Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
332 Atlas of Gastrointestinal Surgery: Pancreas
8
Stomach
Colon
Bed of
pancreatic
abscess
Transverse
mesocolon
Several options are available to achieve drainage. One option is to insert a series of Silastic sump and closed suction
drains into all the various extensions of the abscess (8). In this patient, the lesser sac, the left pericolic gutter, the root of
the transverse mesocolon, and the retroperitoneum at the root of the mesocolon have all been débrided and drained. One
can also leave catheters in place for irrigation. Once the drains and catheters have been inserted, the abdomen is closed.
Débridement and Drainage of Pancreatic Abscess 333
Bed of
pancreatic
abscess
Stomach
Packing
9
Stomach
Pancreas
Transverse
colon
10
Liver
Divided
omentum
As the patient improves, sinograms can be obtained through the drains and eventually all the drains will be slowly advanced out as healing occurs.
Duodenum
Open
packing
Transverse
colon
Another option for drainage is to pack the entire lesser sac and all the extensions of the abscess with Mikulicz’s pads, or soft gauze. The end of each packing needs to be brought out through the wound with a tag on the end (9, 10).
These packs and pads are placed with the intention of changing them every
2 or 3 days, thereby continuing to mechanically débride the abscess cavities.
334 Atlas of Gastrointestinal Surgery: Pancreas
Retention suture with bumper
This technique is particularly effective when complete
débridement has not been possible with the initial
exploration. The upper and lower portions of the
Retention
sutures
11
Packing
wound are closed with large retention sutures of No.
2 nylon with rubber bumpers constructed from No.
16 French catheters (11, 12). The dressing can be
periodically saturated postoperatively with antibiotic
containing solutions. The initial repacking should be
done under general anesthesia in the operating room in
48 to 72 hours. Eventually, however, the repacking
may be performed under heavy sedation in the intensive care unit. The packing changes continue every 2
or 3 days until the abscess is clearly débrided and the
cavity has started granulating. This often takes several
packing changes. At this point, one can insert closed
suction drains and close the abdominal wound.
Another option is to continue the packing until granu-
Packing
lation and wound contracture have progressed to the
point where the cavity is actually closed. This option
takes longer, but is perhaps safer.
12
Diverticularization of the Duodenum and
Pancreatic Drainage for Combined
Duodenal and Pancreatic Trauma
Operative Indications:
The surgical management of combined pancreatic and duodenal trauma can be challenging to the trauma surgeon. These
combined injuries carry a high morbidity and significant mortality. If the combined pancreatic and duodenal trauma is so
severe that the duodenum and ampulla are destroyed and reconstruction cannot be carried out, a pancreaticoduodenectomy may be necessary. If the patient is stable and there has not been excessive blood loss or other associated injuries, this
extensive operative procedure can be carried out with an acceptable morbidity and mortality. But if the patient is unstable, whatever is necessary to control hemorrhage and leakage of bowel and pancreatic juice should be performed and the
patient packed, closed, and stabilized in the intensive care unit, before definitive repair is carried out. In most instances of
combined pancreatic and duodenal trauma, however, the patient can be stabilized, duodenal repair can be carried out,
and pancreatic drainage performed.
Operative Technique:
Virtually all patients with blunt or penetrating trauma should be explored through a long
midline incision. Once the abdomen has been completely explored and only the pancreatic and duodenal injuries found, these lesions are attended to.
336 Atlas of Gastrointestinal Surgery: Pancreas
1
Stomach
Duodenal
wounds
Hepatic flexure
of colon
Stellate injury
to pancreas
Divided
greater
omentum
Body of
pancreas
Depicted here is
a contusion of the duo-
denum with two perfora-
tions and a stellate injury to
the head and neck of the pancreas
(1). In such instances (if the patient is
absolutely stable), one may want to radiographical-
ly rule out a major injury to the biliary tree and/or pancreatic duct. Occasionally,
the ampulla can be cannulated and cholangiography and pancreatography carried out through one of the
duodenotomy wounds. If the ampulla is not easily accessible, contrast can be injected into the gall bladder and then forced into the biliary tree. With an unstable patient, however, visualization and palpation
at the time of surgery may be all one can do to confirm or rule out a major duct injury. If the duodenal
and pancreatic lesions are extensive, but repairable, one may decide to perform the diverticularization procedure. This requires resection of the antrum of the stomach, closure of the duodenum, gastrojejunostomy
Diverticularization of the Duodenum and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma 337
to divert gastric flow, and decompression of the duodenum with a duodenostomy tube. The duodenal injuries are repaired,
and the pancreatic injury is drained. Enteric continuity is reestablished with a gastrojejunostomy.
The duodenal perforations are closed. The midportion of the stomach is divided by firing the GIA stapler twice. The
first portion of the duodenum is divided using the GIA stapler (2). The end of the duodenum is closed around a Foley
catheter, using two inverting purse string sutures of 3-0 silk (3). This catheter serves to decompress the duodenum and
allows for its safe healing. If one of the duodenal closures opens, and a duodenocutaneous fistula develops, having a duodenostomy tube in place should facilitate decompression of the duodenum and closure of the fistula.
Repaired
duodenal
wounds
Duodenum
divided
Stomach
divided
Antrum of
stomach
Omentum
2
338 Atlas of Gastrointestinal Surgery: Pancreas
Duodenostomy
tube
T-tube in
common duct
Gall bladder
fossa
Divided cystic
duct and a.
Liver
Stomach
Common duct
Proximal
jejunum
Pancreatic
Hepatic
flexure of
colon
Repaired
duodenal
wounds
3
injury
The staple line along the lesser curvature of the stomach is inverted with a layer of 3-0 silk Lembert sutures. A gastrojejunostomy is then performed to a proximal jejunal loop (3). This is carried out with an inner continuous layer of 3-0
synthetic absorbable sutures and an outer layer of interrupted 3-0 silk. The surgeon may opt to perform a cholecystectomy and decompress the biliary tree by inserting a T tube. But if the biliary tree is small in diameter—as is often the case—
this step may be omitted. If the biliary tree is of substantial size, one should insert a T tube, particularly if one has not
been able to evaluate the biliary tree via cholangiography, or if an injury to the biliary tree has been identified. The pancreatic injury is débrided carefully to remove devitalized tissue. Great care should be taken to avoid injuring the pancreatic duct. The duodenal closure, as well as the T tube insertion site, are drained with closed suction Silastic drains. The stellate pancreatic injury is also drained with closed suction Silastic drains.
Pyloric Exclusion and Pancreatic
Drainage for Combined Duodenal
and Pancreatic Trauma
Operative Indications:
In some instances in combined duodenal and pancreatic trauma, the injury may not be extensive enough to warrant a hemigastrectomy and diverticularization of the duodenum. In addition, the patient may be unstable, and the surgeon may prefer not to perform a hemigastrectomy, but still desires to divert gastric contents away from the injured duodenum. In these
instances, pyloric exclusion is an attractive alternative to duodenal diverticularization.
Operative Technique:
All abdominal trauma patients are explored through a midline incision. The abdomen
is thoroughly explored to identify all injuries. In this instance, there is a contusion of
the duodenum with two perforations and a stellate injury to the head and neck of the
pancreas. As in the prior procedure, an attempt should be made (if the patient is stable) to look for a major duct injury. If the ampulla has been exposed by one of the
duodenal injuries, cholangiography and pancreatography might be possible. If not,
contrast can be injected into the gall bladder and then forced into the biliary tree.
340 Atlas of Gastrointestinal Surgery: Pancreas
If one decides to perform pyloric exclusion, a distal gastrotomy is made with the electrocautery (1)
and the pylorus is closed from within using a continuous 3-0 synthetic absorbable suture (2).
The gastrotomy is then closed with an inner continuous
Duodenal
wounds
1
Pylorus
Stomach
Gastrotomy
layer of 3-0 synthetic absorbable suture and an outer
layer of interrupted 3-0 silk sutures. A gastroje-
junostomy is performed in a retrocolic fashion
to empty the stomach for the 2- or 3-week
period that the pyloric closure stays intact
(3). The gastrojejunostomy is carried out
with an inner continuous layer of 3-0 synthetic absorbable suture and an outer interrupted layer of 3-0 silk sutures. The duodenal injuries are repaired using two-layer closures if possible. As with duodenal diverticularization, if adequate cholangiography has
not been obtained, or if a biliary injury has
been identified, the gall bladder should be
Pylorus
oversewn
removed and the common duct decompressed with a T tube. If the biliary tree is
small, however, a T tube should not be
inserted. Insertion of a T tube into a narrow
or small-sized extrahepatic biliary tree carries
significant morbidity in and of itself. If post-
Stomach
operatively there is biliary drainage from any
of the drains, one can perform percutaneous
transhepatic cholangiography and decompress
the biliary tree via an external biliary stent.
2
Gall bladder
fossa
Pyloric Exclusion and Pancreatic Drainage for Combined Duodenal and Pancreatic Trauma 341
Liver
Divided cystic
duct and a.
Stomach
T-tube in
common
duct
Repaired
duodenal
wounds
Stellate
injury to
pancreas
Gastrojejunostomy
Common duct
Omentum
Gastrotomy
closure
3
Transverse
mesocolon
The pancreatic injury is débrided carefully and drained with closed suction Silastic drains. The duodenal closures and
the T tube insertion site are also drained with closed suction Silastic drains. The synthetic absorbable suture in the pylorus
will generally stay intact for 2 or 3 weeks, effectively diverting the gastric contents into the jejunum. If the patient does
well, oral intake can be resumed while duodenal healing continues. After 2 or 3 weeks, the pylorus sutures will slough,
and the pylorus will reopen.