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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_848_Библиотеки_им_академика_М_И_Перельмана
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Figure 8: Feeding jejunostomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Chapter 24: Gastrointestinal
omplications
C
Blockage of catheter
Peritonitis due to leakage of intestinal contents
Aspiration pneumonia
Dislodgement of tube (Needs revision as the tract does
not mature before 14 days)
Gastric dilatation due to obstruction of jejunal lumen.
ey Points
K
Stamm type diers from Witzel type as it does not involve
formation of a seromuscular tunnel.
123
ANESTHESIA
General anesthesia
Spinal anesthesia.
POSITION
Supine.
TYPES
Witzel type
Stamm type
Needle catheter
Laparoscopic.
ethods
M
Witzel Type
Antiseptic dressing and draping of the operative eld is
done
A small upper midline incision is given close to
umbilicus
A loop of jejunum is delivered from the incision
The site for ostomy is selected and a purse string suture
is taken around this site
A series of sero-muscular sutures are taken proximal to
this site over a length of 2–3 inches
A stab incision is given over the ostomy site and a
suitable size catheter is passed through it distally into a
bowel for a suitable distance
The purse string suture is tied so as to x the catheter in
place
The proximal sutures are tied around the catheter to form
a sero-muscular tunnel the purpose of which is to keep
the catheter in place
The other end of catheter is taken out through a dierent
incision on abdominal wall and xed to skin
Bowel is xed to peritoneum using sutures
Abdominal wound is closed in layers.
SPLENECTOMY
ndications
I
Splenic trauma (severe injury)
Splenomegaly with hemolytic disorders like:
¾ Hereditary spherocytosis
¾ Sickle cell anemia
¾ Idiopathic thrombocytopenic purpura
¾ Thalassemia
Splenic abscess/Tumors
Hypersplenism causing pancytopenia in conditions like
portal hypertension, leukemia
As a part of other surgeries, e.g. Radical gastrectomy for
gastric tumors.
ANESTHESIA
General anesthesia.
POSITION
Supine.
Figure 9: Splenectomy
124
Section 4: Operative Steps
ethods
M
Antiseptic dressing and draping of the operative eld is done
Incision:
¾ Emergency cases of trauma: Upper left paramedian abdominal incision
¾ Elective cases: Left subcostal (Kocher’s incision)
The spleen is carefully examined under direct vision
The spleen is mobilized downwards by passing left hand between spleen and diaphragm
The posterior lieno-renal ligament is divided with scissors to mobilize the spleen
The hilum of the spleen is dissected to visualize splenic vein and splenic artery
Three ligatures are passed around the artery out of which two are tied proximally and one distally and the artery is divided
between these ligatures
Similarly, splenic vein is also divided between two proximal and one distal suture
The gastrosplenic ligament is then divided along with short gastric vessels and anterior part of lieno-renal ligament avoiding
injury to the pancreatic tail
The spleen is then removed and hemostasis is achieved
A drain is placed and the abdominal wall is closed in layers.
omplications
C
Immediate:
¾ Bleeding from splenic pedicles
¾ Injury to pancreatic tail
¾ Gastric perforation due to fundal ischemia
¾ Injury to diaphragm
Early:
¾ Acute dilatation of stomach
¾ Portal vein thrombosis due to post splenectomy
thrombocytosis
¾ Hematemesis due to stomach congestion secondary
to ligation of short gastric vessels
¾ OPSI (Overwhelming Post Splenectomy Infection)-
Rarely occurs in children and old people characterised
by fever with rigors, hot ushes of skin, fatal
septicaemia
Late:
¾ Pneumococcal, H inuenza infection (capsulated
organisms)
ey Points
K
Spleen syndrome
¾ Left shoulder pain
¾ Left hypochondrial tenderness
¾ Fracture of left lower ribs with splenic trauma
Hypersplenism: Any enlarged spleen with excessive
function leading to pancytopenia, e.g. Hereditary
spherocytosis
Splenosis: Condition when fragments of splenic tissue
spill at the time of rupture of spleen and remain viable in
abnormal anatomical locations
Spleniculii: Accessory spleens
Alternative treatment options for splenic trauma
¾ Splenorraphy- Splenic repair in small partial tears
¾ Partial splenectomy
¾ Omental patching of splenic tear.
HEMORRHOIDECTOMY
MILLIGAN MORGAN OPERATION
Dissection, ligation and excision of primary piles.
ndications
I
3rd and 4th degree piles which bleed
Prolapsed, thrombosed irreducible hemorrhoids.
ANESTHESIA
Spinal anesthesia.
POSITION
Lithotomy with buttocks projecting well beyond the end of
operation table and resting on a sand bag.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Preliminary proctoscopy is done
Gradual anal sphincter stretching is done for 2 to 3
minutes
Skin overlying the hemorrhoid is held with Allis forceps
and pulled outwards
The mucosa over the main pile is held with artery forceps
and pulled downwards
A ‘V’ shaped incision is given in the perianal area around
the pile, the limbs of ‘V’ lying on the muco cutaneous
junction but not extending into the mucosa
The hemorrhoid is dissected by sharp scissors exposing
the lower edge of internal sphincter
Chapter 24: Gastrointestinal
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125
The neck of the dissected pile is transxed or ligated
and excised 1 cm distal to ligature
Haemostasis is achieved and roller bandage soaked in
antiseptic solution is packed in the anal canal
The anal pack is held in place by T bandage.
omplications
C
A. Early
¾ Pain
¾ Reactionary hemorrhage
¾ Constipation due to painful spasm of sphincter
B.
Late
¾ Anal narrowing- If adequate skin bridges are not left
between the excised piles
¾ Fissure formation
¾ Recurrence
¾ Abscess or stula formation.
Figure 10: Hemorrhoidectomy
ey Points
K
Degree of prolapse
3 primary hemorrhoids are present at 3 o’clock, 7 o’clock
and 11 o’clock position
Triangle of exposure of Milligan: When the 3 main piles
are drawn downwards with the help of artery forceps to
form a triangle
Alternative surgical approaches:
1st degree No prolapse
2nd degree Prolapse but reduce spontaneously
3rd degree Prolapse but have to be reduced with the
help of a nger
4th degree Prolapse permanently and cannot be reduced
¾ Submucous excision of piles (Allan Park’s operation)
¾ Injection sclerotherapy
¾ Band ligature of piles (Barron’s banding)
¾ Cryosurgery
¾ Longo’s stapler hemorrhoidectomy
126
Section 4: Operative Steps
SURGERY FOR ANAL FISSURE
It is a condition characterized by breach in mucosa of anal
region.
Figure 11: Surgery for anal ssure
ndications
I
Non-responding to conservative management
Recurrent problem
Chronic ssure.
ethods
M
Lord’s procedure (Finger dilatation of anus)
Internal sphincterotomy
Fissurectomy.
ANESTHESIA
Middle ngers of both the hands are now inserted one by
one in anal opening and the anal canal is stretched and
massaged for about 4 minutes
All four ngers are moved circumferentially to ensure
equal dilatation.
Anal canal is then packed with a roller bandage soaked in
betadine and lignocaine jelly and T-bandaging is done.
B. INTERNAL SPHINCTEROTOMY
Most preferred method.
ethods
M
Antiseptic dressing and draping of the operative eld
is done
Local anesthesia (Lignocaine with adrenaline) is
injected in the perianal area to reduce the chances of
bleeding
A bivalve anal speculum is used to open up the anal canal
The internal sphincter is felt as a tight band around the
blades of speculum
A blade No. 11 is introduced through the perianal
skin at 3 o’clock position and is pushed between the
anoderm and the internal sphincter to just above the
dentate line
The bers of internal sphincter are cut by pushing
the knife laterally till the feeling of a characteristic gritty
sensation which signies that all the bers have been cut
The knife is withdrawn and light dressing is done after
ensuring hemostasis.
Spinal anesthesia
General anesthesia.
POSITION
Lithotomy.
omplications
C
Fecal incontinence
Recurrence.
A. LORD’S PROCEDURE
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Index ngers of both the hands are lubricated with
lignocaine jelly and are inserted one by one in the anus
which is then retracted laterally for about 30 seconds.
dvantages
A
Immediate relief of symptoms
No anal dilatation necessary
Prevents formation of an open wound.
FISSURECTOMY
Least preferred method.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Fissure is excised along with the sentinel pile and
hypertrophied papilla
The internal sphincter bers below it are also split
Anal packing is done and regular Sitz bath are advised
postoperatively.
Chapter 24: Gastrointestinal
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127
ey Points
K
Acute ssure: Simple laceration of anal mucosa along
with severe spasm of anal sphincter muscle
Chronic ssure:
¾ Induration at ssure margins
¾ Visible muscles at base
¾ Skin tag (sentinel pile) at base of ssure
¾ Hypertrophied papilla at upper end
Most common location: Posterior (6 o’clock).
SURGERY FOR ANAL FISTULA
Anal stula is an epithelium lined tract which connects
anal canal and perianal skin.
Figure 12: Coronal section of the anorectal region showing ways of
spread of infection and the development of stulae
CLASSIFICATION
ANESTHESIA
Spinal anesthesia
General anesthesia.
POSITION
Lithotomy.
omplications
C
Recurrence
Non-healing ulcer
Discharging sinus tract formation
Fecal incontinence.
A. FISTULOTOMY
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Per-rectal examination is done to feel the internal
opening
A stula probe is passed through the external opening to
come out through the internal opening
This tract is simply laid open using a knife or diathermy
probe
The edges of the wound are retracted and the granulation
tissue is properly curetted away.
Low Fistula: Internal opening below the anorectal ring
Supercial
Intersphincteric (60%) – Tract passes between
internal and external sphincters
Transsphincteric (30%) – Tract passes through
internal and external sphincters
High Fistula: Internal opening above the anorectal ring
Suprasphincteric – Tract from intersphincteric
plane to ischiorectal fossa
Extrasphincteric – Internal opening above the
dentate line but passes through entire sphincter
mechanism
Pelvi-rectal Fistula: Internal opening is above levator
ani muscle in the rectum.
ethods
M
Fistulotomy
Fistulectomy
Seton treatment
Anal advancement ap.
B. FISTULECTOMY
is procedure is not preferred nowadays until tissue is
required for histopathological examination.
ethod
M
The entire stulous tract is excised around a stula probe.
C. SETON PROCEDURE
It refers to insertion of a foreign body in the stulous tract
to encircle the sphincter muscle.
ndications
I
High stula
Anterior stula in women
Patients with Crohn’s disease.
128
Section 4: Operative Steps
Materials Used
Nylon suture
Prolene suture
Steel wire
Penrose drain.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
A stula probe is inserted from external opening with the
Prolene (or other material) suture in its eye and taken out
through internal opening
Ends of Seton are loosely tied
Seton is gradually tightened and changed at regular
intervals to divide the muscles and promote brosis
The wound heals over a period of time completely
obliterating the stulous tract.
D. ENDORECTAL ADVANCEMENT FLAP
In this technique the internal opening is excised and the
resul ting defect is closed by musculo-mucosal ap of
rectal wall.
ndications
I
Complex anal stula
Recto-vaginal stula
Recto-urethral stula.
ey Points
K
Dentate line denotes the junction of surgical and
anatomical anal canal just below the columns of
Morgagni
Goodsall’s Rule:
¾ All stula that are situated anterior to coronal plane
passing through the center of anus, track radially into
the anal canal
¾ All stula with an opening posterior to this plane track
circumferentially to open into the anorectal canal in
the midline posteriorly
¾ Irrespective of the number of external openings in
case of posterior tracts, there is invariably one internal
opening
Common causes
¾ Anal gland abscess
¾ Tuberculosis
¾ Inammatory bowel diseases
¾ Foreign body trauma
Postoperatively:
¾ Sitz bath
¾ Laxatives.
Hepatobiliary
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Chapter
25
OPEN CHOLECYSTECTOMY
Removal of gallbladder from abdomen is referred to as
cholecystectomy.
ndications
I
Symptomatic cholelithiasis
¾ Biliary colic
¾ Acute cholecystitis
Choledocholithiasis
¾ Gallstone pancreatitis
¾ Cholangitis or obstructive jaundice
Acalculous cholecystitis
Gallbladder dyskinesia
GB Polyp > 10 mm diameter
Porcelain GB
Empyema GB
Emphysematous cholecystitis
GB perforation/Peri-cholecystic abscess
Indications in asymptomatic GB disease
¾ Sickle cell disease
¾ Chronic immunosuppression
¾ In those patients who do not have immediate access
to health facilities like army personnel
¾ Stone size > 3 cm
¾ Multiple calculi with risk of migration into common
bile duct (CBD).
ethods
M
Retrograde Technique
Dissection is rst done in Calot’s triangle proceeding
towards its fundus.
Fundus First Technique
Dissection of fundus is done rst followed by the Calot’s
triangle
Also called as antegrade method of cholecystectomy.
ANESTHESIA
General anesthesia.
POSITION
Supine with a sand bag placed below right hypochondrium.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
An oblique subcostal incision (Kocher’s incision) is
given 4 cm below and parallel to right costal margin
extending from midline to the tip of 9th costal cartilage
130
Section 4: Operative Steps
Skin and subcutaneous tissues are retracted to visualize
anterior rectus sheath which is then divided along the
incision line using scissors or electrocautery to reach
rectus muscle
The rectus muscle is divided using electrocautery to
reach peritoneum
Peritoneum is held between two artery forceps and is
carefully divided along the line of incision to reach the
peritoneal cavity
Gallbladder is visualized and is grasped with two pairs
of sponge holding forceps
¾ One at fundus
¾ Other at Hartmann’s pouch
Three mops are now placed for better visualization of GB
with the help of Deaver’s retractors at:
¾ Hepatorenal pouch to retract right colic exure
downwards
¾ Lower part of wound to retract intestines
¾ Medially to retract stomach
A peanut swab is used to dissect peritoneal fold and
omental adhesions to clear the anatomy of Calot’s triangle
Right angled dissection forceps is now used to dissect
the Calot’s triangle and identify cystic artery
Three silk sutures are passed around cystic duct and
cystic artery out of which two are tied proximally and one
distally on both the structures
First the cystic artery is divided between the ligatures
and then the cystic duct
The gallbladder is now dissected from the liver bed
using electrocautery and hemostasis is achieved
Sand bad below the patient is removed and the
abdominal wound is closed in layers.
omplications
C
Early
¾ Bleeding due to slippage of ligatures
¾ Injury to bile ducts including CBD
¾ Biliary leak through drain
¾ Perforation of intestines
¾ Retained stone in remnant cystic duct
Late
¾ Wound infection
¾ Pancreatitis
¾ Biliary stricture following injury to bile ducts
¾ Gastrointestinal upset
¾ Chronic pain.
Calot’s triangle vs Hepatobiliary triangle
Borders Calot’s Triangle Cholecystohepatic Triangle
(Hepatobiliary triangle)
Inferiorly Cystic duct Cystic duct
Medially Common hepatic duct Common hepatic duct
Superiorly Cystic artery Inferior border of liver
Figure 1: Procedure of open cholecystectomy
ey Points
K
Partial cholecystectomy is indicated when the Calot’s
triangle is obscured due to brosis and inammation
Chapter 25: Hepatobiliary
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131
EXPLORATION OF COMMON BILE
DUCT
CBD is commonly explored at the time of cholecystectomy
due to one of the following indications.
ndications
I
Choledocholithiasis (Presence of stones in CBD)
Intraoperative nding of CBD dilatation
Suspected stones in CBD during cholecystectomy.
ANESTHESIA
Same as open cholecystectomy.
POSITION
Same as open cholecystectomy.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
The steps of this procedure are same as that of open
cholecystectomy except that in this case cystic duct is not
divided initially and is used as traction for CBD
CBD is visualized and the peritoneum over it is incised to
expose its anterior surface
Two stay sutures are taken on the anterior wall of CBD
and bile is aspirated in between them using a syringe to
conrm CBD
CBD is incised with the help of Blade No. 11 and incision
is extended for 1-2 cm
Desjardin’s forceps is used to remove any stones
from CBD following which a choledochoscopy is done to
inspect the biliary tree for any residual stones
Any residual stones are removed by further ushing with
warm saline using a soft catheter
A T-tube is placed in CBD which is then repaired using suture
Other end of T-tube is taken out from skin using a
separate incision
A subhepatic drain is placed and the abdominal wound is
closed in layers.
omplications
C
Duodenal stula
Postoperative pancreatitis
Bile leak through drain
Biliary peritonitis
Residual stone (May present with jaundice)
CBD stricture.
ey Points
K
Kocher Maneuver – Mobilization of second part of
duodenum by dividing the lateral leaf of its peritoneal
covering
Some surgeons prefer primary closure of CBD instead of a
T-tube placement following CBD exploration.
Figure 2: Procedure of exploration of common bile duct
132
Section 4: Operative Steps
LAPAROSCOPIC CHOLECYSTECTOMY
Gold standard surgical treatment for Cholelithiasis.
ndication
I
Same as open cholecystectomy with a few contraindications.
ontraindication
C
Absolute
¾ Refractory coagulopathy
¾ Suspected GB carcinoma
¾ Patient unt to tolerate general anesthesia
Relative
¾ Previous upper abdominal surgery
¾ Cardiac patients
¾ Cholangitis
¾ Diuse peritonitis
¾ Cirrhosis of liver/Portal hypertension
¾ COPD
¾ Cholecystoenteric stula
¾ Morbid obesity
¾ Pregnancy.
ANESTHESIA
General anesthesia.
¾ Third port of 5 mm is made in the right mid-clavicular
line just below the subcostal margin
¾ Fourth port of 5 mm is made in the right anterior
axillary line at the level of umbilicus
Functions of all ports
Ports Size Instrument
inserted
First 10 mm Telescope
attached to a
camera
Second 10 mm Maryland/
Hook dissector
Third 5 mm Grasper Hold the neck
Fourth 5 mm Toothed
grasper
Posterior dissection of the Calot’s triangle is done and
a window is created between cystic duct and cystic artery
Titanium clips are applied on both the structures
using clip applicator and the duct and artery are divided
between the clips
A diathermy hook is used to separate the GB from liver
bed which is then removed from the epigastric/umbilical
port with the help of crocodile grasping forceps
A subhepatic drain is placed in situ and all the incisions
are closed in layers.
Function
Visualize the
peritoneal cavity
and biliary
structures
Dissect the
Calot’s triangle
of GB
Hold fundus of
GB and push it
upwards and
laterally
POSITION
Reverse trendelenburg position with 30° head up and
15° right side up tilt to allow the colon and duodenum
to fall away from the liver edge
Surgeon stands on patient’s left side.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Pneumoperitoneum is created by inserting a veress
needle through a small infraumbilical incision and
connecting it with a CO
of about 14 mm Hg
First 10 mm trocar with cannula is inserted blindly
by extending the infraumbilical incision that was used
for inserting veress needle. The telescope attached to a
video camera is inserted through this cannula to view the
structures of peritoneal cavity
Three ports are then made under camera vision
preventing any injury to intraperitoneal structures:
¾ Second port of 10 mm is made in the epigastrium below
the xiphoid process slightly towards right of midline to
prevent the port from entering falciform ligament
insuator with a preset pressure
2
omplications
C
Same as in case of open cholecystectomy.
A
dvantages of Laparoscopic Procedure
Over Open Procedure
Less postoperative pain
Shorter duration of hospital stay
Less chances of wound infection and dehiscence
Shorter duration of surgical procedure in expert hands
Better cosmetic scar
Less postoperative complications like incisional hernia, etc.
Early return to routine activities.
D
isadvantages of Laparoscopic Procedure
Over Open Procedure
Requires sophisticated machinery and setup
Expensive
Requires expertise.
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