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By M. Malir. Lakeland College. 2019.

Alternatively , one may occlude the transected pancreas Divide the vein between the two ligatures (Fig . If the pancreatic duct is identified , ligature around this artery and divide the vessel distal to occlude this duct with a separate mattress suture . This leaves the specimen attached only by the neck of the pancreas in the region of the portal vein . Closure and Drainage Place a flat closed-suction drainage catheter down to the site Dividing the Pancreas of the divided pancreas and bring the catheter out through a puncture wound in the abdominal wall . Close the incision in If the pancreas is of average thickness , simply apply a 55 mm routine fashion after ascertaining that complete hemostasis linear stapler across the neck of the pancreas . Then remove the stapling device and inspect the cut edge of Postoperative Care the pancreas carefully for bleeding points (Fig . It is frequently necessary to suture ligate a superior pancreatic Attach the drainage catheter to a closed-suction system . If a pancreatic duct fistula have not found it necessary to identify or suture the pancre- is suspected, leave the drain in place for a longer time. Technical considerations in distal Subphrenic abscess may occur, requiring drainage. Middle segment pancreatectomy: a novel technique for conserving Further Reading pancreatic tissue. Is there a role of preservation of spleen-preserving pancreatectomy for end-stage chronic pancreati- the spleen in distal pancreatectomy? If the patient is to undergo resection prior to a 14 day window, immunizations can be administered Malignant tumors of the pancreas deemed resectable by postoperatively once the patient recovers from the operation. Chronic pancreatitis localized to the body and tail following Intraoperative failed endoscopic therapy. Enteric, vascular, or soft tissue injury with port placement Pseudocysts of the pancreatic tail (in select patients where Laceration or injury to major vascular structures endoscopic measures fail). The Splenic parenchymal or hilar injury and hemorrhage early indications for an operation should not change due to the during the operation availability of a minimally invasive approach. Patients require at least 14 days to become fully immu- Splenic preservation is feasible in select patients with nized against encapsulated organisms (Streptococcus pneu- benign tumors, small neuroendocrine tumors, or cystic neo- moniae, Haemophilus influenza type B, and Neisseria plasms without proximity or invasion of the spleen paren- chyma. Recent reports indicate that splenic preservation with division of the splenic artery and vein is safe in select patients. Also, if bleeding were Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Dr. Port placement will be variable depending on should also have an open tray of instruments available for the patient’s body habitus. Once a camera is placed in the supraumbilical location, a secondary port is placed to allow General Considerations for exposure of the undersurface of the liver and palpation of any suspicious lesions. Variant anatomy may present a challenge when divid- are carefully evaluated, and any suspicious lesions are biop- ing the splenic artery where inadvertent division may occur sied and sent for frozen section analysis. Replaced of M1 disease in a patient with pancreatic adenocarcinoma, left gastric vessels may also appear in the operative field. Patient positioning and port placement options are shown After thoroughly exploring the abdomen, expose the in Fig. The importance of the hepatic artery is to have a very clear idea of its location to avoid inadvertent transection during stapling of the splenic artery. This can be done bluntly with fingers if using a hand port or laparo- scopically with a laparoscopic Kitner or other blunt instru- ment. The splenic artery typically runs superior to the pancreas and is tortuous in nature. It can be stapled at any point during the operation and will slow bleeding from the spleen if the spleen is injured during Fig. Once the splenic artery is divided, the spleen will shrink to facilitate extrac- tion. Depending on the thickness of the pancreatic paren- chyma, the splenic vein and parenchyma may be divided together using a 2. Otherwise the splenic vein is freed from the posterior border of the pancreas and stapled separately. The order for division of the parenchyma, splenic artery, and vein is not fixed and can be performed to optimize safety (Fig. Avoiding Damage to Blood Vessels Once the decision has been made to proceed with distal pan- createctomy and splenectomy, locate the splenic artery a few Fig. There are many devices available for tissue tran- volume of blood loss if the splenic capsule is ruptured during section, and this is left to the discretion of the surgeon. The short gastrics are then the pancreas arises when a malignancy in the body obscures divided (if splenic preservation is not planned) up to the gas- the junction between the splenic and portal veins or the tric fundus. If elevation of the tail the pancreas, the transverse mesocolon is lowered away and body of the pancreas together with the tumor should from its retroperitoneal attachments to the pancreas result in a tear at the junction of the splenic and portal veins (Fig. If the pancreas is of average thickness, the portal and superior mesenteric veins exposed after the simply apply a 3. Once the pancreas is divided, the specimen may be clamps may be applied and the laceration repaired. This removed in a medial to lateral fashion with removal of the complication can generally be avoided by careful inspection spleen being the last step in the operation (Fig. The of the tumor after elevating the tail of the pancreas and by spleen is freed from its retroperitoneal attachments as in a observing the area where the splenic vein joins the portal laparoscopic splenectomy (see Chap. If the tumor extends beyond this junction, it is probably The spleen remains attached to the greater curvature of inoperable. These maneuvers are typically performed once the stomach by means of the intact left gastroepiploic and the operation is converted to an open approach. If these structures were not completely divided at the time of mobilizing the stomach, the division can be completed at this point. Keep in mind if the goal is Identifying Splenic Artery splenic preservation, then these vessels should remain intact. For the hand-assisted approach, the specimen can be Palpate (hand port) or visualize (total laparoscopic) the enclosed in a specimen bag and removed through the hand splenic artery along the upper border of the neck of the pan- port incision. In a total laparoscopic approach, the supraum- creas at a point a few centimeters from its origin. If hepatic artery pulsation is normal, open the peritoneum overlying the splenic artery. Stump Closure For the total laparoscopic approach, be sure to have clear visualization of the artery before dividing it. Dividing the Splenic Vein and Pancreas and Removal of the Spleen Converting to an Open Approach Gently elevate the splenic vein by sweeping the areolar tissue away from this vessel until the junction between the splenic The first and foremost indication for conversion is surgeon and portal vein is identified. If there is any concern for the safety of the may be stapled approximately 2 cm proximal to its junction patient or a lack of progression, then the operation should be 92 Laparoscopic Distal Pancreatectomy 847 a b Fig. Marking out the incision ahead of time will pro- closure (this is not supported currently by level I evidence). Postoperative Care References The decision to place a drain is left to the discretion of the surgeon. There is a lack of evidence to support routine drain Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective usage (Conlon et al. If a drain is left trial of the value of intraperitoneal drainage after pancreatic in place, it is recommended to place the drain to gravity to resection. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after If pancreatic fistula develops, it generally resolves pancreaticoduodenectomy? If it does not resolve during that time, endoscopic stenting may facilitate Operations for Pancreatic Pseudocyst 9 3 Carol E. Differentiate chronic pseudocysts from acute collections of Cystogastrostomy or cystoduodenostomy is appropriate fluid associated with acute pancreatitis (which generally only if the cyst is firmly attached to the wall of the stomach resolve without surgery) and from cystic neoplasms. If the cyst is not adherent, perform a Roux-en-Y cystojejunostomy because leakage from this Preoperative Preparation anastomosis is far less dangerous to the patient than is leak- age from the stomach or duodenum. The wall of the pseudocyst must be thick enough for a Rule out the presence of gallstones or bile duct obstruction safe anastomosis, particularly if a cystojejunostomy is per- by sonography, oral cholecystography, or endoscopic ret- formed. Aspirate the cyst before opening it Pitfalls and Danger Points to confirm pancreatic juice without blood. Anastomotic leak Postoperative hemorrhage Mistaken diagnosis (cystadenocarcinoma) Pseudoaneurysm Overlooking an associated pseudoaneurysm Recurrence When arteriography has demonstrated a leaking pseudoan- eurysm of the splenic artery in a large pseudocyst, ask the angiographer to perform preoperative occlusion of the splenic artery. Carver control in the operating room, under emergency conditions, College of Medicine, University of Iowa, quite difficult. Chassin Jaundiced Patient Although jaundice in the presence of a pseudocyst may well be the result of extrinsic pressure by the cyst against the dis- tal common bile duct, it is also important to rule out the pres- ence of calculi or periductal pancreatic fibrosis as the cause of bile duct obstruction. If the jaundice is due to chronic fibrosis in the head of the pancreas, endoscopic stenting or a bypass operation is required. It may be necessary to perform a side- to-side choledochojejunostomy to the defunctionalized limb of the Roux-en-Y distal to the cystojejunostomy. If the retrogastric mass is pulsatile, con- • Cystogastrostomy or cystoduodenostomy or sider seriously whether the mass represents an aortic aneu- cystojejunostomy? Expose the aorta at the hiatus of the dia- phragm, and prepare a suitable large vascular clamp for emergency occlusion of this vessel should it be necessary. If Operative Technique the surgeon has had no previous experience with this maneu- ver, he or she should request the presence of a vascular sur- External Drainage geon. Explore the abdomen and Make a 6- to 8-cm incision in the anterior wall of the identify the pseudocyst. Obtain hemostasis with electrocautery insert a needle into the cyst to rule out the presence of fresh or ligatures. Then insert an 18-gauge needle through the back blood, then incise the cyst wall, and evacuate all of the cyst wall of the stomach into the cyst and aspirate. If the cyst obtained, make an incision about 3–6 cm in length through wall is too thin for anastomosis, insert a soft Silastic catheter the posterior wall of the stomach and carry it through the and bring it out through an adequate stab wound in the left anterior wall of the cyst. Sometimes what Approximate the cut edges of the stomach and cyst by appears to be pus is only grumous detritus. Close the abdomi- ing four or five Allis clamps and then perform a stapled clo- nal incision in the usual fashion after lavaging the abdominal sure using the 90 mm stapler. If the gallbladder contains stones, per- form cholecystectomy and cholangiography. Prepare a seg- the posterior wall of the stomach, cystogastrostomy is the ment of jejunum at a point about 15 cm beyond the ligament 93 Operations for Pancreatic Pseudocyst 851 Fig. Liberate enough of the mesentery of the distal jejunal segment to permit the jejunum to reach the cyst with- out tension. Make a small window in an avascular portion of the trans- verse mesocolon, and delivery the distal jejunal segment into the supramesocolic space. Perform a one-layer anastomosis between the open end of jejunum and the window in the anterior wall. Anastomose the divided proximal end of the jejunum to the antimesenteric border of the descending limb of the jeju- num at a point 60 cm beyond the cystojejunal anastomosis. Align the open proximal end of jejunum so its opening points in a cephalad direction. Pancreatic Resection The techniques of pancreatic resection are described in Chaps. If the culture report of the cyst contents comes back positive, administer the appropriate antibiotics for 7 days. In cases of external drainage, administer antibiotics depending on the culture reports. Leave the drain in place until the amount of fluid obtained is mini- mal and a radiographic study with aqueous contrast material shows that the cyst has contracted to the size of the drain. It may be helpful to instill a dilute antibi- otic solution into the drain at intervals if the cyst is infected. The completed cystojejunostomy is illustrated in Postoperative bleeding into gastrointestinal tract (rare if Fig. Operative and nonoperative management of with pancreatic pseudocyst causing persistent cholestasis. Percutaneous drainage of pancreatic pseudocysts is associated with a higher failure rate Pancreaticojejunostomy (Puestow) for 9 4 Chronic Pancreatitis Carol E. Several variations in this procedure have been described and Chronic pancreatitis producing intractable pain not are referenced at the end of the chapter. Separate the greater omentum from the Pitfalls and Danger Points middle of the transverse colon for a distance sufficient to expose the pancreas. Aspiration cytology in the operating room may be helpful in this Incising the Pancreatic Duct situation. The main pancreatic duct is generally located about one- third the distance of the cephalad to the caudal margin of the Operative Strategy pancreas. If the duct cannot be palpated, inserting a 22-gauge needle and attempting to aspirate pancreatic juice may serve Because the dilated pancreatic ducts are thick walled and to locate the pancreatic duct. If the duct has not been suc- fibrotic, pancreaticojejunal anastomosis is a safe procedure. A sufficient length of gram in the operating room by aspirating 2 ml of pancreatic juice with a 22-gauge needle; then inject an equal amount of C. Apply an Allen clamp incision farther into the head of the pancreas than is shown just proximal to the stapling device. Remove any calculi or sion, and position it side-to-side to the open pancreatic duct. The stapled cut end of the jejunum should be approximated to the tail of the pancreas and the distal jejunum to the head. Now incise the antimesenteric border of jejunum over a Constructing the Roux-en-Y Jejunostomy length approximately equal to the incision in the pancreatic duct using a scalpel or electrocautery. Because the fibrotic Prepare the proximal jejunum for a Roux-en-Y operation as pancreas accepts sutures easily, one layer of sutures is suf- illustrated in Fig.

Incising this fibrous layer where it joins the subcu- taneous fat is a good method for ensuring complete removal In general , placing the incision in a gently oblique (low of the breast tissue while at the same time preserving an even medial to high lateral) or horizontal direction gives the best layer of subcutaneous fat . Although this Alternative Incisions for Mastectomy incision is easy to apply to tumors in the 3 and 9 o’clock If immediate or delayed reconstruction is planned , allow the positions (Figs . A good basic approach is to draw a circle around the didates for modified breast reduction-pattern incisions , tumor or biopsy incision , leaving a 3 cm margin on all sides . Plan the remainder of the incision so the entire areola is References at the end of the chapter describe skin-sparing included in the specimen . After having drawn the circle sparing techniques are used in selected circumstances and around the tumor , preserve as much of the remaining skin as are described at the end . This bunching together of skin is interpreted by many women as a residual tumor and is a cause for great anxiety. It is easily prevented by excis- ing an additional triangle of skin until the incision lies flat on the chest wall (Fig. We prefer to place a sterile tumor in the upper outer quadrant of the breast yet is low Mayo instrument stand over the patient’s head. Depending on the the entire areola and nipple in the patch of skin left on the location of the tumor, mark the medial and lateral extensions specimen (Fig. Attain hemostasis by applying electrocoagulation to dorsi muscle, which is exposed for the first time during this each bleeding point. Apply a moist gauze pad to the opera- Apply Adair clamps or rake retractors, about 2–3 cm tive site. Remove the Adair clamps from the lower skin flap apart, to the cut edge of the skin on the lower flap. Use the same assistant elevate the skin flap by drawing the Adair clamps in technique to elevate the upper skin flap to a point about 3 cm an anterior direction. Then use the electrocautery set on a selected, it should permit wide exposure of the axillary con- medium cutting current to incise Cooper’s ligaments, which tents from the clavicle to the point where the axillary vein attach the subcutaneous tissues to the surface of the breast crosses over the latissimus muscle. Continue elevating the inferior skin flap until the dissection is beyond the breast. At the medial aspect, perforating vessels from the internal thoracic artery After checking to ascertain that complete hemostasis has will be encountered. Preserve these, if possible, to protect been achieved, use a scalpel to incise the fascia overlying the viability of the skin flaps. Use a Richardson retractor to elevate the major pectoral Simultaneous hemostasis is achieved if the first assistant muscle. They may be divided using electrocautery or hemostats, exercise caution when without serious consequence, but be sure to identify and pursuing a vessel that has retracted into the chest wall after preserve the major branch of the lateral pectoral nerve that being divided. We have on occasion, especially in thin emerges just medial to the origin of the minor pectoral mus- patients, observed pneumothorax following this step. When cle and travels along the undersurface of the major pectoral the vessel is not easily controlled by electrocautery or a muscle. Division of this nerve may result in atrophy and hemostat, simply apply a suture-ligature to control it. Dissect the fat and When the lateral margin of the major pectoral muscle has fascia off the anteroinferior edge of the coracobrachialis been reached, use a combination of blunt and sharp dissec- muscle using a scalpel. Directly inferior to this muscle is tion to elevate the edge of the pectoral muscle from its invest- the brachial plexus and the axillary vessels. This maneuver maintains continuity between the dissection of the inferior border of the coracobrachialis in a breast, the pectoral fascia, and the lymph nodes of the axilla. If it is necessary to divide the muscle, use coagulating the major pectoral muscle, which is then elevated with a current to divide this muscle near its insertion (Fig. Deep to the minor pectoral muscle that was divided is a well-defined fat pad Axillary Vein Dissection overlying the junction of the cephalic and axillary veins. Not only is it unnecessary to strip all of the fat from the the scalpel can accomplish this, most surgeons prefer to use brachial plexus, this maneuver produces lifelong painful Metzenbaum scissors. Do not divide the lary vein from the region of the latissimus muscle to the subscapular vein, which enters the axillary vein from clavicle, it is necessary to flex the upper arm. Many pathologists prefer that a third label be attached at the point where the minor pectoral muscle crosses the axillary specimen. The upper boundary of the axillary dissection is the crossing of the clavicle over the axillary vein. Detach the lymphatic and areolar tissue at this point with the electro- coagulator. Now make a scalpel incision in the clavipectoral fascia on a line parallel to and 1 cm below the axillary vein. Do not retract the axillary vein in a cephalad direction, as it might expose the underlying axillary artery to injury during this step. If suspicious nodal tissue is identified cephalad to the axillary neurovascular bundle, biopsy it to document the extent of disease. Dissect the areolar and lymphatic tissues off the inter- costal muscles and ribs going from medial to lateral. When the minor pectoral muscle is encountered, divide it 2–3 cm from its origin with the electrocoagulator (Fig. If this muscle was not divided earlier in the operation, it is not necessary to resect it. As the chest wall is cleared laterally, one or two intercostobrachial nerves are seen emerging from the intercostal muscle on their way to innervate the skin of the upper inner arm. Because these nerves penetrate the specimen, divide them even though it results in a sen- sory deficit in the upper inner arm (Fig. This maneuver exposes the long thoracic nerve that runs along the rib cage in the anterior axillary line in a vertical direction from above downward to innervate the anterior serratus muscle. The thoracodorsal nerve can be identified as it leaves the area of the subscapular vein and runs both laterally and downward together with the thoracodorsal artery and vein to innervate the latissimus dorsi muscle. Because these two nerves run close to the peripheral boundary of the dissection, they should be preserved when no metastatic lymph nodes are seen in their vicinity. Detach the lymphatic tissue inferior to the portion of the axillary vein that crosses over the latissimus muscle. Preserving the long thoracic nerve is complicated by the fact that a number of small veins cross over the nerve in its distal portion. Circumvent this difficulty by moving the partly detached breast in a medial direction so it rests on the patient’s chest after freeing the specimen from the anterior border of the latissimus muscle. Then make an incision in the fascia of the serratus muscle 1 cm medial to the long thoracic nerve. Dissecting this fascia a few centimeters in a medial direction detaches the entire specimen from the chest wall (Fig. We use sterile water, which lyses not only clot and blood, making it easier to spot Fig. Insert two large closed suction drains through puncture wounds into the lower axilla. Bring one catheter deep to the axillary vein and the other catheter across the thoracic wall from the puncture wound to the region of the sternum. Suture each catheter to the skin at the site of the puncture wounds and attach to closed suction drainage (Fig. Be certain there is no signifi- cant tension on the incision; otherwise, postoperative necro- sis of the skin flap may be anticipated. Do not permit either of the skin flaps at the lateral margin of the incision to become bunched up in such a fashion that a “dog-ear” forms. The “dog-ear” deformity can be eliminated by excising a triangular wedge of skin as noted in Figs. When closed suction drainage is used postoperatively, it is not necessary to apply a bulky pressure dressing. Consequently, skin necrosis should be anticipated when purple discoloration Leave the two closed suction drainage catheters in place until appears in the skin flap on the fifth or sixth day following the daily drainage diminishes to 30–40 ml/day or about mastectomy. We use a standardized series of graded ensued, and primary healing of the skin graft may be antici- physical exercises to ensure that the woman regains full pated. It is, of course, Take appropriate steps throughout postoperative treatment to far preferable to prevent skin necrosis in the first place by ensure the patient’s emotional and physical rehabilitation. Wound Infection Aspirate any significant collections of serum underneath the skin flaps with a sterile syringe and needle as Wound infection is uncommon in the absence of skin necessary. Refer the patient for adjuvant chemotherapy or for participa- tion in one of many clinical trials. Follow the patient for local recurrence or the development of Seromas cancer in the opposite breast. Once the initial period of close follow-up is completed, we Collections of serum underneath the skin flap, seromas occur follow these patients annually for life. This problem edema, which can become a disabling complication if appears more commonly in obese patients. On rare occa- trauma, including sunburn, to the arm and forearm of sions, this process continues for several months. If at any time the hand is traumatized case, it is preferable to make an incision under local anesthe- or there is any evidence of infection in the hand or arm, sia and insert a drain. Repeated aspiration over many weeks prompt treatment with antibiotics for 7–10 days, followed may result in infection of the seroma. Lymphedema Lymphedema of the arm is more common in obese patients, Postoperative Complications in those who have undergone axillary radiotherapy, and in those who have experienced skin necrosis, wound infection, Ischemia of Skin Flap or cellulitis of the arm. Lymphedema in the absence of any sign of This is a serious, partially preventable complication. These sleeves should be changed whenever emia is permitted to develop into gangrene of the skin, a they lose their elasticity, generally after 6 weeks. This treat- process that takes 2 weeks or more, some degree of celluli- ment should be instituted whenever one detects an increase tis invariably follows. Generally, elas- collateral lymphatic channels through which the lymph fluid tic compression keeps the condition under control if it has from the arm manages to return to the general circulation. Once the edema has been permitted Blocking these channels increases the incidence and severity to remain for many months, subcutaneous fibrosis replaces 1014 C. Total skin-sparing mastectomy: complications and local recur- compression has been recommended, but few patients toler- rence rates in 2 cohorts of patients. Nipple and areola-sparing mastec- necessary before significant progress is demonstrated with tomy. No data are available comparing these two sequences, so the choice is based on personal preference. Radical mastectomy is occasionally useful in highly selected patients for local control of advanced disease. Operative Technique Preoperative Preparation Incision Same as for modified radical mastectomy (see Chap. Pneumothorax may be produced by perforation in the chest cavity during attempts to control branches of the inter- nal mammary artery. Operative Strategy After elevating the skin flaps by the usual technique, radical mastectomy can be accomplished in one of two sequences. With the technique described below, axillary lymphadenec- tomy precedes removal of the breast from the chest wall. It is also feasible to remove the breast and the major pectoral muscle from the chest wall prior to doing the axillary dissection, as described for modified radical mastectomy. When the breast is removed proceeding from medial to lat- eral, gravity provides sufficient retraction and facilitates C. Adequate excision of advanced disease and nerves are divided between hemoclips during this may necessitate that considerable skin be excised and the dissection. Also detach the upper 2–3 cm of the major pecto- resulting defect closed by a split-thickness skin graft or a local ral muscle from the upper sternum. Incise the areolar tissue and fascia over the surface of the coracobrachial muscle and continue in a medial direction until the coracoid process is reached. This move exposes the Elevation of Skin Flaps junction between the coracobrachial muscle and the inser- tion of the minor pectoral muscle (Fig. Just caudal to The same technique as for modified radical mastectomy is the coracobrachial muscle are the structures contained in the used to elevate the skin flaps (see Chap. They are covered not only by fat and lymphatic tissue but by a thin layer of costocoracoid fascia. Clearing the fascia away Exposing the Axilla from the inferior border of the coracobrachial muscle serves to unroof the axilla and expose the insertion of the minor To perform a complete axillary lymphadenectomy, it is not pectoral muscle. Detach this muscle from its insertion after necessary to remove the portion of the major pectoral muscle isolating it by encircling it with the index finger; use the that arises from the clavicle. Preservation of the clavicular coagulating current to divide the muscle near the coracoid head of this muscle improves the cosmetic appearance of the process (Fig. Consequently, develop a line of separation near the entrance of the cephalic branch can be swept down- by blunt dissection between the sternal and clavicular heads ward by blunt dissection, exposing the axillary vein. Continue this separation to the point where the major pectoral muscle inserts on the humerus. Place the left index finger underneath the sternal head of the Dissecting the Axillary Vein muscle near its insertion and divide the muscle from its insertion with electrocoagulating current (Fig. It is not necessary to clean the fat off the brachial plexus or Complete the line of division between the two heads of the to remove tissue cephalad to the axillary vein. Pick up the muscle proceeding in a medial direction until the sternum is sheath of the axillary vein with Brown-Adson or DeBakey reached. A number of lateral anterior thoracic arteries, veins, forceps and use Metzenbaum scissors to separate the 115 Radical Mastectomy: Surgical Legacy Technique 1017 Fig. Continue this dissection laterally until the unopened scissors have been inserted underneath the adven- subscapular space has been reached; then clear the areolar titia to establish the plane, remove the scissors and insert one tissue from the subscapular space using a gauze pad, bluntly blade of the scissors under this tissue.

All soft tissues including ligaments and facet joints capsules are removed to expose bony surfaces . Such spinal fusion should extend from neutral vertebra proximal to the neutral vertebra distal including all vertebrae within the major curve . Sometimes a series of wedges are excised each including the disc and vertebral end-plates . Harrington instrumentation may also be used , which affords temporary internal fixation and an accessory correction device . The total period of plaster cast immobilisation is usually from 9 to 12 months depending upon the length of the fusion . Recumbency should be for 3 to 4 months , after which the patients can be ambulatory . Like scoliosis a few varieties of kyphosis are non-structural and can be cured easily , whereas others are of structural variety . The causes are :— (i) Traumatic — crush fracture or pathological fracture from secondary metastasis, (ii) Inflammatory — tuberculosis or caries spine, (iii) Calve’s disease. This condition is usually seen in children and the presenting feature is backache and angular kyphosis. According to age the causes can be further classified into — (i) Adolescents — Scheuermann’s disease. Lambrinudi suggesled that the epiphyseal plates are damaged due to excessive flexion of the vertebral column when there is limited flexion in the hips due to tight hamstrings. X-ray shows that bodies of a few thoracic vertebrae are wedged — mostly involved are thoracic 6th to 10th vertebrae. The vertebral bodies may contain small translucent areas near the disc spaces which are known as Schmorl’s nodes. When the deformity is slight and there is little pain, various exercises should be recommended to strengthen the extensor muscles of the spine. When the pain is severe and the deformity is considerable, the patient should lie flat on a firm bed or on a posterior plaster shell. When pain disappears, the patient may be allowed up wearing a brace or plaster jacket by day and sleeping on plaster shell at night. Infection of prostate, Reiter’s disease, psoriasis and ulcerative colitis are somehow or other associated with this disease. Some of the earliest and most characteristic changes occur in the sacroiliac joints, where the disease seems to start. The early lesion is a type of synovitis with increased vascularity and infiltration of lymphocytes and plasma cells. The intervertebral discs are first replaced by vascular connective tissue and then undergo ossification which particularly affects the periphery of the annulus fibrosus and the intervertebral ligaments. Later on ossification of the peripheral region of the discs including spinal ligaments occur so that the whole spinal column is converted into a rod of bone. In the beginning the symptoms are intermittent and only felt on getting up in the morning. A few patients may complain of pains in various joints particularly in the lower limbs. Pain along the distribution of the sciatic nerve or sciatica is sometime complained of, but the peculiarity is that it alternates from one side to the other. Vague symptoms like malaise, fatigue, loss of weight and chest pains are also complained of. Ankylosis of the costovertebral joints results in fixation of the thorax with interference in respiratory movements, so respiratory disease is apt to appear in late cases. In about half of the patients it stops before any significant deformity can be seen. In a small number of cases it may pursue a long course for many years till the entire spine becomes stiff like ‘bamboo spine’. The back forms a continuous curve with dorsal convexity from the head to the sacrum. Some tenderness may be elicited at the sacro-iliac joints in the beginning, but in late cases tenderness over the manubrio-stemal joints and symphysis pubis may be detected. Similar changes are also seen in manubrio-stemal joint and symphysis pubis in late cases. In the spine the vertebral bodies look ‘square’ by losing their normal anterior concavity. Calcification of the intervertebral ligaments and the peripheral parts of the disc spaces can be noticed. When such calcification is completed, the vertebral column looks like a ‘bamboo spine’. Physiotherapy and spinal exercises with deep breathing are helpful in keeping the spine mobile. The patient should sleep on a hard bed or on a plaster cast to prevent occurrence of kyphosis. Indomethacin in the dose of 25 mg thrice daily is also beneficial in moderate cases. Steroids are not help­ ful, except when the disease is associated with severe iritis. When the hips are also stiff, one may perform total hip replacement to get mobility of the body as a whole. In osteoporosis the vertebral bodies become soft and biconcave, whereas in true senile kyphosis the disc spaces become narrowed, though the vertebrae are also slightly wedged. On this basis the spine fractures are classified into two categories — stable fractures and unstable fractures. The students must note that stability does not depend on the fracture itself, but on the integrity of the ligaments, particularly the posterior ligament complex. This complex consists of the supraspinatous ligament, interspinatous ligament, the cap­ sules of the facet joints and possibly also the " ligamcntum flavum. When a person falls from a height the lumbar spine may be compressed; similarly if a weight falls on the head the cervical spine may be compressed. In compression force the nucleus pulposus splits the vertebral end-plates and fractures the vertebra vertically, with greater force the disc material may be forced into the vertebral body. This may occur when the patient falls from the bent position or a weight falls on his bent back. The anterior portion of the vertebral body crushes, but the posterior ligament complex remains intact. Forward hinging injuries are rare in the neck as the chin touches the sternum before hyperflexion can occur. It should be borne in mind that this type of fracture can also be pathological due to malignant de­ posits or osteoporosis. Backward Hinging forces more commonly involve the cervical region rather than lumbar region. There is hardly any chance of thoracic region to be affected by this type of force. In the cervical region this type of injury may be caused by diving into shallow water. It may happen that the young toddler who falls repeatedly on his buttocks may sustain this type of injury which may well be the starting point of spondylolisthesis, which is recognised later in life. When a weight falls asymmetrically on the back or a person falls from a height with the body twisted, such type of injury may occur. A slice of bone is sheared off from the top of one of the vertebral body and the posterior facet may be fractured. Another type of shearing force may be come across in which there is a combination of flexion force with forward shearing — the so-called ‘seat-belt fracture’, which is caused by motor car accident. The pelvis is anchored to the seat by the seat-belt and during accident the body is thrown forwards. The posterior ligaments are torn, there may be no bony fracture, but the upper facet may leap-frog over the lower. In the neck similar type of injury can occur due to fall from a motor cycle or horse. A whip-lash injury of the neck may also tear the posterior ligament and permit Fig. It should be noted that as the facets are relatively horizontally placed in the cervical region, forward dislocation is more common in this region without fracture of the facets. This type of force can also cause ‘true fracture dislocation’ in the thoracic region. The importance of this type of fracture in the thoracic region is that almost invariably paraplegia results as the spinal canal is quite narrow in the thoracic region. In the lumbar spine the transverse processes may be fractured by direct injury and are often missed considering it to be muscle injuries. The patient should be considered as a whole and careful examinations should be performed to exclude injuries to the chest, abdomen, head and the limbs. Head injuries, chest injuries and abdominal injuries are more serious and are threat to life. The limb fractures and dislocations should be excluded and if have occurred should be treated alongwith the spinal injuries. To examine the back, the patient is carefully turned to one side in one piece by two or three persons. An oblique view is also very helpful which is centred through the spinous processes. That is why these fractures should always be treated in a plaster jacket, even though these are stable fractures. The plaster jacket is applied in the neutral position of the spine and not with hyperextension of the spine. The plaster jacket should be kept for 6 weeks, which is replaced by a polythene jacket for another 6 weeks. After that it is replaced by a polythene collar, till consolidation of the fracture is seen on X-ray. Such traction should be continued for 6 weeks, which is followed by a plaster or polythene collar till consolidation of fracture is seen on X-ray. It must be remembered that any neck injury associated with spinal cord damage is best treated with skeletal skull traction. The patients should be turned on their faces several times a day and are taught how to use spinal exercises. Many of these fractures in this region arc however pathological and should be treated accordingly. The patient is turned every two hours on to his side in one piece by three nurses. This method is a safe procedure, which gives adequate facility for proper nursing. However such fractures can also be treated by immobilisation of the spine in plaster bed. The patient is taken to operation theatre and is placed prone on the operating table. If reduction has been achieved, plaster is applied to the posterior half of the trunk upto mid-thigh. For cleaning, which should be done at least once a week, the patient is turned in prone position, the plaster shell is taken off and the back is cleaned and powdered. After 6 weeks the fracture becomes almost stable, so a plaster jacket is applied with the spine in neutral position. The patient should wear this plaster jacket for further 6 to 12 weeks, till union is evident in X-ray. If the facets are still locked, the patient is anaesthetised and gentle manipulation combined with traction may achieve reduction. If this also fails, open reduction should be done operatively under direct vision. When there is considerable bony damage, plates and bolts may be used for internal fixation. But if it is mainly ligamentous injury, bone grafts should be used alongwith plates and bolts for internal fixation, as ligament repair takes longer time and may cause breakage of the plates before complete healing leading to further displacement and injury to the spinal cord. This will cause reduction at the same time will give stability to the affected site. Anterior fusion may also be performed by fusing vertebral bodies anteriorly with bone block inserted into them. In the stage of cord shock there is flaccid motor paralysis, sensory loss and visceral paralysis below the level of the cord lesion. When the stage of shock disappears, the distal part of the spinal cord below the level of transection acts like an independent structure. So all visceral reflexes return, but they act independently without the influence of upper motor neurone. There is spastic paralysis with increased muscle tone, tendon reflexes become exaggerated and clonus appears. Every 2 hours the patient is gently rolled to one side and his back is carefully washed, dried and powdered. If at all bed sores develop, they usually do not heal without excision and skin grafting. But in general hospital it is better to provide continuous drainage through a fine Gibbon catheter. Later on two types of incontinence may be seen:— (i) An automatic bladder which contracts reflexly when the bladder is full to certain extent and (ii) overflow incontinence where bladder continues to distend till it is manually emptied by suprapubic pressure or it is drained when it is extremely full.

This is Exploration and Determination of Operability a far more important consideration than is construction of a jejunal pouch for a reservoir , and we no longer create such a Tumors are considered non-resectable when there is poste- pouch in these cases . Invasion of the body or tail of the pancreas is not a contraindication to operation , nor is invasion of the left lobe of the liver , as these Extent of the Operation structures can be included in the specimen if necessary . When there is only a moderate degree of distant metasta- Microscopic submucosal infiltration may occur in the esopha- sis in the presence of an extensive tumor , a palliative resec- gus as far as 10 cm proximal to a grossly visible tumor and occa- tion is indicated if it can be done safely . Frozen section microscopic dle colic artery , does not contraindicate resection if leaving 38 Total Gastrectomy 355 Fig . If splenectomy is planned , it is fre- This often requires concomitant resection of a segment of the quently done as the next step. It is surprising that in some patients remov- ing a short segment of the main middle colic artery does not impair the viability of the transverse colon so long as there is Splenectomy good collateral circulation. Splenectomy is performed only when tumor encroaches on the spleen or splenic hilum. Incise the avascular lienophrenic Omentectomy, Lymph Node Dissection, ligament that attaches the lateral aspect of the spleen to the and Division of Duodenum undersurface of the diaphragm (Fig. As this incision reaches the inferior pole of the spleen, divide the lienocolic The initial steps are performed as described in Chap. The tail can be elevated gently from the retroperito- tion of the right gastroepiploic vessels at their origin, and neal space. The lesser omentum is divided up superior border of pancreatic tail continues until the pancre- to the esophagogastric junction and the left gastric artery is atic tail is completely dissected and splenic artery and vein ligated and divided at its origin. For the retroperitoneal dissection, splenic vessels and tail of the pancreas, the dissection expose the fascia of Gerota and the left adrenal gland. If should follow the previous dissection plane identified at the there is evidence of tumor invasion, include these structures celiac axis. Care should be exercised to Dissection of the Esophagocardiac avoid injury to left inferior phrenic vessels. Junction: Vagotomy Retract the left lobe of the liver to the patient’s right and Splenic Nodal Dissection Without Splenectomy incise the peritoneum overlying the abdominal esophagus. Using a peanut dissector, dissect the esophagus away from After ligating the left gastroepiploic vessels, short gastric the right and left diaphragmatic crura. Then encircle the vessels need to be ligated and divided close to the splenic esophagus with the index finger and perform a bilateral trun- attachment. Once the short gastric vessels are ligated and cal vagotomy, as described in Chap. Pass the left hand divided, the gastric fundus can be mobilized completely behind the esophagocardiac junction, a maneuver that delin- from the retroperitoneum and spleen. Finally nodal tissues eates the avascular gastrophrenic and any remaining esoph- along the distal splenic artery (station 11d) and the hilum of agophrenic ligaments, all of which should be divided spleen (station 10) are dissected. Deliver the stapled end of the distal jejunum through jejunum from the abdominal cavity and inspect the mesen- the incision in the mesocolon to the region of the esophagus. In some patients defect in the mesocolon to the wall of the jejunum to prevent who have lost considerable weight before the operation, the herniation later. In patients whose jejunal mesentery is short, it may be necessary to divide several End-to-Side Sutured Esophagojejunostomy arcade vessels. Transillumination is a valuable aid for dis- secting the mesentery without undue trauma. The anticipated site of the esophageal transection is at least Generally, the point of division of the jejunum is about 3–5 cm above the proximal margin of the palpable tumor 15 cm distal to the ligament of Treitz, between the second depending on tumor histology. Make an incision in the mesentery Apply a soft Satinsky vascular clamp to distal esopha- across the marginal vessels and divide and ligate them with gus about 2–3 cm above the transection line. Divide and ligate one to three additional arcade ves- esophagus and remove the specimen and ask the patholo- sels to provide an adequate length of the jejunum to reach the gist to perform a frozen section examination of both the esophagus without tension (Fig. With the same needle take a bite at the right lateral margin of the jejunal full thick- ness wall. Apply hemostats to each suture, as none is tied until the posterior suture line has been completed. Once sutures reach corner then first tie the previous corner sutures and then tie running sutures to the corner sutures. End-to-Side Stapled Esophagojejunostomy An end-to-side esophagojejunostomy performed with a circu- lar stapler requires easy access to 4–5 cm of relaxed esopha- gus with good exposure to enable the surgeon to inspect the Fig. Once this device is fired, then apply large right angle clamp to the esophagus 2–3 cm distal to the device to prevent spillage. Grasp just the edge of proximal edge of the anterior wall of the esophagus and release the device. The posterior wall is still attached and preventing esophageal Attach the anvil to the device and be certain the connec- stump retracting into mediastinum. We do not usually use a the stapler so the anvil is approximated to the cartridge. Also watch the angle and tension of rior wall with small cuff of tissue left around the post and stapler. Carefully inspect the staple line before firing device then carefully trim it without cutting purse-string suture. When Bring the previously prepared Roux-en-Y segment of jeju- this has been completed, fire the device by pulling the trig- num and pass it through an incision in the avascular part of the ger. The jejunum should easily reach the counterclockwise, rotate the device, and manipulate the esophagus with 6–7 cm to spare. Gently dilate the lumen of anvil in such fashion as to withdraw the stapler from the the jejunum and insert the lubricated cartridge of the circular anastomosis. It is important to amputate the jejunum close to the anastomosis so no blind loop develops. Attention should now be directed to restoring the continuity When all these sutures have been placed, make an incision of the small intestine by doing an end-to-side anastomosis along the previously marked area of the jejunum and remove between the cut end of the proximal (biliopancreatic limb) the staple line from the proximal segment of the jejunum. This anastomo- Approximate the full thickness layers using running 3-0 sis should be made at least 45 cm from the esophagojejunal Vicryl (Fig. Close the remainder of the posterior the antimesenteric border of jejunum has been selected, use layer with a continuous suture and transition to anterior 38 Total Gastrectomy 361 Fig. To accomplish this, the biliopancreatic limb of the jejunum is approximated to the Roux-en-Y limb with seromuscular stitches. With electrocau- completed in a side-to-side fashion between the antimesen- tery make a 1-cm longitudinal incision on the antimesenteric teric borders of the two segments of the jejunum. Insert a linear cutting stapling device: one fork in the intraluminal staple line for bleeding. Allis clamps to the right- and left-hand terminations of the Be certain the open end of the proximal segment of jejunum is staple line (Fig. Then apply multiple Allis clamps in placed so the opening faces in a caudal direction to prevent between approximating full thickness of both sides of jejunal intussusception. Hoshi Close the remaining potential defects between the mesen- Long-term postoperative management requires all tery of the proximal and distal jejunum with interrupted patients to be on a dietary regimen that counteracts dumping. Liquids should not be consumed during or 1–2 h after Modifications of Operative Technique meals to prevent hyperosmolarity in the lumen of the proxi- for Patients with Benign Disease mal jejunum. Some patients require several months of repeated encouragement to establish adequate caloric intake When total gastrectomy is being performed for benign dis- following total gastrectomy. These structures are divided close to the margins well as continued parenteral injections of vitamin B12 are of the stomach. Second, it is not necessary to remove the necessary for long-term management of patients following spleen or omentum, and the greater curvature dissection can total gastrectomy. Third, dissection of the lymph Complications nodes in the region of the celiac axis, hepatic artery, and pan- creas is not indicated. Except for the foregoing modifications, Sepsis of the abdominal wound or the subphrenic space is the technique is essentially the same as for cancer operations. Wound Closure Leakage from the esophagojejunal anastomosis is the most serious postoperative complication but occurs rarely if Irrigate the abdominal cavity with saline. A minor degree of leakage tube or needle-catheter jejunostomy in malnourished may be managed by prompt institution of adequate drainage patients. Nutritional support is essential, as are systemic been performed with accuracy, we do not insert drains in the antibiotics. Fortunately, a properly per- may be brought out from the vicinity of the anastomosis formed Roux-en-Y anastomosis diverts duodenal and through a puncture wound in the abdominal wall and attached pancreatic enzymes from the leak. Administer enteral feedings by way of the tube jejunostomy Japanese Gastric Cancer Association. If no leakage is identified, a liquid diet resection for gastric cancer: increased survival versus increased is initiated that may be increased rapidly according to the morbidity. This changes the course of the superior mesenteric and middle colic vessels so they travel Tumor directly cephalad, leaving the transverse portion of the duo- Bleeding denum completely exposed. After liberating the right colon by incising the peritoneum of the right paracolic gutter, the renocolic attachments are Preoperative Preparation divided. Continuing in this plane, the surgeon can then free the entire mesentery of the small intestine in an entirely Nasogastric tube avascular dissection. When planning a resection of the third and fourth por- tions of the duodenum, it must be noted that to the right of Pitfalls and Danger Points the superior mesenteric vessels the blood supply of the third portion of the duodenum arises from many small branches Trauma to superior mesenteric artery or vein of the inferior pancreaticoduodenal arcade. These vessels Trauma to pancreas must be dissected, divided, and ligated delicately, one by one, to avoid pancreatic trauma and postoperative acute pancreatitis. The distal duodenum is not attached to the Operative Strategy body of the pancreas to the left of the superior mesenteric vessels: Its blood supply arises from branches of the supe- Because the third portion of the duodenum is located behind rior mesenteric artery, as does that of the proximal jejunum. Liberating the If the pancreas has not been invaded, it is possible to resect right colon and small bowel mesentery from their attach- the third and fourth portions of the duodenum for tumor and ments to the posterior abdominal wall permits the surgeon to then construct an anastomosis between the descending duo- elevate the right colon and entire small bowel to a position denum and the jejunum, so long as the ampulla is not involved. When working in this area, it is essential that the ampulla of Vater be identified early during the dissection. Division of this thin, liga- mentous structure completely frees the right mesocolon. Incision A long midline incision from the midepigastrium to the pubis Liberation of Small Bowel Mesentery gives excellent exposure for this operation. Insert the left index finger underneath the remaining avascu- lar attachments between the mesentery of the small bowel Liberation of Right Colon and the posterior wall of the abdomen; incise these attach- ments until the entire small intestine up to the ligament of Open the peritoneum of the right paracolic gutter with Treitz is free and can be positioned over the patient’s thorax. Insert an index finger to separate the This configuration resembles the anatomy of patients who peritoneum from underlying fat and areolar tissue, which have a congenital failure of rotation or malrotation of the provides an avascular plane. It is not necessary to dissect the greater omentum off the transverse colon during this operation. It is Resection of Duodenum important, however, to continue the division of the paracolic peritoneum around the inferior portion of the cecum and to There is no structure lying over the third and fourth portions move on medially to liberate the terminal ileum, all in the of the duodenum or proximal jejunum at this time. Identify the renocolic ligament at the tumor of the duodenum is to be resected, it is important to 39 Exposure of the Third and Fourth Portions of the Duodenum 365 Fig. It is possible to identify and divide each of the pancreas has been invaded, a decision must be made whether small vessels arising from the pancreas. This frees the duo- a partial or total pancreatectomy is indicated for the patient’s denum and permits resection and anastomosis. If the duodenum is free, dissection is best begun About 1 cm of the duodenum should be freed from the by identifying the blood supply of the distal duodenum, pancreas proximal to the point of transection. As the an end-to-end anastomosis between the proximal duodenum pancreatic head is approached, perform this dissection with and a segment of the jejunum that is brought over for this 366 C. Mere closure of the distal duodenum plus a gastro- serum amylase level remains elevated and the patient shows jejunostomy is not a satisfactory operation, as the proximal any signs of acute pancreatitis, nasogastric suction should be duodenum would eventually dilate to huge proportions and continued until no danger exists. If for some reason the end of the duode- num is suitable for closure but not for anastomosis, a side-to- side anastomosis between the second portion of the Complications duodenum and proximal jejunum is a good alternative. Pancreatitis Anastomotic leaks Closure After the anastomosis has been performed, return the right Further Reading colon and small bowel to the abdomen. Acute pancreatitis is a possible complication small intestine at the ligament of Treitz. Coppa , Heather McMullen , Alan Geiss , and Charles Choy A variety of bariatric procedures, most laparoscopic, are cur- and support groups in order to be well prepared for surgery rently available. Medical workup including evaluations by (described in this chapter) and laparoscopic Roux-en-Y gastric cardiology, pulmonary, gastroenterology, and endocrinology bypass (Chap. References at the end describe addi- placed on a 2-week liquid diet to shrink an enlarged liver and tional procedures in current use. Operative Strategy Preoperative Preparation It is important that the anesthesia team be prepared for a dif- Bariatric surgery requires extensive preoperative preparation ficult airway. Use a bariatric table with adequate padding, which is best conducted through a multidisciplinary team support, and means to secure the patient. All patients should undergo nutritional and psy- in the supine lithotomy position. Preoperative antibiotics are chological evaluations, as well as attend educational sessions given. Deep venous thrombosis prophylaxis requires enoxa- parin and sequential compression devices. Have the anesthe- siologist place an orogastric tube to decompress the stomach and facilitate identification of the distal esophagus. Convert the initial entry port to a 15 mm port to allow placement of the band into the abdomen. Place all tro- cars under direct visualization and use alternative trocars as needed. Inspect the hiatus for evidence of a hiatal hernia and repair this if discovered (Fig. After induction of general perform blunt dissection of the lateral aspect of the phreno- anesthesia and endotracheal intubation, have the anesthesia esophageal ligament with the hook cautery. Position the patient in the dor- dissection is completed, identify and incise the pars flaccida sal lithotomy position and have the abdomen prepped and (Fig. Then Identify the inferior aspect of the right crus with the adjacent adjust patient position into a reverse Trendelenburg position fat pad. Open this space with electrocautery and create a ret- to facilitate exposure of the surgical site. Enter the abdomen with an optical trocar or Veress needle and establish pneu- moperitoneum to 15 mmHg.

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