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Surgical Technique andDicult Situations fromAntonio Longo (Dierent Techniques)
a b
427
54
. Fig. 54.4 a introduction of CAD and xing on the edge
of the prolapsing rectal wall b ve short running sutures
have been apposed circumferentially like parachute cords
to obtain total control of the prolapsing rectum c–d the
circumferential resection by subsequently ring cartridges
stapler
prolapsed rectal cylinder (. Fig.54.5). e tactile
feel is of a hard brous type.
Resection of the anterior prolapse with PPH
01 is not dicult. ree stitches are applied to the
posterior prolapse; the central and le ones
include the ulcer.
Miss the characteristic sound of device during
re. Having extracted the stapler, the tissue is cut, but
not sutured. Massive bleeding from the wound
impedes vision of the wound and suturing.
Tamponing of the wound and strong digital pressure.
e blood pressure of the patient was 145/100. We
ask the anesthetist to lower it pharmacologically.
Aer 10min the pressure has dropped to 95/60. We
check the specimen and it is found that the ulcer is
only partially resected. A deep continuous full-thickness suture of the wound is performed, using Prolene
00, to obtain a good hemostasis. en, starting from
the le side, the continuous suture en block with the
residual solitary ulcer and rectal prolapse is removed
gradually using diathermy and the wound sutured by
. Fig. 54.5 Solitary ulcer of the rectum
separated stitches, Vicryl 00. Postoperatively Hb is
428
A. Longo
54
7.7. e course is characterized by fever (37.2–38°)
the evacuation of blood clots. ere are no other
complications. Constipation and solitary ulcer were
cured.
Very Problematic Case
Technique by Contour Transtar
Nulliparous woman, 35 years old with a history of
severe anorexia. On clinical examination, posterior anal ssure, rectocele and rectal prolapse, and
uterine retroversion with genital prolapse degree I
(B. & W.) were assessed. Under straining: hyperdescending perineum, small rectal procidentia. e
MRI dynamic pelvigraphy, showed under straining; loop rectocele with sigmoid-rectal prolapse,
hyperdescending perineum, horizontalization of
the vagina with retroverted uterus, deep Douglas.
Intervention: evaluation with wad of gauze
shows a rectal prolapse that exceeds 1 cm of the
outer edge of the CAD.Past the stitches of traction,
the prolapsed cylinder was divided in two aps,
anterior and posterior ones, by two linear staplers.
e prolapse was removed using ve cartridge
shots. Since the cylinder removed along 5cm, it
means it has been removed 10cm of prolapse.
e inner lumen of the CAD appeared occupied by tense introexion and rounding of the
anterior rectal wall. To the touch and with bimanual palpation of the rectum and vagina, we realize
that it is a question of a hyper-retroex uterine
body, in such as the cervix is placed upside down
on the anterior vaginal fornix.
Raised with a vaginal spatula, the uterine
body, the sigma prolapsed in the CAD and leaks
out to about 2cm.
e patient was placed in the Trendelenburg
position, a purse-string suture is made 1 cm
above the mechanical suture, and the pursestring is tightened. Circumferentially, full thickness, the rectum was incised just below the
stapled line.
e sigmoidectomy was carried out with the
pull-through technique (about 35cm of sigma).
e sigma was closed proximally by ligation and
pushed, through the open Douglas, into the
abdominal cavity. is creates a sucient space to
pass, bilaterally, a Prolene 00 stitch piercing the
round ligament rst on insertion into the uterus
and then from about 10cm. e maneuver was
facilitated with Klemmer pulling down the liga-
ment itself. With the stitches knotted, a satisfactory suspension of the uterine body with
correction of retroection is obtained. Taking
again the sigmoid stump was opened at as slant
and a purse-string was made. A purse-string was
made on the rectal stump too and the anastomosis
was performed by PPH stapler.
e postoperative course was excellent.
e postoperative MRI dynamic pelvigraphy
showed the correction of all the anatomical
abnormalities, except for an obvious postsurgery
enterocele. Regression of ODS and urgency
aer about 1 month. Despite the good result,
the intervention presented some technical difculties and was made possible thanks to the
small size of the uterus. Patients with a history of
anorexia oen show similar situations to the one
described. Probably the hyper-uterine retroexion, pushing the sigmoid against the sacrum and
forming a barrier, impedes the manifestation of a
complete external prolapse. erefore, the extent
of the prolapse was underestimated preoperatively. Currently in cases where defecography
shows a sigmoid-rectal prolapse, especially in
young patients with uterus retroexed, we prefer
a minimally invasive abdominal approach: the
so intraperitoneal rectosuspension (see below).
54.3 Treatment ofExternal Rectal
Prolapse
As shown in . Fig. 54.1 and . Table 54.1, in
patients with external rectal prolapse, in which
the muscular structure of the rectum and therefore compliance are not compromised, we have
been practicing, since 2007, a new procedure
which we have called so intraperitoneal rectosuspension (SIR).
e procedure is based on the simple principle
that the external rectal prolapse is caused by a force
vector (straining), directed downward, on the
Douglas pouch, which slipping down drags with it,
inevitably, the rectum. In fact, the pelvic peritoneum is the only anatomical structure that supports the upper rectum in the correct anatomical
position. e clinical defecographic demonstration
is that the external rectal prolapse is always accompanied by a deep Douglas or an enterocele. Another
conrmation is that the genital prolapse, leading a
low dislocation of Douglas, always causes a rectal
prolapse, internal or external one. is occurs
Surgical Technique andDicult Situations fromAntonio Longo (Dierent Techniques)
429
54
because the rectum cannot be detached from the
pelvic peritoneum being tenaciously welded to the
perirectal fascia. It follows that pulling up and setting the Douglas peritoneum can achieve the suspension of the rectum in anatomical site.
54.4 SIR Procedure
e SIR procedure consists in xing a V-shaped
Prolene mesh to the posterior vaginal fornix and
the lower peritoneal pouch, and then the strips of
the mesh are threaded through two subperitoneal
tunnels and aer are xed to the lateral muscle of
the abdomen.
e laparoscopic approach is almost always
possible. One trocar of 1cm and two trocars of
0.5 cm of diameter are sucient. e V-shaped
mesh has two 30cm long and 2cm large strips. A
uterine manipulator is useful.
Making a small incision, 2cm above and 2cm
posterior to the anterior superior iliac spines, cutting the fascia, and disassociating the muscular
ber up to the subperitoneum, a curved laparoscopic forceps (Cuschieri, Storz) is introduced.
Following, under laparoscopic vision, the tip of
the forceps, a subperitoneal tunnel can safely be
carried out. e tunnel is performed 2cm above
the peritoneal reection of the colon. Having
reached the third lateral of the round ligament, the
forceps passes through the broad ligament of the
uterus, which is tractioned upward and laterally to
facilitate the maneuver. A spatula introduced into
the vagina exposes the posterior vaginal fornix.
Having opened the posterior peritoneum of the
broad ligament, on the branches of the forceps, a
strip of mesh is grasped and moved outward. e
same steps are performed on the opposite side.
e passage through the broad ligament
allows crossing well above the iliac vessels and
the ureter, avoiding risks of lesions. Reducing
the rectal prolapse using a gauze (. Fig.54.6a)
mounted on a clamp, we achieve an optimal intrapelvic visualization of the Douglas
(. Fig. 54.6b). is facilitates the packing of a
peritoneal tunnel, where the mesh is placed,
which includes by three stitches the posterior
and lateral vaginal fornix, the peritoneum covering the rectum, and the redundant Douglas
(. Fig.54.6c, d). e suspension of the rectum is
modulated pulling the strings (. Fig.54.7). e
mesh is sutured on both sides to the external
oblique muscle, and at least 5cm of strip is tunneled under the muscular fascia, obtaining a so
and dynamic organ suspension.
e totally intraperitoneal approach has the
advantages of avoiding rectal dissection, correcting, at the same time, the deep Douglas. e suspension is so because the rectum isn’t xed to
the sacrum but to the so structure: the abdominal muscle.
In man, the procedure is feasible by varying
the technique. If liing up the Douglas forms a
peritoneal fold that laterally crosses the external
iliac artery, the lateral tunnel is stopped 2–3cm
before reaching the external iliac artery; then,
through a small incision on the peritoneum, the
forceps grips the strips and brings it out.
If the fold of Douglas does not override the
iliac artery, it uses a V-shaped dual mesh: this
allows you to leave a portion intraperitoneally
with a Gore-Tex surface exposed to the viscera. In
these cases, it is necessary to perform a running
suture between the lateral edges of the mesh and
the peritoneum in order to avoid internal herniations. e dual mesh can also be used in women
who have undergone a hysterectomy with bilateral ovariectomy and removal of loose ligaments.
For brevity, we report below the technique pelvic
organ prolapse suspension (POPS), conceived
and practiced by us in 2001 but published in 2007
aer a long follow-up. e technique POPS is recommended for rectal prolapse associated with or
secondary to genital prolapse and/or cystocele.
e technical diculties of SIR and POPS are
very similar so I’ll cover them together.
54.5 POPS Technique
POPS diers from the SIR because the mesh is
sutured to the anterior and lateral fornices of the
vagina or to the posterior and lateral, according,
respectively, to the prevalence of cystocele or
posterior colpocele (. Fig.54.7). In hysterectomized patients, the mesh is passed through a
tunnel made on the vaginal vault. In some cases
to the mesh anchored to the anterior fornix,
another mesh (length about 10cm) is sutured to
the posterior vaginal fornix and to the Douglas,
in the same way described for the SIR procedure
and then bilaterally sutured to the anterior mesh
through two smaller incisions made in the posterior peritoneal page of the broad ligament.
430
A. Longo
a
b
54
c
d
. Fig. 54.6 SIR: surgical steps. a Reduction of the rectal
prolapse using a wad of gauze. b The peritoneum covering the rectum and the Douglas pouch are pushed into
the pelvis. c The semicircular suture includes the posterior
and the lateral vaginal fornices; the lower peritoneal fold
that cover the upper rectum; the redundant Douglas. d
A prolene V-shaped mesh is wrapped in the semicircular
sutures
Surgical Technique andDicult Situations fromAntonio Longo (Dierent Techniques)
431
54
. Fig. 54.7 Similar surgical steps of POPS and SIR pro-
cedure. A V-shaped mesh is xed to anterior and/or to
posterior vaginal fornices (POPS), or to the Douglas (SIR).
Ideal cases Female patients without previous
abdominal or pelvic operations
and normal size uterus
Quite ideal
cases
Problematic
cases
Very
problematic
cases
Male patients
Patients with hysterectomy and
adherence between intestine and
pelvic peritoneum
Patients with large uterus that
need hysterectomy
Patients with hystero-ovariectomy
with absence or brosis in pelvic
peritoneum. Tenacious adherence
between the viscera and pelvic
peritoneum
In both procedures, through two lateral subperitoneal
tunnel, the strips are pulled out and sutured to the lateral
muscle of abdomen
54.5.1 Very Problematic Case
Parous woman, 65 years old, previous myocardiac
infarct, diabetes, obesity. Previous surgery for
appendicitis with peritonitis. PAP test negative,
complete pelvic prolapse with: cystocele degree III,
non-reducible genital prolapse of degree III with
vaginal erosion. External rectal prolapse
(. Fig.54.8). Urinary incontinence, chronic constipation, and active fecal incontinence. Marked anal
hypotonia.
e MRI cinedefecography shows massive
hysterocele. Colonoscopy shows sigmoid diverticulosis.
54
432
A. Longo
. Fig. 54.8 Total pelvic organs prolapse: cystocele III°;
not reducible genital prolapse III°; external rectal prolapse
54.5.2 Description
oftheIntervention
Laparoscopic exploration of the abdominal cavity
shows that the pelvis is totally occupied by the
sigma which has tenacious adhesions with the
pelvic peritoneum, the cecum, and the right parietal peritoneum miss for about 5cm. e adhesions between the sigma and cecum and the
parietal peritoneum are removed. Dissection of
pelvic adhesions turns out to be extremely di-
cult, and during dissection, accidentally, the
sigma was open (probably the patient had previ-
ous perforation of diverticulum). e small perfo-
ration was sutured. Due to the extreme diculties
to dissect the pelvic rectum, we changed the strat-
egy: placement of two lighted ureteral stents.
Via perineal, not without diculty, we performed a rectosigmoid mobilization (Altemeier
procedure). In this way the dissection of the
sigma from the posterior vaginal wall and the
uterus was possible. Given the importance of the
sigmoid diverticulosis, we decided to remove all
the sigma. Aer mobilization of the le colon
exure, via perineal, we removed all the rectosigma and made a mechanical anastomosis L-T
4 cm from the dentate line. Aer this step has
been possible to reduce the uterus-bladder prolapse. A POPS was performed, anchoring the subperitoneal mesh to the anterior vaginal fornix.
e right lateral peritoneal gap, where the mesh
of Prolene remained uncovered, was repaired
with a patch of Gore-Tex. Finally, a plastic shortening of the round ligaments was performed to
straighten the uterus, which tended to retroex in
the small pelvis. Two pelvic drainages were positioned. e patient was kept in TPN for 6 days.
e postoperative course was good. At the
checkup aer 30-day substenosis, we noted the
anastomotic substenosis that was dilated with a
balloon. Aer frequent recurrences of substenosis, 6 months aer surgery, without anesthesia
(because persistence of anal hypotone) we practiced a surgical correction by three incisions and
suturing of the stenotic ring. One year aer the
intervention, anal tone was 25 mmHg and the
patient was said to have regained anal and urinary
continence.
Supplementary
Information
Index – 435
433
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1
Index
435
A–C
A
Abdominal fistulae 217–221
Abdominal gastrectomy 141
Abdominoperanal intersphincteric rectal
resection 331–332
Abdominoperineal rectum
extirpation 319–321
– mesorectum, separation of 320–321
– plastic reconstruction 321
– preparations 320
– subcutis dissection 320
Abdominoperineal resection (APR) 345
Accessory bile ducts 181
Acute cholecystitis 168–169, 179–180
Acute, toxic ulcerative colitis 225
Adenocarcinoma of the esophagogastric
junction (AEG)
– classification and staging 134–136
– difficult situations handled by 143
– intraoperative difficulties
143–144
– patient preparation 137
– surgical technique
137–142
Adipose tissue
– in laparoscopic antireflux surgery 75
– total gastrectomy 158–159
American Society of Colon and Rectal
Surgeons 296
Anal canal-sustaining colectomy
217–218
Anastomosis
– in Parvaiz’s surgical technique, for
rectal cancer 359–361
– intestinal 213, 214
– intracorporeal ileocolic
237–240
– low anterior rectal resection 305–306
– of pouch 217
– sigmoid diverticulitis
290–291
– suturing technique 213
Anterior rectal resection
329–330
Anterior resection syndrome
394
Anthuber’s surgical technique, for rectal
cancer
– difficult situations 312–313
– intraoperative difficulties
313
– laparoscopic approach 310
– left ureter identification
311
– mesenteric artery transection 311
– patient position 310
– preparations 310
– rectum transection 312
Antireflux surgery
– for large hiatal hernias 44
– intrathoracic stomach
63–64
– laparoscopic technique
36–40
Autonomic nerve injury 416
Autonomic pelvic nerves preservation.
See Pelvic nerves preservation,
autonomic
B
Bariatric surgery, MCDA application for
risk assessment in
– alternative propensity scores 15–16
– complications 13
– decision model 12–13
– gastric banding 12–13, 16, 19
– gastric bypass 16, 18
– gastric sleeve 12–13
– gastric sleeve alternatives
16, 19
– influence scores and susceptibility
scores 14–15
– patient characteristic scores 14
– Roux-en-Y gastric bypass
12–13
Benign gallbladder 169–170, 191–192
Benign gastroesophageal disorders 46
Bergamaschi’s laparoscopic-assisted
right colectomy
– intracorporeal ileocolic anastomosis
– advantages 237–238, 240
– disadvantages 238–240
– iso-versus antiperistaltic
240
– totally stapled versus stapled/
handsewn
239–240
– operating room 236
– surgical technique
236–239
Bilateral M. gluteus maximus flap 375
Bile duct stones 169
Biliary reconstruction, in Crafa’s surgical
technique 182
Biliary tract diseases 169–170, 191–192
Biliodigestive/cholecystohepatic fistulas
169
Bioabsorbable material
103–104
Bleeding 369
Blood perfusion, of resection
margins 270
Büchler’s surgical technique, rectal
cancer
– abdominoperineal rectum
extirpation 319–321
– hypogastric nerve damage
prevention 317
– inferior mesenteric vein ligation
316–317
– intersphincteric resection
318, 319
– lamellar border dissection
317
– preparations 316
– troubleshooting 319
– ultra-deep tumors 318
Budde-Rocko’s triangle
174–175
C
Calot’s triangle 178–179, 190–191
Cancer and ulcerative colitis
221
Cantlie’s line 174
CBDS. See Common bile duct stones
(CBDS)
Cholecystitis 190–191
Cholecystoenteric fistula
– Crafa’s surgical technique
181–182
– laparoscopic management of
191–192
Cholecystohepatic fistula
169
Chronic cholecystitis 169
Circular anal dilator (CAD) 420
Colectomy
– anal canal-sustaining
217–218
– and definite ileostomy
218–219
Colon cancer
– laparoscopic right hemicolectomy for
232–233
– open right hemicolectomy for 230–
231
Colon/rectum injury, management
of 342
Common bile duct stones (CBDS)
– Crafa’s surgical technique for
– balloon catheter
184–185
– biliary confluence
exploration 185–186
– choledochoscope insertion
184–185
– common hepatic duct
upstream 184–185
– direct continuous monofilament
suture 185, 187
436
Index
– intraoperative diagnosis 183–184
– intraoperative laparoscopically
guided ERCP 184
– laparoscopic transcystic
approach 184
– postoperative diagnosis
186–187
– preoperative diagnosis
183
– stones, removal of
185–186
– transcystic biliary drain
185–186
– washing with warm saline
184–185
– wire basket insertion 184, 186
– Navez’s surgical technique for
– intraoperative difficulties
in 191–192
– laparoscopic management of 190
– subtotal cholecystectomy
190–191
– technical difficulties 190
Complete excision of the mesocolon
(CME) 244
Corcione’s surgical technique, for gastric
oncology
– difficult situations handled by
– D2 lymphadenectomy 128–129
– distal lymph node dissection 128
– esophagal retraction into
mediastinum 130
– lymphadenectomy along lesser
curvature 129
– mesentery vascular segment
elongation 129–130
– R0 gastrectomy 129
– retrogastric approach with
stomach and omentum 129
– Roux-en-Y transmesocolic
side-to-side esophagojejunal
anastomosis 129
– stapler access closure 130
– remnant gastrectomy
procedures 130–131
Crafa’s surgical technique, for common
bile duct stones
– abnormal anatomy 180
– balloon catheter 184–185
– biliary confluence exploration
185–186
– choledochoscope insertion
184–185
– common hepatic duct
upstream 184–185
– direct continuous monofilament
suture 185, 187
– for extrahepatic bile duct injuries
– biliary reconstruction 182
– intraoperative cholangiogram
182–183
– intraoperative diagnosis 182
– postoperative diagnosis 182
– in difficult laparoscopic
cholecystectomy
– acute cholecystitis 179–180
– adhesions 178
– Calot’s triangle 178–179
– clinical picture 176–177
– conversion 179
– cystic duct stone 179
– cystic lymph node 178
– difficult access 177
– during pregnancy 180
– fundus-first cholecystectomy 179
– gallbladder empyema 180
– imaging 177
– liver cirrhosis with portal
hypertension 180
– obesity 178
– patient’s history 176
– subtotal cholecystectomy 179
– intraoperative diagnosis 183–184
– intraoperative laparoscopically
guided ERCP 184
– laparoscopic transcystic
approach 184
– pathological anatomy
– cholecystoenteric fistula 181–182
– massive gallbladder calcification,
porcelain gallbladder 181
– Mirizzi syndrome 181
– postoperative diagnosis 186–187
– preoperative diagnosis 183
– removal of stones 185–186
– safe steps in laparoscopic
cholecystectomy
– baseline structured surgical
strategy 173
– Budde-Rocko’s triangle 174–175
– Cantlie’s line 174
– CBD plane 174
– cystic artery 174–176
– cystic duct 175–176
– difficulties handled by 175–176
– hepatocystic duct angle 174–175
– infundibulum 174–175
– intraoperative difficulty 173
– transcystic biliary drain 185–186
– variants
– accessory bile ducts 181
– hepatobiliary and arterial
anatomical 181
– intrahepatic gallbladder 180–181
– washing with warm saline 184–185
– wire basket insertion 184, 186
Crohn’s disease
– Greenstein’s surgical technique for
– duodenal fistula 207
– sigmoid and rectal fistulae
207–208
– stricturing disease 208–209
– subacute perforation 204–206
– Vestweber’s surgical techniques for
– anastomosis, suturing
technique 213
– bowel and enteric fistulae,
conglomeration of 222
– bowel with connective tissue
infection 223
– cancer and ulcerative colitis 221
– difficult situations handled in
222–226
– fistulae, abdominal
217–221
– intestinal anastomosis 213
– single-port incisions 212
– stenosis, intestinal
213–215
– ulcerative colitis 217, 222 225–226
Crural repair 43–44
Cystic artery, Crafa’s surgical
technique 174–176
Cystic duct 175–176
Cystic duct stone 179
D
Dallemagne’s surgical technique, for
large hiatal hernias
– anti-reflux procedure 44
– crural repair 43–44
– esophageal dissection 43
– patient setup 42
– postoperative care 44
– stomach reduction into abdominal
cavity 42–43
Dapri’s surgical techniques, S-Foregut
surgery
– intraoperative difficulties in 87
– patient positioning 80–81
– S-gastric resection 83–85
– S-gastric ulcer repair 85–86
– S-Nissen fundoplication
82–83
– umbilical access 80–81
de Manzoni’s surgical technique, for
gastric cancer
–
deviations from standard procedure
– anvil placement in esophageal
stump
161–162
– circular stapled end-to-end
anastomosis 162–163
– circular stapler insertion 161–162
– duodenal invasion 161
– EGJ 161
– gastric conduit along greater
curvature
161–162
– purse-string suture
161–162
– radical surgery with HIPEC
162–163
– intraoperative difficulty
163
– subtotal gastrectomy 160
– total gastrectomy 158–160
Index
437
D–G
Decision analysis and risk
assessment 8–9
– MCDA model, alternative bariatric
procedures 12, 13
– surgical risk factors 12
Definite ileostomy 218–219
Difficult surgical situation 4
Distal gastrectomy, in GIST 99
Duodenal fistula, in Crohn’s disease 207
Duodenal injury, during right
hemicolectomy 246
Duodenum transection
– in gastric resection 123
– with linear stapling device
149
Dyspareunia 416
E
EGJ. See Esophagogastric junction (EGJ)
Endoscopic submucosal dissection
(ESD) 134–135
Enterocutaneous fistula 216
Enteroenteric fistula 216–217
Erectile function management 393–394
Esophageal dissection
– in large hiatal hernias 43
– laparoscopic repair of UDS 68
Esophagogastric junction (EGJ) 98
Exophytic gastric GIST 98
Extrahepatic bile duct injuries, Crafa’s
surgical technique for
– biliary reconstruction 182
– intraoperative cholangiogram
182–183
– intraoperative diagnosis
182
– postoperative diagnosis 182
Extralevator abdominoperineal
resection (ELAPR) 345
F
Female Sexual Function Index (FSFI)
scores 384
Feussner’s surgical technique, for hiatal
hernia
– antireflux surgeries 46
– laparoscopic fundoplication
– access into hiatus 47
– cuff formation and closure 49
– diaphragmatic hernia
closure 48–49
– gastric fundus wrapping 49
– intraoperative situation
49–50
– suture of cuff 49
– preoperative diagnostic
workup 46–47
Fistulae, abdominal
– anal canal-sustaining
colectomy 217–218
– colectomy and definite
ileostomy 218–219
– pouch design 218
– pouch redo surgery
219–221
– surgical treatment 217
Foregut laparoscopic procedures
through SAL. See Dapri’s surgical
techniques, S-Foregut surgery
Fuchs’s surgical technique
– for hiatal hernias
– Collis gastroplasty linear
stapler 56
– esophagus mobilization 55
– fundoplication 56–57
– hiatoplasty 56, 57
– patient preparation 55
– preoperative diagnostic
workup 55
– principles of dissection
55
– short gastric vessels division 56
– rectal prolapse
– operative technique
410–412
– patient preparation 410
Fuerst’s surgical technique, for rectal
cancer
– colonic pouch formation
325
– intersphincteric rectal resection
325–326
– laparoscopic rectal resection 326
– left colon mobilisation 325
– operation technique
324–325
– patient position 324
– preparations 324
– protective ileostomy 325
– trocars insertion 324
Fundus-first cholecystectomy
179
G
Gagner’s surgical techniques,
laparoscopic sleeve gastrectomy
– anterior left fat pad dissection 103
– contraindications 102
– distal antral mobilization
103
– distal staple line oversewing
103–104
– greater curvature mobilization 102
– indications 102
– intraoperative situations
104–106
– left crus exposure and dissection 103
– oversewing intersections
104
– postoperative problems
106–107
– stapling 103–104
– trocar position 102
Gainant’s right hemicolectomy
– abdomen exploration 244
– abdominal wall invasion
246–247
– adherence to liver 247
– definition 244
– duodenal invasion 247
– duodenal resection 247
– greater gastric curve invasion 247
– ileo-colic anastomosis 245–246
– intraoperative complications 246
– mesenterico mesocolic breach 246
– preparation 244
– right colon mobilisation 244–245
– small intestine invasion 247
– surgical approach 244
– tumours adherences 246
– urinary tract invasion 247
– vascular sections 245
Gallbladder
– empyema 180
– intraoperative surgical difficulties
in 191–192
– shrinking of 169
Gallstone disease, surgery for
– bile duct stones with failed
endoscopic extraction 169
– biliodigestive/cholecystohepatic
fistulas 169
– chronic cholecystitis 169
– gallbladder shrinking 169
– operative difficulties in 169–170
– porcelain gallbladder 169
– symptomatic cholecystolithiasis 168
– with acute cholecystitis 168–169
Gastric bypass
– MCDA application for 16, 18
– Stefanidis’s surgical techniques for
– accessory left hepatic artery 91
– gastric pouch 92
– mesenteric defects closure 92
– Nathanson retractor 90
– peritoneal cavity 90
– postoperative course 93
– preoperative assessment 90
– special or unusual
situations 92–93
– Stamm/Witzel technique 92
Gastric cancer
– de Manzoni’s surgical technique for
– classification of patients, with
intraoperative difficulty 163
– difficult situations handled
by 163–164
– subtotal gastrectomy 160
– total gastrectomy 158–160
– laparoscopic approach for
– bursa omentalis opening 122
– duodenum mobilisation and
transection 123
– greater omentum detachment 122