Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

Gall bladder and Biliary Tract

Laparoscopic Cholecystectomy 3 Laparoscopic Bile Duct Exploration: Transcystic Approach 14 Laparoscopic CBD Exploration: Choledochotomy Approach 16 Open Cholecystectomy 18 Common Duct Exploration 25 Sphincteroplasty 32 Side-to-Side Choledochoduodenostomy 37 Resection of a Benign Bile Duct Stricture with Reconstruction Utilizing a Hepaticojejunostomy 42 Resection of a Proximal Cholangiocarcinoma (Klatskin Tumor) with Reconstruction via Bilateral Hepaticojejunostomies 57 Resection of a Proximal Cholangiocarcinoma with Hepatic Lobectomy and Reconstruction with a Hepaticojejunostomy 69 Proximal Cholangiocarcinoma: Palliation by Transhepatic Stenting and Hepaticojejunostomy 79 Resection of Hepatic Duct Bifurcation, Dilatation of Intrahepatic Biliary Tree, and Prolonged Stenting with Transhepatic Biliary Stents for Sclerosing Cholangitis 87 Resection of Choledochal Cyst 97 Transhepatic Stenting for Caroli’s Disease 104 Wedge Resection of Liver and Regional Lymph Node Dissection, Resection of the Extrahepatic Biliary Tree with Hepaticojejunostomy, for Carcinoma of the Gall bladder 114

The Liver

Anatomy of the Liver 123 Hepatic Ultrasonography: Open and Laparoscopic 125 Major Resections: Right Hepatectomy 129 Extended Right Hepatectomy (Right Trisectorectomy) 137 Left Hepatectomy 139 Extended Left Hepatectomy (Trisectorectomy) 145 Minor Resections: Segmental Resection: Right Posterior Sectorectomy 149 Left Lateral Sectorectomy 154 Nonanatomic Resection of Liver 158 Laparoscopic Resection of Liver 162 Resection Simple Cyst of Liver: Laparoscopic and Open 165 Management of Hydatid Cyst 171 Hepatic Hemangioma Enucleation 176 Other Hepatic Procedures: Liver Tumor Ablation 179 Hepatic Artery Infusion Pump 182 Surgical Drainage of Liver Abscess 187

Shunts

Interposition Mesocaval Shunt 193 Distal Splenorenal Shunt 204 Portacaval Shunt 211 Mesoatrial Shunt 222

iv Atlas of Gastrointestinal Surgery

The Pancreas

Longitudinal Pancreaticojejunostomy: Puestow Procedure 231 Distal Pancreatectomy for Chronic Pancreatitis 242 Ninety-Five Percent Distal Pancreatectomy for Chronic Pancreatitis 251 Local Pancreatic Head Resection with Lateral Pancreaticojejunostomy (The Frey Procedure) 254 Duodenal Preserving Pancreatectomy for Chronic Pancreatitis (The Beger Procedure) 260 Accessory Duct Papillotomy for Pancreas Divisum 267 Drainage of Pancreatic Pseudocyst into a Roux-en-Y Jejunal Loop 270 Drainage of Pancreatic Pseudocyst into the Stomach 277 Drainage of Pancreatic Pseudocyst into the Duodenum 281 Pancreaticoduodenectomy (Pylorus-Preserving Whipple Procedure) 284 Palliative Bypasses for Unresectable Periampullary Cancer 306 Distal Pancreatectomy for Tumor 310 Central Pancreatectomy with Pancreaticogastrostomy 317 Laparotomy for Insulinoma 321 Débridement and Drainage of Pancreatic Abscess 326 Diverticularization of the Duodenum and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma 335 Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma 339

The Spleen

Splenectomy 345 Laparoscopic Splenectomy 350 Splenectomy for a Massive Spleen 355 Management of Splenic Trauma by Splenorrhaphy 363 Management of Splenic Trauma By Partial Splenic Resection 368 Management of Splenic Trauma By Mesh Splenorrhaphy 374 Drainage of Splenic Abscess 378

The Esophagus

Antireflux Surgery – An Overview 383 Nissen Fundoplication 386 Laparoscopic Nissen Fundoplication 391 Toupet Fundoplication: Open and Laparoscopic 398 Belsey Mark IV Antireflux Procedure 403 Collis-Nissen Repair for Esophageal Stricture and Shortened Esophagus 411 Short Segment Colon Interposition for Benign Esophageal Stricture 415 Repair of Paraesophageal Hernia 425 Resection of Zenker’s Diverticulum 429 Suspension of Zenker’s Diverticulum 433 Resection of Epiphrenic Esophageal Diverticulum with Esophagomyotomy and Belsey Repair 435 Achalasia: Heller Esophagomyotomy and Belsey Repair 441 Achalasia: Laparoscopic Heller Esophagomyotomy and Toupet Repair 446 Esophageal Spasm: Long Esophagomyotomy and Belsey Repair 451 Open Resection of Esophageal Leiomyoma 457 Video-Assisted Thoracic Surgical Resection of Esophageal Leiomyoma 460 Esophagogastrectomy: Separate Abdominal and Thoracic Incisions 464 Esophagogastrectomy through a Left Thoracoabdominal Incision 475 Transhiatal Blunt Esophagectomy with Esophagogastrostomy 480 Transhiatal Blunt Esophagectomy with Long Segment Colon Interposition 493 Esophageal Reconstruction Following Total Laryngopharyngectomy: Pharyngogastrostomy or Reconstruction Utilizing Free Jejunal Graft 503 Esophageal Reconstruction Using Substernal Colon 512 Boerhaave’s Syndrome: Esophageal Repair 522 Boerhaave’s Syndrome: Esophageal Exclusion, Diversion and Closure 525 Repair of Cervical Esophageal Perforation 530 Repair of Thoracic Esophageal Perforation 533 Repair of Acquired Tracheoesophageal Fistula 537

CONTRIBUTORS

John L. Cameron, MD, FACS

Michael A. Choti, MD Keith D. Lillemoe, MD Mark Talamini, MD Stephen Yang, MD Charles J. Yeo, MD

Department of Surgery Johns Hopkins University School of Medicine Baltimore, Maryland

Corinne Sandone, MA, CMI

Department of Art as Applied to Medicine Johns Hopkins University School of Medicine Baltimore, Maryland

EDITOR’S PREFACE

This is the first of a two-volume atlas that represents the 2ndedition of our work published fourteen years ago. The distinguishing characteristic of the second edition is the same as for the first edition – the artist Corinne Sandone. She has established herself as one of the outstanding surgical illustrators of her era in this country. Her combining of accurate anatomical renderings, with unique angles and perspectives, via her magnificent watercolor technique, make her work unique. Because of her superb contribution, she is not only listed as the illustrator, but also as a coeditor of the atlas.

The first chief of surgery at the Johns Hopkins Hospital, Dr. William Stewart Halsted, was one of the pioneers of gastrointestinal surgery in this country. In the 1880s, when the great surgeons of Europe were attempting to anastomose intestine, with a high failure rate, Halsted was the first to demonstrate that intestinal sutures should include the sub-mucosal layer, and not just the muscular layer of the intestine. This contribution led to the development of the field of gastrointestinal surgery. Halsted also made unique contributions to the area of biliary tract and gall bladder surgery, and was the first surgeon in the world to successfully resect a periampullary tumor. After Halsted’s death, the next great era at Hopkins involved the emergence of cardiac surgery. Dr. Alfred Blalock and his brilliant trainees were important players in the development and emergence of this field.

In the 1970s and 1980s, with new leadership at Hopkins, gastrointestinal surgery again emerged as an important focus for the department. Beginning in the 1970s and extending up until the present, a school of gastrointestinal surgery emerged at Hopkins, which has produced many young surgeons who currently hold important chairs of surgery throughout the country. This atlas includes the techniques, operations, and procedures favored and performed, and in some instances initiated, by these gastrointestinal surgeons. Thus, the operations included in this atlas are not all inclusive in scope. In many instances there are other operations and procedures that are used by others, with equally good results.

Successful gastrointestinal surgical outcomes depend upon the surgeon, however, favorable outcomes depend upon having outstanding and supportive gastroenterologists, radiological interventionists, anesthesiologists, intensivists, nurses, house staff, and another group that is becoming more and more important to the care of patients with gastrointestinal diseases — nurse practitioners and physicians’ assistants.

John L. Cameron

October 2006

ILLUSTRATOR’S PREFACE

The illustrations in this atlas are the result of a 20-year collaboration with many outstanding surgeons, including and especially Dr. John Cameron. Their willingness to have me observe and sketch and, more importantly, their descriptions of steps which could not be observed directly, contributed to the clarity, accuracy and didactic strength of these images. The surgeons’ narratives through the operative steps, including pitfalls and technical details for success, were crucial to my understanding and subsequent depictions of their operative techniques.

Technology has provided new tools for the surgeon and the illustrator in the past two decades. These tools, however, do not replace or substitute for the talent, knowledge, experience and decision-making ability required for success in both fields. Since work was begun on the first edition of this atlas, new equipment in the operative suite - laparoscopic devices, intraoperative ultrasound - has been paralleled by developments in the studio equipment - scanners, digitized drawing tools. These change the way we work, but not the essence of what we do.

The challenge of my work is to provide the clarity, that a camera could never capture, to the operative steps while maintaining the realism of peering into the operative field. Less relevant is whether I achieve this by pushing wet pigment around with a traditional paintbrush or by moving pixels with a digitized pen tool. Many of the paintings in the volume are reprints of the original watercolors, a significant portion have been revised and updated, and many more are new created using a combination of traditional and new media.

It has been my pleasure to work with the surgical teams at Hopkins. The second edition of this atlas will further disseminate their knowledge and techniques, allowing the reader to learn and see what I have had the privilege to observe, understand and illustrate.

Medical illustration began at Johns Hopkins in 1894 with the arrival of Max Brödel to the newly founded School of Medicine. Working with the early Hopkins faculty, Brödel skillfully illustrated the research publications that documented the groundbreaking work of William S. Halsted, Harvey Cushing, William H. Welch, William Osler, Howard A. Kelly and Thomas Cullen. In 1911, the Department of Art as Applied to Medicine was created, formalizing Max Brödel’s training of exceptional young artists to become capable medical illustrators. Currently in it’s 10th decade, the program grants a Master of Arts degree to medical illustrators who train alongside medical students and collaborate with Hopkins clinicians and researchers as their fields evolve.

Corinne Sandone

October 2006

DEDICATION

To all who participate in the care of the patient with a surgical gastrointestinal disease,

particularly those surgeons who trained or spent time here, and are now building

their own schools of gastrointestinal surgery, this atlas is dedicated.

JLC

For Dan, Carlene and Claudia - smart, funny and kind.

GALL BLADDER

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CONTENTS

GALL BLADDER