecum
1
Inflamed
appendix
304 Atlas of Gastrointestinal Surgery: The Colon
Operative Technique
When the diagnosis is reasonably certain, a right lower quad-
rant incision is made. The incision is centered over McBurney’s
point. This point is located one-third the way along a line
drawn from the right anterior superior iliac crest to the umbili-
cus (2). The placement of this incision allows for medial or lat-
eral extension if a cecectomy or right hemicolectomy must be
McBurneyʼs incision
strong likelihood that other pathology may be present.
However, explorative laparoscopy has largely replaced this.
Once the anterior fascia is identified, it is opened just lateral to
the edge of the rectus abdominis muscle. The muscle fibers pres-
performed. Vertical incisions are occasionally used if there is a
2
ent are the internal and external oblique.
These muscles are gently separated in the direction of the fibers, and the
posterior fascia is identified. This is known as a muscle-spreading
technique and results in decreased discomfort for the patient
postoperatively. While gently lifting up on the posterior fascia
with two clamps to prevent injury to internal structures, the
posterior fascia is incised with scissors (3). The incision
must be large enough to allow two of the operator’s fin-
gers to be inserted into the abdomen. Two hand-held
retractors are usually sufficient to assist in exposure.
Posterior
fascia opened
3
Once the abdomen is entered, it is inspected for tur-
bulent fluid. If present, it should be cultured for aero-
bic and anaerobic bacteria. Occasionally, the
Appendectomy 305
appendix is immediately visible. If not visible, the
operator’s two fingers sweep across the right
lower quadrant to identify the cecum. Careful
retraction of the cecum with a Babcock
clamp will lead to the appendix. To remove
a retrocecal appendix, the lateral peritoneal
attachments to the cecum must be incised.
The appendix and base of the cecum should
be delivered outside the abdomen in order to
assure proper removal. A window is created in the
mesoappendix just medial to the base of the appen-
dix. The mesoappendix is clamped with a curved hemo-
stat and divided (4). The appendiceal vessels contained with-
in the clamped mesoappendix are secured with a tie.
4
Cecum
Inflamed
mesoappendix
divided
Two clamps are placed across the appendix at the base of
the cecum. The appendix is divided between the clamps
approximately 5 mm from the base (5). Alternatively,
a single crushing clamp is used to first indent the
appendix 5 mm above the base and then is
placed distal to this indentation. A 2-0 syn-
thetic absorbable tie can be used to ligate
the base of the appendix if placed secure-
ly at the site of the previous indentation.
The appendix is divided between the tie
Appendix
divided
5
and the clamp (not shown).
306 Atlas of Gastrointestinal Surgery: The Colon
Alternatively, the mesoappendix as well as the base of the
appendix may be divided with a linear stapler (6). Each of
these methods prevents spillage of gastrointestinal contents.
6
7
The remaining visible mucosa of the appendix is
touched with the electrocautery device (7).
Staple line
on mesoappendix
Staple line
on appendix
Pursestring
suture
Appendectomy 307
8
Furthermore, the appen-
diceal stump can be inverted. An
assistant holds the cecum with a
sponge while a single pursestring of
2-0 silk is placed circumferentially in the
base of the cecum 5 mm from the appen-
diceal stump (8).
The appendix is inverted and the suture is secured (9).
The abdomen is irrigated with an antibiotic-containing solution.
No drains are required following removal of the acutely inflamed
appendix. However, a periappendiceal abscess may require drainage
with a closed suction drain. The wound is closed in layers. The poste-
rior fascia is closed by grasping the edges with a curved hemostat and
running the closure with a 3-0 synthetic absorbable suture while maintain-
ing direct visualization of the abdominal contents. The anterior fascia is
closed with a heavier suture in an interrupted fashion. Based on the degree of
contamination, the skin edges are either closed with a subcuticular stitch, with
interrupted sutures spaced widely apart, or left open and packed.
9
Stump
inverted
Laparoscopic Appendectomy
Operative Indications
Appendectomy can be accomplished with minimally invasive techniques allowing the patient to resume normal activity soon-
er with less discomfort at a comparable cost to the open procedure. The limited exposure obtained in the open procedure
does not allow for sufficient visualization of pelvic or upper abdominal organs when searching for alternative causes for the
patient’s symptoms. Furthermore, wound infection rates are higher with open surgery. The laparoscopic approach can be
more difficult if the patient presents with a large appendiceal abscess or longstanding rupture with several loops of bowel
adherent to the right lower quadrant. In that situation, initial drainage of the abscess with delayed (interval) appendecto-
my or a midline incision is recommended. Preoperative preparation includes broad-spectrum antibiotics and prophylaxis
against deep vein thrombosis.
Operative Technique
As in all laparoscopic procedures, positioning the patient correctly is paramount to performing the procedure. Gastric and
bladder decompression are performed to minimize the risk of bowel or bladder injury and to maximize visualization. The
patient is placed in the lithotomy position with at least the left arm tucked to the side. The abdomen is prepped and draped
widely. The video monitors are placed near the head or foot of the bed and the operating surgeon stands at the patient’s
left side. Laparoscopic appendectomy can usually be performed with three 10-mm working ports or two 10-mm ports and
one 5-mm port. The camera port is inserted first. A vertical midline incision is made below or just above the umbilicus. A
Veress needle can then be inserted and when low intra-abdominal pressure is achieved, the abdomen is insufflated.
Laparoscopic Appendectomy 309
Alternatively, entrance to the abdominal cavity can be obtained by dissecting down to the peritoneum and entering
the abdomen under direct visualization (the Hasson technique). A blunt end Hasson trocar is placed into the abdomen.
The stylet is removed, and the abdomen is insufflated. The Hasson trocar is secured with two 3-0 nylon sutures, which
are placed on each side of the trocar. The Hasson technique is favored over the blind insertion of the Veress needle and
trocar in patients who have had previous abdominal surgery.
Once the abdomen has been insufflated, a 30-degree
camera is placed through the trocar and the abdomen is
systematically explored. Obtaining cultures of turbid fluid
is not as easy as in an open procedure. However, if a
pocket of fluid is identified, an aspirating needle with a
syringe on the end can be introduced under direct vision
through the abdominal wall and a sample of the fluid
removed for culture.
To assist in exploration, a second 5 or 10 mm trocar
is inserted under direct visualization in the left midclavic-
ular line, lateral to the umbilicus. If a diseased appendix
is identified and an appendectomy is planned, a 5- or
10-mm suprapublic trocar is also placed (1).
1
310 Atlas of Gastrointestinal Surgery: The Colon
Appendix
Cecum
Laparoscopic appendectomy can usually be per-
formed with very little mobilization of the cecum
unless the appendix is retrocecal. In the case of
a retrocecal appendix, the cecum is gently
retracted via the superior port and the
lateral peritoneal attachments to the
2
cecum are divided with endoshears.
Once the appendix is visualized it can
Terminal
ileum
be grasped with a bowel clamp or
Babcock clamp from the inferior port.
This allows sufficient traction on the appen-
dix to easily expose the mesoappendix.
Using the superior port, a window is created in the
mesentery medial to the appendix with a hook cautery or
endoshears (2 and 3).
Appendix
3
Mesoappendix
Laparoscopic Appendectomy 311
The appendix is grasped and elevated with a bowel
4
clamp. A linear stapler is inserted through the lat-
eral or suprapublic port and the appendix is
divided 5 mm from the cecum (4).
The division of the mesentery is completed by a second
application of the stapler, this time using vascular staples (5).
The divided mesentery is observed for absolute hemostasis.
5
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