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318
10.5 Small-Bowel Resection
Fig. 10.5.2a Small-bowel resection. Exposure and dissection.
For best exposure, hold the segment to be resected against the abdominal wall with instruments or retaining sutures. After dividing the
mesentery in an avascular area, resect the intestinal segment using a
linear stapler at an appropriate distance from the pathological process.
Fig. 10.5.2b Small-bowel resection. Exposure and dissection.
Divide the bowel with the linear stapler. Close and transect the mesentery
with the vascular linear stapler.
컅 Fig. 10.5.3 Small-bowel resection. Side-to-side enteroenterostomy.
Place the resected segment in a sterile bag. If a functional end-to-end
anastomosis is to be achieved with a stapler, place the two intestinal
stumps side by side and hold them in place with retaining sutures placed
on the antimesenteric side. Resect the antimesenteric tip of the staple
closure with scissors to create antimesenteric openings for the jaws of the
stapler (see insert). Insert the jaws into the two intestinal lumina opened
by the corner resections. One application is sufficient if you are using a 60mm stapler. When using a 30-mm stapler, two consecutive applications
are required. Check the inner suture line for bleeding. Do not attempt to
control bleeding by electrocautery; the rows of staple sutures will conduct heat and might result in thermal necrosis. Use laparoscopic sutures
to achieve hemostasis.
Fig. 10.5.4 Small-bowel resection. Closing the small intestine and 컄
mesentery.
After removing the stapler, close the remaining lumen defect with a run-
ning laparoscopic suture or with a stapler. Close the mesenteric defect
with clips (see insert).
Trocar Placement
319
Fig. 10.5.5a−c Small-bowel resection. Alternate technique of end-to-
end anastomosis: triangular anastomosis.
After open removal of the resected segment, oppose the two open intestinal stumps with three everted retaining sutures. Place these sutures
at the mesenteric attachment (6 o’clock), 10 o’clock, and 2 o’clock.
Tightening the sutures pulls the stumps into the shape of a triangle. Evert
the edges of each leg of the triangle and close the defect with a linear stapler. Animal studies have shown that overlapping staple sutures have minimal adverse effect on healing.
왓
a cb
320
10.5 Small-Bowel Resection
Complications
Note the specific complications associated with establishing the
pneumoperitoneum and placing the trocars. Few complications
are to be expected if the surgeon’s stapling technique is precise.
We refer here to experience with staplers acquired in open procedures.
In laparoscopic repair of pathological changes from Crohn’s disease, the surgeon should avoid using staples since these may
become focal points of renewed inflammation. No clinical data
are yet available on the incidence of complications occurring
with techniques other than staples. Successful results have only
been demonstrated in animal studies to date.
Intraoperative Complications
Bleeding
Corrective action: Bleeding must be controlled completely. If
this is not possible, immediate conversion to an open procedure
is indicated.
Cyanotic Wound Edges
Corrective action: Cyanotic wound edges near the sutures must
be resected. If difficulties occur, conversion to an open procedure is indicated.
Immediate Postoperative Complications
Anastomotic Breakdown, Peritonitis
Corrective action: Conventional laparotomy.
Bibliography
Lange V, Meyer G, Schardey HM, Gutschow C, Schildberg FW. Verschiedene
Techniken für die laparoskopische Dünndarmanastomosierung. Chirurg
1993; 64:408.
Schönleben K, Brune IB, Günterh M. Rekonstruktive laparoskopische Eing-
riffe an Dünndarm und Magen. Chir. Prax. 1991/92; 44:303.
Schönleben K, Brune IB. Laparoskopische Eingriffe am Dünndarm. In
Schönleben K, Brune IB. Laparo-Endoskopische Chirurgie, p. 195.
München: Marseille; 1993.
Fig. 10.5.6 Palliative small-bowel bypass anastomosis.
Bypass anastomoses may be used in the presence of inoperable pathologic changes that obstruct the intestine and necessitate palliative measures. The technique involved is a side-to-side anastomosis with the endoGIA stapler. We recommend completing the anastomosis as follows: Close
the introduction site through which the stapler was inserted perpendicular to the axes of the two legs of the intestine lying side by side. This helps
reduce influx and drainage problems.
The operation is completed by carefully letting down the CO
pneumoperitoneum. We recommend placing fascial or muscular sutures
in the larger incision wounds (15-mm trocar) to minimize scarring and
hernias.
2
10.6 Laparoscopic Ly sis of Adhesions
A. Pier , F . Götz
Goals and Methods
To lyse adhesions, or to abstain is often a dilemma facing the
surgeon especially in the patient with subacute or chronic, re-
current complaints after one or several abdominal operations
that may have resulted in adhesion formation.
The extent and shape of the adhesions detected must fully account for the presenting clinical syndrome and the disruption of
intestinal motility and bowel patency, while other disorders
must be excluded as possible causes. The surgeon should exercise restraint if these three conditions are not met. Typical indications for laparoscopic lysis of adhesions include mechanical
ileus due to adhesive bands; localized adhesions stenosing a
bowel loop; and at times vague, other times more definite, but
always recurrent episodes of abdominal bloating and colicky
pain, while symptoms of other organic and functional disorders
have been excluded. There are several laparoscopic techniques
for lysis of adhesions (see Table 10.6.1). We prefer bipolar elec-
trocautery followed by sharp dissection. A “frozen abdomen”
with extensive, firm cord-like, and flat adhesions is an indication for open laparotomy through a large incision and methodical lysis of adhesions and temporary exteriorization of the small
bowel, as the various bowel loops are freed up.
Special Considerations
321
Indications
− Recurrent partial mechanical ileus of the small bowel (incomplete small bowel obstruction).
− Early postoperative mechanical ileus after an intraabdominal
operation for any cause.
− Chronic recurrent abdominal distension and colicky pain
that is resistant to nonoperative treatment following an earlier, of ten remote laparotomy.
Contraindications
Acute and complete mechanical ileus with advanced dilatation
of the intestinal loops following an intraabdominal operation:
Treat by conventional laparotomy.
Note: Laparoscopy is contraindicated in the presence of severely
enlarged and distended intestinal loops with thinning of the intestinal wall.
Surgical Risks and Informing the Patient
Laparoscopic lysis of adhesions requires a high level of surgical
expertise. Often the surgeon is forced to convert to an open procedure. At present, reliable morbidity and mortality data are not
available.
Candid preoperative discussion with the patient before lysis of
adhesions is more important than before any other laparoscopic
procedure. The suffering as perceived by the patient is severe,
and his or her expectations are high. Patients must understand
that they are consenting to a difficult operation that cannot
guarantee relief of symptoms, and that laparotomy may become
necessary and that intraoperative conversion to laparotomy
does not represent a complication.
Table 10.6.1 Different lysis techniques.
1. Aquadissection or hydrodissection (see Figs. 10.6.6 and 10.6.7).
2. Blunt dissection.
3. Lysis of avascular adhesions using internal ligature.
4. Lysis of avascular adhesions using bipolar electrocautery (see
Figs. 10.6.8−10.6.10).
5. Lysis of avascular adhesions with Roeder loop and knot (see
Fig. 10.6.12).
6. Stapling technique (see Fig. 10.6.11).
7. Clip technique (see Fig. 10.6.13).
Generally it is not possible to perform the steps typically involved in establishing the pneumoperitoneum. Often you will
have to insert the Veress needle repeatedly before gaining
access to the free peritoneal cavity. See Figs. 10.6.3−10.6.5,for
the specific technique of establishing the pneumoperitoneum.
There is a simple technique for locating an adhesion-free site for
placing the laparoscope using a Veress needle and a 15-cm injection needle. After making a stab wound with a scalpel, insert
the Veress needle or the injection cannula into the area assumed to be free of adhesions. If the usual safety tests are positive, conduct an additional 360-degree rotation test of the
needle to ensure that no adhesions are present. Next establish
the pneumoperitoneum at an insufflation rate of 1 l/min. Once
this is done, insert the laparoscope trocar directly through the
abdominal wall (not according to Semm’s Z technique). Open
trocar placement by the “Hassan” technique is an alternative.
Anesthesia
General anesthesia.
Special Preparations
Prior to elective laparoscopic lysis of adhesions, the patient
should thoroughly empty the bowels. The presence of acute me-
chanical ileus is an exception to this rule. Further preparations
include:
− Nasogastric tube.
− Indwelling urinary catheter.
− Preoperative antibiotic prophylaxis with 2 g of cefotam dihydrochloride and 0.5 mg of metronidazole prior to making the
skin incision.
Special Considerations
In a patient who has undergone several previous operations, es-
tablishing a pneumoperitoneum and performing subsequent laparoscopy may be impossible if adhesions prevent the surgeon
from gaining access to the peritoneal cavity. In about 8% of
cases, lysis of abdominal adhesions injures the intestines or results in laparoscopically uncontrollable bleeding. Immediate
conversion to open laparotomy is indicated in such cases.
Establishing the pneumoperitoneum with a Veress needle can
produce complications in patients who have undergone pre-
vious operations. Intestinal loops adherent to the anterior
abdominal wall are easily injured.
Positioning
Flat supine.
Position of Operating Team
(Fig. 10.6.1).
Trocar Placement
(Fig. 10.6.2).
322
10.6 Laparoscopic Lysis of Adhesions
Monitor
Light source
with camera
module
st
1
assistant
Surgeon
Electroautery unit
Aspirator/irrigator set
Fig. 10.6.1 Lysis of adhesions.
Equipment and position of the
operating team.
The surgeon stands to the left or
right of the patient, depending
on the anticipated site of adhesions. The first assistant stands
opposite the surgeon with the
monitor and CO
insufflator in his
2
or her field of vision. The operat-
ing room nurse stands behind
the instrument table at the
patient’s feet.
Insufflator
OR nurse
Fig. 10.6.2 Lysis of adhesions. Placing the laparoscope in patients with
previous abdominal procedures.
The port sites for the laparoscope and instrument trocars depend on the
locations of scars from previous operation. Make the incision as far from
the scar as possible. Where the placement of the Veress needle is uncertain, perform a mini-laparotomy using a pursestring suture to seal the abdomen or insert the trocar under direct vision using Semm’s method (see
Fig. 10.6.3−10.6.5). Open trocar placement is an alternative.
T1 Laparoscope
T1
Trocar Placement
323
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Start the recording unit.
II Establishing the pneumoperitoneum
1. Select pressure plateau according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a periumbilical skin incision (approx. 1 cm).
4. Insert the Verress needle.
5. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests.
6. Perform insufflation procedure.
Caution: insufflate infants at 1 l/min maximum.
III Various techniques for inserting the laparoscope/camera trocar
Method A: Percutaneously with Veress needle.
1. Find an unscarred area of the abdomen.
2. Insert the Veress needle percutaneously through a small incision in the skin.
3. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests.
4. Insert trocar with tapered blunt-tip stylet, after pneumoperitoneum has been initiated.
Method B: Mini-laparotomy.
1. Enter the abdominal cavity through a mini-laparotomy in an
unscarred area of the abdomen.
2. Advance the trocar into the abdominal cavity without the sty-
let.
3. Place a pursestring suture to seal the abdomen against CO
loss.
Method C: Special trocar.
1. Enter the abdominal cavity through a mini-laparotomy and
place a pursestring suture.
2. Advance the special trocar with a blunt stylet into the abdomi-
nal cavity.
3. Secure the trocar with holding sutures.
Method D: Semm’s technique (Figs. 10.6.3−10.6.5).
1. Periumbilical incision and dissection down to the peritoneum.
2. Advance a blunt trocar to the peritoneum. Note: Do not use a
stylet.
3. Advance the laparoscope into the trocar to 1 cm above the peritoneum.
4. Observe the reflection of the light. A bright light reflection indicates adhesions; a loss of light intensity indicates an open cavity free of adhesions.
5. Open the peritoneum with the tip of the stylet if an open cavity
is found.
6. Insert the laparoscope and inspect the insertion site.
7. “Bluntly” advance the laparoscope/camera trocar.
IV Lysis of adhesions
Sharp dissection using a Roeder loop and knot applicator (see
Fig. 10.6.12).
1. Transect the adhesion close to the parietal peritoneum.
2. Place the Roeder loop around the adhesion.
3. Grasp and elevate the transected adhesion.
4. Tighten the sliding Roeder knot with a grasper to close the loop
loosely around the adhesion.
5. Move the ligature loop to the base of the transected adhesion
and tighten it completely to ligate the base.
6. Transect the excess adhesion above the ligature and remove it.
Lysis of adhesions using sutures.
1. Place 5.5-mm and 10.5-mm instrument trocars under laparoscopic visualization.
2. Expose the adhesion.
3. Insert an internal ligature (polyglycolic acid 0; metric 3.5)
through a 10.5-mm instrument trocar with the Roeder knot applicator. Loop the ligature around the adhesion and pull it back
out through the same trocar.
4. Tie an extracorporeal knot.
5. Advance the extracorporeal knot and ligature to the base of the
adhesion.
6. Cut the suture material and remove the loose end.
7. Introduce a second ligature close to the abdominal wall.
8. Cut the suture material and remove the loose end.
9. Transect and remove the adhesion.
Lysis of adhesions using a stapler (see Fig. 10.6.11).
1. Select the stapler according to the thickness of the tissue.
2. Introduce the stapler.
3. Place the jaws around the structure to be stapled so that the
2
tissue is between the markings.
4. Fire the stapler once to apply staples on both sides of the transected adhesion.
Lysis of adhesions using a clip applicator (see Fig. 10.6.13).
1. Expose the vascularized adhesion.
2. Apply clips close to the abdominal wall and close to the intestine.
3. The jaws of the clip applier must completely surround the adhesion.
4. Transect the adhesion between the clips with scissors.
Lysis of adhesions using bipolar electrocautery (see Figs. 10.6.8−
10.6.10).
1. Introduce a 5.5-mm trocar for the electrocautery instrument.
2. Expose the adhesion.
3. Coagulate tissue close to the abdominal wall with bipolar electrocautery.
Caution: Maintain a distance of at least 1 cm between electrocautery and the intestine.
4. Transect the adhesion in the coagulated area.
324
10.6 Laparoscopic Lysis of Adhesions
Operative Technique
컅 Fig. 10.6.3 Lysis of adhesions. Locating a trocar insertion site free of ad-
hesions.
Slowly advance the trumpet-valve laparoscope/camera trocar with
tapered stylet down to the peritoneum before connecting the insufflator.
Next remove the stylet and insert the laparoscope. Advance the laparoscope with the attached fiberoptic line to 1 cm above the peritoneum. Rotate the trocar with the laparoscope on the peritoneum (insert) to locate a
cavity that is free of adhesions. If the light falls on adhesions, it will be reflected. Cavities without adhesions appear darker because there is more
light diffusion.
컅 Fig. 10.6.4 Lysis of adhesions. Opening the peritoneum.
Where the lack of reflected light indicates a cavity free of adhesions, carefully open the peritoneum with the tip of the tapered stylet. Hold your fin-
ger against the tube of the trocar to prevent uncontrolled penetration.
Trocar Placement
325
Fig. 10.6.5 Lysis of adhesions. “Bluntly” advancing the laparoscope/
camera trocar.
Remove the stylet and inspect the peritoneal incision (about the size of a
pea; see insert). If the cavity is indeed free of adhesions, advance the tip of
the trocar through the existing peritoneal incision. Keep the laparoscope
about 1 cm behind the tip of the trocar so you can verify the correct posi-
tion of the trocar on the monitor. When the trocar is fully inserted, ad-
vance the laparoscope to its final position.
Fig. 10.6.7 Lysis of adhesions. Sharp dissection of adherent intestinal 컄
loops from the parietal peritoneum.
After injecting the saline solution, incise the peritoneal tissue with
straight scissors. This allows the saline to escape and leaves a preformed
cavity between the two tissue surfaces, allowing the surgeon to dissect
along the interface. We recommend dissecting with a swab and scissors. If
a perforation occurs, suture it laparoscopically or by conventional
method. Finally, place a drain and initiate prophylactic antibiotic treatment.
Fig. 10.6.6 Lysis of adhesions. Hydrodissection.
You may use this technique if laparoscopic exploration reveals intestinalloops adhering to the abdominal wall and the tissue interface is not
readily discernible. Insert a sharp cannula (insert shows cross section) and
inject about 10−20 ml of saline solution into what appears to be the interface between the peritoneum and the serosa. The pressure of the injected
fluid will separate the individual layers of tissue at the line of least resistance within a safe plane.
326
MINIMAL 1 cm distance
10.6 Laparoscopic Lysis of Adhesions
Fig. 10.6.8 Lysis of adhesions. Bipolar electrocautery.
The following figures illustrate various techniques for the lysis of adhesions. To reduce the danger of injury to the intestine, remain close to the
parietal peritoneum when dissecting.
Adhesions between the greater omentum and anterior abdominal wall
can be coagulated close to the parietal peritoneum. Note that with any
coagulation technique the heat will cause the tissue to shrink. To avoid
damaging the intestine, maintain a distance of at least 1 cm between the
electrocautery and the intestinal loop. Use bipolar electrocautery in lysis
of adhesions as well. Due to its mode of action, monopolar electrocautery
can generate current leakage that may result in a remote cautery effect
with delayed intestinal necrosis.
Fig. 10.6.9 Lysis of adhesions. Sharp dissection.
Use transillumination to locate poorly vascularized areas in omental adhesions. These can be sharply dissected close to the parietal peritoneum
without having to be coagulated first. In case of doubt, coagulate peritoneal vessels branching into the adhesion with bipolar elecrocautery. Observe safety precautions (see Fig. 10.6.8).
Fig. 10.6.10 Lysis of adhesions. Coagulating adhesions close to the
abdominal wall.
Bipolar electrocautery is sufficient for lysis of small omental adhesions.
The heat of coagulation is sufficient to liquify the fatty tissue and elimi-
nates the need for sharp dissection with scissors.
Fig. 10.6.11 Lysis of adhesions. Stapler technique.
A stapler can be used to transect vascularized omental adhesions. Place
the jaws around the adhesion so that the tissue is between the markings.
Use a measuring device to determine the proper size if needed. The stapler simultaneously closes the adhesion on both sides of the transection
with a central blade.
Complications
327
Fig. 10.6.12 Lysis of adhesions. Roeder loop and knot ligature.
After sharply transecting the vascularized adhesion, place a Roeder loop
and knot close to the base with a Roeder knot applicator. Using an adapta-
tion of the appendectomy technique, grip and elevate the tissue stump to
be ligated with graspers to ensure correct placement of the Roeder knot.
If the structure is vascularized, ligate it in continuity with an internal liga-
ture looped around it and tie an extracorporeal knot down to the struc-
ture. Then transect it.
Complications
Intraoperative Complications
Perforation of the Colon or Small Intestine
(Fig. 10.6.14).
Injuries to the hollow organs from placing the Veress needle
occur relatively frequently during lysis of adhesions.
Perforation of the Small Intestine when Advancing the Laparoscope
(Fig. 10.6.15).
Injuries to the Serosa
Dissection of fused intestinal loops often unavoidably results in
injuries to the serosa.
Corrective action: Seal these injuries with fibrin glue.
Injuries to the serosa and muscular coat.
Corrective action: Place interrupted seromuscular sutures.
Immediate Postoperative Complications
Paralytic Ileus
A postoperative paralytic ileus can occur for three to five days. If
the condition persists, mechanical ileus and peritonitis must be
excluded.
Peritonitis
Corrective action: Conventional surgical treatment with laparotomy.
Fig. 10.6.13 Lysis of adhesions. Transecting an adhesion between two
surgical clips.
One can ligate fine adhesions with metal or absorbable surgical clips and
then sharply transect between them. To avoid clip loosening and subsequent bleeding, do not use metal clips if the adhesoin has a diameter
larger than 3.5 mm or smaller than 1 mm (see also Fig. 4.1.71).
Fig. 10.6.14 Lysis of adhesions. Complication: Perforation of an adherent
instestinal loop with the Veress needle.
As the illustration shows, an open cavity free of adhesions was initially
found in a patient with suspected intraabdominal adhesions. However,
the surgeon has advanced the Veress needle too far and penetrated the
intestinal wall.
Prevention: Performing the proper safety test (aspiration test, “slurp” test,
and rotation test) helps the surgeon recognize this complication early and
avoid gas insufflation.
Corrective action: If the perforation site is only as wide as the Veress
needle, simply repair the lesion with fibrin glue and place a drain. Larger
injuries must be sutured.
Note: The manometer test is positive in this complication.