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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Laparoscopic Splenectomy
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269
spleen is placed in the bag and the remaining attachments are divided, once the bag
is closed the opening of the bag is brought out of the abdomen. Often times, several
maneuvers are required to remove the specimen. First, the incision can be extended.
Second, nger fracturing or morcellating the spleen with ringed forceps will allow
piecemeal removal.
Once the specimen is removed, the laparoscope is reintroduced to inspect for
hemostasis in the surgical eld, visceral injury, the presence of spilled specimen or
accessory spleens. The surgical bed should be irrigated and suctioned. All trocars
should be removed under direct visualization and the abdomen is desufated. It is
our practice to close the fascia of all ports greater than 5mm. The skin is closed with
subcuticular sutures and the topic skin adhesive.
4.5 Indications forConverting toanOpen Procedure
There are several indications for conversion to an open procedure. These may include:
hemodynamic instability during insufation, uncontrollable coagulopathy/hemorrhage, massive splenomegaly such that you cannot place the spleen in the extraction
bag, and need for unanticipated additional procedures For massive splenomegaly,
preoperative consideration can be given to hand-assisted laparoscopic splenectomy.
4.6 Post Operative Care, Outcomes, andComplications
Patients who undergo a laparoscopic as opposed to open splenectomy have shorter
lengths of stay, faster return to a regular diet, and improved pain. The most common
complication of splenectomy is bleeding, followed by thromboembolic events. Rare
complications include pancreatic injury/stula, or OPSI.In addition to the preoperative vaccinations, post-operative vaccines are critical to preventing
OPSI. Vaccinations should be administered 2 weeks post-operatively for urgent/
emergent splenectomy patients who did not undergo preoperative vaccination. If
there is concern that the patient will be lost to follow-up in this scenario, vaccines
should be given prior to discharge. Any asplenic immunosuppressed patient will
need boosters in 3months, otherwise pneumococcal and meningococcal boosters
are administered every 5years.
References
1. Misiakos EP, etal. Laparoscopic splenectomy: current concepts. World J Gastrointest Endosc.
2017;9(9):428–37. https://doi.org/10.4253/wjge.v9.i9.428.
2. Stasi R, etal. Long-term observation of 208 adults with chronic idiopathic thrombocytopenic
purpura. Am J Med. 1995;98(5):436–42. https://doi.org/10.1016/s0002- 9343(99)80342- 8.
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3. Chaturvedi S, Arnold DM, McCrae KR.Splenectomy for immune thrombocytopenia: down but
not out. Blood. 2018;131(11):1172–82.
4. Perrotta S, et al. Hereditary spherocytosis. Lancet. 2008;372(9647):1411–26. https://doi.
org/10.1016/S0140- 6736(08)61588- 3.
5. Shamim AA, et al. Laparoscopic splenectomy for trauma. JSLS. 2018;22(4):e2018.00050.
https://doi.org/10.4293/JSLS.2018.00050.
6. Wu Z, etal. Comparative treatment and literature review for laparoscopic splenectomy alone ver-
sus preoperative splenic artery embolization splenectomy. Surg Endosc. 2012;26(10):2758–66.
https://doi.org/10.1007/s00464- 012- 2270- z.
7. Mourtzoukou EG, et al. Vaccination of asplenic or hyposplenic adults. J Br Surg.
2008;95(3):273–80.
N. Lunardi and H. B. Prince
Part IV
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Small Bowel and Appendix Surgery
Small Bowel Resection andAnastomosis
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LaurenRaff andTristaReid
1 Indications
Small bowel resection with primary anastomosis is a common procedure in all surgical populations for a wide variety of indications including mass (benign or malignant), obstruction (partial or complete), ischemia/necrosis, trauma, perforation,
hemorrhage, stula, stricture, intussusception, and congenital anomalies. Though
many techniques have been described, outcomes remain similar so long as basic
surgical principles, such as adequate exposure, gentle tissue handling, absence of
tension, adequate tissue perfusion, and meticulous hemostasis, are followed [1].
2 Preoperative Preparation
Pre-operative history and physical exam should be performed focusing on the gastrointestinal (GI) system and should include a thorough review of the patient’s prior
surgical history. Patients with small bowel obstruction may report nausea, vomiting,
abdominal distension, abdominal pain, and decreased or absent bowel function.
Small bowel malignancy may present with obstructive symptoms (partial or complete) or bleeding (upper GI or lower GI bleeding), weight loss, intussusception, or
abdominal pain. Peritoneal signs on physical exam should prompt emergent surgical intervention.
Imaging can be obtained for further work-up and should be based on the patient’s
history and symptoms, severity of illness, and differential diagnosis. Upright chest
L. Raff (*) · T. Reid
Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
e-mail: Lauren_raff@med.unc.edu; trista_reid@med.unc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_22
273© The Author(s), under exclusive license to Springer Nature
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and upright or left lateral decubitus abdominal plain lms can quickly evaluate for
intra-abdominal free air and small bowel obstruction. Computed tomography (CT)
of the abdomen/pelvis with oral and intravenous (IV) contrast provides much higher
quality imaging that can help identify the etiology and precise location of the
patient’s pathology. Upper GI with small bowel follow through (UGI SBFT) is a
series of uoroscopic images obtained after the patient drinks oral contrast that can
identify both anatomic abnormalities and functional (motility) problems.
Enteroscopy and capsule endoscopy can help visualize intra-luminal pathology that
imaging studies may miss. CT angiography and tagged red blood cell (RBC) scan
can help localize intraluminal hemorrhage.
The patient should be made nil per os (NPO) prior to surgery. If there is any preoperative concern for increased risk of aspiration or bowel obstruction, a nasogastric tube should be inserted to decompress the stomach prior to induction of
anesthesia. Bowel prep is typically not needed prior to small bowel surgery. Preoperative multi-modal pain medical can be administered to help reduce postoperative pain. If an elective laparotomy is planned, an epidural or spinal injection
can be considered to help reduce post-operative narcotic requirements.
L. Raff and T. Reid
3 Positioning andAnesthesia
All patients should undergo induction of general anesthesia with endotracheal intubation. Rapid sequence induction is used for emergent procedures or in patients at
increased risk of aspiration. The patient should be placed in the supine position and
a foley catheter should be inserted. For an open procedure, the arms are placed out
and secured on padded arm boards. For laparoscopic procedures, one or both arms
should be tucked by the patient’s side to maximize the range of the surgeon’s position. An orogastric or nasogastric tube is placed to decompress the stomach and
proximal small bowel, if not placed pre-operatively. Sequential compression devices
should be placed on the lower legs bilaterally, so long as there are no contraindications, for mechanical deep venous thrombosis (DVT) prophylaxis. Subcutaneous
heparin or enoxaparin should be administered prior to incision based on the patient’s
thrombosis risk (as measured by the Caprini Score for Venous Thromboembolism)
and the patient/procedural bleeding risk [2]. In general, unless the patient has active,
large volume GI bleed or another absolute contraindication to anticoagulation, most
surgical patients undergoing this operation should receive pre-operative chemoprophylaxis as well as mechanical prophylaxis. All hair in the operative eld should be
removed using an atraumatic electric clipper and the abdomen should then be
widely prepped with chlorhexidine and draped [3]. A single dose of IV antibiotics
should be administered within 1hour of incision [4].
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4 Open Small Bowel Resection
The classic approach for a small bowel resection and anastomosis is via an open
incision. Typically, a vertical midline incision is used in patients over the age of
2years and a transverse incision is used for children younger than 2years. Open
resection is the preferred approach if the patient is unstable or is unable to tolerate
abdominal insufation. Additionally, if the patient has obstruction with signicant
small bowel dilation or dense adhesive disease, the open approach may be better,
though this can be dependent on the operating surgeon’s comfort and prior experience with laparoscopy.
Open midline incision is performed in the standard fashion and should be located
near the suspected location of the small bowel pathology. A vertical incision is performed in adults so it can be easily extended superiorly or inferiorly if more exposure is needed. Once the abdomen is entered, a self-retraining retractor is placed to
aide in operative exposure. The small bowel should be gently eviscerated from the
abdominal cavity. Adhesiolysis can be performed as indicated with sharp dissection
using Metzenbaum scissors or with blunt dissection and cautery. The small bowel
should be assessed fully from the ligament of Treitz to the ileocecal valve in order
to identify the diseased segment and also to determine the length of remaining
bowel after the planned resection. In general, attempts should be made to preserve
a minimum of 30% or at least 100cm of small bowel to prevent short bowel syndrome [5]. This is of particular importance if the ileocecal valve has been resected
and for patients who may require or have had multiple small bowel resections over
their lifetime (i.e. Crohn’s disease).
Prior to performing the bowel resection, sterile towels should be placed beneath
and around the small bowel segment to minimize contamination of the surgical eld
due to spillage of intraluminal contents. Once the towels are in place, the proximal
and distal transection sites should be selected. A window can be created at the junction of the bowel wall and distal mesentery. The bowel resection can be performed
with either a stapler or sharply with a scalpel between two non-crushing bowel
clamps. The mesentery is then divided using an energy device, such as the
LigaSure™ (Covidien, Manseld MA) or the Harmonic Ultrasonic© scalpel
(Ethicon, Cincinnati OH). Alternatively, sections of mesentery can be serially
clamped and sharply divided with a Metzenbaum scissors (Fig.1). Silk or Vicryl
ties can then be used to permanently ligate blood vessels. In cases where the patient
is hemodynamically unstable, a gastrointestinal anastomosis (GIA) stapler with
vascular loads can be used to quickly remove the damaged portion of bowel. It is
important to divide the mesentery more proximally when resecting a malignant
tumor to obtain an appropriate number of lymph nodes (nine or more) to guide further oncologic management, as well as resect margins of 8–10cm proximal and
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Fig. 1 Metal clamps are
placed across the distal
mesentery in opposite
directions with the tips
pointing inwards. A
Metzenbaum scissors is
then used to divide the
mesentery sharply. Silk or
Vicryl ties are used to
ligate the mesenteric
vessels. This mesenteric
division should occur more
proximally when resecting
small intestine for
malignancy
L. Raff and T. Reid
distal to the mass. [6] If the patient is hemodynamically unstable and damage control surgery is needed, the stapled ends of the small bowel can be left in discontinuity while the patient is taken to the ICU for resuscitation with a plan for a delayed
anastomosis versus ostomy. With either immediate or delayed anastomosis after a
traumatic injury, the leak rate for small bowel anastomoses was only 3% in one
series [7]. If the patient is otherwise stable, open small bowel anastomosis can be
performed using either a hand-sewn or stapled technique.
5 Hand-Sewn Anastomosis
A hand-sewn anastomosis may be performed in either one or two layers, so long as
the diameters of the proximal and distal bowel are approximately equal. The two
ends can be oriented in an end-to-end, side-to-side (functional end-to-end), or endto- side fashion. There is no difference in leak rate between single and double layer
anastomoses [8, 9]; this can be left to individual surgeon preference. After the two
ends are aligned in the selected orientation, an enterotomy must be made in each
segment. This can be performed by excising the staple line (if performing an endto- end) or by making a longitudinal incision on the anti-mesenteric bowel wall (if
performing a side-to-side). A single layer anastomosis or the inner layer of a two
layer anastomosis can be performed with either a running transmural technique or
using interrupted simple sutures. We prefer to use monolament absorbable suture,
often 2-0 or 3-0 polydioxanone (PDS®) suture (Ethicon, Cincinnati OH). It is critical to take full thickness bites to prevent anastomotic breakdown or leakage as the
submucosal layer of the small bowel provides strength to the anastomosis [1]. The
outer layers (anterior and posterior) of a two layer anastomosis is performed with
interrupted Lembert sutures using braided permanent suture, Vicryl, or PDS®,
again depending on surgeon preference.
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6 Stapled Anastomosis
Stapled anastomoses can usually be performed faster than hand-sewn and are associated with equivalent rates of clinically evident leakage, morbidity, and postoperative mortality [10, 11]. The proximal and distal stapled ends of bowel are
typically aligned in a side-to-side fashion and two stay sutures are placed—one at
the staple line and the other more distally—to temporarily secure the two segments
in proper alignment (Fig. 2). Small enterotomies are then made on the antimesenteric side of each segment near the stapled ends. A linear stapling device (e.g.
GIA stapler) of either 60 or 80 mm is then inserted with one arm through each
enterotomy (Fig. 3). The stapler should be loaded with a “bowel-load” stapler
Fig. 2 Stay sutures are
placed at the proximal and
distal aspects of the
side-to-side small bowel
anastomosis to assist in
maintaining alignment
during stapler placement
Fig. 3 Small enterotomies are made on the antimesenteric side of each limb of small bowel. The
arms of a GIA stapler are then passed into the enterotomies and the stapler is advanced as shown
with the tips pointed downwards. The stay suture is used to pull the small bowel upwards toward
the handle of the stapler. A Debakey forcep is used to retract downward on the mesentery in
between the two stapler arms to ensure that the mesentery is not caught within the staple line
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L. Raff and T. Reid
cartridge, which typically utilizes staples of 2.5mm thickness. After conrming that
the mesentery of each segment of bowel is not caught within the stapler, the linear
stapler is closed. At this time, the surgeon should also ensure that the anti- mesenteric
portion of the bowel wall of each segments is properly aligned. The stapler is then
red, creating a large enteroenterostomy, also referred to as the “common channel.”
The stapler is removed and an Army Navy retractor can be used to inspect the luminal staple line for hemostasis and patency. If needed, the staple line can be oversewn with a running monolament absorbable suture to reinforce the area and
assure hemostasis (Fig. 4). The common enterotomy can then be closed using a
single or double-layer hand-sewn technique (as described above) or by ring across
the common enterotomy with a linear stapler (either a TA or GIA stapler) (Fig.5).
Fig. 4 Army Navy
retractors are used to
expose the mucosal aspect
of the interior staple line to
assess for bleeding. The
staple line can be oversewn
with a running suture as
shown
Fig. 5 The common enterotomy can be closed with a Connell stitch using 3-0 PDS.Care must be
taken to ensure full thickness bites with each pass of the needle. The Connell stitch provides hemostasis and also inverts the bowel wall inwards so that the serosal edges are approximated.
Alternatively, the common enterotomy can also be closed with a simple running stitch or a linear
stapling device, such as the TA or GIA stapler
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If the common enterotomy is closed using a stapler, some surgeons choose to oversew the staple lines with interrupted or running Lembert sutures to create a second
layer (Fig.6). Most surgeons place one or more interrupted sutures distally to reinforce the end of the staple line where the two bowel segments diverge, also called
the “crotch stitch.” The mesenteric defect can then be closed primarily using either
running or interrupted sutures, taking care not to injure the blood vessels running
through the mesentery (Fig.7). This can be accomplished by taking small bites of
the peritoneal lining over the mesentery and limiting tension on the sutures/knots.
Fig. 6 Interrupted
Lembert sutures can be
placed to create the second
layer of a double layer
anastomosis or to reinforce
the staple line of the
common enterotomy. A
nal suture is placed at the
most distal aspect of the
common channel staple
line to reduce tension on
that area, also called the
“crotch stitch”
Fig. 7 The completed
anastomosis. The size and
patency of the anastomosis
can be assessed by placing
the thumb and forenger
on either side of the
completed anastomosis and
gently pinching them
together
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