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Top Tips in Gastrointestinal Surgery EDITED BY Ciaran J. Walsh MB, BSc, MCh, FRCSI Arrowe Park Hospital, Upton, Wirral, UK Neville V. Jamieson MA, MD, FRCS Addenbrooke's Hospital, Cambridge, UK Victor W. Fazio MB, MS, FRACS, FRACS(Hon), FACS The Cleveland Clinic Foundation, Cleveland, USA FOREWORD BY Sir Roy Calne

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Page ii © 1999 by Blackwell Science Ltd Editorial Offices: Osney Mead, Oxford OX2 0EL 25 John Street, London WC1N 2BL 23 Ainslie Place, Edinburgh EH3 6AJ 350 Main Street, Malden MA 02148 5018, USA 54 University Street, Carlton Victoria 3053, Australia 10, rue Casimir Delavigne 75006 Paris, France Other Editorial Offices: Blackwell Wissenschafts-Verlag GmbH Kurfürstendamm 57 10707 Berlin, Germany Blackwell Science KK MG Kodenmacho Building 710 Kodenmacho Nihombashi Chuo-ku, Tokyo 104, Japan The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the copyright owner. First published 1999 Set by Graphicraft Limited, Hong Kong Printed and bound in Great Britain at the Alden Press Ltd, Oxford and Northampton The Blackwell Science logo is a trade mark of Blackwell Science Ltd, registered at the United Kingdom Trade Marks Registry DISTRIBUTORS Marston Book Services Ltd PO Box 269 Abingdon, Oxon OX14 4YN (Orders: Tel: 01235 465500 Fax: 01235 465555) USA Blackwell Science, Inc. Commerce Place 350 Main Street Malden, MA 02148 5018 (Orders: Tel: 800 759 6102 781 388 8250 Fax: 781 388 8255) Canada Login Brothers Book Company 324 Saulteaux Crescent Winnipeg, Manitoba R3J 3T2 (Orders: Tel: 204 837 2987) Australia Blackwell Science Pty Ltd 54 University Street Carlton, Victoria 3053 (Orders: Tel: 3 9347 0300 Fax: 3 9347 5001) A catalogue record for this title is available from the British Library ISBN 0-632-04253-2 Library of Congress Cataloging-in-publication Data Top tips in gastrointestinal surgery/ edited by Ciaran J. Walsh, Neville V. Jamieson, Victor Fazio. p. cm. ISBN 0-632-04253-2 1. Gastrointestinal system Surgery. I. Walsh, Ciaran J. II. Jamieson, Neville V. III. Fazio, Victor W., 1940- . [DNLM: 1. Digestive System Surgical Procedures. WI 900T6737 1999] RD540. T66 1999 617.4'3059dc21 DNLM/DLC for Library of Congress 98-38634 CIP For further information on Blackwell Science, visit our website: www.blackwell-science.com

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CONTENTS List of Contributors Foreword Preface Opening and Closing the Abdomen Excising Old Scars: One Cut, Two Scalpels C.J. Walsh Making a Smooth Curve Around the Umbilicus R.W. Motson Finding the Midline in a Fat Abdominal Wall J.H. Scholefield Around the Falciform Ligament, not Through It R. Miller Closing the Abdomen F. Seow-Choen Mass Closure with Two Sutures C.J. Walsh Double-Loop Deep-Tension Suture for Abdominal Wall Closure A.S. Soin Subcutaneous Skin Closure P.H. Gordon xii xvii xix 1 2 3 4 5 6 7 9

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A. Rubin Retraction for Pelvic Surgery A. Walsh Let Air into the Lesser Sac C. Fazio 11 12 14 14 15 16 17 19 19 20 21 < previous page page_iv next page > . Lee The Schneeden Stitch C.This version of Total HTML Converter is unregistered. Walsh Retractors and Exposure in the Pelvis V. Walsh Greased Thread C.W.J.J.R. Walsh Babcocks for Haemostasis C. Dark Hole J. Masters Making the Best of a Short Suture Length in a Deep.J. Walsh Ureteral Catheter Drainage R.J.W.C.J. Puntis Identification of the Two Free Suture Ends in a Standard Two-Layer Anastomosis P.J. McLoughlin Retracting the Uterus in Pelvic Surgery C. page_iv Page 1 of 1 < previous page page_iv next page > Page iv General Surgical Techniques How to Sew in a Drain M.

P. McEntee Packing of the Liver for Liver Traumathe Cambridge Technique N. page_v Page 1 of 1 < previous page page_v next page > Page v Oesophagogastric Surgery Retraction of the Left Lobe of the Liver to Expose the Oesophagogastric Junction N.V. Paterson-Brown Transhiatal Oesophagectomy Using a Vein Stripper R.G. Motson Hepatobiliary Surgery Clearance of the Vena Cava During Right-Sided Hepatic Resection O. Henderson Packing the Traumatized Liver G. Jamieson 23 24 26 27 29 31 33 34 35 < previous page page_v next page > . Molloy Gastric Bypass for Morbid Obesity H.J.W.J. Sugerman A Partial Gastrectomy Without Clamps on the Gastric Remnant R.M. Jamieson Hand-Sewn Anastomosis for High (Intrahiatal) Oesophagojejunostomy S. Garden Mobilization of Left Lobe of Liver and Isolation of Suprahepatic Inferior Vena Cava J.This version of Total HTML Converter is unregistered.V.

J. Gellman Pancreaticojejunostomy Following Whipples Pancreaticoduodenectomy A. page_vi Page 1 of 1 < previous page page_vi next page > Page vi A Safe Technique for Anastomosing a Normal Calibre Bile Duct G. Masters Pancreatic Surgery Safe Approach to Superior Mesenteric Vein and Neck of Pancreas W. Particularly When This is of Narrow Calibre.This version of Total HTML Converter is unregistered. Cooperman and L.P. Henderson Four Tips That Facilitate Pancreaticoduodenal Resection A. Friend Improved Access to the Gall Bladder at Open Cholecystectomy C. to a Roux Loop of Jejunum P.J. Garden 37 39 40 41 43 45 46 48 53 55 < previous page page_vi next page > . Wells Excision of the Gall Bladder A. Kingsnorth A Strategy for Pancreatic Necrosectomy A. McEntee Technique for the Anastomosis of the Common Bile Duct.D. Walsh A Snugger for Peroperative Cholangiograms During Open Cholecystectomy A. Siriwardena and O. Silen Exposure of the Pancreas J.J.M.

Hyland The 554 Ileostomy C. Motson Technique to Avoid the Posterior Wall When Oversewing a Perforated Duodenal Ulcer R. Puntis Choosing Levels of Resection in Small Bowel Crohn's Disease V. Phillips Loop Ileostomy M.G. Fazio Ball-Bearing to Detect Small Bowel Strictures R.C. Hall.A.S. page_vii Page 1 of 1 < previous page page_vii next page > Page vii Surgery of the Duodenum and the Small Intestine Reconstruction Technique after Resection of Duodenal Wall W.This version of Total HTML Converter is unregistered. C. Miller Stoma Surgery Siting an Ileostomy K. Keighley 57 59 60 61 63 65 67 69 71 73 < previous page page_vii next page > .B.W.W. Myers and R.R.W.K. Molloy How to Make a Feeding Jejunostomy M. Barry and J. Fazio Method of Dividing Small Bowel Mesentery in Crohn's Disease V. Lawrence Jr How to Avoid Mucosal Perforation When Performing a Ramstedt's Pyloromyotomy R.

L.R.S. Thomson Reversal of Ileostomy K.This version of Total HTML Converter is unregistered. Lee> Wound Closure After Take-Down of a Stoma R.J.P. page_viii Page 1 of 1 < previous page page_viii next page > Page viii The Loop End Ileostomy V. Miller Repair of Paracolostomy Hernias P.H. Brain Mobilization of the Hepatic and Splenic Flexures of the Colon F.W. Barry and J. Fazio Mobilization of Stomas J. Vukasin and R. Scholefield Closure of Loop Ileostomy P.H. Hyland Stapled Closure of Loop Ileostomy J. Walsh Appendicectomy Without Breaching the Integrity of the Intestine A.W. Seow-Choen 87 89 < previous page page_viii next page > . Beart Jr 74 77 78 79 81 82 83 Colon and Rectal Surgery Identification of the Left Ureter 85 P.W. Gordon Acute Appendicitis? Re-Examine Abdomen When Patient Anaesthetized on Operating Table 87 C.J.

W.M. Lee Laparoscopic Vascular Stapler to Facilitate Pelvic Sidewall Clearance A. Beck Identification of the Inferior Mesenteric Artery During Anterior Resection of the Rectum R. page_ix Page 1 of 1 < previous page page_ix next page > Page ix Taking Down Splenic Flexure V.This version of Total HTML Converter is unregistered. Beck Placement and Repair of Purse-String Sutures D. Fazio Mobilization of the Splenic Flexure R.J. Beck Proximal Ligation of the Ileocolic Artery D.E.R.W.W.E. Miller Anterior Resection of the Rectum Using the Circular Stapling Device (Double-Staple Technique) P. Fazio Achieving Adequate Bowel Length for Anastomosis After a Left Colonic Resection D.J. Walsh Hartmann's Operation in Presence of Colon Obstruction C. Walsh Getting the Colon to Reach V.E. Miller Needle Decompression of the Obstructed Colon C. Cohen 90 91 92 93 95 96 99 101 103 104 107 < previous page page_ix next page > .

Walsh Thumbtack to Arrest Bleeding from Presacral Veins C.J.M. Fazio Use of Hydrodissection to Mobilize the Rectum in Redo Pelvic Surgery E. Seow-Choen Getting the Small Bowel to Reach V. Bokey Reusable Transanal Anvils F.This version of Total HTML Converter is unregistered. Seow-Choen Inserting Transanal Staplers in Ultra-Low Anterior Resection F.109 Line Recurrence R.J.L.W. Walsh Dealing with Presacral Bleeding During an Abdominoperineal Resection R.J. Sugerman Combined Supine and Prone Jack-Knife Position for Abdominoperineal Resection of the Rectum C. Moran Alternatives to Colonic J-Pouch 112 V. Heald and B.J.W.G. Molloy 113 115 116 117 118 119 121 123 125 < previous page page_x next page > . Church Stapled Ileoanal Pouch Procedure H. page_x Page 1 of 1 < previous page page_x next page > Page x The Moran Triple-Stapling Technique: A Fail-Safe Precaution Against Implantation Staple.J. Fazio Insertion of the Stapler for an Ileal Pouch-Anal Anastomosis J.

Church Transanal Dissection Using Electrocautery: Get the Right Angle C.D. Lee The 'Looped Pulley' Suture in Perineal Wound Closure Under Tension R.S. Rubin Cutting Seton for Fistula-in-Ano R. Miller Perianal Wound Care J.This version of Total HTML Converter is unregistered. Walsh Easier Haemorrhoidectomy J.W. Lee Rubber-Band Ligation of Haemorrhoids Made Easier P.H. Wells Seton Insertion for Fistula-in-Ano R. O'Connell Exposure for Transanal Excision of Rectal Lesions J. Scholefield Injection of Haemorrhoids P. Rubin Lubrication to Find the Induration A.M.W.R. Thomson Index 127 128 130 131 133 135 138 139 139 141 141 143 < previous page page_xi next page > .R.J. page_xi Page 1 of 1 < previous page page_xi next page > Page xi Anorectal Surgery A Better View in Anorectal Surgery P.J.R.P.J.

1514 Jefferson Hwy. Brain MS.M. Dublin 4. MMedSc(Anatomy). Professor of Surgery. Senior Registrar. MB. USA V. 128 Ashford Avenue. OH 44195. Beart Jr MD. USA A. 1275 York Avenue. FRACS. FACS. Los Angeles. Cleveland. Department of Surgery. New York.M. Concord Hospital. 9500 Euclid Avenue. FRCSI. Professorial Surgical Unit. Bokey MD. Turnbull Professor and Chairman. The Cleveland Clinic Foundation. NY 10522. FACS.W. Department of Surgery. Ireland R. Hills Road. Ochsner Clinic. FACS. University of Southern California. Chairman. CA 90033-4612. Fazio MB. Institute for Laparoscopic Surgery at Dobbs Ferry. ChB. NY 10021. FRACS. St Vincent's Hospital Elm Park. Department of Colorectal < previous page page_xii next page > . Concord. Cooperman MD. Department of Colorectal Surgery. Barry MD. Division of Colon and Rectal Surgery. MS. Colorectal Service. Dobbs Ferry. Chairman. Cohen MD. USA A. Church BSc(HumBio). UK J. FRACS(Hon). FRACS. Australia A. Beck MD. USA D. Addenbrooke's Hospital. Chief. NSW 2139. Consultant in Neonatal and Paediatric Surgery.L. Rupert B. FRCS.E. Professor of Colon and Rectal Surgery. Cambridge CB2 2QQ. FACS.W.J.L. LA 70121. page_xii Page 1 of 1 < previous page page_xii next page > Page xii LIST OF CONTRIBUTORS K. Department of Colon and Rectal Surgery.This version of Total HTML Converter is unregistered. Memorial Sloan-Kettering Cancer Centre. Staff Surgeon. USA E. New Orleans.

Friend MA. Gordon MD. Department of Surgery. City General. OH 44195. Edinburgh EH3 9YW. Hyland MCh. FRCSC. Cleveland. The Cleveland Clinic Foundation. ChM. Heald MChir.B. Hills Road. Cambridge CB2 2QQ. UK J. Keighley MS. Stoke-on-Trent ST4 6QG. Queen Elizabeth Hospital. Canada C. Professor of Hepatobiliary Surgery. Barling Professor and Head of Department of Surgery. Dublin 4. Jamieson MA. Newcastle Road. USA O. MD. Professor of Surgery and Oncology. USA P. University of Birmingham. Hampshire RG24 9NA. BChir. Edgbaston. Consultant Surgeon.H. Basingstoke. MD. Chairman.M. Department of Surgery. Consultant Surgeon. Cambridge CB2 2QQ. UK M. Cellman MD. FRCS. Consultant Colorectal Surgeon. Aldermaston Road. 9500 Euclid Avenue.V.R. Dobbs Ferry. 128 Ashford Avenue.J. Birmingham B15 2TH. FRCSI. Hills Road. ChB. Montreal.J. FRCS(Ed&Glas). OH 44195. Cleveland. Henderson MB.J. FACS. FRCS. UK R. Addenbrooke's Hospital.This version of Total HTML Converter is unregistered. UK L. UK P. Ireland N. McGill University. page_xiii Page 1 of 1 < previous page page_xiii next page > Page xiii Surgery. Colorectal Research Unit. University Department of Surgery. Garden MD. UK < previous page page_xiii next page > . North Staffordshire Hospital. Addenbrooke's Hospital. and Director of Colon and Rectal Surgery. Quebec H3T 1E2. Institute for Laparoscopic Surgery at Dobbs Ferry. MB. FRCS. ChB. 9500 Euclid Avenue. USA J. FRCS. Department of General Surgery. 3755 Cote St Catherine Road. Elm Park. Consultant Surgeon. Hall MB. FRCS. Consultant Surgeon. Lauriston Place. The Cleveland Clinic Foundation. FACS. NY 10522. The North Hampshire Hospital. St Vincent's Hospital. Royal Infirmary of Edinburgh.

McLoughlin MS. BS. Cambridge CB2 2QQ. UK R. UK R. UK B. UK C. Consultant Surgeon. 1053 Great Western Road. FRCS. Richmond. UK W. Consultant Surgeon. FRCS. Mater Misericordiae Hospital.R. Bury St Edmunds IP33 2QZ. Department of Surgery. LRCP. Ireland J. page_xiv Page 1 of 1 < previous page page_xiv next page > Page xiv A. Hampshire RG24 9NA. MB. Middlesex HA1 3UJ. Myers SRN. Colorectal Research Unit. Masters MS. The North Hampshire Hospital. Consultant Urologist. FRCS(Urol). Derriford Hospital. Castle Hill Hospital. MS. Colchester CO4 5JL. Kingsnorth BSc. FRCS. Professor of Surgery. VA 23298. Plymouth PL6 8DH. Gartnavel General Hospital. Hardwick Lane. FRCS(Gen). Box 11. FRCS. Consultant Surgeon. Department of Surgical Gastroenterology. Hills Road. Moran MCh. Colchester General Hospital. 1200 E. UK < previous page page_xiv next page > . West Suffolk Hospital. USA P. Eccles Street. Addenbrooke's Hospital. Division of Surgical Oncology. McEntee FRCSI.P. Basingstoke. Department of Surgery. Molloy MD. UK R.W. St Mark's and Northwick Park Hospitals Trust. UK G. Consultant Surgeon. FRCSI. UK A. Wirral. Consultant Surgeon. ENB216. Turner Road. Watford Road. Harrow. MRCS. Lawrence Jr MD. Arrowe Park Hospital. Consultant Surgeon. Derriford Road. Aldermaston Road. Broad Street. Consultant Colon and Rectal Surgeon. Clinical Nurse Specialist in Stoma Care. Merseyside L49 5PE. Dublin 7. Hull HU16 5JQ.G.W.J. Medical College of Virginia. GBSCN.This version of Total HTML Converter is unregistered. FRCS. Glasgow G12 OYN. Professor Emeritus. Miller MS. Lee MD. Academic Surgical Unit. Motson MS. Upton. University of Hull.

Consultant Surgeon. FRCSI. Heath Park. Consultant Colorectal Surgeon. FRCS. Department of Surgery. Boston. Seow-Choen MBBS. Reader in Surgery. Watford Road.R.This version of Total HTML Converter is unregistered. Department of Colorectal Surgery. Clinical Professor of Surgery.C. Senior Lecturer and Consultant Surgeon.S. UK R.A. Surgeon-in-Chief. FAMS. Addenbrooke's Hospital. FRCS. page_xv Page 1 of 1 < previous page page_xv next page > Page xv P. Beth Israel. MS. Singapore 169608 W. UMDNJ-Robert Wood Johnson School of Medicine Affiliated Hospitals. Department of Surgery. NJ 07060. Harvard Medical School. Silen MD. Soin MS.S. St Mark's and Northwick Park Hospitals Trust. BS. University Hospital. Deaconess Medical Centre. Cardiff CF4 4XN. Department of Surgery. Johnson and Johnson Distinguished Professor of Surgery. FRCS. Lauriston Place. FRCS. Nottingham NG7 2UH. USA J. UK R. Ireland S. Outram Road. Royal Infirmary of Edinburgh. MS. University of Cambridge Clinical School. Senior Lecturer in Surgery. 330 Brookline Avenue. Harrow. Lauriston Place. Middlesex HAl 3UJ. Paterson-Brown MPhil. UK < previous page page_xv next page > . Hills Road. Singapore General Hospital. University Department of Surgery. Plainfield. Department of Surgery. UK A. FATS. O'Connell MD.J. Puntis PhD. Emeritus. Edinburgh EH3 9YW. UK M. Mater Misericordiae Hospital. Edinburgh EH3 9YW. Rubin MD. Eccles Street. UK F. Dublin 7. Consultant Surgeon. University of Wales College of Medicine. FRCS(Gen). Siriwardena MD. MA 02215. 1010 Park Avenue. USA A. Royal Infirmary of Edinburgh.K. Phillips MB. Cambridge CB2 2QQ. FRCS(Ed). Scholefield ChM.H. Head and Senior Consultant Surgeon. FRCS.

page_xvi Page 1 of 1 < previous page page_xvi next page > Page xvi H. Watford Road. Upton. UK < previous page page_xvi next page > . Interim Chief.P. Division of General Surgery. Consultant Surgeon. Virginia Commonwealth University. MCh. UK P. Peterborough PE3 6DA. UK A. Consultant Surgeon. University of Southern California. Harrow. Richmond. David M. Vukasin MD. Vice-Chairman. Arrowe Park Hospital.J. Imperial College School of Medicine. USA C. Thomson DM. Hume Professor of Surgery. Los Angeles. MS. BSc. MB. FRCS. Walsh MB. St Mark's Hospital. USA J.This version of Total HTML Converter is unregistered. Merseyside L49 5PE. Middlesex HA1 3UJ. Clinical Instructor in Surgery. Consultant Surgeon. CA 90033-4612. VA 23298. Honorary Clinical Senior Lecturer. Peterborough District Hospital. Department of Surgery. Sugerman MD. Wells MS. Wirral. BS.D. FRCSI. Northwick Park.J. Medical College of Virginia.S. FRCS.

The diagrams are especially helpful since technical surgery is a practical subject. A copy should be on the bookshelves of every operating theatre.This version of Total HTML Converter is unregistered. The source of the tricks is often forgotten and has probably been seen and practised by many residents who have worked for a given surgeon who. with good vision and exposure. learned it from his teacher. The good surgical technician usually proceeds in a business-like manner without hurry. Often. There is something to be learned for everyone and one little tip makes the difference between success and failure in a patient who is in a critical condition or when experienced assistance is not available. I found the compilation wide-ranging and of considerable interest and learned some new tricks myself. page_xvii Page 1 of 1 < previous page page_xvii next page > Page xvii FOREWORD This is a 'how to do it' book of tips for the general surgeon which have been gathered together from a number of authors who have used these techniques with what they perceive as advantage over the years. not only to surgeons in training but also to those who have trained. himself. ROY CALNE < previous page page_xvii next page > . much more easily demonstrated with a clear and simple diagram than a profusion of words. little technical quirks enable normally difficult manipulations to be conducted with ease. yet completes the procedure in a short time with little fuss. I can recommend this book.

We would like to thank each of the contributors who have made this book possible. Georgan Deka. tricks they know that will make an operation. As in other walks of life there is often no one right way of doing things. page_xix Page 1 of 1 < previous page page_xix next page > Page xix PREFACE As we go through our surgical training we pick up technical tips from the various people that we work for. as well as the Blackwell Science team. Sonya Waring. Liz Cadman.V. We hope that you find them useful in your practice of gastrointestinal surgery. Throughout our training we are exposed to a limited number of surgeons and therefore to a limited number of tricks of the trade.This version of Total HTML Converter is unregistered. FAZIO < previous page page_xix next page > . quicker or just simply better. or part thereof. This book attempts to put together a range of tips in operative gastrointestinal surgery. We would like to acknowledge the efforts of Anthony Walsh. JAMIESON V.W. easier. safer. They all have their own little ways. WALSH N. C.J. However this compilation offers a variety of techniques that have been tried and tested by the contributors and found to be of significant value in their surgical practice.

Neville V..4/3059 Gastrointestinal system--Surgery. Ciaran J. 1999 RD540. 9780632042531 9780632062577 English Gastrointestinal system--Surgery. cover next page > .This version of Total HTML Converter is unregistered. Jamieson. Fazio. cover Page 1 of 1 cover next page > title: author: publisher: isbn10 | asin: print isbn13: ebook isbn13: language: subject publication date: lcc: ddc: subject: Top Tips in Gastrointestinal Surgery Walsh.T66 1999eb 617.. Victor W. Blackwell Publishing Ltd.

thus Figure 1 < previous page page_1 next page > . The traditional method of sequentially incising on either side of the scar is unsatisfactory because when you cut down one side of the scar with a scalpel the wound springs open and tension is lost. page_1 Page 1 of 1 < previous page page_1 next page > Page 1 OPENING AND CLOSING THE ABDOMEN Excising Old Scars: One Cut. 1. All that remains is to make a Vshaped cut with a single scalpel at each end of the wound.J. The distance between the parallel blades will accommodate most previous laparotomy wounds. C.This version of Total HTML Converter is unregistered. Now with one movement down the length of the wound both sides of the scar will be cleanly detached from the surrounding skin. Walsh Excising an old midline abdominal scar is usually desirable for cosmetic reasons. Two Scalpels. As a result a single clean cut is very difficult when excising the other side of the scar and a jagged edge may result. Place two scalpels side by side and hold them as shown in Fig.

Making a Smooth Curve Around the Umbilicus R. When the umbilicus is released from the Lane's clamp there is a smooth curve of the incision as it passes around the umbilicus and the skin is divided perpendicularly like the rest of the incision (Fig.This version of Total HTML Converter is unregistered. W. Figure 2 < previous page page_2 next page > . page_2 Page 1 of 1 < previous page page_2 next page > Page 2 bringing the two edges together to form a long. Motson Negotiating the umbilicus on a midline incision often results in an irregular incision as the scalpel blade is turned to avoid the umbilicus. 2). This tip was shown to me by Mr Bruce George when we were registrars at The Royal London Hospital. The following tip will avoid this problem. A Lane's tissue-holding forceps is used to grip the umbilicus and the assistant retracts on the Lane's forceps to deviate the umbilicus from the midline. thin ellipse of scar tissue which is easily dissected off the underlying subcutaneous tissue. A straight incision is then made along the midline.

A plane in the fat invariably opens which invariably exposes the linea alba. Finding the Midline in a Fat Abdominal Wall J. I have noticed that using this technique tends to separate the fat from the midline over 2 cm or so and this helps in obtaining good bites of the sheath in closing the wound. Scholefield Finding the linea alba in the midline of the anterior abdominal wall in an obese patient can be difficult and bloody. < previous page page_3 next page > . Once the skin and dermis have been incised in the midline. Fowler of The Royal London Hospital. Although initially I was concerned about bruising in the fat and subcutaneous tissues this has not been a problem in practice. I was shown a rapid and relatively bloodless reliable method of finding the linea alba in such patients by my former colleague Professor Robert Steele. I have used this technique on many occasions and commend its use to other surgeons. The surgeon and the assistant insert a large pack into each wound edge and exert strong traction with both hands in the wound.H.This version of Total HTML Converter is unregistered. in a direction towards their own abdomens (Fig. The plane opened is almost bloodless. page_3 Page 1 of 1 < previous page page_3 next page > Page 3 To my knowledge this was first described by a member of the 1983 surgical travelling club and was also described by Mr C. 3).G. the subcutaneous fat of the anterior abdominal wall can be incised superficially to a depth of a few millimetres. This may need to be repeated several times along the length of the wound.

page_4 Page 1 of 1 < previous page page_4 next page > Page 4 Figure 3 Around the Falciform Ligament. On extending the wound cephalad one encounters the falciform ligament. even using electrocautery. one extends cephalad and caudad for as long as required. dissection can be unnecessarily bloody.This version of Total HTML Converter is unregistered. Instead go to one or other side where the falciform < previous page page_4 next page > . This contains numerous small vessels and if one continues in the midline. not Through It R. Miller After gaining access to the peritoneal cavity at the beginning of a laparotomy through a midline incision.

Derek Alderson in Bristol taught me this. This is relatively avascular and the dissection proceeds more quickly. Figure 4 < previous page page_5 next page > . Closing the Abdomen F.This version of Total HTML Converter is unregistered. page_5 Page 1 of 1 < previous page page_5 next page > Page 5 ligament fuses with the parietal peritoneum on the anterior abdominal wall and go along this line with electrocautery. Seow-Choen Mass closure is the technique most commonly employed by surgeons to close the abdomen after a midline incision.

use two closing sutures rather than one. 4). After the semilunar line at this point.J. Mass Closure With Two Sutures C. mass closure is easy. Failure to achieve this ratio makes wound closures more prone to early and late failure. Furthermore you do not have to struggle with a short end of suture material when placing the final stitches in the dark recesses of an undermined wound apex. Start one at each end of the wound and tie them in the middle. In this way you are not tempted to get one suture to 'make do' as you approach the far end of the wound and you avoid a suboptimal suture: wound length ratio. I make it easy by starting superiorly where it is easy to close the abdomen. The linea alba is reconstituted by closing the anterior rectus sheaths alone. I close only the anterior rectus sheath (Fig. linea alba and rectus sheath. To help achieve the optimal ratio.This version of Total HTML Converter is unregistered. When I get halfway between the umbilicus and pubic symphysis. This problem is especially acute during the last few bites as the surgeon struggles to get good bites of the peritoneum. page_6 Page 1 of 1 < previous page page_6 next page > Page 6 The problem as usual is accidental needle-stick injury to the small bowel. without increasing wound dehiscence rates and without fear of bowel injury. the posterior rectus sheath is non-existent and therefore there is no posterior sheath. Walsh When performing mass closure of midline abdominal incisions the ideal suture to wound length ratio is 4: 1. < previous page page_6 next page > . Using this technique.

page_7 Page 1 of 1 < previous page page_7 next page > Page 7 Double-Loop Deep-Tension Suture for Abdominal Wall Closure A. The first bite starts at the skin more than 2 cm away from the edge and traverses the skin. to emerge from the peritoneal aspect of the abdominal wall. all taken in the same transverse plane. 5). Each stitch involves four bites (see in Fig. The third bite takes the full thickness of the ipsilateral muscle from without. It is used particularly in cases of abdominal wound dehiscence and closure of the abdomen after re-operation(s) for peritonitis/intra-abdominal sepsis. The second bite passes from within to include the full thickness of the contralateral muscle. This technique is invaluable when closing the abdomen when the tissues of the wound edge are of poor quality. 1 nylon on a 90-mm cutting needle interrupted. Technique.S. subcutaneous tissue and muscle. Using no. Soin Indications. full-thickness deep-tension sutures are placed approximately every 2 cm along the wound.This version of Total HTML Converter is unregistered. finally emerging from within across the full thickness of the Figure 5 < previous page page_7 next page > .

This version of Total HTML Converter is unregistered. emerging at the skin more than 2 cm away from the edge. The tension of the closure is evenly distributed throughout all layers in an interrupted fashion. < previous page page_8 next page > . page_8 Page 1 of 1 < previous page page_8 next page > Page 8 contralateral abdominal wall. The sutures are removed after 6 weeks and sound healing is the rule rather than the exception. Liver and Renal Transplant Unit. This simple technique achieves good apposition of the muscle layer and allows closure even if some muscle is debrided and lost underneath otherwise healthy skin edges. allowing better vascularity and allowing secure healing even in the difficult cases described. The suture is then tightened until the skin and muscle are apposed and knotted on the outside with or without a rubber tubing covering the suture as it lies across the wound to prevent the suture from cutting into the skin. This technique is employed in the Cambridge Hepatobiliary. with a remarkably low incidence of late incisional hernia formation. Source.

< previous page page_9 next page > . particularly well suited for transverse or oblique incisions but applicable for vertical incisions as well. clean.H. The short end is cut and the needle is then passed through the incision to exit at some distance from the skin level. thus burying the knot in the subcutaneous tissue. The suture is not drawn tight. The subcuticular closure is continued on each side with the last pass which enters the subcutaneous tissue and exits the subcuticular tissue at the very apex. patients often consider the quality of the skin closure as a benchmark of our technical skills. This closure of the incision. Although it is of minimal overall importance. the needle is then passed through the subcuticular tissue of the apex in a reverse direction to the subcutaneous tissue of the opposite side and the suture tied. P. begins with a 3/0 or 4/0 absorbable suture entering in the subcutaneous tissue and exiting through the subcuticular tissue of the mid-portion of the incision. By pulling the suture taut and cutting it at skin level the knot is buried and there is no external suture visible. Gordon In the vain world in which we live. A mirror-image suture is placed on the opposite edge of the incision and a knot is tied so that it will rest in the subcutaneous tissue. neat and well approximated skin edges without evidence of suture material often impress and please patients.This version of Total HTML Converter is unregistered. page_9 Page 1 of 1 < previous page page_9 next page > Page 9 Subcutaneous Skin Closure.

A. page_11 Page 1 of 1 < previous page page_11 next page > Page 11 GENERAL SURGICAL TECHNIQUES How to Sew in a Drain M.C.This version of Total HTML Converter is unregistered. Puntis If a drain is used it needs to be fixed firmly in place. I black silk take a bite of skin close to the drain and tie a loose stitch at the centre of the black silk Figure 6 < previous page page_11 next page > . Using no.

This stitch will not slip down the drain. It is helpful to mark the free end of the inner layer by looping it inside an artery forceps. Identification of The Two Free Suture Ends in a Standard Two-Layer Anastomosis P. When the inner layer is complete and the finishing knot is to be tied. 6c). gastroenterostomy) may involve using two identical sutures for the inner and outer layers. which will be held reliably in place for as long as it is needed. Cut off the needle. It is vital that when you encircle the drain prior to tying the surgeon's knot the silk passes squarely around the drain.g. Now tie a surgeon's knot.This version of Total HTML Converter is unregistered. This stitch can be tied without letting go of the silk so the tension can be maintained and with practice you will not even need an assistant to hold the drain. 7a & b). tie a single throw and without letting go of the silk come back to the front of the drain (Fig. round to the front a surgeon's knot.W. page_12 Page 1 of 1 < previous page page_12 next page > Page 12 (Fig. pass it obliquely up the drain before tying the single knot (Fig. 6b). Lee A two-layer anastomosis (e.R. < previous page page_12 next page > . Take one end of the black silk in each hand and pass the ends around behind the drain. it is then a simple matter to select the correct free suture to use (Fig. When you pass the silk back around the drain. Repeat this three timesaround the back a single throw. 6a).

This version of Total HTML Converter is unregistered. page_13 Page 1 of 1 < previous page page_13 next page > Page 13 Figure 7 < previous page page_13 next page > .

This technique was shown to me by Mr John Hall. page_14 Page 1 of 1 < previous page page_14 next page > Page 14 The Schneeden Stitch C. for example gastroenterostomy or enteroenterostomy. Let Air into the Lesser Sac C. Walsh This technique is very useful for the anterior 'all coats' layer of a two-layer gastrointestinal anastomosis.J. By wiggling < previous page page_14 next page > . The two surfaces are often applied to one another and the surface tension between the two can make identification and separation difficult.J. Walsh Separation of the greater omentum from the transverse mesocolon is an important manoeuvre common to a variety of different operations. Consultant Surgeon at Peterborough District Hospital. It has the advantage of being haemostatic and also of burying the mucosa by inverting the suture line. first gain access to the lesser sac by breaking through the lesser (gastrohepatic) omentum with the tip of the left index finger. The manoeuvre depends on being able to accurately identify each tissue layer as well as the plane between the two (the lesser sac). for example gastrectomy and colectomy. This quite simply is a running over and over stitch but starting and finishing each pair of bites on the inside rather than the outside of the bowel wall.This version of Total HTML Converter is unregistered. transparent greater omentum. particularly in the very thin patient with a very flimsy. To facilitate the separation of the two surfaces. This inverts the anterior all coats layer and all that remains is for the anterior seromuscular sutures to be placed.

It is not always easy to accurately identify the vessel as it often recedes below the free edge of the peritoneum and may be associated with a small mesenteric haematoma. Rather than directly suturing the area with the traditional 2/0 rescue stitch or applying an artery forceps along its curvature and risk damaging other mesenteric vessels.J. Walsh 1 Damage to a small mesenteric vessel will often require suture ligation rather than simple ligation for both accuracy and security.This version of Total HTML Converter is unregistered. the situation is rapidly and accurately dealt with by applying a Babcock tissue clamp just beyond the free edge of the peritoneum and incorporating the small but expanding mesenteric haematoma. As a result it may not be amenable to the accurate placement of the tip of an artery forceps. air will enter into the lesser sac and separate the back of the greater omentum from the front of the transverse mesocolon. This tip was shown to me by Mr John Hall at Peterborough District Hospital. This will arrest the bleeding and prevent extension of the haematoma and gentle traction upwards on the Babcock clamp will permit accurate placement of a figure-of-eight haemostatic stitch. particularly in Crohn's disease. This tip was shown to me by Dr Jeff Milsom whilst at The Cleveland Clinic. Babcocks for Haemostasis C. Now dissection of one from the other is significantly easier. < previous page page_15 next page > . page_15 Page 1 of 1 < previous page page_15 next page > Page 15 the finger around and then removing it.

Among other reasons for the choice in these settings are their handling and knot tying properties. respectively. As a result there will be a great reduction in the coefficient of friction and the suture will now glide freely through the tissues without any alteration in the knot tying properties. Should you be in a situation where a side hole has been made in a large vein which needs to be preserved rather than tied off. the situation can be rapidly brought under control by placing a Babcock across the rent in the vein. < previous page page_16 next page > . can be abrasive and traumatic to the bowel if drawn through it at anything other than right-angles. Both sutures. Greased Thread.This version of Total HTML Converter is unregistered. Walsh Polyglactin (Vicryl) and chromic catgut sutures are often favoured for bowel anastomoses and stoma formation.J. but chromic catgut in particular. C. page_16 Page 1 of 1 < previous page page_16 next page > Page 16 2 Vascular clamps and sutures are not usually readily available on general surgical or gastrointestinal sets. To get around this. This will act as a vascular clamp and allow you to generate distal and proximal control in the traditional way whilst procuring the appropriate vascular instruments and sutures for the repair. place a dab of glycerol on the tips of the thumb and forefinger and run the suture length through them.

Rubin When ureteral catheters are to be inserted in a gastrointestinal surgical patient to aid identification of the ureters in pelvic dissection. < previous page page_17 next page > . the distal part of the ureteral catheters can be placed into the Foley catheter by using a no. The catheters are held in place with a 'twisty' of paper-covered or plastic-covered wire from a plastic food-storage bag. 8a).J.This version of Total HTML Converter is unregistered. 14 Medicut to perforate the neck of the catheter (Fig. the ureteral catheter is placed through the plastic cover into the lumen of the Foley catheter (Fig. The no. 8b). 8d) and allows the monitoring of adequate urinary output throughout the procedure. page_17 Page 1 of 1 < previous page page_17 next page > Page 17 Ureteral Catheter Drainage R. This enables both ureteral catheters to empty into the Foley drainage bag (Fig. After the needle is removed. The cover is removed and this process is repeated 180º away. 57 ureteral catheter then fits through the plastic cover surrounding the needle with ease.

This version of Total HTML Converter is unregistered. page_18 Page 1 of 1 < previous page page_18 next page > Page 18 Figure 8 < previous page page_18 next page > .

This version of Total HTML Converter is unregistered. The roll can be retained in place with the middle blade of a Goligher retractor. This is laid out at the root of the small bowel mesentery (the caecum may also be mobilized to improve retraction) and then partially unrolled over the small bowel. *Reproduced from McLoughlin.J. which you need to use to throw your knot. J. < previous page page_19 next page > . 9). Oxford. a simpler solution is to slip a length of any available suture material (e. It takes only a few seconds but can save a lot of aggravation. McLoughlin When working deep in the pelvis or abdomen you will occasionally complete a suture line with only a short length remaining.g. page_19 Page 1 of 1 < previous page page_19 next page > Page 19 Retraction for Pelvic Surgery A. This was shown to me by Gary Lieskovsky of Los Angeles. & O'Boyle. Masters An effective technique to prevent the small bowel tumbling into the pelvis during pelvic surgery is to use a caeser roll (a gauze roll 20 cm × 10 m). Making the Best of a Ahort Suture Length in a Deep. Blackwell Science. This in effect provides an extension to your suture. Vicryl) through the loop using a pair of right-angled forceps (Fig. Dark Hole* J. While you can struggle to tie the knot with what is usually a short loop of suture. The rigidity of the roll prevents loops of small bowel herniating down into the pelvis as often happens when conventional large swabs are used. allowing you to throw the knot and it can be pulled out before cutting the ends to length. P. (eds) (1995) Top Tips in Urology.

At the end of the < previous page page_20 next page > . the uterus is liable to bleed when this retracting stitch is cut out at the end of the operation. Walsh When performing rectal surgery in females it is often helpful to retract the uterus forwards by suturing the uterine fundus to the bottom end of the lower midline incision.This version of Total HTML Converter is unregistered. To prevent this potential source of postoperative bleeding. page_20 Page 1 of 1 < previous page page_20 next page > Page 20 Figure 9 Retracting the Uterus in Pelvic Surgery C.J. either as a single or double bite and then sewn to the abdominal wall. take a double bite of the uterine fundus with an absorbable suture and then tie this suture snugly before passing the needle through the lower end of the incision and tying the uterus to the skin. If a stitch is merely passed through the uterine fundus.

For the lower pelvis my preference is for the Brabbee's retractor (Fig. 10c) which comes in a narrow 5 cm and a narrower 4 cm blade. Retractors and Exposure in the Pelvis V. page_21 Page 1 of 1 < previous page page_21 next page > Page 21 operation you merely need to cut the suture at the level of the skin. In the mid-pelvis the best retractor of the mesorectum and rectum is a lipped St Mark's retractor (Fig.and eyestrain for the surgeon. a lighted Deaver retractor (Fig. Light attachments make the operation much easier. during the anterior dissection of the rectum. This tip was shown to me by Mr Thornton Holmes at Peterborough District Hospital. Fazio A variety of good pelvic retraction instruments are available. This may be aided by bladder or uterine suspension using a 0 chromic stitch and securing this to the inferior angle of the midline wound or the cross bar of a self-retaining retractor. In the upper pelvis.W. 10b). This leads to neck. It is broad to allow for bladder retraction. At different points in the operation (in the pelvis) different retractor types are used. 10a) is used initially. The same instruments are useful for the early part of the posterior pelvic dissection between the investing layer of fascia of the rectum and Waldeyer's fascia. These are used in preference to headlights as the movement and contortions of the pelvic surgeon make even the most secure headlights move. This retractor type allows entry into the very narrow male pelvis and further allows elevation as well as forward retraction of the mesorectum and < previous page page_21 next page > . This will release the uterus with an absorbable haemostatic stitch still in place in the fundus.This version of Total HTML Converter is unregistered.

MA. Inc. The key to pelvic deflection is traction and counter-traction and in this context the counter-traction is easily generated using a narrow straight-bladed lipped retractor such as a Britetrac retractor (Fig. NY. page_22 Page 1 of 1 < previous page page_22 next page > Page 22 rectum. ((ac) Courtesy of Electro Surgical Instrument Company.W. narrow width 55 and 40 mm. (b) St Mark's deep pelvic retractor: (i) long without lip (62 mm × 178 mm).. (c) Deep pelvic retractor (known at The Cleveland Clinic as 'Vic's toy').This version of Total HTML Converter is unregistered. standard blade width 65 and 50 mm. (iii) short without lip (56 mm × 127 mm). (ii) long with lip (62 mm × 178 mm). Figure 10 (a) Deaver retractor with handle (50 mm × 300 mm). (d) Britetrac retractor. Rochester.) < previous page page_22 next page > . (d) Courtesy of Johnson & Johnson Professional. Brabbee. Raynham. (c) originated by Dr G. 10d).

Mobilization of the left lateral segment by dividing the left triangular ligament is often used to improve exposure. page_23 Page 1 of 1 < previous page page_23 next page > Page 23 OESOPHAGOGASTRIC SURGERY Retraction of the Left Lobe of the Liver to Expose the Oesophagogastric Junction. Figure 11 < previous page page_23 next page > .This version of Total HTML Converter is unregistered. N. but may result in damage to the liver with tears to the liver substance with resultant bleeding and is unnecessary if the following tip is used. Jamieson The left lateral segment of the liver commonly lies across the front of the oesophagogastric junction and tends to get in the way during surgery to this region. V.

The anterior layer of sutures are then placed into the oseophagus as demonstrated in Fig. However. conventional handsewn anastomosis can be extremely difficult in this area. This lifts the left lobe out of the way and allows excellent exposure of the oesophagogastric junction. 12a. Paterson-Brown Although many surgeons prefer stapled anastomosis to a hand-sewn oesophagojejunostomy following radical total gastrectomy and lower distal oesophagectomy this is not always possible. The lip of the retractor is placed under the posterior edge of the left lateral segment of the liver and gentle retraction applied in an anterior and lateral direction.This version of Total HTML Converter is unregistered. Once all the anterior sutures have been placed in position they can < previous page page_24 next page > . stay sutures are placed as high in the oesophagus as possible and a soft right-angled clamp positioned gently above the stay sutures. particularly after a failed attempt using a circular stapler. The distal oesophagus is then transected in the appropriate place and the Roux-en-Y limb of jejunum fashioned and brought up into the upper abdomen. taking care to position the forceps close to the needle and the distal part of the suture so as not to damage the part of the suture which will be used for tying the knot. with the needles running from outside to inside. Following lower oesophagectomy and excision of the surrounding crura. page_24 Page 1 of 1 < previous page page_24 next page > Page 24 Leave the left triangular ligament intact and use a lipped St Mark's pelvic retractor instead of the usual smoothbladed upper abdominal retractors (Fig. 11). Hand-Sewn Anastomosis for High (Intrahiatal) Oesophagojejunostomy S. These are then clipped with artery forceps.

This version of Total HTML Converter is unregistered. page_25 Page 1 of 1 < previous page page_25 next page > Page 25 Figure 12 < previous page page_25 next page > .

in that the anterior layer of sutures helps to hold open the lumen of the proximal bowel. previously placed through the oesophagus. exposing the posterior wall. The abdominal part of the operation with mobilization of the distal oesophagus is carried out in the standard fashion. The posterior sutures are then placed between the posterior wall of the oesophagus and the Roux-en-Y limb of jejunum with the knots tied on the inside as shown in Fig. facilitating placement of the posterior sutures while at the same time making it easier to complete the anterior layer of anastomosis. The head is placed on the vein stripper and secured to the distal segment of cervical < previous page page_26 next page > . This technique is identical to that used for a high hepaticojejunostomy anastomosis and has the advantage over the standard technique of suturing the posterior wall before the anterior wall. These are passed from inside to outside through the anterior layer of the Roux-en-Y limb of jejunum and then tied. Transhiatal Oesophagectomy Using a Vein Stripper R. 13b). Molloy The technique described is an alternative method for dissecting or mobilizing the thoracic oesophagus during a transhiatal oesophagectomy. The vein stripper is taken out through the side of the cervical oesophagus via an enterotomy (Fig. G. The anterior layer of the anastomosis is now completed by picking up the needles from the anterior layer of sutures. 12b. The cervical oesophagus is also exposed in the traditional way and then a vein stripper is passed up the oesophageal lumen from distal to proximal. page_26 Page 1 of 1 < previous page page_26 next page > Page 26 be used to retract the opening of the distal oesophagus.This version of Total HTML Converter is unregistered.

This version of Total HTML Converter is unregistered.e. i.J. The rest of the oesophagectomy and subsequent anastomosis in the neck continues in the usual fashion. especially for patients addicted to 'sweets'. Gastric Bypass for Morbid Obesity H. page_27 Page 1 of 1 < previous page page_27 next page > Page 27 Figure 13 oesophagus after the cervical oesophagus has been transected (Fig. The Achilles' heel of the stapled gastric bypass has been < previous page page_27 next page > . the oesophagus is stripped rather than bluntly mobilized. 13c). Sugerman Gastric bypass has been shown to be an effective and safe operation for the treatment of morbid obesity (body mass index (BMI) ³ 35 kg m-2 (100 lbs) above ideal body weight) and more effective than a vertical banded gastroplasty. The vein stripper is then pulled distally.

page_28 Page 1 of 1 < previous page page_28 next page > Page 28 disruption of the staple line in up to 35% of patients. Figure 14 < previous page page_28 next page > .This version of Total HTML Converter is unregistered. US Surgical Corp. We have found that directly superimposing three applications of a PI 90® two-row horizontal stapler (Autosuture Company. Some surgeons have resorted to transecting the stomach to minimize this complication. which is associated with weight regain and a high frequency of marginal ulcer. Norwalk. however.. We have not had any leaks from the staple line using this technique which appears to be much simpler and safer than dividing the stomach. a disastrous complication in the severely obese in whom peritonitis may be very difficult to recognize. 14). If the three applications of staples are not exactly superimposed we have fired the PI 90® stapler a fourth time. CT. this increases the risk of anastomotic leak. and as effective. USA) is associated with a 1% frequency of staple-line disruption in over 800 patients (Fig.

Motson This technique is particularly useful when the gastrectomy extends high on the lesser curve. The stomach is then divided 1 cm at a time above the Peyr's clamp and a running suture is used to close the stomach sequentially (Fig. page_29 Page 1 of 1 < previous page page_29 next page > Page 29 A Partial Gastrectomy Without Clamps on the Gastric Remnant R. A double-armed suture is stitched through the lesser curve above the clamp and tied in the centre of the suture (Fig. The second suture is then run down the new lesser curve to invert the initial suture line and tied to the first suture (Fig. W. It is often helpful to give a scalpel to the assistant to make the successive 1-cm incisions along the clamp. One needle is then set aside. Following mobilization of the stomach. < previous page page_29 next page > . One continues until the amount remaining in the clamp is the correct width for either gastroenterostomy or anastomosis of the duodenum. as appropriate (Fig. 15b).This version of Total HTML Converter is unregistered. while following the suture oneself. 15c). 15d). from the greater to the lesser curve. a large Peyr's crushing clamp is placed diagonally across the stomach. close to the oesophagus. 15a).

page_30 Page 1 of 1 < previous page page_30 next page > Page 30 Figure 15 < previous page page_30 next page > .This version of Total HTML Converter is unregistered.

the right hepatic vein can be clearly visualized and encircled with a silastic sling using the right-angled dissector. upwards. < previous page page_31 next page > . The dissection is continued medially and upwards towards the right hepatic vein.J. Dissection and division of the right triangular ligament is normally undertaken from below. Garden Inadvertent caval injury or bleeding from short hepatic veins may complicate right-sided hepatic resection. The liver is mobilized from its peritoneal attachment using diathermy. page_31 Page 1 of 1 < previous page page_31 next page > Page 31 HEPATOBILIARY SURGERY Clearance of the Vena Cava During Right-Sided Hepatic Resection O. 16). The right lobe of the liver is easily and gently retracted by the assistant's hand. At this point. the short hepatic and caudate veins are divided between Ligaclips. Access to the abdomen for hepatic resection is normally achieved through a bilateral subcostal incision and by employing fixed costal margin retraction. The hepatocaval (Makuuchi's) ligament can be incised over a right-angled dissector which has been passed between the ligament and cava. Having identified the infrahepatic vena cava. Larger veins or a large accessory inferior right hepatic vein are best suture ligated with a 4/0 or 5/0 polypropylene (Prolene) suture. The described technique has proved invaluable in minimizing this risk before resection is undertaken.This version of Total HTML Converter is unregistered. A large gauze swab or pack should be placed between the hand and the liver to prevent slippage of the right lobe back into the operating field (Fig.

Figure 16 < previous page page_32 next page > . page_32 Page 1 of 1 < previous page page_32 next page > Page 32 Mobilization of the liver in this way ensures that during the lateral hilar and hepatic parenchymal dissection. the surgeon can avoid damage to the vena cava and minimize the risk of uncontrolled venous haemorrhage.This version of Total HTML Converter is unregistered.

17). Figure 17 < previous page page_33 next page > . J. Step 2: The second line of dissection is the gastrohepatic ligament that is opened superiorly until it comes to the same point of dissection as the left triangular ligament at the left hepatic vein.M. In 20% of the population there may be an accessory left hepatic artery traversing the superior portion of this ligament. Henderson The trick to mobilizing the left lobe of the liver and isolating the retrohepatic vena cava is based on three lines of dissection (Fig. page_33 Page 1 of 1 < previous page page_33 next page > Page 33 Mobilization of Left Lobe of Liver and Isolation of Suprahepatic Inferior Vena Cava. Step 1: The first line of dissection is the left triangular ligament which needs to be dissected medially to the left hepatic vein.This version of Total HTML Converter is unregistered.

This gives a safe plane into the back of the suprahepatic vena cava that will then very easily be joined to the mobilized right lobe of the liver if total hepatectomy is being performed or there is a need to cross clamp the suprahepatic vena cava.P. Once these three lines of dissection have been made. As the superior portion is approached this is then brought forward to join the above described two points. the overlying peritoneum needs to be incised and divided along the whole length of the retrohepatic vena cava. McEntee A significant proportion of patients with liver trauma can be managed non-operatively. Commencing at the infrahepatic portion of the inferior vena cava. The simplest and best way to control haemorrhage from deep lacerations not in direct communication with the peritoneal cavity (i. no attempt should be made to open < previous page page_34 next page > . surgery is required but significant problems are created in the belief that suturing of 'bleeders' deep within the parenchyma of a fractured liver is required for haemastasis. Many units of blood may be lost in the process and because of difficult access. inferior vena cava (IVC) or hilar lesions) is to pack the liver properly. page_34 Page 1 of 1 < previous page page_34 next page > Page 34 Step 3: The third line of dissection is the left side of the retrohepatic inferior vena cava. If the bleeding is seen to be coming from deep within the lacerated liver. Packing the Traumatized Liver G.This version of Total HTML Converter is unregistered. suture ligation is rarely effective.e. For those who continue to bleed. the retrocaval plane can then be developed by retraction to the left of the posterior leaf of peritoneum overlying the vena cava.

first above the liver < previous page page_35 next page > . page_35 Page 1 of 1 < previous page page_35 next page > Page 35 up the lacerations. We recommend simply packing the liver as follows. anteriorly and finally inferior to obtain complete and adequate compression of the right lobe. The left lobe is similarly compressed with packing around its entire circumference. V. Packs may be gently removed after 48 h. superiorly. The left lateral ligament is divided with scissors and diathermy from the splenic tip to the IVC.5 cm) is placed over the traumatized surface which helps to keep the opposing lacerated surfaces from pressing together and facilitates retraction. Following the Pringle manoeuvre the traumatized liver is mobilized completely from its peritoneal attachments. Large gauze swabs (45 cm × 45 cm) are then packed behind the right lobe along the entire lateral margin of the IVC and packing continued laterally. If necessary the 'packed' patient can then be safely transferred to an appropriate surgical unit.This version of Total HTML Converter is unregistered. No attempt is made to mobilize the liver. Packing of the Liver for Liver Trauma The Cambridge Technique N. A medium gauze swab (22. The right lateral ligament is divided and mobilized completely on the surface of the right lobe up to the level of the suprahepatic cava and posteriorly to the retrohepatic IVC. Repacking may be required but this is unusual.5 cm × 22. Attempts to mobilize the liver to resect or suture the injured segments can exacerbate the situation. Jamieson Substantial liver trauma can result in heavy bleeding which is difficult to control. Broad gynaecological rolls (20-cm wide and 10-m long) are carefully packed in a layered fashion.

Most cases of liver trauma can be safely managed in this fashion which is used routinely in our unit. The patient is returned to the operating theatre after an interval of 48 h and the abdomen reopened. broad-spectrum antibiotics commenced and the patient transferred. to the intensive care unit. This reapposes the edges of the lacerations in the liver substance and arrests the haemorrhage. and then more layers are packed firmly against the undersurface of the liver between it and the stomach and bowel. The abdomen is then closed in the usual fashion. intubated and ventilated. the key being to carefully pack the layers of gynae roll around the liver so that the edges of the liver lacerations are gently but firmly apposed and to wait for a full 48-h period before re-exploration and removal of these packs. page_36 Page 1 of 1 < previous page page_36 next page > Page 36 between it and the diaphragm. < previous page page_36 next page > . The layers of gynae roll are carefully removed.This version of Total HTML Converter is unregistered. As many as 5 or 6 gynae rolls may be needed to achieve firm reapposition of the liver substance. pushing the liver up against the diaphragm and the previously placed layer of gynae roll. soaking any adherent areas with saline so that they can be peeled away without any trauma to the liver. There will usually be excellent haemostasis at this stage and the abdomen is then simply closed once again. Satisfactory haemostasis is usually readily achieved and further exploration and repacking is seldom required.

This version of Total HTML Converter is unregistered. McEntee Anastomosing a dilated bile duct to a Roux loop or the duodenum is rarely a problem. accurate positioning of sutures can be difficult when dealing with a normal or small calibre duct. page_37 Page 1 of 1 < previous page page_37 next page > Page 37 A Safe Technique for Anastomosing a Normal Calibre Bile Duct G. However.P. I use a technique based on Figure 18 < previous page page_37 next page > .

18a). The sutures are simply held in rubber-shod haemostats with no attempt to approximate the bile duct and bowel wall until all sutures have been accurately and evenly placed (Fig. three to four sutures are placed through the anterior wall of the bile duct and held in rubber-shod haemostats. page_38 Page 1 of 1 < previous page page_38 next page > Page 38 one initially popularized by Professor Blumgart and his group to facilitate such anastomoses. The needles of the sutures placed initially through the anterior wall of the bile duct are now mounted and the suture passed through the anterior wall of the bowel. Using 5/0 absorbable suture material (PDS) on a 20-mm needle. 18c). completing the anastomosis. lifting the anterior wall of the bile duct and improving access and vision for the posterior wall. 18b). 18d). The lateral sutures are held in rubber-shod haemostats to provide retraction and the other sutures cut with the knots inside the anastomosis (Fig. and the sutures tied. < previous page page_38 next page > . The posteriorly placed sutures are then all held firmly and the bowel wall 'parachuted' along the sutures to approximate it to the bile duct. They are then tied down sequentially. all sutures being placed evenly spaced and left loose to be tied when all of the sutures have been placed under optimal vision with the whole of the anterior wall anastomosis still open (Fig.This version of Total HTML Converter is unregistered. This technique has the dual advantage of facilitating exposure of the posterior wall of a small duct while preventing inadvertent 'catching' of the posterior wall during insertion of the anterior sutures. with the exception of the medial and lateral corner sutures which are placed so that the knots will lie on the outside of the bile duct and bowel. leaving the needles attached (Fig. The sutures are retracted in an upward direction. The posterior wall sutures are now placed through the bile duct and the bowel wall in such a fashion that the knots will lie on the inside of the anastomosis.

Friend The technique involves construction of a Roux loop in the usual way. The malleable probe. a small incision is make in the Roux loop to enable a malleable probe to be passed into the jejunum (Fig. The end of this is closed with staples and oversewn with PDS sutures. At a point some 810 cm proximal to this. page_39 Page 1 of 1 < previous page page_39 next page > Page 39 Technique for the Anastomosis of the Common Bile Duct. to a Roux Loop of Jejunum P.This version of Total HTML Converter is unregistered. having been adapted to form a gentle curve. 19).J. is then passed from Figure 19 < previous page page_39 next page > . The posterior wall of the choledochojejunostomy is then constructed using interrupted 5/0 PDS sutures with the knots on the outside. A small incision is made in the Roux loop at this point. The common bile duct is anastomosed to the antimesenteric border of the Roux loop close to its end. Particularly When This is of Narrow Calibre.

The anterior wall of the anastomosis is then constructed with interrupted 5/0 PDS. Walsh Access to the gall bladder at the time of an open cholecystectomy may be improved by putting your hand up over the dome of the liver between it and the right hemidiaphragm. particularly in children. air is let in and the liver and thus the gall bladder descends. By so doing the 'vacuum' between the right hemidiaphragm and the liver is broken. page_40 Page 1 of 1 < previous page page_40 next page > Page 40 within the jejunum through the partially constructed anastomosis and into the common bile duct.This version of Total HTML Converter is unregistered.J. This technique is beneficial where the anastomosis involves a common bile duct of narrow calibre. The probe is then withdrawn from the jejunum and the small incision proximally in the Roux loop is closed with PDS sutures. I have found this technique to be very helpful particularly in paediatric liver transplantation but also in other cases of choledochojejunostomy. It enables the anterior wall of the anastomosis to be constructed without risk of inadvertently picking up mucosa from the posterior wall of the anastomosis. Improved Access to the Gall Bladder at Open Cholecystectomy C. < previous page page_40 next page > . This simple manoeuvre can often improve exposure to the gall bladder and the common duct when exposed through a Kocher incision.

Place a second ligature around the cyst duct and slide it towards the common duct but do not tie it. After a successful cholangiogram simply slide off the quill and use the ligature to tie off the cystic duct.D. Take the plastic quill which has been used for drawing up the cholangiogram contrast material. Open the cystic duct and place both ends of the untied ligature through the quill (Fig. snug down the plastic quill on the cystic duct by pushing down on the quill at the same time as pulling up on both ends of the ligature. tie the gall bladder side of the cystic duct in the usual way. 20b). Instead.This version of Total HTML Converter is unregistered. 20c). page_41 Page 1 of 1 < previous page page_41 next page > Page 41 A Snugger for Peroperative Cholangiograms During Open Cholecystectomy A. With your assistant holding the catheter in place. Place the cholangiography catheter in the cystic duct in the usual way. Moreover the ligature needs to be released afterwards to remove the catheter and a new ligature used to tie off the cystic duct. Make both ends of equal length. Wells Securing a cholangiography catheter in the cystic duct with a ligature can sometimes be a bit of a fiddle. Secure it in place by clamping the top of the quill and the ligature with an artery forceps (Fig. < previous page page_41 next page > .

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Excision of the Gall Bladder. A. Masters During either open or laparoscopic excision of the gall bladder, the plane between the gall bladder wall and its hepatic bed may be difficult to identify depending upon the degree of previous inflammation. Injection of 510 ml of saline just beneath the peritoneal covering of the gall bladder will develop this plane and facilitate bloodless excision.

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PANCREATIC SURGERY

Safe Approach to Superior Mesenteric Vein and Neck of Pancreas W. Silen The key to exposure of the superior mesenteric vein and inferior border of the neck of the pancreas is the gastrocolic vein, a remarkably constant large tributary entering the vein on its anterior surface. The superior pancreaticoduodenal vein also usually joins the portal vein near its anterior surface at the superior portion of the pancreatic neck. In addition, a long and tortuous anomalous hepatic artery arising from the superior mesenteric artery sometimes passes behind the pancreas, or actually lies within the pancreas itself. To avoid these hazards, and to visually expose this dangerous area, the hepatic flexure and lateral half of the transverse colon should be mobilized completely. The confluence of the right greater gastroepiploic and middle colic veins to form the gastrocolic trunk is then easily and clearly visualized at the base of the transverse mesocolon, so that it can be dissected to its entrance into the superior mesenteric vein and ligated securely. This manoeuvre will expose a large expanse of the superior mesenteric vein and inferior surface of the pancreatic neck. With a small vein retractor, the latter is retracted superiorly, and the anterior surface of the portal vein is gently dissected free of the pancreas under direct vision until the vein emerges superiorly from behind the pancreas. Such visualization can easily demonstrate and protect superior

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Figure 21 Arterial supply and venous drainage of the pancreas. pancreaticoduodenal venous tributaries or anomalous hepatic arteries (Fig. 21). Only after these manoeuvres, and not before, should a slender finger be inserted into the cramped space between these major veins and the pancreas, as shown in most surgical atlases.

Exposure of the Pancreas J.M. Henderson Lessons learned in the exposure of the pancreas for distal splenorenal shunt, when there is portal hypertension, are also valuable for exposure of the pancreas at other times! (Fig. 22). Step1. In the initial approach through the lesser sac, exposing the neck and head of the pancreas requires

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sweeping the mesocolon down and away until the operator comes to the anterior surface of the pancreas. The 'splenocolic ligament' so defined can then be divided with the splenic flexure being displaced inferiorly. page_47 Page 1 of 1 < previous page page_47 next page > Page 47 Figure 22 separating the adhesions from the back of the antrum of the stomach and the pylorus where this tends to fuse to the transverse mesocolon. The plane now opened and clearly defined between the split mesocolon below and the spleen < previous page page_47 next page > . The danger of not separating these planes appropriately is 'drifting' into the mesocolon and middle colic vessels. To gain optimal access to the tail of the pancreas. Step 2. The secret to this is dissection close to the posterior wall of the stomach. the splenic flexure of the colon should be taken down and the plane on the left lateral side of this developed to join dissection in the lesser sac.This version of Total HTML Converter is unregistered.

This is particularly important. The same is done to the gastroduodenal artery and the proximal side is tied. If the lesion is deemed unresectable. 23). Four Tips that Facilitate Pancreaticoduodenal Resection A. and easy when there is splenomegaly displacing the tail of the pancreas caudally and medially. The manoeuvre greatly facilitates exposure. utilized since 1980. clipped and tacked to the drape. early division of the bile duct and gastroduodenal artery allows the interface between portal vein and neck of pancreas to be visualized and entered. Cooperman and L. < previous page page_48 next page > . page_48 Page 1 of 1 < previous page page_48 next page > Page 48 above. shortens and facilitates the operation (Fig. To perform this manoeuvre the distal bile duct is first tied and a stay suture is placed on the proximal duct and secured to the drapes with a haemostat. the proximal duct may be used for bypass. leads to the posterior surface of the tail of the pancreas. This secures and provides traction to the liver. This manoeuvre. Gellman Tip One Assessing Resectability of Head of Pancreas Lesions In assessing resectability of head of pancreas lesions.This version of Total HTML Converter is unregistered.

page_49 Page 1 of 1 < previous page page_49 next page > Page 49 Figure 23 Tip Two Pancreaticoduodenal Resection Division of the Difficult Pancreas The commonly caught way of tunnelling between pancreas and mesenceric portal vein is to pass a finger blindly and bluntly from above (liver side of vein) rather than from below (mesenteric side). This is done as follows (Fig. 24): 1 Four stay sutures are placed in the upper and lower borders to secure the transverse pancreatic vessels.This version of Total HTML Converter is unregistered. 3 Tease the vein from the pancreas under direct vision using a fine scissors or tonsil clamp. 4 If difficulty is encountered it can be visualized directly and teased away from the vein. < previous page page_49 next page > . This is done until a difficult area is encountered. The safer way is under direct vision from below upwards. 2 Follow the middle colic vein to the superior mesenceric vein. If there is difficulty in dissection the pancreas is divided to that point and the same process continued.

the anterior capsule and pancreatic duct are incised for 2 cm using cautery (Fig. < previous page page_50 next page > . The following modification has been helpful in keeping the incidence of postoperative fistulae clown to 6% or less. This doubles the diameter of the pancreatic duct. Starting at the free edge of the resected pancreas. The pancreaticojejunal anastomosis is the source of morbidity following pancreaticoduodenal resection. The jejunum is then anastomosed in a side-to-side fashion using two layers of interrupted Prolene sutures. 25). page_50 Page 1 of 1 < previous page page_50 next page > Page 50 Figure 24 Tip Three The Pancreaticojejunal Anastomosis.This version of Total HTML Converter is unregistered. An inner layer of duct to mucosa sutures is surrounded by an outer layer of serosubmucosa to capsule sutures.

This version of Total HTML Converter is unregistered. page_51 Page 1 of 1 < previous page page_51 next page > Page 51 Figure 25 < previous page page_51 next page > .

Diversion of bile avoids bile reflux and this may help Figure 26 < previous page page_52 next page > . 26). This alleviates tension from the other anastomoses. 1 The hepaticojejunostomy is done first with a singlelayer anastomosis of interrupted Vicryl. page_52 Page 1 of 1 < previous page page_52 next page > Page 52 Tip Four Reconstruction After Pancreaticoduodenal Resection The following method used in the last 150 resections has resulted in minimal delay in gastric emptying (Fig. 2 A side-to-side duct-to-mucosal anastomoses is made with interrupted Prolene sutures in two layers.This version of Total HTML Converter is unregistered. 3 Resection of the pylorus alleviates gastric stasis.

4 The jejunojejunostomy is created last in an end-to-side fashion. The jejunum is therefore divided 6080 cm from its previously divided proximal end. the jejunum has been divided just beyond the duodenojejunal flexure. The pancreatic remnant now remains to be sutured to the jejunum.This version of Total HTML Converter is unregistered. A two-layer anastomosis is now performed in which the outer layer of sutures is a capsuleto-serosa layer of which the posterior layer is inserted first. Kingsnorth Following standard Whipples resection or pylorus preserving resection. The distal loop is brought up through the mesocolon to the left of the middle colic artery to lie side-to-end to the divided pancreatic stump. The bile duct is then sutured end-to-side to this length of jejunum 510 cm distal the first anastomosis. A duct-to-mucosa layer is now performed in two stages beginning with the posterior layer utilizing < previous page page_53 next page > . This is achieved to an isolated Roux loop. For convenience this Roux loop is fashioned and anastomosed as a pancreaticojejunostomy before any other reconstructive anastomosis because it lies posterior to all the other structures in the upper abdomen. Pancreaticojejunostomy Following Whipples Pancreaticoduodenectomy A. page_53 Page 1 of 1 < previous page page_53 next page > Page 53 slow gastric emptying which can be rapid after pyloric resection. The author's technique is to bring this free end up through the mesocolon to the right of the middle colic vessels and anastomose it end-to-end to the stomach remnant or the duodenal stump.

27a). Approximately 610 sutures will achieve duct-to-mucosa anastomosis and no stents are used. The two-layer anastomosis is completed with an anterior capsule-to-serosa suture and the completed Figure 27 < previous page page_54 next page > . page_54 Page 1 of 1 < previous page page_54 next page > Page 54 absorbable sutures (Fig.This version of Total HTML Converter is unregistered.

gentle manual dissection with a blunt suction device or loose swabs allows necrotic material to be cleared. general surgeons with an interest in pancreaticobiliary surgery may be involved in their management. silastic drains are placed into the residual cavity to allow postoperative closed irrigation. Access is then gained to the lesser sac by dividing the gastrocolic omentum or by entering the transverse mesocolon. 27b. Pus and fluid are aspirated. and fixed costal margin retraction employed. Largebore. Digital necrosectomy may be associated with intraoperative bleeding from damage to adjacent vessels and we therefore employ hydrostatic dissection. If access to the subhepatic space can be achieved safely. Garden Patients with infected pancreatic necrosis complicating acute pancreatitis require necrosectomy. Superficial fluid collections and pancreatic ascites are drained and samples sent for microbiological analysis. A serious complication of necrosectomy is haemorrhage and this article describes the strategy evolved in Edinburgh by Professor Sir David Carter to minimize the risk of bleeding. Sterile saline is injected at moderate pressure into the lesser sac cavity using a catheter-tipped syringe. This procedure dislodges necrotic tissue which can then be removed. As the tissue planes become clearer. soft. Siriwardena and O. A Strategy for Pancreatic Necrosectomy A. Whilst there is a trend for these patients to be managed in specialist units. A transverse upper abdominal incision is used. page_55 Page 1 of 1 < previous page page_55 next page > Page 55 configuration of the reconstruction after the Whippies resection is shown in Fig. < previous page page_55 next page > . cholecystectomy with intraoperative cholangiography can be performed.J.This version of Total HTML Converter is unregistered.

This version of Total HTML Converter is unregistered. and this is more difficult to deal with than a lesion in the jejunum or ileum. 28. these operations are somewhat complex. Although it has been suggested that large duodenal defects not involving the ampulla of Vater can be closed with the serosal surface of a loop of jejunum or a full-thickness pedicle patch graft of jejunum. adequate excision of a benign lesion of the duodenum without a pedicle requires a major resection of the duodenal wall. a carcinoma of the ascending colon may locally invade the duodenum and require generous resection of the duodenal wall. since local resection is appropriate. page_57 Page 1 of 1 < previous page page_57 next page > Page 57 SURGERY OF THE DUODENUM AND THE SMALL INTESTINE Reconstruction Technique After Resection of Duodenal Wall W. Reconstruction of the duodenal defect requires a generous incision across the pylorus into the wall of the stomach to provide tissue for the reconstruction. Also. and the duodenal defect is actually closed with gastric walla technique similar to that of Finney pyloroplasty. Lawrence Jr A benign small bowel tumour is usually resected easily if the lesion is on a pedicle. Occasionally. A simple method of reconstruction that we have employed after extensive duodenal resection is shown in Fig. < previous page page_57 next page > .

page_58 Page 1 of 1 < previous page page_58 next page > Page 58 Figure 28 < previous page page_58 next page > .This version of Total HTML Converter is unregistered.

. even individual fibres can be divided by the ampoule file without the risk of perforating the mucosa. rather than using a scalpel. Denis Browne or artery forceps to split the hypertrophic muscle. Motson After delivering the pyloric tumour through the abdominal wound. W. try using a sterile ampoule file which slowly saws through the muscle fibres (Fig. 29). As one approaches the mucosa. page_59 Page 1 of 1 < previous page page_59 next page > Page 59 How to Avoid Mucosal Perforation When Performing a Ramstedt's Pyloromyotomy R. Figure 29 < previous page page_59 next page > .This version of Total HTML Converter is unregistered.

Figure 30 < previous page page_60 next page > . Molloy When closing a perforated duodenal ulcer one needs to ensure that the suture does not pick up the posterior duodenal wall whilst closing the anterior perforation. 30). To help prevent this complication. G.This version of Total HTML Converter is unregistered. R. place a Lahy forceps in the actual perforation in order to lift the anterior wall forward and prevent the stitch from catching the posterior wall (Fig. page_60 Page 1 of 1 < previous page page_60 next page > Page 60 Technique to Avoid the Posterior Wall When Oversewing a Perforated Duodenal Ulcer.

C. 31d).This version of Total HTML Converter is unregistered. In our experience. Place another purse-string using 3/0 Vicryl. Put 23 ml of water in the balloon so that you can feel it through the bowel wall and manipulate it down the bowel.) < previous page page_61 next page > . reliable and economical feeding jejunostomy to be made using an 18 French guage (FG) latex Foley catheter. 31c). Cut off the end of the catheter. (See How to sew in a drain. Pass alternate stitches through the gut and peritoneum (Fig. Pull up the two catgut purse-strings and tie them. push it through the mucosa and into the bowel. This technique allows a quick. make sure it passes distally. Puntis Enteral feeding after major surgery is becoming an important issue. Place two concentric 3/0 chromic catgut purse-string sutures in a proximal jejunal loop (do not use Vicryl for this as it may then be difficult to remove the catheter when feeding is no longer needed) (Fig. Make sure there is not a knuckle of catheter caught between stitches.A. 11. Complete the procedure by fixing the catheter to the skin with a black silk cross garter stitch. 31b). p. this helps to prevent the catheter becoming blocked (Fig. Make a short skin incision about 23 cm from the wound edge. Pass the catheter through using two Roberts clamps (Fig. Open the bowel in the centre of the purse-string using diathermy to the serosa and then grasping the end of the catheter with a FraserKelly clamp. Pull gently on both ends of this stitch until the bowel is snug against the peritoneum. 31a). page_61 Page 1 of 1 < previous page page_61 next page > Page 61 How to Make a Feeding Jejunostomy M.

This version of Total HTML Converter is unregistered. page_62 Page 1 of 1 < previous page page_62 next page > Page 62 Figure 31 < previous page page_62 next page > .

curlicue vessels or point of obstruction.W. Fazio The proximal extent of the disease is first assessed by noting the presence of fat wrapping.This version of Total HTML Converter is unregistered. Non-diseased bowel proximal to the affected segment may be dilated but there is no mesenteric thickening. Palpation between finger and thumb at the mesenteric edge of the bowel allows one to determine the proximal limit of resection. One is able to palpate a step between the edge of the bowel wall and the mesentery. A segment with Figure 32 Cross-sections through the distal ileum and its mesentery. At this point a definite step is palpable between the mesentery and the mesenteric bowel margin. < previous page page_63 next page > . The best guide to the proximal extent of disease is palpation along the enteric mesenteric margin. page_63 Page 1 of 1 < previous page page_63 next page > Page 63 Choosing Levels of Resection in Small Bowel Crohn's Disease V.

page_64 Page 1 of 1 < previous page page_64 next page > Page 64 Figure 33 Planned site of mesenteric division is outlined as are the proximal and distal lines of resection. < previous page page_64 next page > . while small aphthous ulcers in otherwise soft pliable bowel will not.This version of Total HTML Converter is unregistered. 33) of macroscopically normal bowel proximal and distal to the diseased segment is adequate. Para-ileal lymph node enlargement in the mesentery corresponds well to the limits of ulceration of the mucosa. Recurrence rates do not increase when there is microscopic disease at the resection margins. significant mucosal disease will be associated with mesenteric thickening and there is no palpable step between the edge of the bowel and the mesentery (Fig. Deep longitudinal ulcers at the cut edge will require further resection. 32). Having chosen the proposed site of transection it is important to inspect the bowel when it is divided. A 2-cm margin (Fig.

The preferred technique is to use a sequence of overlapping Kocher clamps and suture ligate the mesentery (Fig. Score the peritoneum along the intended line of mesenteric division using electrocautery and therefore produce a 'dotted line' to guide subsequent dissection. Fazio When resecting small bowel. This in turn may lead to a more extensive small bowel resection than originally planned. up to. 34). ensuring that these overlap the tips of the < previous page page_65 next page > . page_65 Page 1 of 1 < previous page page_65 next page > Page 65 Method of Dividing Small Bowel Mesentery in Crohn's Disease V. place two haemostats across the mesenteric vessels. By scoring the peritoneum in this way the mesentery will spring open and thin down somewhat. Dissection begins at the mesenteric margin of the small bowel.W. First identify the proximal and distal point of resection by scoring the mesentery with electrocautery. the standard technique of dividing the mesentery is to identify the avascular space between vascular arcades. A small window is made with electrocautery and the ileal mesentery clamped between Kocher clamps.This version of Total HTML Converter is unregistered. but not past. divide between them and then ligate the vessels. When the small bowel and its mesentery are affected by Crohn's disease this technique is hazardous. The marked thickening of the mesentery due to lymphadenopathy and fat wrapping often makes it impossible to identify the avascular windows even with the help of transillumination. their tips. The mesentery is divided between the clamps. The traditional method of dividing the small bowel mesentery may lead to damage to the mesenteric vessels and the development of a spreading mesenteric haematoma. A second pair of clamps is placed on the next segment of mesentery to be divided.

Stitch enters at the tip of one Kocher clamp (A) and emerges at the tip of the overlapping one (B). page_66 Page 1 of 1 < previous page page_66 next page > Page 66 Figure 34 Technique for division of small bowel mesentery using overlapping Kocher clamps and suture ligation. By overlapping the Kocher clamps. previous pair. < previous page page_66 next page > . The vessels in the mesentery are controlled by suture ligation with heavy absorbable suture material. The mesentery is divided in a likewise fashion to the preselected site at the other mesenteric border of the bowel.This version of Total HTML Converter is unregistered. no segment of small bowel mesentery escapes suture ligation.

< previous page page_67 next page > . Simply lift the loops of intestine one after the other and let the weight of the ball-bearing carry it towards the duodenum. easy and reliable way to detect small bowel strictures.This version of Total HTML Converter is unregistered. Drop this into the small bowel at the site of the initial enterotomy made to perform either a resection or stricturoplasty. I suggest you do not use a Foley catheter. and the procedure repeated until the DJ flexure has been reached. page_67 Page 1 of 1 < previous page page_67 next page > Page 67 Ball-Bearing to Detect Small Bowel Strictures R. This is an extremely quick. Instead use a sterile metal ball-bearing with a 2-cm diameter.5-cm ball-bearing for children. First let it run in a retrograde direction towards the DJ flexure. Most commonly this is done by placing 5 ml in the balloon of a Foley catheter and then trawling this through the small bowel to detect narrowings. Afterwards simply roll the ball-bearing back in an orthograde direction towards the ileocaecal valve. Miller At the time of bowel resection or stricturoplasty for Crohn's disease. You might need a 1. the stricture can be dealt with. This can be cumbersome and time consuming. it is important to determine if there are any further small bowel strictures which need to be dealt with. If there are any significant strictures the ball-bearing will be held up.

The rectus muscle may slip laterally during this manoeuvre resulting in suboptimal construction of the ileostomy aperture. A no. Barry and J. Kocher clamps are placed on the subcutaneous fat and fascia of the midline wound opposite the stoma site and retracted medially. it is our practice to fashion the stoma site before proceeding with a midline incision (Fig. An Allis forceps is used to gently elevate the skin overlying the centre point of the previously marked stoma site. page_69 Page 1 of 1 < previous page page_69 next page > Page 69 STOMA SURGERY Siting an Ileostomy K. This technique ensures that the stoma is correctly sited through the rectus muscle. A small saline-soaked swab is then placed in the stoma cavity before proceeding with a midline incision. without distortion of the layers of the abdominal wall. Dissection proceeds in the standard fashion with excision of subcutaneous fat. Hyland An end ileostomy or loop ileostomy (as required) is usually constructed after resection of benign or malignant colorectal disease.This version of Total HTML Converter is unregistered. 10 blade is positioned directly at the tip of the Allis forceps and a disc of skin excised. 35). This should allow for insertion of two fingers into the abdominal cavity (for the surgeon who uses size 7 or 8 gloves). Whenever it is decided preoperatively that an ileostomy is necessary. < previous page page_69 next page > . A cruciate incision is make in the anterior rectus sheath and an artery forceps inserted in a perpendicular fashion to split the rectus peritoneum.

< previous page page_70 next page > . page_70 Page 1 of 1 < previous page page_70 next page > Page 70 Figure 35 The abdominal cavity is opened after the ileostomy site is fashioned.This version of Total HTML Converter is unregistered.

K. 6 and 9 o'clock and place intervening sutures as necessary. The problem with such an approach is that the small bowel mesentery is at 12 o'clock so there the second serosal bite must be omitted.. In addition. C. C. C. 36a) before the suturing is completed in the usual way with the addition of intervening stitches as necessary (which omit the incorporation of the serosa). Inferiorly at 6 o'clock. Myers and R. Phillips There are no published guidelines to ideal ileostomy length and configuration. when the sutures are tied the superior margin becomes shorter than the others and the ileostomy spout faces upwards.S. Hall.S. 3. Mucosal followed by serosal bites some distance proximal on the bowel wall are taken before stitching the skin. Inevitably. the effluent should be directed forward and slightly downwards.K. Sutures are placed at 10 and 2 o'clock on either side of the small bowel mesentery.This version of Total HTML Converter is unregistered. the serosal stitch is placed 4 cm proximally (Fig. & Phillips. (1995) The 554 ileostomy.5-cm superior margin (Fig. Surgical technique. 1385. R. < previous page page_71 next page > . In these positions it is possible to place a serosal stitch 5 cm proximally before taking a subcuticular bite of skin. British Journal of Surgery 82 (10). Stomatherapies request a spout long enough to avoid skin excoriation but not so long in women as to be incompatible with their feminine body image. It is usual when constructing an ileostomy to place sutures at 90° to each other at 12. C. Myers. *Reproduced from Hall. The resulting ileostomy has a 2-cm inferior margin and a 2. page_71 Page 1 of 1 < previous page page_71 next page > Page 71 The 554 Ileostomy*. 36b).

page_72 Page 1 of 1 < previous page page_72 next page > Page 72 Figure 36 Discussion.This version of Total HTML Converter is unregistered. < previous page page_72 next page > . It is not necessary when using this technique to use aids to stoma eversion. Care must be taken when placing serosal stitches in the proximal bowel wall to avoid full thickness penetration as this can lead to fistula formation particularly in Crohn's disease. This is a simple technique that produces a good result every time.

In this way. this acts as a collar and holds the proximal limb in an everted manner. Provided the enterotomy is small. of Allis forceps so that the proximal limb of the loop ileostomy can be fully everted. a rod is hardly ever necessary. It is sometimes used as the sole treatment for patients with severe perianal and colonic Crohn's disease. Provided the patient is not grossly obese. The next tip is to place three sutures in the distal limb whilst it is easily identifiable. Loop ileostomy is also an invaluable method of faecal diversion for restorative proctocolectomy. Furthermore.This version of Total HTML Converter is unregistered. I have found that the use of a rod to prevent retraction is hardly ever necessary. Keighley Loop ileostomy is a common method of faecal diversion for low colorectal anastomosis in patients who have had a good mechanical bowel preparation. The distal component almost becomes invisible. If the enterotomy is small.B.R. Loop ileostomies are usually badly constructed. the antimesenteric border of the proximal limb of the loop is grasped with a pair. We use clear PDS sutures from the subcuticular portion of the cut edge of the skin < previous page page_73 next page > . avoidance of a rod makes stoma management much easier in the early postoperative period. page_73 Page 1 of 1 < previous page page_73 next page > Page 73 Loop Ileostomy M. The 'trick' is to make only a very small enterotomy in the distal loop that is delivered on to the abdominal wall. It affords the safest method of faecal diversion since a loop ileostomy does not compromise the blood supply of the colon in patients having low colorectal anastomoses in the pelvis. Many surgeons place a rod underneath the loop ileostomy which makes subsequent stoma management extremely difficult. or two pairs.

The bulky and foreshortened ileal mesentery may make it difficult to deliver the terminal ileum through the trephine in the anterior abdominal wall. Staple off the end of the ileum and invert the staple line with a running absorbable suture. 37). Attempts to manipulate it through may lead to damage to mesenteric vessels with bleeding and devascularization. Identify a point on the ileum proximal to the staple line which is suitable for formation of a loop stoma. Now mark the downstream and upstream sides by placing sutures of different colours. page_74 Page 1 of 1 < previous page page_74 next page > Page 74 to the seromuscular layer of the bowel.W. The Loop End Ileostomy V. Similarly. A 'natural apex' of this loop will become apparent based on the anatomy of the mesenteric arcades.This version of Total HTML Converter is unregistered. The message is: make the enterotomy in the distal limb small then the bowel can be folded back on itself to sit comfortably without a rod. To do this. picking up the serosa of the emerging bowel so that these sutures help to stabilize the loop ileostomy against the abdominal wall. for example catgut and Vicryl. in the antimesenteric border of the bowel I cm either side of the tape. bend the distal ileum over on itself (as one might do in forming a J-pouch). This will facilitate opening the correct part of < previous page page_74 next page > . Fazio Fashioning an end ileostomy in the obese patient may be difficult. Make a small hole in the mesentery at the mesenteric edge of the bowel with a haemostat and pass a linen tape around the small bowel at this point. sutures are placed from the skin edge to the proximal everted component. In these obese patients it is often easier to perform a loop end ileostomy (Fig.

Because you placed sutures of different colours on either side of the tape there is now no doubt in your mind which side of the loop is to be incised to fashion the ileostomy in the correct orientation. In this way the haemostat can be passed through the mesenteric window by pulling on the tape on the other side of the bowel. This ensures that the haemostat passes through the previously made mesenteric window.This version of Total HTML Converter is unregistered. page_75 Page 1 of 1 < previous page page_75 next page > Page 75 the loop when the stoma is ultimately being fashioned. Place a clamp through the abdominal wall trephine from outside to in and pick up the linen tape looped around the distal ileum. In these obese patients it is wise to use a bridge under the loop ileostomy. < previous page page_75 next page > . Our preference is to use one blue (Vicryl) stitch upstream and one brown (catgut) stitch downstream on the loop and in this way it is the same every time and one just remembers that 'brown goes down'. The bowel is opened after the main abdominal wound has been closed and dressed. The ileostomy bridge can now be picked up in the jaws of the haemostat and delivered through the same mesenteric window and secured. To do this. Gently tease the ileal loop through the abdominal wall making sure it does not twist. grip the tape with a straight haemostat close to one side of the bowel and then cut the tape on the other side of the haemostat.

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but by a series of strong stay-sutures (usually eight) placed around its circumference. Tension on the anterior abdominal wall is provided by the assistant's hand or by using retractors. not by surgical instruments. 38). Thomson The closure of a temporary stoma (ileostomy or colostomy) demands careful dissection in the plane between the bowel and the various layers of the anterior abdominal wall. It should be possible to achieve complete mobilization of the stoma (Fig.S.P. The stoma is held. This dissection is facilitated by the plane being under appropriate tension.This version of Total HTML Converter is unregistered. page_77 Page 1 of 1 < previous page page_77 next page > Page 77 Mobilization of Stomas J. It is very important to check the Figure 38 < previous page page_77 next page > .

39). It is our own practice to place four sutures through the mucocutaneous junction at 3. Hyland Reversal of an end or loop ileostomy is facilitated by careful traction of the base of the stoma.This version of Total HTML Converter is unregistered. < previous page page_78 next page > . as if undetected and not repaired this injury could lead to postoperative perforation. page_78 Page 1 of 1 < previous page page_78 next page > Page 78 bowel for serosal or seromuscular injury. When restoration of intestinal continuity necessitates a laparotomy (patients with a Hartmann's procedure or a mucous fistula). The ends of each suture are grasped in turn with Figure 39 Upward traction is provided by placement of four sutures at the mucocutaneous junction. 9 and 12 o'clock positions (Fig. Barry and J. the above procedure to mobilize the stoma(s) may be carried out as the first stage. Perform the laparotomy with a new set of instruments. Reversal of Ileostomy K. 3/0 Vicryl on a 20-mm round-bodied needle is ideal for this purpose. The stoma is then sealed prior to rescrubbing and retowelling. 6.

40). The suture ends are cut to release the mosquito forceps. The four mosquito forceps are then held together perpendicular to the anterior abdominal wall and twisted in a clockwise direction to wrap the four sutures for a common distance of 45 cm. it is both simple and effective.This version of Total HTML Converter is unregistered. largely because of the size disparity between the two limbs. This traction method is particularly useful to ensure that all intraperitoneal adhesions to the stoma have been divided. The artery forceps is now held by the operator to provide excellent atraumatic traction of the stoma. as dissection proceeds in standard fashion around the base of the stoma and through the layers of the anterior abdominal wall. This accumulated wrap is double-looped over one limb of an artery forceps which is then closed to prevent slipping of the wrap. < previous page page_79 next page > . one limb of the stapler is inserted into each of the afferent and efferent limbs of the ileum (Fig. In the case of a loop ileostomy. Stapled Closure of Loop Ileostomy J. closure of the loop ileostomy has gained a reputation as a technically difficult procedure. However.H. Using a linear stapler such as the TLC75 (Ethicon) or the GIA (Autosuture). Scholefield Loop ileostomy offers a number of advantages over loop colostomy as a method of defunctioning a low anastomosis in the pelvis. we close the intestinal lumen with a single layer of interrupted 3/0 Vicryl sutures before returning the small bowel to the abdominal cavity. page_79 Page 1 of 1 < previous page page_79 next page > Page 79 a mosquito forceps. A stapled side-to-side anastomosis overcomes this difficulty. The stoma is mobilized to the peritoneal cavity.

Reference Berry. In large patients this may need to be done in two steps. D. A reload of the same stapler is then fired across the top of the side-to-side anastomosis to excise the old ileostomy spout and close the top of the side-to-side anastomosis (Fig. page_80 Page 1 of 1 < previous page page_80 next page > Page 80 Figure 40 The two limbs of the ileostomy are rolled towards each other such that the mesentery is excluded from the staple line. We have used this technique in over 50 cases with a mean operating time of 30 rain and without any leaks whatsoever.This version of Total HTML Converter is unregistered. J. (1997) A new technique for closure of loop ileostomy.H. British Journal of Surgery 84. & Scholefield. < previous page page_80 next page > . 325326. The stapler is fired and removed from the ileum. 40).P.

Lee Loop ileostomy has become the preferred method of covering low colorectal anastomoses.R. Figure 41 < previous page page_81 next page > .This version of Total HTML Converter is unregistered. page_81 Page 1 of 1 < previous page page_81 next page > Page 81 Closure of Loop Ileostomy. Closure of the loop can be a difficult and tedious procedure.W. P. It is important that all adhesions involving both limbs be divided and that sufficient length of both limbs be mobilized for the closure anastomosis.

side-to-side anastomosis of at least 7cm length. This wound takes many weeks to finally heal. Closure of the bowel defect by hand is difficult and produces a narrow lumen.K. I am grateful to N. and yet not formally closing the wound with the associated risk of infection. < previous page page_82 next page > . Phillips for showing me this. A tip to avoid this delay in wound healing. The purse-string is left long so as to be found and removed easily at a clinic visit or a nursing visit some weeks later. The end result is a small. 41b). yet leave the wound open to drain. Wound Closure after Take-Down of a Stoma R. page_82 Page 1 of 1 < previous page page_82 next page > Page 82 Once the loop has been ellipsed and dissected down to the peritoneal level. using a linear cutter and a straight linear stapler (Fig.This version of Total HTML Converter is unregistered. it is helpful to extend the circular defect vertically either proximally or distally for a distance of 34 cm (Fig. it is recommended that the closure then proceeds as a stapled. Use a tapercut needle. is to place a subcuticular Prolene purse-string around the circumference of the wound and then draw the purse-string tight. A 'mini laparotomy' is created which facilitates easy and full dissection of the loop. This purse-string technique will reduce the skin defect by more than 75%.S. This should be done full thickness including the anterior abdominal wall and the skin. cosmetically acceptable punctate scar. Miller After take-down of an ileostomy or colostomy many surgeons like to leave the stoma wound open because of the risk of infection. 41e-f).

This version of Total HTML Converter is unregistered. The stoma is then Figure 42 < previous page page_83 next page > . non-absorbable suture to a point that only two fingers can be admitted alongside the bowel. 42. The stoma and hernia contents are completely mobilized through a laparotomy without disrupting the mucocutaneous anastomosis. The repair is reinforced with a 1-mm Goretex 10 cm × 12 cm sheet fashioned as shown in Fig. The hernia sac is resected when possible and the resultant fascial defect is closed with a large. page_83 Page 1 of 1 < previous page page_83 next page > Page 83 Repair of Paracolostomy Hernias P. The sheet is divided 3/4 of the way through its midpoint.W.5 cm proximal to the end of the original cut.5-cm cuts are made at 45° angles radiating from a point 1. Vukasin and R. Six additional 1. Beart Jr Herniation complicates 3040% of stomas. Repair with the following technique gives durable results with minimal morbidity. but relocation is often not desirable or feasible. creating an eight-point star. monofilament.

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encircled by the sheet from the inside such that it lies against the peritoneum dorsal to the rectus sheath, covering the sutured defect, with the 'fingers' of the star splayed over the bowel pointing away from the fascia. The remaining slit of the sheet is closed snugly about the bowel with 3/0 silk. The sheet is then stretched to its full size and secured to the abdominal wall with a herniastapling device or silk sutures.

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COLON AND RECTAL SURGERY

Identification of the Left Ureter P.H. Gordon One of the most dreaded complications of colon surgery is injury to the ureter. It is acknowledged that the best way of avoiding damage to any structure is its identification and keeping it out of harm's way. To this end, a guide to the ureter during conduct of a sigmoid resection or left hemicolectomy is the easily identifiable but often overlooked intersigmoid fossa. In the midportion of the sigmoid mesocolon, near its attachment to the posterolateral abdominal wall, is a small depression in the peritoneum known as the intersigmoid fossa. It serves as a reliable guide to the underlying ureter. Once this peritoneum is incised, the sigmoid mesentery is displaced medially (Fig. 43), permitting the visualization of the left ureter which is then seen coursing proximally and distally over the iliac vessels. Once identified, the ureter should remain free of injury.

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Figure 43

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leaving a few millimetres not inverted (Fig. 44). detection of this occult mass will aid appropriate placement of the appendicectomy incision. 1 First.This version of Total HTML Converter is unregistered. This allows the appendix to be inverted with ease. This completely devascularizes the inverted appendix which will then slough off into the caecal lumen. page_87 Page 1 of 1 < previous page page_87 next page > Page 87 Acute Appendicitis? Re-Examine Abdomen When Patient Anaesthetized on Operating Table C. the presence of a mass not previously palpable in the awake patient may prompt one to choose an incision through which a right hemicolectomy can be performed rather than a grid-iron incision.J.J. In older adults. < previous page page_87 next page > . devascularize the appendix by ligating the mesoappendix. Walsh In cases of suspected acute appendicitis re-examine the abdomen after the patient is anaesthetized. Appendicectomy Without Breaching the Integrity of the Intestine A. 3 Use a probe to invert the appendix into the caecal lumen. Inversion appendicectomy enables a normal appendix to be removed without this risk. Bowel is opened with the potential for bacterial soiling of the peritoneum. 4 Tie an absorbable ligature tightly around the base of the appendix after withdrawing the probe. 2 Crush the base of the appendix with a haemostat. The vessels on the appendix side should be ligated separately and not in bunches. Brain Incidental appendicectomy may increase the risk of sepsis during an otherwise clean laparotomy. In children.L.

This version of Total HTML Converter is unregistered. 5 Insert a purse-string suture into the caecal wall to invert the ligated stump. This is then buried with a purse-string suture. The base is tightly ligated on withdrawing the probe. < previous page page_88 next page > . He has used this on numerous occasions for more than 10 years and has yet to have a complication. The author was taught this technique while training in paediatric surgery. An inflamed appendix cannot be treated in this manner. page_88 Page 1 of 1 < previous page page_88 next page > Page 88 Figure 44 The devascularized appendix is inverted into the caecum. Inversion appendicectomy is not new and appears to be safe.

are safest and fastest mobilized by curving the incision towards the colon and dissecting as near the flexures as possible (Fig.This version of Total HTML Converter is unregistered. however. This is the true bloodless plane of the flexures and will enable efficacious mobilization. F. page_89 Page 1 of 1 < previous page page_89 next page > Page 89 Mobilization of the Hepatic and Splenic Flexures of the Colon. Seow-Choen It is safest and easiest to mobilize the ascending. The hepatic and splenic flexures. 45). Figure 45 < previous page page_89 next page > . descending and sigmoid colon by starting mobilization at the white line representing the congenital peritoneal adhesions and then to reflect the colonic mesentery medially to isolate the vascular pedicles.

particularly if Figure 46 Transverse extension of midline laparotomy wound to facilitate mobilization of the difficult splenic flexure.W. By downward and medial traction on both transverse and left colon. allowing direct electrocautery dissection of the new transverse mesocolon to further 'ease out' the colon and mesocolon from the spleen. Very occasionally access to the splenic flexure via a midline laparotomy wound can be very difficult both in the asthenic as well as the obese patient. If the patient is in the Lloyd-Davies position. Fazio Usually the best approach to the splenic flexure is a combination of left colon mobilization along the white line of Toldt (taking the incision anterior to. entering the lesser sac and progressing to the left towards the flexure. but not breaching. < previous page page_90 next page > . the flexure at the splenic hilum is eased out.This version of Total HTML Converter is unregistered. page_90 Page 1 of 1 < previous page page_90 next page > Page 90 Taking Down Splenic Flexure V. Gerota's prerenal fascia) and dissection of the greater omentum from the transverse colon. mobilization of the splenic flexure may be facilitated by the operator standing between the patient's legs.

If progress slows down. exposure may be facilitated by making a T-extension of the wound in a left transverse direction (Fig. page_91 Page 1 of 1 < previous page page_91 next page > Page 91 the flexure is high and/or 'embedded' into the hilum of the spleen. This transverse extension of the midline laparotomy wound for difficult splenic flexures was shown to me by Dr Rupert Turnbull. just stop. Mobilization of the Splenic Flexure R. In this instance one can deflate the colon by needle decompression (see Needle decompression of the obstructed colon. 92). On occasion there is a tendency to continue this dissection without altering the exposure and as one goes higher and further up into the darker reaches of the left upper quadrant the procedure can become quite tedious. 46). Miller Most surgeons approach the splenic flexure mobilization by first dividing the adhesions along with the left paracolic gutter. p.This version of Total HTML Converter is unregistered. Very occasionally the splenic flexure may be overly distended. even when the surgeon is in the correct plain of dissection. Pull downwards gently on the transverse colon. What was once a difficult high splenic flexure often now comes down into the wound and makes further mobilization significantly easier. In this instance. < previous page page_91 next page > .

J. page_92 Page 1 of 1 < previous page page_92 next page > Page 92 Needle Decompression of the Obstructed Colon C. < previous page page_92 next page > . There is no need to place a purse-string suture around the puncture wound. This is best done by needle decompression. When the colon is decompressed the needle can be removed and the puncture wound in the colon cleaned with an antiseptic solution. Remove the sucker attachment from the suction tubing and insert into the end of the tube a 21-gauge intravenous needle. If possible. By using an oblique angle to enter the lumen you not only reduce the likelihood of leakage from the puncture. Pass the needle obliquely into the colonic lumen through one of the taenia coli. perform the puncture in a segment of colon to be resected. By using this technique a grossly dilated colon can be quickly decompressed and it is then possible to get on with the operation.This version of Total HTML Converter is unregistered. Many surgeons use this technique but it was first shown to me by Mr John Rogers at The Royal London Hospital. but also by keeping the needle-tip towards the 'ceiling' of the distended loop you can aspirate flatus and decompress the colon without the needle getting blocked with the liquid stool lying in the dependent portion of the loop. Walsh In cases of gross large bowel obstruction it is impossible to even 'get into the abdomen' until the colon has been decompressed.

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Hartmann's Operation in Presence of Colon Obstruction C.J Walsh If for some reason you feel obliged to perform a Hartmann's operation for a patient with a distal colon obstruction, I advise dividing the proximal colon with a cutting linear stapler rather than between clamps. Use a 9-cm rather than a 6-cm instrument on the obstructed colon. After early division of the colon the end can be wrapped in an antiseptic-soaked swab and tucked away whilst the resection proceeds. Doing this early on in the case often facilitates the mobilization of the more distal diseased segment of colon, there is no clamp to take up space in an already crowded abdominal cavity and you may be confident that the staple line will not fall off or leak. Later, when fashioning the end colostomy, all manner of crushing bowel clamps may fall off the obstructed left colon whilst manipulating the clamp and the contained dilated oedematous end of bowel through the trephine in the abdominal wall. The gross faecal contamination of the wound and peritoneal cavity which ensues will greatly increase the morbidity and mortality of the operation. The use of a cutting linear stapler virtually eliminates the risk of contamination during this manoeuvre. After the stoma trephine is made within the left rectus muscle, a Babcock clamp is passed from outside into the peritoneal cavity and the stapled end of bowel delivered gently in the correct orientation through the abdominal wall. Often the colon is extremely dilated and it is not desirable to make an end stoma with the entire circumference of the bowel as for an elective case. In such cases the majority of the length of the staple line can be oversewn and one corner of the stapled-off bowel

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end can be delivered and used to fashion the colostomy (Fig. 47).

Figure 47

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Getting the Colon to Reach V. W. Fazio Manoeuvres that facilitate getting the colon to reach the low rectum or anus after anterior proctosigmoidectomy include: high ligation of inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) at level of aorta (Fig. 48); second ligation of IMV at inferior border of pancreas (Fig. 48); full splenic flexure mobilization;

Figure 48 Steps to facilitate delivery of the colon into the pelvis.

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Should the former fail. or exceptionally one may consider ileal interposition between the hepatic flexure and distal rectum. rarely one might want to consider a caeco. These techniques are usually sufficient to bring a well-vascularized colonic pedicle to the lower rectum or anal canal. division of the splenic flexure attachments. division of the inferior mesenteric artery at its aortic takeoff.g. Additional left colon length is obtained with the following procedures: division of the lateral colonic attachments. then division of both branches of the mid-colic vessels can be performed.to low rectal.E. Difficulty in obtaining tension-free bowel occurs more commonly with a left-sided (e. Achieving Adequate Bowel Length for Anastomosis after a Left Colonic Resection D. Occasionally other manoeuvres are required and these include the following. Beck After completing the appropriate resectional procedure. Very. thus leaving the hepatic flexure or mid-ascending colon as the new proximal line of transection and this is supplied by the ileocolic vessels through the marginal arcades. colorectal) anastomosis. or caeco-anal anastomosis.This version of Total HTML Converter is unregistered. Delivery of proximal colon through the window between the ileocolic vessels and the superior mesenteric vessels. and < previous page page_96 next page > . sufficient proximal and distal mobilization provides tension-free bowel ends for a secure anastomosis. page_96 Page 1 of 1 < previous page page_96 next page > Page 96 division of base of transverse mesocolon to mid-colic vessels.

In some cases. In most patients. or ileocolic artery. (b) Transverse colon is brought through the ileal mesenteric opening to reach the pelvis. the ischaemic bowel must be resected and additional vessels divided to provide the required length.This version of Total HTML Converter is unregistered. Figure 49 (a) Opening in mesentery is created medial to the ileocolic artery and vein. these vessels will provide adequate blood supply to the proximal transverse colon or hepatic flexure. which can be made to reach to the rectum with one or two techniques. If these manoeuvres do not provide adequate bowel length. If this occurs. the middle colic vessels will have to be divided proximally and the blood supply of the residual colon will need to be based on the right. However. page_97 Page 1 of 1 < previous page page_97 next page > Page 97 division of the inferior mesenteric vein at the inferior border of the pancreas. < previous page page_97 next page > . this may compromise the blood supply to the remaining colonic end. branches of the distal middle colic artery and veins may need to be divided.

Another option is to completely mobilize the right colon and turn it to the right (counterclockwise). reverses the direction of the colon. Fazio (Cleveland Clinic). (b) Right colon is turned (counterclockwise) to allow the hepatic flexure to reach the pelvis. 50). so it is important to remove the appendix. One method is to make an opening in the ileal mesentery medial to the ileocolic artery and vein. This manoeuvre moves the caecum to an abnormal position.This version of Total HTML Converter is unregistered. < previous page page_98 next page > . This rotates the caecal tip to the right middle abdomen (towards the liver). then bring the proximal colon through this opening to reach the pelvis. Development of appendicitis would produce confusing signs and symptoms. Byron Gathright (Ochsner Clinic) and Dr V. and provides enough length for the hepatic flexure to reach the pelvis (Fig. These techniques were initially learned from Dr J. (Fig.W. right colic vessels are divided. page_98 Page 1 of 1 < previous page page_98 next page > Page 98 Figure 50 (a) Right colon is mobilized. 49). and appendix is removed.

51). This is especially important when a circular intraluminal stapler is used. US Surgical Corp. These interrupted 4/0 or 3/0 braided sutures (e. suture placement too near the bowel end results in their tearing through the bowel. Finally. If the sutures are placed too close. Leaving excess tissue adjacent to the clamp may < previous page page_99 next page > . Beck Proper technique is critical to obtaining a good anastomosis. intraluminal stapling entails use of purse-string sutures to hold the bowel over the stapler cartridge and anvil during staple closure. To work properly. D. Norwalk. silk or braided polyester) hold the purse-string suture to the bowel ends and assist in pulling it tightly around the shaft. This can be repaired with a pulley stitch (Fig.g. Wayne. gaps in the bowel ends will appear when the suture is tightened. the sutures must be placed correctly (12 mm from the bowel ends and 23 mm apart). it is important that the bowel be divided close to the clamp before the clamp is released. USA).This version of Total HTML Converter is unregistered.E. USA) or with a stapling device (Pursestring 65. NJ. If the sutures are placed too far apart or some sutures tear through the bowel. whereas placing the sutures too far back from the bowel ends produces an excessive bulk of tissue around the shaft. with a fenestrated purse-string clamp (Purse String device. CT. Davis & Geck. As originally described. If a purse-string clamp is used. This nonconstricting purse-string suture may be corrected by carefully cutting the bowel overlying the suture in two or more places to release additional suture to 'bunch-up' more of the bowel end.. the bowel will not close properly around the stapler shaft. page_99 Page 1 of 1 < previous page page_99 next page > Page 99 Placement and Repair of Purse-String Sutures. This purse-string suture can be placed by hand (with a baseball or in-and-out suture technique).

This version of Total HTML Converter is unregistered. Releasing the clamp before dividing the bowel may result in inadequate tissue to hold the purse-string sutures. Davis & Geck). Many surgeons use clamps to hold the bowel ends while placing purse-string sutures or to hold the bowel open to aid placement of the anvil or stapler. which may prevent the stapler from closing and firing properly. and the needles can be bent several times during withdrawal to allow the needles to be removed from the clamp into the confined pelvis.g. 2/0 monofilament polypropylene. If they < previous page page_100 next page > . page_100 Page 1 of 1 < previous page page_100 next page > Page 100 Figure 51 Repair of purse-string suture: (a) gap identified in pursestring suture. double-armed TS-9. Both needles are placed through the clamp. result in too much tissue at the purse-string. Several problems can occur with the use of these clamps. Difficulties in using the purse-string clamp low in the pelvis are minimized by use of a double-armed suture (e. (b) gap is closed with pulley sutures.

Beck In performing an ileocolic or right colonic resection. Use of solid-end clamps eliminates the chance of this happening. the ileocolic artery and vein are encircled and the vessels < previous page page_101 next page > .E. If open-ended clamps (e. Fazio at The Cleveland Clinic. ligation of the ileocolic artery and vein are required.W. After the fingers are bent up. Large clamps increase the difficulty of inserting an anvil in bowel with a diameter close to that of the anvil. After incision of this mesentery. page_101 Page 1 of 1 < previous page page_101 next page > Page 101 are placed too far from the bowel end and too tightly. it is possible for the purse-string to go through the end of the clamp and the clamp or the purse-string suture will have to be cut. the avascular plane between the right colic and ileocolic artery is identified (Fig. Proximal Ligation of the Ileocolic Artery D. 52a). 52c). Several of these techniques were learned from Dr V. The index and middle finger of the surgeon's right hand (palm up) are inserted between the duodenum and ileocolic artery. 52b). the avascular plane between the ileocolic and superior mesenteric artery (SMA) is identified (Fig. The small bowel is elevated superiorly by the assistant and the avascular plane between the duodenum and the ileocolic artery is incised (Fig.g. Early vascular ligation is accomplished in the following manner. If the indication for resection is a malignancy. proximal ligation of these vessels is preferred. the bowel wall may be injured which can result in leakage despite a secure anastomosis. The peritoneum is incised with the electrocautery. The index and middle finger of the surgeon's left hand then replace the right fingers.This version of Total HTML Converter is unregistered. By bending these two fingers up. Babcock clamps) are used.

page_102 Page 1 of 1 < previous page page_102 next page > Page 102 Figure 52 (a) Incision of the avascular plane between duodenum and the ileocolic artery. (c) Isolation of the ileocolic artery below the superior mesenteric artery. (b) Elevation of the ileocolic artery.This version of Total HTML Converter is unregistered. < previous page page_102 next page > .

being in front of the presacral nerves but behind the fascia propria of the rectum. and ligated close to the arterial takeoff from the SMA. divided.This version of Total HTML Converter is unregistered. The IMA is the guide to the plane of dissection which facilitates nerve preservation and total mesorectal excision. The first structures to find are the gonadal vessels. Miller Accurate identification of the inferior mesenteric artery (IMA) is a critical early part of an anterior resection. One of the keys to developing the correct plane at this point is your traction on the sigmoid mesentery to the patient's right with the assistant offering counter-traction on the left. This is not only critical to facilitate ligation. first dissect along the white line of Toldt dividing the congenital adhesions between the sigmoid colon and the parietal peritoneum above the level of the sacral promentary on the patient's left side.W. page_103 Page 1 of 1 < previous page page_103 next page > Page 103 can be thinned. Standing on the patient's right side. Following initial sharp dissection with either scissors or electrocautery. Correct location for division of the artery and vein is confirmed and they are clamped. air is seen to enter the areolar tissue and the plane between the sigmoid mesentery and the parietes opens up. Dissect or sweep these laterally (gently or they will bleed). but also because the IMA is the key to the correct plane for subsequent pelvic dissection. Next look for the ureter and < previous page page_103 next page > . Identification of the Inferior Mesenteric Artery During Anterior Resection of the Rectum R. This technique was learned from Dr V. whether this be a high or low tie. Fazio at The Cleveland Clinic.

This technique. and in particular the identification of the smooth rolled edge which represents the posterior aspect of the IMA. smooth rolled edge of tissue. Hand-suture treatment is cheap.R. Ethicon UK. W975) is recommended: it is strong. Next find the sympathetic nerve fibres which run distally to form the presacral nerves. This is the posterior aspect of the IMA and lies just anterior to the sympathetic nerve fibres. reliable and accurate. W. has no memory. was taught to me by John Northover at St Mark's Hospital.This version of Total HTML Converter is unregistered. Pass an index finger behind the smooth rolled edge towards the patient's right side and hook the finger gently forwards. thus tenting up the peritoneum over your index finger tip. As you approach the midline with the combination of sharp and blunt (peanut) dissection you will come across a glistening. Anterior Resection of the Rectum Using the Circular Stapling Device (Double-Staple Technique) P. Number 0 Ethibond (braided polyester on a round-bodied 30-mm needle. You are now around the IMA pedicle and the vessel can be skeletonized at any level of your choice and divided. Once the purse-string suture has been placed in the < previous page page_104 next page > . suture no. ties easily and requires only three throws on the knot. once again check that the proximal left ureter does not get into the tips of the clamp. Lee The proximal purse-string can be inserted using the Autosuture purse-string device. the Ethicon modified Fournell clamp or by hand. page_104 Page 1 of 1 < previous page page_104 next page > Page 104 push that laterally off the mesentery. Prior to clamping the IMA at this point.

53). Aesculap. This prevents slippage and gives a snug hold against the central rod (Fig. UK). Sheffield. the ends of the linear staple line on the rectal stump should be gently grasped (one rachet only) at each end with long Babcock forceps (230 mm. page_105 Page 1 of 1 < previous page page_105 next page > Page 105 Figure 53 proximal end of the bowel (as a whip stitch). Once the surgeon is ready to perform the stapled anastomosis. By moving the long Babcocks it is possible to position the central spike of the gun either immediately adjacent to the staple line or so < previous page page_105 next page > . the first throw of the purse-string tie should be a double one.This version of Total HTML Converter is unregistered. The stapling gun is then inserted by a second operator per anum and passed up to and pushed against the linear rectal staple line.

The Babcocks are removed once the central shaft and spike have penetrated the rectum (Fig. page_106 Page 1 of 1 < previous page page_106 next page > Page 106 Figure 54 that the spike comes through the staple line (i. 55).This version of Total HTML Converter is unregistered.e. This technique is also useful and very safe when passing the instrument barrel up through a very < previous page page_106 next page > . usually because of previous fibrosis in the pelvis. This procedure is made simpler and safer if the top-end operator leans over. while using his/her right hand to feel and guide the stapler barrel from the top end (much in the fashion of a railroading procedure in urology) (Fig. in the optimal position for the circular stapled anastomosis). Sometimes it proves difficult for the second operator to pass the stapling gun per anum up to the linear staple line. grasps the shaft of the previously inserted circular stapling instrument and guides it up through the rectum him/herself. 54).

Laparoscopic Vascular Stapler to Facilitate Pelvic Sidewall Clearance A. The anterior dissection is also performed under direct vision along the rectovaginal septum in women.This version of Total HTML Converter is unregistered. anterior or posterior to Denonvillier's fascia in men. abdominoperineal resection or various exenterative procedures performed for cancer.M. involves scissors and/or cautery dissection under direct vision in the areolar plane posterior to the visceral plane of the mesorectum. or anterior to the bladder in exenterations. < previous page page_107 next page > . Cohen The optimal approach to pelvic dissection for excision of the rectum in low anterior resection. page_107 Page 1 of 1 < previous page page_107 next page > Page 107 Figure 55 short anorectal stump to the low staple line of an ileoanal pouch procedure.

Division of this 'lateral ligament' should be performed with minimal blood loss and risk to the autonomic nerves without violating the mesorectal envelope. Areola tissue does not exist. In many patients. page_108 Page 1 of 1 < previous page page_108 next page > Page 108 Figure 56 Dividing the middle Haemorrhoidal pedicle. The plane of the lateral dissection may be along the parietal fascia or further lateral along the hypogastric artery adventitia. and identification of the main parasympathetic nerve trunk (S3) posterolaterally. Cautery dissection is often inadequate and may damage neural structures. The lateral dissection is more problematic. preservation of the major autonomic nerve trunks is desired to maximize late urinary and sexual function. Placement < previous page page_108 next page > .This version of Total HTML Converter is unregistered. After posterior and anterior clearance. Scissor dissection with haemoclips is often laborious and difficult in the presence of a large tumour within a narrow pelvis. the surgeon must deal with the anterolateral tissue.

The stapler is easily placed parallel to the S3 nerve.8-mm long staples) to provide a fail-safe routine.J.J. The intraluminal mucus beyond a colorectal cancer is one obvious danger which should not be allowed to contaminate the operative field. Heald and B. The Moran Triple-Stapling Technique: A Fail-Safe Precaution Against Implantation Staple-Line Recurrence R. Prevention of such contamination demands reliable 'sealing' of the excised specimen and extensive lavage of the lumen distal to the seal before transection or stapling of the bowel which is to remain within the patient. The 30-mm vascular stapler facilitates division of these anterolateral pedicles with bidirectional (medial and lateral) vascular control and with minimal risk to the autonomic nerves.This version of Total HTML Converter is unregistered. page_109 Page 1 of 1 < previous page page_109 next page > Page 109 of large clamps with subsequent suture ligation usually damages the autonomic nerves. Similarly. the port site recurrence debate should point us towards 'Listerian' principles to prevent implantation of malignant cells on to tissues made vulnerable by surgery. Moran The laparoscopic revolution has stimulated reappraisal of techniques and attitudes across the whole field of surgery. The Moran triple-stapling technique uses a PI 30® or PI 55® linear stapler with the green cartridge (4. even with poor visualization. and the 23 'fires' free the pelvic sidewall. Thus the dual hazards of cut and crushed host tissues and viable malignant cells are eliminated. narrow PI 30® can reach to the bottom of the narrowest < previous page page_109 next page > . better pain relief is the most obvious example. The long.

this routine for the safe sealing of an oncological specimen whose circumferential margins must also be carefully audited must surely become a basic principle in oncological gastrointestinal surgery. A second green cartridge for the PI is now used to close the anorectal stump about 1 cm distal to the first 'pathologist's' staple line . and in cases very close to the distal edge of the tumour a proctoscope can be used to inspect the lumen below the closed instrument before it is fired. Placement of the first staple line is beyond the finger and thumb of the operator squeezing the bowel distal to the rectal cancer. 57). It is essential that there is a good clearance between them before the knife is used to cut hard against the stapler. page_110 Page 1 of 1 < previous page page_110 next page > Page 110 male pelvis. The spike of the circular stapler is then delivered and the double-stapled anastomosis can then be fashioned in the usual manner . water is to be preferred to saline as it is osmotically destructive to malignant cells.This version of Total HTML Converter is unregistered. Sometimes this clearance between the staple lines is quite difficult to achieve and firm forward and downward pressure on the PI 30r may be needed to force the open instrument over the muscle whilst drawing backwards on the first staple line with a finger and thumb. It must be confessed that the pathologists do not like the staples in the bottom of their specimen. The distal lumen is now thoroughly washed with water plus a mild antiseptic. < previous page page_110 next page > . The first closure of the handle does not fire the staples. or even a Satinsky clamp. The second squeeze of the handle fires the staples and seals the specimen. Nevertheless. so as to clear its distal edge safely ( in Fig. and either instrument provides a closing pin which can reliably encompass the distal anorectal muscle tube below a total mesorectal excision specimen. after it is fired but before the gap is opened by pressing the release button .

This version of Total HTML Converter is unregistered. page_111 Page 1 of 1 < previous page page_111 next page > Page 111 Figure 57 < previous page page_111 next page > .

This can be technically difficult and in about 1030% of cases where a colonic J-pouch is planned it has to be abandoned in favour of a straight colo-anal anastomosis. This is especially valuable for when the anastomosis comes to lie within the sphincter mechanism and thus of particular benefit in males with a narrow pelvis and a long anal canal. (Z'graggen. M. 58).A. This technique was described in a pig model by Z'graggen et al. Stoupis.. This avoids the problems of getting a thickened mesocolon and double loop of colon into the narrow confines of the pelvis. S. D. Wildi. Maurer. C. Figure 58 < previous page page_112 next page > . Mettler. & Buechler.. W.W.This version of Total HTML Converter is unregistered. C. K.. page_112 Page 1 of 1 < previous page page_112 next page > Page 112 Alternatives to Colonic J-Pouch V. Fazio After a very low anterior resection it is often desirable to perform a colonic pouch anal anastomosis. Another alternative here is the use of a colonic reservoir using a coloplasty technique (Fig..

p. usually to the right of the rectum and well away from the principal phlegmon or recurrence (Fig. The technique is also very useful in adhesiolysis. The suction irrigator is introduced and 50100 ml of warm saline are pumped into the current plane (anterior and medial to the hypogastric plexus). A1487). Gastroenterology 112. A laparoscopic suction irrigator (LSI) is used (Fig.This version of Total HTML Converter is unregistered.L. A small incision is made in the peritoneum. 59b). 59a). E. Use of Hydrodissection to Mobilize the Rectum in Redo Pelvic Surgery. This opens up the plane and greatly facilitates dissection. < previous page page_113 next page > . Bokey This technique is especially valuable in redo pelvic surgery or surgery for recurrent disease. page_113 Page 1 of 1 < previous page page_113 next page > Page 113 (1997) A novel colonic reservoir and comparison of it's short term function with a straight coloanal and colonic J-pouch anastomosis in the pig. especially when multiple loops of small intestine are stuck in the pelvis.

This version of Total HTML Converter is unregistered. page_114 Page 1 of 1 < previous page page_114 next page > Page 114 Figure 59 < previous page page_114 next page > .

page_115 Page 1 of 1 < previous page page_115 next page > Page 115 Reusable Transanal Anvils F. the intraluminal stapler is inserted transanally. whereas the anvil is detached and inserted into the proximal colon. I sterilize used anvils of different sizes and insert them into the stapler shaft for transanal insertion. the used anvil is removed and the current anvil and shaft attached in the normal fashion for anastomosis (Fig.This version of Total HTML Converter is unregistered. Following satisfactory transanal insertion. 60). Figure 60 < previous page page_115 next page > . Seow-Choen In the performance of a stapled double-purse-string anterior resection. The insertion of the intraluminal stapler without the cone-headed anvil is traumatic and often lacerates or catches redundant mucosa and sometimes this results in a less than satisfactory anastomosis.

Seow-Choen Insertion of a transanal intraluminal stapler may be difficult during the performance of a double-stapled ultralow anterior resection.This version of Total HTML Converter is unregistered. The anal canal of about 3 cm hardly allows for a lot of manipulation. I use two pairs of Allis clamps at the anal verge for counter-traction (Fig. In this fashion. Figure 61 < previous page page_116 next page > . 61). Indeed excess force will perforate the linearly stapled rectal stump. insertion of a transanal intraluminal stapler is usually easy and safe. page_116 Page 1 of 1 < previous page page_116 next page > Page 116 Inserting Transanal Staplers in Ultra-Low Anterior Resection F.

provided of course you do not injure a vessel in bringing it down into the pelvis. Fazio Abandonment of the pelvic ileal pouch anal anastomoses is a reality with estimates ranging from 2 to 10% (5% is a probable or likely average figure). then length will not be a problem and the ileal reach will be sufficient.This version of Total HTML Converter is unregistered. Lengthening manoeuvres for the J-pouch include: division of the ileocolic vessels. Whether or not the proposed pouch will reach to the lower pelvis can be assessed by retracting the most dependent part of the ileal loop (usually 1530 cm from the ileocaecal valve) to the symphysis pubis. thus leaving the ileum supplied by the marginal branches of the superior mesenteric artery (SMA). This is due to the restriction of 'ileal reach' by the superior mesenteric vessels. Particular care needs to be paid to ileal reach in patients undergoing ileal pouch anal anastomosis for familial adenomatous polyposis (FAP). division of adhesions around the third part of the duodenum. an S-pouch may be considered as the exit conduit gives you a further 3 cm of reach. If the apex of this ileal loop reaches beyond the lower border of the symphysis pubis. and incising the peritoneum overlying the SMA to generate some more 'give' in the peritoneum. If the reach appears to be a problem with a J-pouch. W.or W-pouch. page_117 Page 1 of 1 < previous page page_117 next page > Page 117 Getting the Small Bowel to Reach V. Likewise a trial descent can also be performed with an S. Once you have performed the proctectomy the extent of reach can be simulated by placing a Babcock clamp at the apex of the J-loop and bringing it down in proximity of the levators. as the presence of < previous page page_117 next page > .

When the horizontal staple line has been placed low across the rectum there is very little room to accommodate the cartridge. places his/her left hand in the patient's pelvis and grasps the stapler with his/her right hand (Fig. The surgeon. When the operation has proceeded to a stage where the anastomosis is to be done. who is on the patient's right. 62).M. The cartridge can be placed so that < previous page page_118 next page > . nestling in the stump. This necessitates removal of the anal stump and a handsewn anastomosis. an assistant stands between the patient's legs and dilates the anus gently to accommodate three fingers. The surgeon now inserts the cartridge through the anus. using his/her left hand (in the pelvis) to support the anorectal stump and even to gently push the internal sphincter over the edge of the stapler.This version of Total HTML Converter is unregistered. The surgeon can feel when the stapler cartridge is through the sphincters. To avoid an uncontrolled and potentially dangerous cartridge insertion I suggest a bimanual technique. In a patient with tight sphincters where a large cartridge is being used (I prefer a 33-mm stapler) there is a real danger of the cartridge tearing the bowel or even being thrust through the transverse staple line. Church One of the trickiest stages of a double-stapled ileal pouchanal or colo-anal anastomosis is the transanal insertion of the end-to-end stapler. Insertion of the Stapler for an Ileal Pouch-Anal Anastomosis J. page_118 Page 1 of 1 < previous page page_118 next page > Page 118 desmoids or desmoplastic reaction within the mesentery often causes a foreshortening of the mesentery. The anvil has been removed and the blunt end of the cartridge must be inserted through the sphincters into the anal stump.

US < previous page page_119 next page > . Stapled Ileoanal Pouch Procedure H. the rectum and anal cuff are stapled as close as possible to the dentate line and levator ani muscles with a 30-mm horizontal stapler. USA) and the J-pouch is anastomosed to the anus with a Premium Plus EEA 31® (Autosuture Company. A 15-cm ileal J-pouch is constructed with two firings of a 90-mm GIA® stapler (Autosuture Company. The surgeon then hands the stapler to the assistant.. US Surgical Corp. Sugerman When performing a one-stage stapled ileoanal pouch procedure.This version of Total HTML Converter is unregistered. page_119 Page 1 of 1 < previous page page_119 next page > Page 119 Figure 62 the rod will protrude either in the centre or just inferior to the centre of the transverse staple line. The surgeon regloves and the anastomosis proceeds.J. CT. Norwalk. who rotates the knob to extrude the rod.

in a few instances.This version of Total HTML Converter is unregistered. USA).. 63). CT. Our frequency of anastomotic leak using this technique has decreased from 15% to 11%. page_120 Page 1 of 1 < previous page page_120 next page > Page 120 Figure 63 Surgical Corp. the horizontal staple line disrupted on several occasions when advancing the EEA 31® stapler from below. mandated a temporary ileostomy. Our current technique is to superimpose two applications of a PI 30® stapler for the closure of the anal stump (Fig. Since using that technique in over 130 patients. In our initial experience with this technique. Two-thirds of these leaks < previous page page_120 next page > . This then necessitated a hand-sewn closure and increased our frequency of anastomotic leaks and. Norwalk. there has been no disruption of the staple line upon insertion of the EEA 31® stapler.

visualization of this area and therefore accurate sharp dissection can be difficult. page_121 Page 1 of 1 < previous page page_121 next page > Page 121 can be safely managed without ileal diversion if the leak is proven to be confined to the pelvis by water-soluble contrast enema and there are no signs of peritonitis. In such a circumstance the rectum can be everted and the medium PI 30® horizontal stapler placed from below with its long plane vertical. as it is not as wide. Combined Supine and Prone Jack-Knife Position for Abdominoperineal Resection of the Rectum C. To overcome this problem do the perineal portion of the operation with the patient in the prone jack-knife position. < previous page page_121 next page > . Walsh Anterior dissection and mobilization of the rectum from the prostate can be difficult in the male patient with a bulky or locally advanced anterior rectal tumour requiring abdominoperineal resection.This version of Total HTML Converter is unregistered. When the patient is in the more traditional Lloyd-Davies position.J. Again it is fired twice to obtain two superimposed rows of staples. This dissection between the anterior rectal wall and the prostate is one of the most important parts of the operation from an oncological point of view in this patient population. The abdominal portion of the operation is performed with the patient supine on the operating table and the steps are the same as the conventional method of performing the procedure. We prefer the PI 30® to a reticulated 30-mm stapler. Occasionally the pelvis is too narrow to place the PI 30® stapler on the distal level of dissection on the levator ani muscles. permitting a lower application on the anal canal. Divide the proximal colon with a cutting stapler rather than dividing it between clamps.

thus facilitating an oncologically sound resection. the nylon tape previously placed around the proximal (colonic) end of the resection specimen is pulled out through the perineal wound and the specimen everted. Dissection is completed down to the pelvic floor in the standard fashion. < previous page page_122 next page > .This version of Total HTML Converter is unregistered. One can now perform the dissection between the anterior rectal wall and the prostate with clear vision and easier access. The buttocks are taped apart. The patient is then turned over and placed in the prone jack-knife position. The perineum is closed in the traditional manner after securing haemostasis. the midline incision is closed in the usual way and the end stoma fashioned. page_122 Page 1 of 1 < previous page page_122 next page > Page 122 The end of the colon can then be covered with a small swab soaked in antiseptic solution until you are ready to fashion the stoma. A nylon tape is placed and tied around the distal colonic end. Performing the perineal dissection of an abdominoperineal resection in the prone jack-knife position was shown to me by Dr Ian Lavery at The Cleveland Clinic. the skin shaved and the perineum prepped and draped after placing an anal purse-string. The perineal dissection is performed in the standard fashion. On entering the pelvic cavity posterior to the rectum. This combination of prone jack-knife position and eversion of the specimen is the key to the procedure. Drains are placed in the pelvis and brought through the anterior abdominal wall via separate stab incisions.

C. This tip is a bit of an old chestnut and has been told to me by so many people that I am not sure to whom it should be credited. mechanical advantage is very poor when trying to drive the tack into the sacrum and the one from the notice-board may bend or break. Attempts at electrocautery often make matters worse and it is not possible to drive a suture through the outer table of sacral bone.J. 64a). For all this it does work and there are many surgeons for whom it has literally saved the day. Dissection in this plane may lead to bleeding from presacral veins (Fig. < previous page page_123 next page > . Even great pelvic surgeons occasionally find themselves on the wrong side of this fascia. Firstly. titanium is very inert and theoretically at least should reduce the risk of an unhealed perineal sinus should this procedure be used during the course of an abdominoperineal resection. Sterilizing one from the notice-board will suffice but ideally a titanium tack designated for this purpose should be used. There are two main reasons for this preference. On occasion this can be torrential and sometimes even life threatening. albeit deliberately. Secondly. in patients with locally advanced rectal cancers. Walsh The correct plane for pelvic dissection during an anterior resection or abdominoperineal excision of the rectum is in front of Waldeyer's fascia.This version of Total HTML Converter is unregistered. Prior to packing the pelvis and coming back on another day. page_123 Page 1 of 1 < previous page page_123 next page > Page 123 Thumbtack to Arrest Bleeding from Presacral Veins. On occasion a piece of crushed skeletal muscle (rectus muscle) or calcium alginate felt can be compressed between the sacrum and the pin thus further aiding haemostasis. try a thumbtack (drawing-pin).

T. (From Nivatvongs.) < previous page page_124 next page > . 590.This version of Total HTML Converter is unregistered. page_124 Page 1 of 1 < previous page page_124 next page > Page 124 Figure 64 (a) Venous system of the sacrum (sagittal view). (1986) The use of thumbtacks to stop massive presacral hemorrhage. D. & Fang. Diseases of the Colon and Rectum 29. S. (b) Thumbtack occlusion of a bleeding basivertebral vein.

This can be deflated after 24 h and the tube removed if there is no further bleeding. When this occurs during an abdominoperineal resection tamponade can be affected by placing a Sengstaken tube into the pelvis via the perineal wound and inflating the gastric balloon (Fig. Figure 65 < previous page page_125 next page > .G. McCourtney. page_125 Page 1 of 1 < previous page page_125 next page > Page 125 Dealing With Presacral Bleeding During an Abdominoperineal Resection R. Molloy Presacral bleeding following pelvic dissection can on occasion be very difficult to stop. This tip was shown to me by Mr J. 65).This version of Total HTML Converter is unregistered.

66b). remembering the acute angulation of the rectum of the anal canal. In this position. prevents soiling during the case and absorbs operative blood loss.R. O'Connell The majority of local anorectal surgical procedures are facilitated by use of the jack-knife prone position as commonly favoured by surgeons in North America. Placing a suture around the swab to facilitate retrieval is a modification of the technique originally taught to me by Dr Bruce Woolfe.This version of Total HTML Converter is unregistered. < previous page page_127 next page > . This keeps mucus and faecal matter out of the operative field. with head-down tilt. page_127 Page 1 of 1 < previous page page_127 next page > Page 127 ANORECTAL SURGERY A Better View in Anorectal Surgery P. Insertion of the swab is facilitated by using an Eisenhammer bivalve retractor and a Russian or bear's paw dissecting forceps. The swab may be easily retrieved if retained by a 0/0 nylon stay suture. exposure of the anal canal and lower 1/3 rectum is further improved by insertion of an opened 10 cm × 10 cm gauze swab (Fig. 66a) into the middle 1/3 of the rectum (Fig. Colorectal Surgeon at The Mayo Clinic.

(b) Swab in position mid-rectum.M. 67a). < previous page page_128 next page > . Anal retractors allow good exposure of the lower rectum but above this level the rectal walls tend to fold together (Fig. Exposure for Transanal Excision of Rectal Lesions J.This version of Total HTML Converter is unregistered. Note: swab has 'Ratex' radiopaque line on swab for identification (black) and nylon suture for retrieval (blue. page_128 Page 1 of 1 < previous page page_128 next page > Page 128 Figure 66 (a) Opened 10 cm × 10 cm gauze swab. double ligature at swab). Church One of the difficulties of open transanal excision of rectal lesions is adequate exposure.

If the sponge is kept bulky it will separate the rectal walls and improve exposure (Fig. < previous page page_129 next page > . (b) A sponge has been placed above the lesion where it improves exposure by separating the rectal walls. Sometimes two sponges are needed. 67b). page_129 Page 1 of 1 < previous page page_129 next page > Page 129 Figure 67 (a) An anal retractor permits a view of a low rectal tumour but the view is suboptimal because the retraction does not support the rectal walls at the level of the lesion.This version of Total HTML Converter is unregistered. and occasionally a proctoscope is necessary to retrieve them. A simple way of gaining exposure is to place a small sponge (swab) into the rectum just above the lesion.

This tip was first shown to me by Dr Jeff Milsom whilst at The Cleveland Clinic. Figure 68 Use a heavy artery forceps to bend the tip to 90°. Walsh Transanal electrocautery dissection is a useful technique. < previous page page_130 next page > . avoid undermining and prevent unwanted burns to the mucosa distal to the point of dissection. bend the tip of the electrocautery spatula to 90° using a strong straight artery forceps (Fig. page_130 Page 1 of 1 < previous page page_130 next page > Page 130 Transanal Dissection Using Electrocautery: Get the Right Angle C.This version of Total HTML Converter is unregistered.J. In this way you will keep the plane of dissection at right-angles to the mucosa. To ensure more accurate dissection. 68). Situations where it may be used to advantage include excision of low rectal polyps and when raising a full thickness flap as part of an advancement flap repair of a rectovaginal fistula.

69). page_131 Page 1 of 1 < previous page page_131 next page > Page 131 Easier Haemorrhoidectomy J.This version of Total HTML Converter is unregistered. In so doing the surgeon reduces the blood loss from the anal verge. Injection of 0. The surgeon must of course still preserve the skin and mucosal bridges. < previous page page_131 next page > .25% Marcain with adrenaline into each of the identified and marked haemorrhoids followed by massaging of the injection into the surrounding tissue not only simplifies identification of the submucosal planes but also provides postoperative analgesia. Scholefield Haemorrhoidectomy is a common procedure but one which is often badly taught. A tip which I have found useful is to start the excision of the skin component of the haemorrhoid a few millimetres further away from the haemorrhoid than might at first seem appropriate (Fig.H. This allows the surgeon to avoid the spongy tissue in the skin component of the haemorrhoid and identify the internal anal sphincter more easily.

page_132 Page 1 of 1 < previous page page_132 next page > Page 132 Figure 69 < previous page page_132 next page > .This version of Total HTML Converter is unregistered.

W.This version of Total HTML Converter is unregistered. < previous page page_133 next page > .R. This secures an adequate view of the other side to facilitate the second injection (Fig. injection of first. Lee In the UK. If the first injection occludes the view down the proctoscope. a 1. 70c). right posterior and left lateral position (Fig. This is easier to perform. saves the patient an additional injection and often facilitates the injection of a larger volume of sclerosing fluid. Conventionally ~3 ml of the solution has been injected submucosally into the apex of the three pile masses in the right anterior. P. page_133 Page 1 of 1 < previous page page_133 next page > Page 133 Injection of Haemorrhoids.and second-degree haemorrhoids using 5% phenol in almond oil is often the preferred method of treatment. Equally satisfactory results can be obtained by two slightly larger injections at the 3 o'clock and 9 o'clock positions (Fig.5-cm ball of cotton wool is placed over the injected area and pushed slightly proximally. 70b). 70a).

page_134 Page 1 of 1 < previous page page_134 next page > Page 134 Figure 70 < previous page page_134 next page > .This version of Total HTML Converter is unregistered.

page_135 Page 1 of 1 < previous page page_135 next page > Page 135 Rubber-Band Ligation of Haemorrhoids Made Easier P. 1 The surgeon requires two free hands for grasping the haemorrhoid and placement of the bands. Sheffield.This version of Total HTML Converter is unregistered. 71). Figure 71 < previous page page_135 next page > . UK).R. Lee There are three useful tips when using the standard McGivney haemorrhoid ligator (Aesculap. If a nursing assistant is not available to hold the proctoscope it is a simple matter to ask the patient to hold the proctoscope handle with his or her own right hand (Fig. The patient should be in the left lateral position.W.

UK) are used to grasp the haemorrhoid.This version of Total HTML Converter is unregistered. Sheffield. This procedure is made much easier if standard long Lloyd-Davies sigmoidoscope biopsy forceps (350 mm) (Aesculap. 72). Use of the longer instrument means that the proctoscope view is not partially occluded by the handles of the shorter grasping forceps and that the surgeon's head can 'stand off' from the proctoscope facilitating a much better view (Fig. Sheffield. page_136 Page 1 of 1 < previous page page_136 next page > Page 136 2 Short claw toothed forceps (St Georges seizing forceps. 3 If the rubber-bands are placed too low on the haemorrhoid and encroach on the anal canal epithelium the patient experiences excruciating pain. Aesculap. UK) are frequently recommended to draw the haemorrhoid into the banding gun. The only treatment is immediate removal of the bands. Figure 72 < previous page page_136 next page > . by no means an easy task in an anxious patient in pain.

The rubber-bands are grasped with long straight artery forceps clicked down one rachet (to steady the bands). Figure 73 < previous page page_137 next page > . They are then cut through with a single firm movement with a 15-gauge knife-blade on a long 160-mm scalpel handle (no. Sheffield. page_137 Page 1 of 1 < previous page page_137 next page > Page 137 An assistant to hold the proctoscope is mandatory. UK) (Fig.This version of Total HTML Converter is unregistered. 7 BP Swan Morton. 73).

This version of Total HTML Converter is unregistered. 74) approximates the skin edges with much less Figure 74 < previous page page_138 next page > .J. The 'looped pulley' suture (Fig. This is also true of transsacral longitudinal incisions. Rubin When wide perineal excision is required there may be tension on the perineal wound. page_138 Page 1 of 1 < previous page page_138 next page > Page 138 The 'Looped Pulley' Suture in Perineal Wound Closure Under Tension R.

They can be left in place for several weeks. Then the suture is directed between the exiting point and the skin edge on the side opposite from which the routine suture exits the skin edge. In this way the examining finger slides over the tissues more easily and it is easier to differentiate normal supple tissues from abnormal indurated tissues. on occasion. Lubrication to Find the Induration A. A tip is to lubricate the perianal area and the examining finger with KY jelly.J. particularly in patients with multiple perianal fistulae associated with Crohn's < previous page page_139 next page > . Three or four such sutures are all that are required to buttress the closure of the perineum.D. Wells The induration which so often is the tell-tale sign of perianal sepsis or a fistula tract can. This suture was shown to me by Dr Robert Paradny who was my Chief resident when I was a Surgical Resident at Mt Sinai Hospital in New York City. 0 or no. A routine heavy (no.This version of Total HTML Converter is unregistered. We usually employ three or four 'looped pulley' sutures along the wound and then close the skin with clips. Seton Insertion for Fistula-in-Ano R. Rubin It is often quite difficult to insert a seton into a fistulous track after the track has been probed with a blunt probe that has passed through the track. page_139 Page 1 of 1 < previous page page_139 next page > Page 139 tension than a routine vertical mattress suture. 1) vertical mattress suture is placed. This forms a pulley. be difficult to detect with the gloved examining finger.

page_140 Page 1 of 1 < previous page page_140 next page > Page 140 disease where there may be several external openings and one internal opening. dull-side forward. 2 JLM taper needle which is essentially the size of a retention needle. With the probe in place a no. from the internal opening along the course of the probe in an inside-out direction with the probe in place by passing the needle blunt-side first and then carrying it through to the outside where the seton can then be tied loosely (Fig. Figure 75 < previous page page_140 next page > . 75). 1 Ethibond suture is inserted by using a double-arm swaged needle with a no.This version of Total HTML Converter is unregistered. The swaged needle is passed backward.

Perianal Wound Care J. the tighter the seton becomes and this can easily be tightened in the clinic. fissure. In some. The more bands you put on. delay in healing for long periods may occur because: 1 the wound is not shaped to allow maximum drainage.S.This version of Total HTML Converter is unregistered. Miller One tip that I picked up from the Minneapolis/St Paul group of colorectal surgeons is in the management of trans-sphincteric fistula-in-ano with a cutting seton. An easy way to tighten the seton is to construct the original seton from a double band of the sloops used to sling arteries by vascular surgeons. The sloops are tied together on the outside and then to tighten them. Baron's bands used for banding haemorrhoids. To get around these problems: 1 It is important to ensure that there is an adequate external wound (a Salmon back-cut) to establish good drainage (Fig. This double loop is brought through the fistula track having divided the skin and possibly the internal sphincter in the line which will be cut by the seton. thereby avoiding repeated trips to theatre for replacement of the seton. Thomson Most perianal wounds (following operations for fistula. 2 hairs from the wound edge grow into the granulation tissue. 76a). can be loaded on to the vascular sloops and then back up against the knot. pilonidal disease and operations to remove the rectum) heal without difficulty. 3 exuberant granulation tissue prevents epithelialization.P. < previous page page_141 next page > . page_141 Page 1 of 1 < previous page page_141 next page > Page 141 Cutting Seton for Fistula-in-Ano R.

3 Apply a silver nitrate stick to the exuberant granulation tissue followed by the application of a dry dressing (Fig. Micropore tape may be applied to the edge of the wound before shaving to act as a 'fly-paper' to collect the shaved hairs (Fig. 10 scalpel blade (a razor is not satisfactory for this) and the effectiveness checked with a magnifying lens. 76b) and thus prevent them landing in the granulation tissue. Momentary stinging may occur. which must also be checked by using a magnifying lens. 76c). page_142 Page 1 of 1 < previous page page_142 next page > Page 142 Figure 76 2 The wound edges should be shaved with a no.This version of Total HTML Converter is unregistered. < previous page page_142 next page > .

22 Britetrac retractor 22 < previous page page_143 next page > . finding midline 34 abdominoperineal resection laparoscopic vascular stapler 1079 positioning for 1212 adhesiolysis. methods for 956 ileal pouch anastomosis see ileal pouch-anal anastomosis appendicectomy after left colonic resection 98 inversion 878 appendicitis. after left colonic resection 968 Brabbee's retractor 21. closure 59 anterior rectus sheath 56 double-loop deep-tension suture 78 mass closure problem avoidance 56 two-suture method 6 subcutaneous skin closure 9 abdomen.This version of Total HTML Converter is unregistered. antrum and pylorus to mesocolon 467 anastomosis colo-anal 112 common bile duct 3940 high (intrahiatal) oesophagojejunostomy 246 ileal pouch-anal see ileal pouchanal anastomosis normal calibre bile duct 378 pancreaticojejunal 501 purse-string suture placement 99101 two-layer identification of free suture ends 1213 Schneeden stitch 14 anorectal surgery 12742 improving the view 1278 patient position 1278 anterior rectus sheath. thumbtack occlusion 1234 bile duct common duct anastomosis to Roux loop 3940 division in pancreaticoduodenal resection 48 normal calibre. closure 6 anus colon reaching. hydrodissection technique 11314 adhesions. opening 15 excising of old scars 12 finding linea alba 34 incision around falciform ligament 45 smooth curved incision around umbilicus 23 abdominal mass 87 abdominal wall closure see abdomen. bleeding. anastomosis technique 378 bowel length. A abdomen re-examination under anaesthesia in appendicitis 87 abdomen. page_143 Page 1 of 1 < previous page page_143 next page > Page 143 INDEX. small bowel stricture detection 67 basivertebral vein. for haemostasis 1516 ball-bearing. re-examination of abdomen under anaesthesia 87 B Babcock clamps. closure fat.

partial. greased 16 colon 85125 hepatic/splenic flexures see hepatic flexure. version Page 1 of 1 < previous page C caeser rolls 19 Cambridge technique. ureteral 1718 cholangiograms.This page_144 of Total HTML Converter is unregistered. in pancreaticoduodenal resection 48 page_144 next page > Page 144 < previous page page_144 next page > . peroperative. for morbid obesity 278 gastric remnant. Schneeden stitch 14 F falciform ligament. anterior resection of rectum 1047 drains. prevention 52 gastroduodenal artery. alternatives 112 colonic reservoirs 112 coloplasty 112 colorectal cancer. without clamps on gastric remnant 2930 gastric bypass. 22 double-loop deep-tension sutures 78 double-staple technique. sewing in. incision around 45 familial adenomatous polyposis (FAP) 11718 fistula-in-ano cutting seton 141 seton insertion 13940 G. splenic flexure left length increasing methods 968 resection. partial gastrectomy without clamps on 2930 gastric stasis. gall bladder access at open cholecystectomy 40 excision 43 see also cholecystectomy gastrectomy. surgery 5767 E electrocautery. packing for liver trauma 356 catheters. perforated. in colonic obstruction 934 mobilization 778 wound closure after take-down 82 common bile duct. method 1112 duodenal ulcer. ileocolic artery ligation 1013 colonic J-pouch. reconstruction technique 578 duodenum. bowel length after 968 methods to reach low rectum/anus 956 obstruction Hartmann's operation in 934 needle decompression 92 right mobilization after left colon resection 98 resection. resection. prevention of staple-line implantation 109 colostomy end. transanal dissection 130 enteral feeding. jejunostomy 612 enteroenterostomy. snugger for 412 cholecystectomy 43 gall bladder excision 43 improved gall bladder access 40 snugger for peroperative cholangiograms 412 chromic catgut. 22 deep pelvic retractor 21. anastomosis to Roux loop of jejunum 3940 Crohn's disease division of mesentery 656 haemostasis using Babcock clamps 15 seton insertion for fistula-in-ano 13940 small bowel resection level 634 D Deaver retractor 21.oversewing technique 60 duodenal wall.

proximal ligation 1013 ileocolic resection. repair 834 hydrodissection. separation from transverse mesocolon 1415 gynae rolls 36 H haemorrhage Babcock clamps for 1516 basivertebral vein. procedure 11921 stapler insertion for 11819 'ileal reach'. mobilization 89 hepaticojejunostomy 52 hepatic resection. in colonic obstruction 934 hepatic flexure. restrictions 117 ileocolic artery. thumbtack occlusion 124 hepatic trauma 346 prevention in pancreatic necrosectomy 55 see also presacral veins haemorrhoidectomy easier procedure 1312 postoperative analgesia 131 haemorrhoids drawing into banding gun 136 injection 1334 rubber-band ligation 1357 haemostasis. paracolostomy. Babcock clamps for 1516 Hartmann's operation. page_145 Page 1 of 2 < previous page page_145 next page > Page 145 gastroenterostomy.This version of Total HTML Converter is unregistered. clearance of vena cava 312 hepatobiliary surgery 3143 hepatocaval ligament 31 hernia. rectum mobilization 11314 I ileal pouch-anal anastomosis ileal reach and lengthening methods 11718 one-stage stapled. ileocolic artery ligation 1013 ileostomy 554 712 loop see loop ileostomy loop end 746 mobilization 778 reversal 789 . Schneeden stitch 14 general surgical techniques 1122 glycerol. greasing of suture threads 16 greater omentum.

page_145 789 reversal siting 6970 wound closure after take-down 82 induration. alternatives 112 ileal. 53 jejunostomy. anal anastomosis 11921 lengthening manoeuvres 11718 L Lane's forceps 2 laparoscopic suction irrigator (LSI) 113. incision around falciform ligament 45 laparotomy wound. clearance of vena cava 312 retraction and oesophagogastric junction exposure 234 Page 2 of 2 < previous page page_145 next page > . isolation 334 intersigmoid fossa 85 intestinal obstruction see colon.This version of Total HTML Converter is unregistered. splenic flexure access 90 lesser sac. 114 laparoscopic vascular stapler 1079 laparotomy. air into 1415 linea alba. feeding 612 jejunum pancreas anastomosis 501 Roux loop see Roux loop J-pouch colonic. obstruction J jejunojejunostomy 52. finding in obese patients 34 liver mobilization. lubrication to locate 139 inferior mesenteric artery (IMA). identification 1034 inferior vena cava retrohepatic 33 in right-sided hepatic resection 312 uprahepatic. left lobe 334 resection.

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liver (cont.): transplantation, common bile duct anastomosis to Roux loop 40 traumatized, packing 345 Cambridge technique 356 Lloyd-Davies forceps 136 'looped pulley' suture 1389 loop ileostomy closure 812 loop end 746 reversal 789 side-to-side anastomoses 80, 81, 82 siting 6970 stapled closure 7980 without a rod 734 M Makuuchi's ligament 31 mesenteric vessels damage and haemostasis method 15 see also inferior mesenteric artery (IMA); superior mesenteric vein mesentery colon see mesocolon division levels/sites 634 method 656 ileal, after left colonic resection 97 suture ligation 656 mesocolon, transverse adhesion separation 467 separation of greater omentum 1415 Moran triple-stapling technique 10911 N needle decompression, obstructed colon 92 O. obesity finding midline in abdominal wall 34 loop end ileostomy 746 morbid, gastric bypass 278 oesophagectomy, transhiatal using vein stripper 267 oesophagogastric junction, exposure, liver lobe retraction 234 oesophagogastric surgery 2330 oesophagojejunostomy, high (intrahiatal), anastomosis 246

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page_146 oesophagojejunostomy, high (intrahiatal), anastomosis 246 omentum, greater, separation from transverse mesocolon 1415 P packing, traumatized liver 346 pancreas arterial supply and venous drainage 46 division 4853 exposure method 468 head exposure 467 lesion resection 4853 neck exposure 467 safe approach method 456 necrosis 55 tail, exposure 478 pancreatic necrosectomy 55 pancreaticoduodenal resection 4853 reconstruction after 523 pancreaticoduodenectomy, Whippies 535 pancreaticojejunal anastomosis 501 pancreaticojejunostomy 535 pancreatic surgery 4555 paracolostomy hernia, repair 834 pelvic dissection bleeding from presacral veins 1234, 125 laparoscopic vascular stapler 1079 pelvic surgery laparoscopic vascular stapler 1079 redo, rectum mobilization 11314 retractors used 212 small bowel retraction 19 uterus retraction 201

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pelvis, exposure and retractors for 212 perianal sepsis, induration location 139 perianal wound, care 1412 perineal wound, closure, 'looped pulley' suture 1389 Peyr's clamp 29 Polyglactin (Vicryl), greased 16 position, jack-knife 1212, 1278 presacral veins, bleeding Sengstaken tube use to arrest 125 thumbtack method to arrest 1234 proctectomy, small bowel lengthening methods after 11718 proctosigmoidectomy, anterior 956 purse-string sutures anterior resection of rectum 1045 inversion appendicectomy 88 placement and repair 99101 wound closure after stoma takedown 82 pyloromyotomy, Ramstedt's, mucosal perforation prevention 59 pylorus, resection 52 R Ramstedt's pyloromyotomy, mucosal perforation prevention 59 rectal surgery 85125 rectum abdominoperineal resection, positioning for 1212 anterior resection circular stapling device 1047 colonic pouch-anal anastomosis after 112 inferior mesenteric artery identification 1034 stapled, double-purse-string 115 transanal staplers and 116 colon reaching, methods for 956 excision, laparoscopic vascular stapler 1079 lesions, transanal excision, exposure 1289 mobilization, in redo pelvic surgery 11314 resections, bleeding from presacral veins 1234, 125 sponges in, during transanal excision of lesions 1289 swab insertion for anorectal surgery 1278 retractors used in pelvic surgery 212 Roux loop 52 common bile duct anastomosis to 3940 oesophagojejunostomy 246 pancreaticojejunal anastomosis 501 pancreaticojejunostomy after Whippies resection 535 S sacrum, venous drainage 124 St Mark's retractor 21, 22, 24 scars, old abdominal, excising 12 Schneeden stitch 14 Sengstaken tube, presacral bleeding control 125 seton cutting, for fistula-in-ano 141 insertion, for fistula-in-ano 13940 skin, subcutaneous closure 9 small bowel mesentery see mesentery small intestine ball-bearing to detect strictures 67 lengthening methods for anastomoses 11718 needle-stick injury prevention 6 resection level in Crohn's disease 634 retraction for pelvic surgery 19 surgery 5767 tumour resection 57

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antral adhesions 467 stomas 6984 herniation. in deep dark hole 19 two suture method. tumour implantation prevention 109 stapler circular. 91 taking down 901 'splenocolic ligament' 478 S-pouch 117 staple-line. for anterior resection of rectum 1047 circular intraluminal 99 insertion for ileal pouch-anal anastomosis 11819 laparoscopic vascular 1079 transanal 116 stapling ileal anal pouch anastomosis 11921 loop ileostomy closure 7980 Moran triple-stapling technique 10911 stomach. safe approach method 456 suprahepatic inferior vena cava.This version of Total HTML Converter is unregistered. repair 834 mobilization 778 temporary. closure of abdomen 6 whip 103 T Toldt. for peroperative cholangiograms 412 splenic flexure mobilization 89. page_148 Page 1 of 2 < previous page page_148 Page 148 snugger. white line 90 . isolation 334 sutures different colours in loop end ileostomy 746 double-loop deep-tension 78 drain positioning 1112 greased thread 16 high (intrahiatal) oesophagojejunostomy 246 identification of free ends in two-layer anastomosis 1213 'looped pulley' 1389 purse-string see purse-string sutures Schneeden 14 short. closure 778 wound closure after take-down 82 stoma surgery 6984 subcutaneous skin closure 9 superior mesenteric vein.

holes. identification 856 ureteral catheter. retraction in pelvic surgery 201 V vein. Whipples pancreaticoduodenectomy 4855 whip stitch 105 wound care. smooth incisional curve around 23 ureter. 'looped pulley' suture 1389 wound dehiscence. perianal 1412 wound closure. insertion in ultra-low anterior resection 116 tumours. drainage 1718 uterus. left. electrocautery 130 transanal excision of rectal lesions 1289 transanal staplers. white transanal anvils. abdominal double-loop deep-tension sutures after 78 prevention 6 Page 2 of 2 < previous page page_148 . perineal. implantation on staple lines 109 two-scalpel technique 12 U umbilicus. page_148 line 90 Toldt. haemostasis using Babcock clamp 16 vein stripper. reusable 115 transanal dissection. in right-sided hepatic resection 312 venous drainage pancreas 46 sacrum 124 Vicryl. greased 16 W.This version of Total HTML Converter is unregistered. transhiatal oesophagectomy 267 vena cava.