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Figure13.1.“OKguys,nowit’senough.Ithinktheabdomenisclean…”
•
Theconceptofradicaldebridementoftheperitonealcavityisbased
onthepremisethatfibrinisanidusformicrobialimplantation,hence
therecommendationtopeeloffeverybitoffibrincoatingperitoneal
surfacesandviscera.Theprocedureistedious,resultsinexcessive
bleeding from the denuded peritonealsurfaces and endangersthe
integrityofanalreadyfriableintestine.Itdidnotwithstandthetestof
aprospectiverandomizedstudycomparingittoamoreconservative
approach.Itisobsoleteandharmful—justforgetit!
•
Despite the dictumthat it isimpossible effectively to drain the
free peritoneal cavity, drains are still used and often misused.
Their aim must be restricted to the evacuation of an ‘established’
abscess(when theresidualcavity wouldnot collapse orcannot be
filled with omentum or adjacent structures),to allow theescape of
potentialsecretions(e.g.bile,pancreaticjuice)or,rarely,toestablish
acontrolledintestinalfistulawhenexteriorizationisnotpossible.To
preventintestinalerosion, softdrainsshould beleftinplacefor the
shortest duration possible and well away from bowel wall. In
general, active-suction drainage may be more effective than the
passive kind, and infectious complications can be reduced by
choosing‘closed’systems.Drainsoftenprovideafalsesenseof
security and reassurance ( Figure 13.2). We have all seen a
moribund postoperative patient with an abdomen ‘crying’to be reexplored with a surgeon in denial because his tiny four-quadrant
drains are dry andnon-productive. (By the way, this is particularly
trueofdrainsinsertedtodealwithpostoperativehemorrhage;atiny
trickleofblood fromadrainmayhide ahugeintra-abdominalclot.)
Drainsinsertedclosetoananastomosis“justincaseitleaks”
are more likely to cause an anastomotic dehiscence than to
establish a controlled fistula. Read more about drains in the
dedicatedchapter( Chapter39).
•
The role of postoperative peritoneal lavage, through tube drains
left in place for this purpose, is at best questionable. Is it really
possibletoirrigatethe whole abdominal cavity? In our experience,
suchtubesarerapidlywalled-offbyadhesionsandadjacenttissues.
At the end ofthe day, you will be irrigatingnothing more than the
drains’tracks.
Figure13.2.“Whichofthedrainsisdraining?”
Aggressivemodalitiesofmanagement
Indoubtfulcasesdonotwaittoolong
Beforeexploring,foritisquitewrong
ToactuponthesloganWaitandSee,
Whenlookingmayprovidetheremedy.
ZacharyCope
Most IAI patients respond to the combination of adequate source
control, appropriate antibiotics and competent supportive management.
Mightafewothersneedmore?Inthe1980s,itwasbelievedthatfailure
of the initial standard operation could be accounted for by either
persistingorrecurringinfectiondiagnosedtoolate.Waitingforovertsigns
ofinfection ororganfailure asthe indicationfor‘on demand’abdominal
re-exploration was thought to be at best questionable. Hence the
emergence of an aggressive management approach in the form of
planned relaparotomy and open management of the abdomen
(laparostomy). These two modalities were often combined (they are
discussedmoreextensivelyinPartIV—“AftertheOperation”):
•
Plannedrelaparotomy pushesthe processofsource controlto its
limit. By staging repeatedoperative interventions to followthe first
‘index’procedureforperitonitis,thesurgeonmakesacommitmentto
return to the abdominal cavity again and again to re-explore,
evacuate,wash-out,debrideor resectas needed,until thedisease
processis definitivelycontrolled.This doggedpursuit is justifiedby
local intra-abdominal conditions rather than the patient’s overall
status.
•
Openmanagement(laparostomy)is,inconcept,anextensionto
peritoneal toilet by providing maximal drainage for the purulent
abdomen.Itfacilitatesfrequentre-explorations.Inaddition,itserves
asprophylaxistotheabdominalcompartmentsyndrome—inthe
earlydaysthough,thisadvantagewasnotfullyappreciated.
Early results of these methods seemed promising, particularly in the
managementofinfectedpancreaticnecrosisbutwerelessfavorablein
casesofpostoperative peritonitis, perhaps because the sickestpatients
wereincluded. Intestinalfistulas plaguedsimple openmanagement, but
this problem was somewhat minimized by the introduction of modern
temporaryabdominalclosure(TAC)techniques.
However, prospective randomized studies, imperfect as they were,
giventhedifficultiesinpatientenrolmentandstratification,failedtoshow
anadvantagefortheplannedrelaparotomypolicyandpointedtoahigher
complicationrate—insurgery,thereisnofreelunch!Thepossibilitywas
raisedthatrelaparotomyconstitutesa‘secondhit’inpatientsinwhomthe
inflammatoryresponsewasalready‘switched-on’,escalatingtheSIRS.It
is more likely though that sick patients were subjected to a double
iatrogenic insult: frequent trips out of the ICU and overly traumatic,
intempestive surgical manipulations. Is there still a place for this
aggressive management? We believe there is one, in a very small
minority of carefully selected patients at the hands of expert teams.
Wholesaleapplicationandrelegatingtherelaparotomyperformance
tojuniorstaffattheendoftheORslatearerecipesfordisaster.Our
indicationsforthese modalitiesare summarizedin Table13.1.Please
continuereadingaboutthistopicin Chapter48.
Needforperitonealcultures?
A70-year-oldmalepatientundergoesalaparotomyforperforatedsigmoiddiverticulardisease
withgeneralizedfecalperitonitis.Areyouoneofthosesurgeonswhowouldsendaspecimen
of peritoneal fluid for culture? If so, how often do you follow-up the results and modify
accordingly your antibiotic regimen? What indeed can be gained by culturing Mr. Average
Citizen’sfeces?
This is a typical example of community-acquired secondary
peritonitis. The microbiologyof this type of IAI is predictableand
respondsreadilyto an empiric broad-spectrumantibiotic regimen,
initiatedpre-operatively,thatincludesanti-anaerobiccover. Inmost
cases,cultureresultswouldbecomeavailableonlywellaftercompletion
oftheantibioticcourse.
However,peritonealculturesareusefulinthefollowingscenarios:
•
Primary peritonitis where there is no intra-abdominal source of
infection; the fluid contains an organism that has migrated from
somewhereelse.
•
Nosocomial secondary peritonitis (acquired in an already
hospitalized patient); the best example being postoperative
peritonitis.
•
Tertiary peritonitis which is commonly associated with a peculiar
microbiology(seeabove).
•
Peritonitis in the immunocompromised patient (AIDS, on
chemotherapy).
•
Patientswhoarealreadyonantibiotics,forwhateverreason.
•
Patientswithahistoryofmethicillin-resistantStaphylococcusaureus
(MRSA).
“Shakiness of the hand may be some bar to the
successful performance of an operation, but he of a
shakymindishopeless.”
SirWilliamMacEwen
1
Ifyou wanttoreadmuchmoreaboutthistopic,thenfindacopyofSourceControl.Schein
M,MarshallJ,Eds.Berlin,Heidelberg,NewYork:Springer,2002.
Chapter14
Theintestinalanastomosis1(andstomata)
MarkCheetham,MosheSchein,PaulN.Rogers,AriLeppäniemi,Danny
RosinandJonathanE.Efron
Thischapter hasbeensubdivided intothefollowingtwo
sections:
1.
Intestinalanastomosis.
2.
Intestinalstomata.
1
Theintestinalanastomosis
1
Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny
Rosin,JonathanE.Efron
Bestistheenemyofgood:thefirstlayeristhebest—why
spoilit?
Theidealanastomosis
Theideal intestinalanastomosisis theonewhichdoes notleak.
Leaks,althoughrelativelyrare,areadreadedandpotentiallydeadly
disaster ( Chapter 47). In addition, the anastomosis should not
obstructbutallownormalfunctionofthegastrointestinaltractwithinafew
daysofconstruction.
Figure14.1.“Giveittome,nurse…Thiswillbeaperfectanastomosis!”
Any experienced surgeon thinks thathis ownanastomotic technique,
adoptedfrom his mentorsand with atouchof personalvirtuosity,is the
‘best’. Many methods are practiced: end-to-end, end-to-side orside-toside;single-versusdouble-layered,interruptedversuscontinuous,using
absorbable versus non-absorbable and braided versus monofilament
suture materials. Weeven know some obsessive-compulsive surgeons
(doyouknowany?)whocarefullyconstructathree-layeredanastomosis
inaninterruptedfashion.Nowaddstaplerstothemix.Sowheredowe
stand?Whatispreferable?( Figure14.1).
Prosandcons
Numerousexperimentalandclinicalstudiessupportthefollowing:
•
Leakage:theincidenceofanastomoticdehiscenceisnotinfluenced
by the method used, provided the anastomosis is technically
sound; constructed withwell-perfused bowel without tension,
andrenderedwaterandairtight.
Stricture: the single-layer anastomosis is associated with a lower
•
riskofstricture formation than the multi-layeredone.Strictures are
also commoner following the end-to-end anastomosis performed
with the circular stapler (especially when the smaller sizes are
used).
•
Misadventure: intra-operative technical failures with staplers are
morefrequentdueto‘misfires’.Andyouknowtherule:“toolsinthe
handsoffoolsarepronetodisasters.”
•
Speed: stapled anastomoses, on average, are slightly faster than
those sutured by hand. The fewer the layers, the faster the
anastomosis and the continuous method is swifter than the
interruptedone.Inpractice,thetimeconsumedinplacingtwohandfashionedpurse-stringsutures fora stapledcircularanastomosisis
identicaltothatrequiredtocompleteahand-sutured,single-layered,
continuousanastomosis.
•
Suturematerial
:braidedsutures(e.g.silkorVicryl®)‘saw’through
tissues and, experimentally at least, are associated with greater
inflammation and activation of collagenases than monofilament
material (e.g. PDS®, Monocryl®, Maxon™ or even Prolene®).
Chromic catgut is too rapidly absorbed to support (alone) an
anastomosis. Monofilament slides better through the tissues and,
whenusedinacontinuousfashion,isself-adjustableallowingequal
distribution of the tension around the entire circumference of the
anastomosis.
•
Cost: staplers are much more expensive than sutures and, thus,
generally not cost-effective. The single-layer continuous technique
requireslesssuturematerial,andisthereforemoreeconomicalthan
theinterruptedmethod.
The choice of anastomotic technique: international
perspective
To gauge the current ‘anastomotic philosophy’ around the world we
conducted an informal poll among members of the international online
surgical forum — SURGINET.And here is a summary of the prevailing
trends:
•
Staplersvs.hands.Aminorityofsurgeonsareaddictedto‘stapleronly’ or ‘hand-only’ technique. Most use both techniques on a
selective basis. The emphasis is to avoid staplers on ‘non-
healthybowel’—e.g.edematous,irradiated—orinwhatthey
wouldconsider‘difficultcircumstances’.
•
Location. Most would use staplers for esophageal anastomoses
andforanastomosisoftherectum.Fashioninganewgastriclesser
curvature and closure of the duodenal stump during gastrectomy
areother popular indicationsfor staplers. Inallothersites,hand-
suturingismorepopular.
•
Suturematerial. Absorbable material is used by the vast majority.
ThebraidedVicryl®ispopularbutthosewhopreferthecontinuous-
runningtechnique(seebelow)optformonofilamentssuchasPDS®,
Maxon™orMonocryl®.
•
Singlevs.two-layeredanastomosis/interruptedvs.continuous.
Interestingly, European surgeons tend to practice a continuous
single-layer anastomosis using a monofilament. Single-layer
interrupted is practiced by many, especially in ‘difficult
circumstances’or for the sigmoid and rectum. Old school teaching
prevails still in some places where two-layered anastomoses are
preferred — both continuous, but more commonly the inner layer
continuous (absorbable) and the outer interrupted (absorbable or
not).
Ourrecommendations
‘Our’inthiscasemeans(withthepermissionoftheotherEditors)what
Moshethinks—wecannotwritefourdifferentchaptersbasedoneachof
our dogmas, can we? (Danny, for example, prefers staplers from the
mouthto the anus,while Ari alwaysusescontinuous absorbable intwo
layers…).
Well, using the WTLS (what the literature says) test, since all
methods,ifcorrectlyperformed,aresafe,nobodycanfaultyouforusing
the anastomotic method with which you are most familiar and
comfortable.However,applyingtheIIWM(ifitwereme)conceptthisis
our(MS)bias:
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