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_841_Библиотеки_им_академика_М_И_Перельмана.pdf
Surgical Technique andDicult Situations fromGiovanni de Manzoni (Conventional)
3. Problematic cases: if at least one of these characteristics is present
5 Voluminous tumors of the upper third
5 Bulky lymph nodes especially at station n. 10
5 Previous chemotherapy
5 Cirrhotic patient with periesophageal/peri-
gastric varices
4. Very problematic cases: if one of the following
characteristics is present
5 Tumors invading adjacent organs T4b
5 Esophageal or duodenal invasion
i. Especially if also other previous charac-
teristics are present (BMI >35; cirrhosis;
preoperative chemotherapy)
21.6 Dicult Situations: Personal
Experience
Case 1
161
21
. Fig. 21.14 transection of esophagus 2 cm above of
the visible tumor margin
abdominal wall is reopened; aer a careful
inspection, two of the four drain tubes are
removed and the laparotomy is closed [1].
21.5 Classication ofPatients
According toIntraoperative
Diculty
1. Ideal cases: if all these characteristics are present
5 Young patient (<50years old)
5 Normal BMI
5 No previous major abdominal operations
5 Early tumor
2. Not quite ideal cases: if at least one of these
characteristics is present
5 Obese patient
5 Previous upper mesocolic abdominal surgery
5 Voluminous tumor of the medium or lower
third
Situation
A 71-year-old male patient with cT1sm N0 cardiac
adenocarcinoma on Barrett’s esophagus and subrenal aortic aneurysm of 5.5 cm.
Dilemma
What is the appropriate surgical strategy for this
patient?
Solution
A simultaneous surgical approach has been chosen
performing EVAR as the rst step and then Ivor
Lewis esophagectomy.
Outcome
Postoperative course was uneventful; the patient
has been discharged on the 14th postoperative
day. At 1-month follow-up, angio-TC showed a type
2a endoleak that has been managed conservatively.
Case 2
Situation
A 72-year-old female patient with cT3N+ adenocarcinoma of the gastric body underwent total
gastrectomy and D2 lymphadenectomy at another
hospital. Lymphadenectomy of the hepatoduodenal ligament was complicated by an ischemic
injury of the common bile duct with the result
of a biliary leakage. At the admission to our unit,
the patient was septic and the CT scan showed an
intra-abdominal abscess.
162
G. de Manzoni et al.
Dilemma
Reoperation with hepaticojejunostomy or conservative management?
Solution
A stuloscopy was performed and a drainage tube
was left in the intra-abdominal abscess. Then a percutaneous transhepatic biliary drainage was placed
and a systemic antibiotic therapy was started.
Outcome
The result was the closure of the biliary stula with
a residual stricture of the common bile duct. Serial
endoscopic treatments with balloon dilatations
and stent insertions are needed.
Case 3
Situation
A 51-year-old male patient with cT3 N+ adenocarcinoma of gastric fundus with cardiac invasion
managed by total gastrectomy and a D2 lymphadenectomy.
A transabdominal intramediastinal Roux-en-Y
esophagojejunostomy was performed; intraoperative methylene blue test was positive. It was not
possible for an intra-abdominal oversewing.
Dilemma
Anastomosis takedown or left thoracotomy with
oversewing?
Solution
We performed a left thoracotomy and oversewing
of the anastomosis that was incomplete for one
third of its circumference. We also placed a nasogastric tube in suction for 1 week.
Outcome
No anastomosis leakage, no complications but
refeeding was started later than usual.
References
1. de Manzoni G, Roviello F, Siquini W.Surgery in the multimodal management of gastric cancer. Milan:
Springer; 2011.
2. Cordiano C, de Manzoni G, Guglielmi A. Treatment of
gastric carcinoma. Italian Society of Surgery, Rom.1996.
3. Japanese Gastric Cancer Association. Japanese gastric
cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011;14:113–23.
4. Kakeji Y, Tsijitani S, Baba H.Clinicopathological features
and prognostic signicance of duodenal invasion in
patients with distal gastric cancer. Cancer. 1991;68:38–43.
5. de Manzoni G, Giacopuzzi S, Zanoni A.Treatment of
esophageal and hypopharyngeal squamous cell carcinoma. Milan: Springer; 2011.
21
163
Individual Surgery for Benign Gallbladder and Bile Ducts Diseases
Contents
Chapter 22 Introduction – 165
MichaelKorenkov, Christoph-omasGermer,
andHaukeLang
V
Chapter 23 Surgical Technique and Dicult Situations
from Francesco Crafa – 169
FrancescoPaoloPrete, MarioBaiamonte,
FrancescoRuotolo, FrancescoBavetta,
andFrancescoCrafa
Chapter 24 Surgical Technique and Dicult Situations
from Benoit Navez – 187
BenoitNavez
165
Introduction
MichaelKorenkov, Christoph-omasGermer, andHaukeLang
22.1 Patients withSymptomatic
Cholecystolithiasis – 166
22.2 Patients withAcute Cholecystitis – 166
22.3 Patients withChronic Cholecystitis,
“Shrinking” oftheGallbladder andPorcelain
Gallbladder – 167
22.4 Patients withFailed Endoscopic Extraction
ofBile Duct Stones – 167
22.5 Patients withBiliodigestive or Cholecystohepatic
Fistulas – 167
22.5.1 Classication ofIntraoperative Diculties – 167
22
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_22
166
M. Korenkov et al.
A surgery of gallstone disease is indicated by the
following patient groups:
1. Patients with symptomatic cholecysto lithiasis
2. Patients with acute cholecystitis
3. Patients with chronic cholecystitis, “shrinking” and porcelain gallbladder
4. Patients with failed endoscopic extraction of
bile duct stones (“unusual” anatomy of the
papilla vateri, previous B-II surgery, “xed”
common bile duct stone, etc.)
5. Patients with biliodigestive or cholecystohepatic stulas (Mirizzi II)
Unfavourable background for surgery is liver cirrhosis, severe obesity, extended previous abdominal surgery, acquired or congenital body deformities
as well as a third trimester of pregnancy.
22.1 Patients withSymptomatic
Cholecystolithiasis
22
Laparoscopic cholecystectomy is considered as a
gold standard for the surgical treatment of patients
with symptomatic cholecystolithiasis. e dicultdecision situations occur by unusual anatomy of
Calot’s triangle especially in combination with the
above-mentioned unfavourable background.
An ideal technical performance of laparoscopic
cholecystectomy aims a separate preparation of
cystic artery and cystic duct and their transection
aer unequivocal identication of both structures.
Before the transection, a terminal connection of
both tubular structures with a gallbladder wall
should be identied. e following situations can
make an intraoperative orientation dicult:
5 Very short and dilated cystic duct
5 Very short cystic artery in combination with an
arch-shaped right hepatic artery curve (the socalled caterpillar hump of right hepatic artery)
5 Combination of 1 and 2 (especial unfortu-
nate)
Patients with Morbus Bechterew deformities and
gibbus formation or patients in the third trimester
of pregnancy require a special placement of trocars (. Fig.22.1).
In case of dicult presentation of surgical
situs or problematic triangulation, additional trocars should be placed.
. Fig. 22.1 Patient with severe gibbus formation by
Morbus Bechterew. In this case, a standard patient positioning and usual trocar placement were not possible
22.2 Patients withAcute
Cholecystitis
e technical diculties occur most oen in the
following situations:
5 A gallbladder is dicult to grasp. In spite of
puncture and aspiration of gallbladder content, it is not possible to grasp a gallbladder
wall with a standard 5mm grasper.
Recommendable is to change the 5-mm trocar
to 10/12-mm trocar with the use of a 10-mm
Babcock grasper.
5 Severe inltrating of the gallbladder neck. In
this situation, a usual dissection of the
Calot’s triangle is not possible. Recommendable is an anterograde preparation of the
gallbladder from the apex to the neck. Such
preparation is most oen related with diffuse bleeding from liver bed, which can be
sometimes very intensive. Using of argon
beamer or bipolar coagulation can be necessary. Recommendable is a “small step dissection” with meticulous haemostasis aer
each step. Aspects of the subtotal cholecys-
Introduction
167
22
tectomy and using of linear stapler are discussed in detail in the chapter of Crafa etal.
(7 Chap. 23).
5 Combination from the acute cholecystitis and
intrahepatic gallbladder. In such case for the
planning of further surgical procedure, accessibility of the gallbladder neck for the dissection should be evaluated. If a safe exposition
and transection of cystic artery and cystic
duct are possible, the following options are
available:
5 Step-by-step gallbladder preparation from the
liver bed according to the following pattern:
“dissection of the small gallbladder segment–
assured haemostasis– next step”.
5 Resection of liver bed in apex area.
5 Transvesical approach with opening of the
gallbladder, removing of stones and gallbladder wall resection with mucosa destruction on the posterior wall (argon beamer,
mono- and bipolar coagulation). Before the
destruction of the mucosa, a meticulous
examination and biopsy if necessary should
be performed.
If the gallbladder neck is not suitable for dissection, the following options should be discussed:
5 Anterograde preparation
5 Conversion to an open approach
5 Break the operation (estimation the risk of
perforation!)
22.3 Patients withChronic
Cholecystitis, “Shrinking”
oftheGallbladder
andPorcelain Gallbladder
with acute cholecystitis or biliodigestive/cholecystohepatic stulas.
22.4 Patients withFailed
Endoscopic Extraction ofBile
Duct Stones
On this occasion, the problem is that in a lot of
clinics the laparoscopic bile duct exploration is
not a routine surgical procedure. In such situation, every surgeon should decide if his surgical
expertise and technical know-how in his clinic are
sucient for the assured performance of this procedure. If such is not the case, a conventional
technique of bile duct revision should be used.
22.5 Patients withBiliodigestive or
Cholecystohepatic Fistulas
Patients of this group will be operated mostly conventional, although there is a positive experience
with the use of endoscopic technique. Patients
with cholecystohepatic stulas (Mirizzi II) mostly
have severe adhesive process in a cholecystohepatic junction. ereby there is a considerable
inammatory contraction of the gallbladder neck
and a hepatoduodenal ligament and absence of
Hartmann’s pouch. A consequent dissection in
this area can lead to long segment bile duct injury.
In the case of suspected cholecystohepatic stulas,
a subtotal cholecystectomy is recommendable.
22.5.1 Classication
ofIntraoperative Diculties
Technical diculties by surgical treatment of
patients of this group are similar dependes on
anatomical specics to diculties by patients
e operative diculties for surgery of benign
gallbladder and biliary tract diseases can be classied as summarised in . Table22.1.
168
M. Korenkov et al.
. Table 22.1 Grading of operative diculties for benign gallbladder and biliary tract diseases
Grading Case type
I (ideal cases)
It is easy to operate; every operative technique
is technically unproblematic
II (not quite ideal)
Some minor technical diculties may occur;
some operative techniques can be more dicult
as others
III (problematic)
Dicult to operate; some operative techniques
are considerably more dicult than others
IV (very problematic)
Every operative step is very dicult
Slender or normal-weight patient without body
abnormalities
No previous major abdominal surgery
No perivesical inammatory or brotic changes
Usual anatomy of Calot’s triangle
Orthotopic gallbladder position
Moderate obese patient (BMI around 30kg/m
Otherwise similar to grade I
Overweight patient (BMI > 35kg/m
Previous major abdominal surgery
Acute or chronic cholecystitis
Liver cirrhosis
Biliodigestive or cholecystohepatic stulas
Acquired or congenital body deformities
Third trimester of pregnancy
Extreme form of grade III factors
2
)
2
)
22
169
Surgical Technique
andDicult Situations
fromFrancesco Crafa
FrancescoPaoloPrete, MarioBaiamonte, FrancescoRuotolo,
FrancescoBavetta, andFrancescoCrafa
23.1 Safe Steps inLaparoscopic
Cholecystectomy – 171
23.2 Dicult Laparoscopic Cholecystectomy:
When? – 175
23.3 Anticipating aDicult Cholecystectomy – 175
23.3.1 Dicult Access (Diculty II-III) – 175
23.3.2 Obesity (Diculty II-III) – 176
23.3.3 Adhesions fromPrevious Procedures
(Diculty II-IV) – 176
23
23.4 Technical Aspects inDicultLC – 176
23.4.1 Cystic Duct Stone, Short Cystic
Duct (Diculty: II-III) – 177
23.4.2 Acute Cholecystitis (Diculty: II-IV) – 178
23.4.3 Gallbladder Empyema (Diculty: III-IV) – 178
23.4.4 Laparoscopic Cholecystectomy During
Pregnancy (II) – 178
23.4.5 Cirrhosis oftheLiver withPortal
Hypertension (III-IV) – 178
23.5 Abnormal Anatomy – 178
23.6 Variants – 179
23.6.1 Intrahepatic Gallbladder (II-IV) – 179
23.6.2 Hepatobiliary andArterial Anatomical
Variants (II-III) – 179
23.6.3 Accessory Bile Ducts (II-III) – 179
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_23
23.7 Pathological Anatomy – 179
23.7.1 Massive Gallbladder Calcication, Porcelain
Gallbladder (IV) – 179
23.7.2 Mirizzi Syndrome (III-IV) – 179
23.7.3 Cholecystoenteric Fistula (III-IV) – 180
23.8 Extrahepatic Bile Duct Injuries – 180
23.8.1 Intraoperative Cholangiogram (IOC) – 181
23.9 Common Bile Duct Stones – 181
23.9.1 Intraoperative Laparoscopically Guided
ERCP (Diculty II) – 182
23.9.2 Laparoscopic Transcystic Approach
(Diculty II-III) – 182
23.9.3 Laparoscopic Choledochotomy forCBD Stones
(Diculty II-IV) – 182
Reference – 185
Surgical Technique andDicult Situations fromFrancesco Crafa
171
23
e most common biliary tract procedure currently performed is the laparoscopic cholecystectomy. Laparoscopic cholecystectomy (LC) is
the current standard treatment of symptomatic
gallstones and one of the most common procedures being performed by the general surgeons all over the world for cholelithiasis and
acute cholecystitis. A number of diverse factors
including biliary anatomy and disease severity
may render LC challenging, especially to the
surgeon ascending the learning curve. Dicult
cholecystectomy may be associated with serious complications and a high conversion rate,
and no consensus is found among surgeons on
how to manage dicult laparoscopic cholecystectomy. We present our current strategies to
manage dicult cholecystectomy, classifying
the diculty of the cases we discuss by intraoperative diculty as:
I Ideal cases (i.e. easy to operate, no problems)
II Not quite ideal cases (some minor diculties
may occur)
III Problematic cases (dicult to operate, some
operative techniques are considerably more
dicult than others)
IV Very problematic (“horrible”) cases (every
operative step is dicult)
e patient is in lithotomy position (supine, with
legs spread) and is prepared as per eventual cholangiography. ree 5mm trocars and one 10mm
trocar are inserted; if a common bile duct exploration is planned, two 5mm trocars and two 10mm
trocars are used.
e rst trocar is always inserted using a modied “open” technique: a transverse 10–15 mm
long infra-umbilical incision is performed for
camera introduction, with exposure of the fascial layer, longitudinal incision along the “linea
alba” below the umbilicus and direct visualisation
of the peritoneum prior to insertion of the rst
10mm port, to induce pneumoperitoneum.
A second 5mm incision is performed in the
right hypochondrium, over the mid-clavicular
line about 5–8cm below the rib margin.
level in the le hypochondrium.
A 5 mm incision approximately at the junction of the upper third and lower 2/3 of a line
between the xiphoid and umbilicus completes the
access (. Fig.23.1). is access can be of 10mm
in case of CBD exploration.
e surgeon stands between the patient’s legs,
with the assistant on the patient’s right side. e
following instruments are used: a 30° 10 mm
laparoscope, a harmonic scalpel and two reusable
grasping forceps.
23.1 Safe Steps inLaparoscopic
Cholecystectomy
Before facing a dicult LC, it is important to have
a baseline structured surgical strategy in mind.
Our standard approach to cholecystectomy
applies to both technically easy and dicult LC
and follows the same key steps:
5 Access and identication of structures (cre-
ation of pneumoperitoneum, insertion of trocars, rst exploration)
5 Exposure (with separation of all eventual
adhesions limiting correct visualisation of the
area containing cystic duct and artery)
5 Isolation of the cystic duct and cystic artery
followed by their closure and division
5 Dissection of the gallbladder
5 Extraction
5 Check of haemostasis, biliostasis and closure
of the surgical accesses
. Fig. 23.1 Trocar placement for laparoscopic
cholecystectomy