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308
10.3 Comments on Laparoscopic Appendectomy
The postulated advantages of this method are accompanied by
two disadvantages:
5. Coagulation of the appendiceal artery with electrocautery:
Coagulation close to the base with electrocautery can produce
thermal necrosis of the cecal stump. Using a technique other
than electrocautery is significantly safer and more reliable.
6. Possible contamination in the abdomen: Thorough irrigation
of the abdomen and generous placement of drains is recommended.
What are the consequences for daily clinical practice? In the pre-
sence of abdominal symptoms of uncertain etiology, particularly
in young women and obese patients, laparoscopy is indicated as
an additional diagnostic procedure for a broad range of cases. Laparoscopic appendectomy without the use of electrocautery is
indicated only for nongangrenous appendicitis that has not
spread to the mesoappendix in the absence of lower abdominal
peritonitis. We have successfully reduced postoperative complications by avoiding the use of electrocautery, which can lead to
necrosis of the cecum and mesoappendix. As a general rule, the
respective laparoscopic operation should be performed in the
same manner as the open procedure, i. e., in an appendectomy,
electrocautery should not be used to coagulate the stump of the
appendix and the mesoappendix. Since controlled studies have
not revealed a clear advantage in using the laparoscopic approach, we do not believe that laparoscopic appendectomy is indicated as a routine operative procedure.
Ligating the appendix with a linear endoscopic stapler is technically the best alternative to using electrocautery, but especially
in view of increasing sensitivity to health-care costs, it is not
economical enough for routine use. A simple alternative for only
slightly infected appendices is to use oversized absorbable clips
to close the mesoappendix. This general departure from bipolar
electrocautery dissection, initially regarded as the standard
technique, is in our opinion an expression of the postoperative
problems experienced with this technique.
In summary, diagnostic laparoscopy for appendicitis is indicated
to confirm the diagnosis. Primary laparoscopic appendectomy is
indicated only in selected cases in the presence of obesity or in
the early stages of inflammation limited to the appendix itself in
the absence of frank periappendicitis or lower abdominal peritonitis. In such patients it would appear reasonable to continue a
possible laparoscopy first, by a therapeutic extension, rather
than to resort to open operation.
Conventional appendectomy in patients of normal weight only
requires a small, muscle-sparing incision in the lower abdomen.
A meta-analysis based on 21 prospective, randomized studies
thus came to the conclusion that there are only marginal advan-
tages for laparoscopic appendectomy with regard to postoperative complications, pain, impairments of gastroinstestinal function or convalescence. It is thus reasonable to restrict the indicationsforlaparoscopicappendectomy toobesepatientsortothose
cases with a suspected diagnosis for whom an exploration would
be desirable. In his review,Fingerhut(1999)wasevenmoreexplicitandposedthequestionofwhether the introduction of laparoscopy to the treatment of acute appendicitis had resulted in any
changes.On the basis of a critical analysis of 17controlledstudies
(almost 1800 patients) and 2 randomized studies it was found
that the reality of appendicitis treatment strongly depended on
the conditions under which controlled studies were performed
for the comparison of open and laparoscopic operations. In spite
of the cited studies, three questions remain unanswered:
1. The competition between laparoscopic appendectomyversus
open appendectomy has appreciably improved the results
after appendectomy. Can the results after appendectomy really be further improved?
2. Is there a necessity for further randomized, controlled studies?
3. Should we not finally agree that laparoscopic appendectomy
is “out” as a routine procedure?
Bibliography
Becker H, Neufang T. Appendektomie 1997 − Offen oder geschlossen?
Chirurgie 1997; 68: 17
Fingerhut A, Millat MD, Borrie FMD. Laparoscopic versus Open Append-
ectomy: Time to Decide World J. Surg. 1999; 23: 835−845
Götz F, Pier A, Bacher C. Die laparoskopische Appendektomie. Chirurg 1991;
62: 253−256
Hansen JD, Smithers BM, Schache D, Wall DR, Miller BJ, Minzies BL. World J.
Surg. 1996; 20: 17−21
Hebebrand D, Troidl H, Spangenberger W. Laparoskopische oder klassische
Appendektomie? Eine prospektive, randomisierte Studie. Chirurg 1994;
65: 112−120
Karaoman M, Fernandes F, Werthmann K. Ergebnisse einer retrospektiven
Studie zur laparoskopischen Appendektomie. Chirurg 1994; 65: 1126−
112 9
Müller JM. Videoendoskopische Chirurgie, eine Standortbestimmung: Dt.
Ärztebl. 1999; 96: A-1779−1785 (Heft 26)
Ortega AE, Hunter JG, Peters JH. Prospective randomized comparison of la-
paroscopic appendectomy versus open appendectomy: Laparoscopic Appendectomy study group. Am Surg 1995; 169:208−212.
Ortega AE, Hunter JG, Nahrstedt U. Argumente kontra laparoskopischer Ap-
pendektomie. Chir. Gastroenterol 1995; 11: 262−266
Sauerland S, Lefering R, Holthausen K, Neugebauer E. A Meta-Analysis of Stu-
dies Comparing Laparoscopy with Conventional Appendectomy Progress
in Surgery 1998; 25: 109−114
Tate JJ, Dawson JW, Chung SC. Laparoscopic versus open appendectomy;
prospective randomized trial. Lancet 1993; 342: 633−637
10.3 Comments on Laparoscopic Appendectomy
R.−J. Fitzgibbons
Drs. Götz, Pier and Eichen are to be congratulated for their
thorough and comprehensive discussion of all aspects of laparo-
scopic appendectomy including preoperative evaluation, differ-
ential diagnosis, operative technique and treatment of complications.
The role of laparoscopy in the management of patients with
suspected acute appendicitis remains controversial. A consen-
sus conference held in Europe recently concluded that variability exists in the literature but laparoscopy appears to be useful
in increasing diagnostic accuracy for patients with suspected
acute appendicitis. In addition, laparoscopic appendectomy is
associated with a decreased rate of wound infection, and results
in an earlier return to normal activity. However, the participants
in the consensus conference determined that the cost was
Indications
309
greater, hospital stay was not different and short-term postoperative pain was not dramatically different. A recent metaanalysis of nine randomized clinical trials involving
1,360 patients determined that there was a statistically signifi-
cant advantage favoring laparoscopic appendectomy because of
the diminished postoperative pain, earlier restoration of liquid
and solid diet, the reduced complication rate (most notably
wound infection), shorter hospital stay, and earlier return to
normal activities. The operative time for laparoscopic append-
ectomy was longer. Nevertheless, skepticism exists among
many surgeons concerning the benefits of laparoscopic append-
ectomy. Indeed, retrospectively, single center series have not
been nearly as convincing. Many surgeons feel that there is little
advantage for laparoscopy as compared to a small, muscle-splitting right lower quadrant incision. Finally, laparoscopic append-
ectomy is clearly more expensive and there is a trend toward an
increased incidence of intraabdominal abscess, although this
has not achieved statistical significance.
For these reasons, we prefer a selective approach. Laparoscopy
is recommended for patients suspected of having acute appen-
dicitis if there is the slightest doubt about the diagnosis. It is an
excellent diagnostic mode to inspect other organs and determine the patient’s true cause of symptoms. It is preferable to the
limited exploration which can be achieved through a right
lower quadrant McBurney incision. However, for patients with
straightforward, unequivocal signs of appendicitis, we prefer
appendectomy through a conventional incision. In addition to
the equivocal diagnosis, we also recommend laparoscopic appendectomy for obese patients in whom a large laparotomy in-
cision would be required.
I concur with most of the technical aspects which are so beautifully illustrated in this chapter. The dregree of detail, including
the illustrations of improper techniques is unparalleled in most
atlases of this type. There are some minor details described in
this chapter which are at variance with my practice. The authors
state that they routinely use a nasogastric tube for these
patients and we feel that this would be unnecessary. We prefer
to place the patient supine without using stirrups as is il-
lustrated in Figure 10.1.5. Trendelenburg position is avoided for
fear of allowing purulent material to collect in the subphrenic
space.
The trocar placement that we use is slightly different from that
described by the authors. We place an 11-mm cannula in the
umbilicus for the optics, followed by the placement of a second
11-mm cannula well below the pubic hairline, just to the left of
the midline. Extreme care must be taken when placing this
cannula to avoid bladder injur y. Finally, a 5-mm cannula is
placed in the right upper quadrant. We feel that this results in
the best cosmesis. Both the surgeon and the first assistant are
positioned on the left side of the table. The surgeon (assuming
he is right handed) controls the optics with his left hand and the
primary cannula with his right hand. The first assistant is responsible for the suprapublic 11-mm cannula.
The techniques for the appendectomy itself are wonderfully illustrated in this chapter with several different alternatives for
dividing the mesoappendix and actually removing the appendix
itself. We rarely use the stapling device for this procedure. Although very effective, it is difficult to justify the expense. For the
majority of patients, bipolar electrocautery is preferred for the
mesoappendix, followed by ligation of the appendix itself with
a pre-tied loop suture. The author’s caution against the use of a
chromic cat gut, but do not state why. Ironically, this is the one
place where chromic is still used in our practice. We prefer
chromic to pre-tied sutures made of other materials because of
the ability to cinch the knot with security.
Finally, the authors illustrate several techniques for removing
the appendix by pulling it back into the cannula. We would prefer the use of a plastic protective pouch. If the appendix is removed through the trocar sleeve, it is suggested that this be
taken off the operative field and not used again as it would obviously be contaminated.
The authors discuss various complications with suggestions for
corrective action. They recommend repeat laparoscopy for
patients who develop an intraabdominal abscess. We would
generally prefer a nonoperative percutaneous drainage in this
situation.
10.4 Meckel’s Diverticulectomy
F. Götz, A. Pier
Goals and Methods
A Meckel’s diverticulum is a remainder of the vitelline duct
which can persist in various vestigial forms (Fig.10.4.1). It is
most frequently encountered as a bag or pouch of the an-
timesenteric wall of the distal ileum (10−150 cm proximal to the
ileocecal valve). The length and thickness of the diverticulum
may vary, and it may or may not have a mesenteric root. The
malformation becomes clinically significant if heterotopic GI
tract mucosa are involved in creating disorders such as a bleeding ulcer, perforation, peritonitis, or adhesions. Paralytic ileus
may or may not accompany any of these conditions. Volvulus or
intussusception of the intestine may result. In the presence of
intestinal disorders such as regional enteritis (Crohn’s disease)
and tuberculosis, it can itself become involved with these dis-
eases. It may also be the site of benign or malignant tumors. A
macroscopically normal Meckel’s diverticulum may contain mi-
croscopically detectable pathologic tissue changes that can pro-
duce complications. The disorders lack a definite pattern of
symptoms; they may appear as or mimic appendicitis, ileus
(paralytic or mechanical), intestinal blee ding of uncertain
origin, or “acute abdomen,” such as PID in women, colon diverticulitis, etc. The objective of operation is radical resection.
Indications
Surgical intervention is indicated when the presence of a
Meckel’s diverticulum is confirmed. The same applies to the
various vestigial forms (see Fig. 10.4.1). Excluding a Meckel’s
diverticulum is a standard procedure in the treatment of suspected, but unconfirmed appendicitis and attempted appendectomy.
310
abc
10.4 Meckel’s Diverticulectomy
d
Fig. 10.4.1 Meckel’s diverticulum. Vestigial forms of vitelline duct remnants.
a Strand of connective tissue between the Meckel’s diverticulum and the
umbilicus. The strand may occur with or without a diverticulum and
can extend from the umbilicus to the ileum or the mesentery.
b Partial obliteration of the vitelline duct with an enterocystocele.
c Partial obliteration of the vitelline duct with a cystic dilatation in the
middle segment.
e
Contraindications
− Generalized peritonitis from causes other than involvement
of the diverticulum.
− Distended ileum from intestinal obstruction not due to the
diverticulum.
− General risk factors that do not allow a prolongation of the
primary operation, if the diverticulum is only incidental.
− Primary procedures requiring a high degree of asepsis, such
as those involving vascular structures, transplantations, and
laparoscopic hernia repairs.
d Patent vitelline duct with tendency of an umbilical granuloma forma-
tion.
e Umbilical cyst. The cyst can herniate to the outside and undergo
necrosis or become infected, causing chronic inflammation (umbilical
granuloma).
Special Preparations
Since a Meckel’s diverticulum often lacks specific clinical symptoms and is only detected during diagnostic laparoscopy in the
presence of suspected appendicitis or “acute abdomen,” the
preoperative preparations will depend on the acute clinical syndrome for which primary operation is undertaken.
If peritonitis and acute paralytic ileus are present, conventional
laparotomy is indicated. Place a nasogastric tube and urinary
catheter.
Surgical Risks and Patient Information
The patient should be informed that a diverticulectomy may become necessary during appendectomy or an exploratory procedure. The patient should also be made aware of the risk of
anastomotic breakdown, paralytic ileus, and postoperative
bleeding.
Note: The patient must be informed when a diverticulum has
been detected and left in place. If the diverticulum is to be re-
sected later, the patient should receive clear guidelines and rec-
ommendations.
Anesthesia
General anesthesia.
Patient Positioning
Position the patient horizontally; place female patients in
lithotomy position (Fig. 10.4.2).
Complications
311
Step-by-Step Procedure
I Technical preparatoions
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Prepare a gastroscope.
4. Start the video recording unit.
II Establishing the pneumoperitoneum
1. Select pressure level according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−mm Hg for adults).
2. Make a periumbilical skin incision (approx. 1 cm).
Caution:
− In infants and small children, do not insert the laparoscope/
camera trocar in the umbilical region, since this could result
in damage to the urinary bladder or bleeding from the
umbilical artery. Insert the laparoscope/camera trocar near
McBurney’s point.
− In the presence of a patent vitelline duct, insert the laparo-
scope/camera trocar at McBurney’s point.
3. Insert the Veress needle.
4. Perform safety tests: injection, aspiration, suction, manometer,
and rotation tests.
Caution: only insufflate infants at 1 l/min maximum.
III Laparoscopy
1. Insert the laparoscope/camera trocar with a tapered stylet
using Semm’s technique (see also open trocar placement).
2. Explore the peritoneal cavity visually (see Fig. 2.5.1).
3. Insert the instrument (working) trocars in the left and right
lower abdomen under laparoscopic visualization (see
Fig. 10.1.2).
4. With the patient in a slight head-down position, run and inspect the small intestine using an atraumatic grasper.
5. Determine the diagnosis and indication for operation.
IV Surgical treatment
A Narrow-based Meckel’s diverticulum (loop technique; see
Figs. 10.4.5−10.4.7):
− Place two Roeder knots near the base.
− Apply tension to the diverticulum.
− Transect the base between the proximal and distal Roeder
knots.
− Remove the resected tissue through a large trocar.
B Broad-based Meckel’s diverticulum (stapler technique; see
Figs. 10.4.10 and 10.4.11).
− Apply tension to the diverticulum.
− Use a measuring gauge to determine the thickness of the
tissue.
− Place the stapler near the base of the diverticulum at a right
angle to the lumen of the intestine.
− Remove the resected diverticulum through the 12-mm trocar.
C Suture technique (see Figs. 10.4.8 and 10.4.9):
− Apply tension to the diverticulum.
− Place an intestinal clamp near the base of the diverticulum.
− Transect the tissue above the clamp and remove the diverticulum through the 10 or 15-mm trocar extractor sleeve.
− Close the wound in the intestine with a running suture (use
absorbable suture material, 4 × 0; metric 1.5).
E Anastomosis with absorbable anastomotic rings (see
Figs. 10.4.14 and 10.4.15):
− After transecting the intestine and removing the diverticulum, place one pursestring suture at each end of the remaining open bowel lumina.
− Insert the absorbable anastomotic rings.
− Tighten the pursestring sutures.
− Push the two sections of the anastomotic rings together.
6. Close the mesenteric defect with three or four interrupted sutures.
7. Remove the instrument trocars under laparoscopic visualization.
Caution: Residual bleeding from the trocar incisions may occur.
Position of Operating Team
(Fig. 10.4.3).
See laparoscopic appendectomy.
Trocar Placement
(Fig. 10.4.4).
See also laparoscopic appendectomy, p. 291.
Alternatively, the surgeon may insert an additional 5.5-mm in-
strument (working) trocar under laparoscopic visualization into
the left lower abdomen, level with the anterior superior iliac
spine (see Figs. 10.4.5−10.4.15; steps C−E).
Complications
Intraoperative Complications
Injury to the Intestinal Wall
Corrective action: If the seromuscular coat is damaged, place in-
terrupted sutures; correct serosal defects with fibrin glue.
15–20°
Fig. 10.4.2 Meckel’s diverticulum. Positioning.
The patient is positioned with the head down and rolled into a right lateral
position with the legs abducted as in laparoscopic appendectomy (see
Fig. 10.1.5).
312
Monitor
10.4 Meckel’s Diverticulectomy
st
assistant
1
Surgeon
Electroautery unit
Fig. 10.4.3 Meckel’s
diverticulum. Position
of the operating team
and equipment.
The surgeon, assistants, and equipment are positioned
as for a laparoscopic
appendectomy (see
Fig. 10.1.6).
Insufflator
T3
OR nurse
T1
Aspirator/irrigator set
Fig. 10.4.4 Meckel’s diverticulum. Trocar placement.
Since a Meckel’s diverticulum is generally an incidental finding during appendectomy, primary trocar placement follows the technique used for laparoscopic appendectomy. When using a stapler to remove the diverticulum, place a 12-mm working trocar for the stapler in the left lower abdomen (T2) and a 5-mm trocar for the grasper in the right lower abdomen
(T3). Alternatively, insert an additional instrument 5.5-mm trocar in the
left lower abdomen level with the anterior superior iliac spine under laparoscopic vision using the technique described in the following section
(see steps C−E).
T1 Camera trocar for forward-viewing laparoscope
T2 12-mm instrument trocar (stapler)
T3 5.5-mm instrument trocar
T2
Open trocar placement is an alternative.
T2
T3
T2
T3
Complications
313
Fig. 10.4.5 Narrow-based Meckel’s diverticulum. Placing a Roeder knot.
Place the patient in Trendelenburg position. This makes it easy to push the
small intestine out of the lower into the upper abdomen. If exploratory la-
paroscopy has revealed a narrow-based Meckel’s diverticulum, the rest of
the procedure will be similar to laparoscopic appendectomy. Grip the tip
of the diverticulum with an atraumatic grasper (T3) and apply tension.
Place a Roeder knot near the base (T2). See chapter 2.3 for knot-tying
technique.
T3
2–3 mm
Fig. 10.4.6 Narrow-based Meckel’s diverticulum. Resection between
two Roeder knots.
Place a second ligature approximately 1 cm above the first one. Now
transect the tissue between the ligatures (T2). The remaining stump
should not be longer than 3 cm. An alternate technique is to use bipolar
electrocautery above the first ligature to coagulate the diverticulum like
in an appendectomy. Then, transect the diverticulum with hooked scissors.
T3 Atraumatic grasper
Fig. 10.4.7 Narrow-based Meckel’s diverticulum. Removing the trans-
ected diverticulum through an appendix extractor sleeve.
After resecting the diverticulum with scissors between the two Roeder
knots in the coagulated area, remove it through a 10-mm appendix ex-
tractor tube (T3). The tube should project 2−3 mm beyond the trocar.
When withdrawing the converter, make sure that the resected tissue is
completely retracted into the tube to avoid jamming the flap valve. See
also p. 303 for complications.
Fig. 10.4.8 Broad-based Meckel’s diverticulum. Resecting the diverticulum.
If exploratory laparoscopy of the small intestine reveals a broad-based
Meckel’s diverticulum, compress the base of the diverticulum with a long
grasper or intestinal clamp held at a right angle to the lumen of the intestine. Keep the grasper in place until the suture is completed. Resect the
diverticulum above the grasper with scissors (see Fig. 10.4.4 for key to in-
strument numbers).
314
10.4 Meckel’s Diverticulectomy
T3
T2
Fig. 10.4.9 Broad-based Meckel’s diverticulum. Placing a single line of
interrupted sutures through all tissue layers.
The defect in the intestinal wall may be repaired above the grasper by
placing a line of sutures. Use absorbable suture material (3 × 0; metric 2).
The sutures should encompass all tissue layers; terminate the sutures with
pre-tied knots (see chapter 2.3).
Note: this technique may require use of a third instrument trocar (T4; see
Fig. 10.4.4 for key to instrument numbers).
Fig. 10.4.10 Broad-based Meckel’s diverticulum. Placing a stapler near
the base.
An alternate technique for managing a broad-based Meckel’s diverticulum is to use a stapler as described in Fig. 10.4.6. Grasp the diverticulum with the jaws of the stapler perpendicular to the lumen of the intestine. Make sure the tissue lies between the markings on the jaws. Depending on the size of the diverticulum, several magazines may have to
be used (see Fig. 10.4.11; see Fig. 10.4.4 for key to instrument numbers).
Fig. 10.4.11 Broad-based Meckel’s diverticulum. Stapler technique.
The line of staple sutures can be extended by repeated stapler applications as necessary (T2).
Fig. 10.4.12 Broad-based Meckel’s diverticulum. Segmental small-bowel
resection.
If the base of the diverticulum is extremely wide, a segmental resection of
ileum may be indicated. Dissect the mesentery, and close both ends of
the intestine with rubber sheathed intestinal clamps. Place retaining sutures at each end. Next, resect the segment and anastomose the intestine
(see following illustrations).
Complications
315
Fig. 10.4.13 Broad-based Meckel’s diverticulum. Anastomosis following
segmental bowel resection.
Close the posterior wall with a running suture (absorbable suture mate-
rial, metric 2/3 × 0). Next, suture the anterior wall, check for proper
diameter of the lumen, and close the mesenteric defect with interrupted
sutures.
Stenosis of the Intestinal Lumen due to Suture or Staples
Corrective action: Perform segmental resection and end-to-end
anastomosis to close the intestinal defect. Conventional surgery
may be recommended.
Immediate Postoperative Complications
Anastomotic Breakdown, Peritonitis
As in conventional surgery, anastomotic breakdown is rare if
proper technique is carefully adhered to.
Corrective action:
− In the presence of generalized peritonitis, revision laparotomy is indicated. Resect a sufficiently large segment of
ileum, and close the resulting defect with an end-to-end
anastomosis. Irrigate the site, place a drain, and close the
abdominal wall.
− If the suture fails resulting in localized inflammation and stenosis, laparotomy and segmental resection are also indicated
(further procedure as in laparoscopy).
Fig. 10.4.14 Broad-based Meckel’s diverticulum. Anastomosis with absorbable anastomotic rings.
The defect in the small intestine may also be closed using the compression anastomosis technique shown here. Introduce the radiopaque absorbable implant into the abdomen through a 15-mm skin incision after
placing pursestring sutures on each end of the small intestine.
Fig. 10.4.15 Broad-based Meckel’s diverticulum. Anastomosis with absorbable anastomotic rings.
Place the pursestringed bowel ends over the anastomotic rings and
tighten the pursestrings using an extracorporeal Roeder Knot. By mating
the two rings the inverted bowel ends are joined. Anastomosis occurs, the
compressed bowel ends necrose and the rings one eliminated through
normal intestinal passages.
316
10.5 Small-Bowel Resection
Late Complications
Stricture or Stenosis Due to Scarring
Stricture or stenosis due to scarring are rare complications.
Corrective action: In the presence of clinically significant stricture interfering with intestinal motility, resection of the stenotic
segment by laparotomy is indicated.
Mechanical Ileus
Corrective action: Lysis of adhesions via laparoscopy (see chapter 10.6) or via conventional open operation.
10.5 Small-Bowel Resection
K. Schönleben
Bibliography
Kapral W. Das Meckel-Divertikal. Pro und Kontra der routinemäßigen Ent-
fernung. Zbl. Chir. 1988; 113:298.
Madsen MR. Laparoscopy in the diagnosis of bleeding Meckel’s diver-
ticulum. Surg. Endosc. 1994; 8:1346.
Meckel JF. Beiträge zur vergleichenden Anatomie, p. 91. Leipzig: Reclam;
1808.
Mischinger HJ, Berger A, Colombo T, Kronenberger L. Bleibt die Suche nach
dem Meckel’schen Divertikel bei der Appendektomie nach wie vor ein ak-
tuelles Problem im chirurgischen Alltag? Chirurg 1989; 60:549.
Schäfer G, Wesch G, Linder MM. Das Meckel’sche Divertikel in einer chirur-
gischen Klinik. Akt. Chir. 1988; 23:236.
Schreiber HW. Meckel-Divertikel. In Baumgartl F, Kremer K, Schreiber HW.
Spezielle Chirurgie für die Praxis, vol. II/2, p. 284. Stuttgart: Thieme; 1972.
Simmen HP, Angwerd R. Meckel-Divertikel als Quelle von Fehldiagnosen.
Operative Konsequenzen. Helv. chir. Acta 1985; 22:657.
Steinau G, Schippers E, Skopnik H, Schumpelick V. Laparoskopische Resek-
tion eines blutenden Meckel’schen Divertikels − laparoskopische Eingriffe
bei voroperierten Patienten. Chirurg 1994; 65:559.
Goals and Methods
Localized disorders involving only the small bowel that may be
treated by resection are rare. With the exception of duodenal
disorders, they do not generally represent a challenge for the
surgeon. Since every part of the small bowel is accessible and its
mesentery is mobile and facilitates reconstruction, procedures
involving segments of the small bowel are natural candidates
for laparoscopic surgery.
Indications
− Localized Crohn’s disease.
− Short radiation strictures.
− Short ischemic lesions due to localized mesenteric vascular
obstruction.
− Benign tumors (polyps, leiomyomas, and fibromas) or isolated localized malignant tumors (i. e., carcinoids).
− Bleeding from angiodysplasia or diverticula localized by angiography and/or endoluminal endoscopy (here, a combined
laparoscopic and endoluminal endoscopic approach may be
indicated).
− Palliative interintestinal or gastrointestinal bypass anastomoses for inoperable tumors.
Surgical Risks and Patient Information
As in any surgical procedure in which both conventional and laparoscopic alternatives are available, the patient should be informed of the advantages and disadvantages of both procedures. Specific risks include failure of the anastomosis as well
as postoperative pathological conditions that may result from
the underlying disorder. The choice of procedure is a decision
reached jointly by the surgeon and the patient. If the patient
desires a laparoscopic procedure, he or she must give written
approval for the surgeon to convert to laparotomy if technical or
anatomic difficulties are encountered. The surgeon must inform
the patient that this is a new procedure for which long-term results are not yet available. The surgeon should be prepared to
discuss his or her own experience, and should document the
discussion with the patient.
Specific Preparations
Place a nasogastric tube and indwelling urinary catheter. No
further preparations are required. The type and scope of preoperative diagnostic studies depend on the underlying disorder.
Usually, a laparoscopic procedure will not require any additional diagnostic studies. Preoperative diagnostic studies must
exclude any contraindications.
Contraindications
− Patients who have undergone several previous operations.
− Conf irmed interloop abscesses or internal fistulas.
− Generalized peritonitis.
− Cancer surgery with intent to cure.
N.B.: Each one of these may only represent a relative contraindication, based on individual findings and surgeon’s experience
and judgement.
Anesthesia
General anesthesia.
Trocar Placement
317
Positioning
Place the patient supine with both arms abducted on an operating table that may be inclined in different positions. The hips
are slightly flexed, and the legs are abducted and fixed on support rests. Patient positioning may be modified according to the
specific location of the pathologic processes within the abdomen (i. e., superior or inferior intestinal segment, right or left
side).
Trocar Placement
(See Fig. 8.7.2).
Establish the pneumoperitoneum up to 14 mm Hg, and insert
the laparoscope/camera trocar 10-mm in the superior umbilical
fossa. Usually, four instrument trocars are required. These are
inserted under laparoscopic visualization at a sufficient dis-
tance from the pathological process depending on its location.
We recommend using 11- or 12-mm trocars, which may then be
adapted to the required instruments with reducing sleeves or
adapters. Appropriate reducing systems are also available for
the 15-mm instrument trocars (use d for inserting the stapler).
Open trocar placement is an alternative.
The resected segment is best removed through the largest tro-
car incision (15-mm trocar when using the 60-mm linear stapler). We recommend the following technique: Grasp the sealed
specimen bag through the large trocar sleeve. Draw the bag into
the lumen of the sleeve. Now extract the sleeve from the abdomen. This brings the opening of the sterile bag outside the
abdominal cavity. Insert a grasper into the bag and extract the
resected specimen. This technique reduces the danger of contaminating the abdominal wall. In rare cases, it may be necessary to extend the trocar incision when extracting resected intestinal segments.
Step-by-Step Procedure
1. Establish the pneumoperitoneum and perform exploratory laparoscopy through the laparoscope/camera trocar inserted in
the superior umbilical fossa.
2. Identify and localize pathological changes. Place three to four
instrument trocars as required at suitable working locations.
Place the patient in the optimal position and adjust the posi-
tion of the monitor as required.
3. Hold the section of the small intestine to be resected against
the abdominal wall. Dissect the corresponding segment of the
mesentery. Dissect and coagulate or clip the mesenteric root
of the intestinal segment. Next transect and close both ends of
the intestinal segment as well as both of the remaining bowel
ends with a linear stapler, through healthy perfused tissue.
4. Place the resected segment in a sterile bag, and temporarily
move it to a “garage” location within the abdominal cavity.
5. Close the resulting intestinal defect by anastomosis. Repair the
mesenteric defect with clips or a running suture.
6. Recover the sterile bag with the resected specimen through
the largest trocar port.
7. Let down the pneumoperitoneum and close the wound. It may
be necessary to place fascial sutures in the largest incision.
Operative Technique
Fig. 10.5.1 Small-bowel resection. Procedure.
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