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_785_Библиотеки_им_академика_М_И_Перельмана
.pdf
448 Paul N. Rogers
incision must be extended. In most cases, however, for the insertion of a simple
aortic tube graft, an incision as described is adequate.
Proximal control Upon entering the peritoneal cavity, the diagnosis is
immediately confirmed by the presence of a large retroperitoneal hematoma. The
first priority is to obtain control of the aorta proximal to the aneurysm. In the
majority of patients who are stable at this stage (with a contained retroperitoneal
leak), there is time to approach the aorta above the aneurysm just below the level
of the renal arteries. In patients who are unstable, rapid control of aortic bleeding
may be obtained by approaching the aorta just under the diaphragm and temporarily applying a clamp there until the infrarenal aorta can be dissected.
Subdiaphragmatic aortic control Remember how you do truncal vago-
tomy? Of course, you do not! So, pay attention. Incise the phrenoesophageal ligament overlying the esophagus (feel the nasogastric tube underneath). With your
index finger, bluntly mobilize the esophagus to the right; forget about hemostasis
at this stage. Now, feel the aorta pulsating to the left of the esophagus, dissect
with your index finger on both sides of the aorta until you feel the spine. Apply a
straight aortic clamp, pushing it “onto” the spine. Leave a few packs to provide
hemostasis and proceed as discussed next.
Infrarenal aortic control Returning to the matter of isolation of the aor-
tic neck, note that the main principle to be observed is to avoid disturbing the
retroperitoneal hematoma while gaining control of the proximal aorta. Once
you enter the retroperitoneum at the neck’s level, dissect bluntly using your
finger or the tip of the suction apparatus to identify and isolate the neck of the
aneurysm. Once the neck is identified, carry on down both sides of the aorta
until the vertebral bodies are reached. Do not attempt to encircle the aorta with
a tape. Apply a straight aortic clamp in an anteroposterior direction with the
tips of the jaws of the clamp resting against the vertebral bodies. Placement of
this clamp is facilitated by placing the index and middle fingers of your nondominant hand on either side of the aorta so that the vertebral bodies can be
palpated. The jaws of the open clamp are then slid along the backs of the fingers
until the clamp lies in the appropriate position. Now, you can remove the subdiaphragmatic clamp.
Juxtarenal neck Occasionally, the aneurysm extends close to the origin
of the renal arteries. If this is the case, then the neck of the aneurysm will be
obscured by the left renal vein, which may be stretched anteriorly. Care must be
taken that the vein is not damaged. It may be divided to facilitate access to the
aneurysm neck. This is done by very gently mobilizing the vein from the underlying aorta. It should be ligated securely as close to the vena cava as prudence
41 Abdominal Aortic Emergencies 449
permits. If this is done, then the vein may be ligated with impunity, and the kidney will not be endangered because collateral venous drainage will take place via
the adrenal and gonadal anastomoses. How do you know that effective proximal
control has been achieved? Simple—the retroperitoneal hematoma stops pulsating. If it pulsates, your clamp is not properly placed. Reapply it!
Distal control The next part of the dissection to identify the common
iliac arteries is often more difficult. Under normal circumstances, the pelvis is
the site of accumulation of much of the retroperitoneal hematoma, and the iliac
arteries are buried within this. The arteries are difficult to locate not only because they are buried in hematoma, but also because with the aorta clamped
proximally there is no pulsation to guide the operator. In most patients, however,
the presence of atheroma in the vessels makes palpation in the depths of the hematoma possible. Again, the use of the suction apparatus facilitates isolation of
the iliac vessels. Otherwise, dig with your fingers within the hematoma and “fish”
the iliacs out. As with the aorta, no attempt should be made to encircle the iliac
vessels with tapes. This invariably produces damage to the iliac veins, which is a
disaster. It is sufficient to clear the anterior and lateral aspects of the iliac vessels
and apply clamps in an anteroposterior manner as before.
An alternative—balloon control After proximal control has been achieved
and when the iliacs are immersed within a huge hematoma, you may also rapidly
open the aneurysm sac and shove a Foley or large Fogarty catheter into each iliac
artery, inflating the balloons to produce temporary distal control.
Aortic replacement Once the proximal and distal arterial tree is con-
trolled, incise the aneurysm sac in a longitudinal fashion. Evacuate the clot and
control back-bleeding from any patent lumbar arteries and the inferior mesenteric artery with sutures within the aneurysm sac. A small self-retaining retractor placed within the aneurysm sac to retract its cut edges facilitates this and the
next few stages of the procedure. The proportion of patients in whom aortic replacement with a simple tube graft can be achieved varies widely from surgeon
to surgeon and center to center. We believe that in the majority of patients inser-
tion of a tube graft can be achieved quite satisfactorily. The advantages of this are
that limitation of dissection in the pelvis minimizes the risk of damage to the
iliac veins and damage to the autonomic nerves in the pelvis. Furthermore, there
seems little point in extending the length of what is already a challenging operation by inserting a bifurcation graft unnecessarily. Obviously, there are circumstances when a tube graft is not acceptable, namely, when the patient has occlusive
aortoiliac disease, when the iliac arteries are also significantly aneurysmal, or in
some situations when the bifurcation is widely splayed so that the orifices of the
common iliac arteries are far apart.
450 Paul N. Rogers
Take care when fashioning the aorta to receive the graft. The longitudinal
incision in the aortic sac should be terminated at both ends by a transverse incision
so that the incision becomes T shaped at each end. The limbs of the “T” at either
end should not extend more than 50% of the circumference of the normal aorta.
Suture the graft in place using monofilament material so that a parachute
technique can be used. This allows you to visualize clearly the placement of the
individual posterior sutures. Large bites of the posterior aortic wall should be
taken because the tissues in this situation are often very poor. Furthermore,
leaks that occur after completion of the anastomosis are notoriously difficult to
repair if they are situated at the back wall. Once the upper anastomosis has been
completed, a clamp is applied to the graft just below the anastomosis, and the
clamp on the aorta is then released. Assuming there are no significant leaks at
the upper end, attention is turned to the distal anastomosis. This is completed in
a similar fashion to the proximal anastomosis. Back-bleeding from the iliac vessels should be checked before the distal anastomosis is completed. Likewise, the
graft should be flushed with saline and one or two “strokes” of the patient’s own
cardiac output to clear it of thrombotic junk. If there is no back-bleeding, it may
be necessary to pass balloon embolectomy catheters into the iliac systems to
check that there has been no intravascular thrombus formation. Once the distal
anastomosis has been completed and found to be secure, the iliac clamps should
be released individually, allowing time for any hypotension to recover before the
second clamp is removed. The anesthesia team will appreciate a warning from
you that the time is approaching for removal of the clamps, allowing them to be
well ahead with fluid replacement. Inadequate fluid replacement at this stage will
result in significant hypotension when the iliac clamps are released.
A word about heparin It is clearly not sensible to administer systemic
heparin prior to cross-clamping in patients who are bleeding to death from an
aortic rupture. In patients in whom surgery has been carried out for suspected
rupture, however, and in whom no rupture is found at operation, systemic heparinization according to the surgeon’s normal practice should be carried out. It is
permissible, however, to heparinize locally the iliac vessels once the aneurysm sac
has been opened and back-bleeding from the small vessels has been controlled.
Heparinized saline may be flushed down each of the iliac vessels in turn before
reapplying the iliac cross-clamps. No consensus on the need for this practice has
been reached, and in the vast majority of patients it appears to be unnecessary.
Abdominal closure The large retroperitoneal hematoma and visceral
swelling resulting from shock, resuscitation, reperfusion, and exposure commonly produce severe intra-abdominal hypertension, which becomes manifest
after closure of the abdomen. Rather than closing under excessive tension, use
temporary abdominal closure as discussed in > Chaps. 40, 43, 52.2 and come
41 Abdominal Aortic Emergencies 451
Fig. 41.1. AAA: common outcome
back to close the abdomen later. Avoidance of abdominal compartment syn-
drome is crucial in these physiologically compromised patients, in whom any
further derangement may be the straw that breaks the camel’s back.
In emergency operations for AAA, simplicity of the operation is a key for
survival: rapid and atraumatic control, avoidance of injury to large veins, tube
graft, minimal blood loss, and rapid surgery.
Many patients who reach the operating table will survive the operation only
to die in its aftermath, usually from associated medical illnesses such as myocardial infarction. A successful outcome therefore requires excellent postoperative
intensive care unit (ICU) care as well as competent surgery. The operation is only
half the battle.
In ruptured AAA, the operation is commonly the beginning of the end—the
end arriving postoperatively (
>
Fig. 41.1).
Endovascular Repair
As aortic stent grafting has become an established treatment for AAA in the
elective patient, interest has developed in the use of the same techniques in patients
with ruptured AAA in the hope of reducing the operative mortality from the current 40–50%. Emergency endovascular aneurysm repair (eEVAR) is now confined
to a few major centers but may become more commonplace as familiarity with
the necessary arrangements increases. The limitations of this treatment are the
need for pre-op CT, an expensive stock of modular prostheses, and immediate
452 Paul N. Rogers
availability of appropriately skilled surgeons and radiologists. The patient needs
to be stable enough to cope with the delay to obtain CT images that are required
to obtain the measurements for the stent graft. This procedure is appropriate for
only a minority of patients at present, but it is hoped that more will be suitable in
the future as techniques improve.
Free Intraperitoneal Hemorrhage (see > Table 11.1)
Most AAA patients with a free intraperitoneal rupture will not reach surgery.
In the few who do, rapid proximal control is even more crucial. Other causes of
nontraumatic intraperitoneal bleeding are rare and include ruptured visceral
artery aneurysms. If this is encountered, then the commonsense principle of first
stopping the bleeding by suture ligation or packing is followed by an assessment
of the need for revascularization. Splenic artery aneurysms are the most common
of these lesions; they occur most often in women, and rupture is a disaster particularly associated with pregnancy. When exposure and thus proximal and distal
control are difficult, do not forget the option of endoaneurysmorrhaphy: open the
sac of the aneurysm, control the bleeding with finger pressure or balloon catheters,
and suture the proximal and distal openings from within. Currently, more and
more of such aneurysms are diagnosed on CT and managed angiographically by
the radiologist—in stable patients, of course.
Aortic Occlusion
The emergency of aortic occlusion is characterized by acute ischemia of the
legs with mottling of the skin of the lower trunk. It occurs for three reasons:
Saddle embolus A large clot originating from the heart occludes the aortic bifurcation. The patient most likely will have signs of atrial fibrillation or a
recent history of acute myocardial infarction.
Aortic thrombosis The patient probably has a history of pre-existing arterial disease suggestive of aortoiliac involvement. Occasionally, this disaster will
occur unannounced in a patient who is desperately ill for some other reason.
Extreme dehydration, for example, may cause “sludging” of major vessels if there
has been some preexisting atheroma. Malignancy may produce intra-arterial
thrombosis.
Aortic dissection Suspect this if there is a history of interscapular pain
associated with obvious hypertension. Look for evidence of other pulse deficits
or signs of visceral ischemia suggesting involvement of other aortic branches.
41 Abdominal Aortic Emergencies 453
Management
Management depends on the etiology and the presence of any relevant
underlying pathology. Embolism may often be dealt with easily by bilateral transfemoral embolectomy under local anesthetic. Thrombosis on pre-existing atheroma
is a more difficult problem. Catheter thrombectomy is unlikely to be successful in
either the short or the long term. If the patient is very fit (unlikely), aortofemoral
bypass may be indicated. More likely, an extra-anatomic bypass (axillofemoral)
may be feasible, always assuming that any underlying illness is not likely to cause
the patient’s demise in the immediate future. Often, these patients are not fit for
any intervention, and the aortic thrombosis is an indication that the end is near.
Aortic dissection is a complex illness, and its management is variable. The
mainstay is control of hypertension and relief of major vessel occlusion by endovascular “fenestration” of the dissection. The details of this therapy are beyond
the scope of this book.
Reference
Hardman DT, Fisher CM, Patel MI, et al. (1996). Ruptured abdominal aortic aneurysms:
who should be offered surgery? J Vasc Surg 23:123–129.
Abdominal Drainage
Moshe Schein · Paul N. Rogers
The more imperfect the technique of the surgeon the greater the necessity for
drainage. (William Stewart Halsted, 1852–1922)
The history of abdominal drainage is as old as the history of surgery.
However, abdominal drainage was always a subject of controversy, practiced in
confusion and subjected to local dogmas. Hence, 100 years ago there were ardent
enthusiasts of drainage, like Robert Lawson Tait (1845–1899), who stated: “When
in doubt drain!” There were the skeptics, like Yates (1905), who understood that
“Drainage of the general peritoneal cavity is a physical and physiological impossibility.” And, as always, there were the undecided, such as Joseph Price (1853–
1911): “There are those who ardently advocate it, there are those who in great part
reject it, there are those who are lukewarm concerning it, and finally, some who,
without convictions, are either for or against it … as chance or whim, not logic
may determine.”
A century has passed, during which operative surgery and supporting care
have progressed astonishingly, but what about drainage? Who should we drain after an emergency operation for abdominal contamination and infection tonight?
Percutaneous drainage of primary and postoperative abdominal abscesses
and collections is discussed in > Chap. 49.
42
Classification of drainage
Surgeons may drain the abdomen for the following reasons:
Therapeutic:
To provide egress for established intra-abdominal contamination or infec-
tion (e.g., periappendicular abscess, diffuse fecal peritonitis)
To control a source of infection that cannot be controlled by other means by
creating a “controlled” external fistula (e.g., for a leaking duodenal suture line)
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_42, © Springer-Verlag Berlin Heidelberg 2010
455
456 Moshe Schein · Paul N. Rogers
Prophylactic:
To prevent recurrent infection (e.g., hoping that by evacuating residual se-
rum and blood it will prevent abscess formation)
To control “prospective” or “expected” leakage from a suture line (e.g.,
drainage of a colonic anastomosis, duodenal closure, or cystic duct closure)
To warn about complications (believing that drains would sound the warn-
ing bell about postoperative bleeding or anastomotic leakage)
But, rather than dwell on the subject using rigid classifications, let us deal
with it through the eyes of a general surgeon: what is the current practice, and
what should the current practice be concerning drainage after common abdominal procedures?
What Is the “Current Practice”?
The published literature is not much help when exploring the prevalence of
abdominal drainage after emergency surgery. Therefore, we polled the opinions of
general surgeons who are members of SURGINET (an international surgical discussion forum on the Internet) on their approach to abdominal drainage.
Common Situations During Which Drains May Be Used
Question: Should you place a drain after an appendectomy for gangrenous
appendicitis? This is not “simple” or “phlegmonous” appendicitis but gangrenous
appendicitis: the appendix is black; there is some fluid around it or in the pelvis
but no frank pus (> Chap. 28).
Answer: Only 2% of responders would leave a drain in this situation.
Question: Should you place a drain after an appendectomy for perforated
appendicitis with local pus formation? So, now the appendix is perforated, you
remove it and suck out the pus floating around it. Occasionally, you break the
adhesions formed by omentum or small bowel and expose a small abscess; when
you insert the suction into the pelvis, you evacuate a few milliliters of pus. The
procedure you did could have been open or laparoscopic (> Chap. 28).
Answer: Only 20% of responders would consider drainage in this situation.
42 Abdominal Drainage 457
Question: Would you place a drain after an appendectomy for perforated
appendicitis with diffuse pus formation? Here, we deal with one of those ad-
vanced, neglected cases, in which the perforated appendix is associated with pus
“everywhere”—in the pelvis, right paracolic gutter, and even the upper abdomen
(> Chap. 28).
Answer: Again, 80% of responders would not use a drain, but there was a
geographical pattern: while almost none of the North American and Latin surgeons would drain, many of the surgeons in Asia would. This difference has to
do with how surgeons view the value for drainage in diffuse peritonitis; see separate section for discussion.
Drainage in Acute Appendicitis (> Chap. 28)
As elsewhere in this book, we are not going to burden you with a detailed
review of the literature available regarding drainage in acute appendicitis short of
mentioning one recent superb meta-analysis of such studies by Petrowsky et al.
(2004), which concluded: “Drainage did not reduce postoperative complications
and even appeared harmful in respect to the development of fecal fistula (the development of fecal fistula was observed only in drained patients) … drains should
be avoided in any stage of appendicitis.” We agree: drainage after appendectomy
for phlegmonous or gangrenous appendicitis is unnecessary. It seems that most
surgeons understand this. But, what about perforated appendicitis with local pus
formation? Even though the literature cannot support—and even condemns—
drainage in such situations, a fifth of our responders would leave a drain. “Formed”
or “noncollapsible” abscesses are considered by many to be a good indication for
drainage, and this is probably why some surgeons feel compelled to leave a drain
in any collection of pus. But, the abscesses associated with perforated appendicitis
are never noncollapsible; after you break down the walls and evacuate the pus, the
potential space for the abscess is filled up by adjacent bowel, mesentery, and omentum. So, the source of infection has been removed, the peritoneum has been
cleansed by “peritoneal toilet,” now let the superb peritoneal defense mechanisms,
supported by a short course of systemic antibiotics, complete the eradication of
bacteria without being disturbed by a foreign body (i.e., drain).
Insecure closure of the appendix stump as a justification for drainage
sounds anachronistic: “secure” closure is possible (even in the rare event when
the appendix is perforated at its base) by including in the suture or stapler line a
“disk” of adjacent cecal wall. Almost a quarter of our responders would use
drains if the appendicitis is associated with diffuse peritonitis; but, as we discuss
later in this chapter, those are the people who advocate drainage in generalized
intra-abdominal infection, and drainage in this situation—after the source con-
trol of infection has been achieved—is an exercise in futility.
458 Moshe Schein · Paul N. Rogers
Question: Would you place a drain foll owing an open or laparoscopic chol e-
cystectomy for severe acute cholecystitis? Now, you are performing a “difficult”
laparoscopic cholecystectomy on advanced acute cholecystitis. The dissection is
not easy; it is time consuming and associated with irritating ooze from the liver.
Or, perhaps you are forced to convert to an open procedure to complete the procedure. Would you leave a drain in the gallbladder bed or below the liver
(> Chap. 20.1)?
Answer: A third of the responders would leave a drain.
Drainage After Cholecystectomy
for Acute Cholecystitis (
Based on a large body of data showing no advantage whatsoever for drainage, toward the end of the open cholecystectomy era routine drainage—once a
holy cow of gallbladder surgery—was disappearing from many centers. But, if routine drainage is not beneficial in open cholecystectomy, why should it be in the
laparoscopic one?
That most postcholecystectomy collections, whether composed of bile, serum, or blood, remain asymptomatic and are self-absorbed by the peritoneum
was well known from ultrasonographic studies during the open cholecystectomy
era. However, drains are much more effective in draining bile than evacuating
feces or pus. Thus, it would be reasonable to leave a drain if the surgeon has a
reason to worry about an unsolved or potential bile leak; for example, if the cystic duct opening cannot securely be controlled in subtotal cholecystectomy; bile
staining in the lavage fluid or in the gallbladder bed (hinting at the possibility
that a duct of Luschka has been missed), or what appears to be a nonperfect closure of the cystic duct for whatever reason. So, most patients do not need a drain,
but if you are worried about the possibility of bile leak, leave a drain! Most drains
produce almost nothing; only very rarely would the prophylactic drain become
therapeutic by draining a large and persisting amount of bile. It is very impor-
tant that drains with such hazy indications are removed as soon as possible. A
dry drain after 24 hrs indicates that it has served its limited role. Lastly, Howard
Kelly (1858–1943) said that, “Drainage is a confession of imperfect surgery.” Do
not confirm this statement in your practice; it may be better to convert to an open
procedure and safely suture an ultrashort cystic duct than rely on faulty clip
closure and a drain.
>
Chap. 20.1)
Question: Would you place a drain following repair of a perforated peptic
ulcer with an omental patch? You have just repaired a perforated duodenal ulcer
with a patch of omentum. Would you leave a drain (> Chap. 18)?
Answer: Eighty percent of the responders would not.
Соседние файлы в папке Библиотека им академика М.И. Перельмана